BISMARCK, N.D. — North Dakota hospitals beginning Tuesday must alert patients in non-emergencies whether air ambulances are covered under the patient’s insurance.

The new legislation was spurred by patients increasingly hit with unexpected sky-high bills that could force some into “financial ruin,” North Dakota Insurance Commissioner Jon Godfread said.

It may seem like an easy decision for a patient in a non-emergency situation to be transported to another medical facility across the state: Take an hour-long flight in an air ambulance, or spend most of the day in the back of one on a highway.

But Godfread said few are warned of the sticker shock surely to follow.

From 2013 to July 2016, the state Insurance Department has received 32 complaints from patients totaling $1.7 million for air ambulance services within the state, or more than $55,000 on average, Godfread said.

Air ambulances provide valuable life-saving services in North Dakota but they have been “over-utilized” in recent years for non-emergency situations, Godfread said. Air ambulance companies also are “very, very aggressive” in their collection efforts, he said.

The requirement does not affect emergency air ambulance services.

“If you are by the side of the road in a ditch and it’s an emergency, the all goes out the window,” Godfread said. “But that’s not the point of this at all.”

Beginning Jan. 1, the legislation also will limit the amount that can be charged by air ambulance companies that don’t have agreements with major insurers in the state. Those non-participating companies would only be allowed to charge the average of air ambulance companies that have agreements.

Godfread and West Fargo Republican Sen. Judy Lee, the bill’s sponsor, said that provision could prompt legal action, similar to a lawsuit filed against legislation passed two years ago that imposed more rules for operators.

That legislation said only air ambulance services that are listed with certain health care providers can qualify to be on a primary call list. But federal judge last year ruled the legislation was pre-empted by the federal Airline Deregulation Act and was unenforceable by the state.

Godfread and Lee said the new legislation regulates insurance coverage of air ambulances, not the services and should withstand a legal challenge.