Ontario resident Madelyn MacNeill considered herself healthy and didn't expect to be rushed to hospital for emergency surgery while visiting her parents in Nova Scotia this past summer.Nor did she expect the almost $13,000 bill for ground and air ambulance transportation that arrived weeks after she returned to Ontario."When I opened up the bill and saw it was $12,800, my jaw dropped. I was in quite a bit of shock," the 27-year-old said. "I can't afford to pay that amount of money all upfront. It boggles my mind."MacNeill has been offered an interest-free payment plan of $50 a month. She figures it will take her 21 years to pay off the bill.Back in June, MacNeill, who lives in Toronto, was working from home and hadn't seen her family for a while. She figured she'd drive home to Nova Scotia, self-isolate for 14 days and continue to work out there, while also enjoying some family time.However, on the last day of isolation, MacNeill experienced back problems. Days later, an ambulance was required to take her to the hospital in New Glasgow.Once there, it was determined she had herniated two discs and needed emergency surgery in Halifax, about 150 kilometres away. MacNeill was told there were no ground ambulances available, so she was transported by air and underwent surgery right away. Although she expected a bill for the ground ambulance, she said, "at no time was I told I would be footing the bill for the air ambulance or any sort of cost associated with the inter-hospital transfer."It's a cautionary tale for anyone travelling between provinces, especially during COVID-19. MacNeill said she has Ontario provincial health coverage as well as insurance through her work, and never imagined she would need travel health insurance while in another part of Canada."Every time I travel out of the country, I always purchase traveller's insurance, but I honestly never thought that I would need travel insurance for inter-provincial travel. I always thought in Canada we had universal health care," she said.Out-of-province visitors pay moreAmbulance travel within a province can be pricey and cause financial hardship, a situation highlighted by CBC's Marketplace in 2015.Fees for ground ambulance for provincial residents vary from a low of $45 in Ontario to a high of $385 in Alberta. Manitoba, which in 2015 had the highest ground ambulance fees in the country, has lowered its fee to no more than $250. Some provinces, such as Alberta, provide free ground ambulance service for seniors.All provinces charge non-residents more for ambulance services, though not all provinces post the fees online. Despite numerous requests, some did not provide CBC News with this information.Of those that did, Nova Scotia had the highest fee: $732.95 for ground ambulance for people from other provinces. (The fee for residents is $146.55.)Air ambulance fees are even costlier for out-of-province residents. Of those provinces that post fees or provided information, P.E.I. and Nova Scotia do not charge residents for air ambulance service, but people from other provinces who require it are billed $12,000. Both provinces, along with Newfoundland and Labrador, say the fees cover the cost of providing the service.Health-care consultant Mary Jane Hampton said ambulances are not part of the Canada Health Act, the federal legislation that sets out what is universally covered. "It's a complicated business, but when the Canada Health Act was written, the only things that were covered in that legislation that would be insured were things that happened inside a hospital and services that are performed by a doctor," Hampton said.She notes that ambulances in Nova Scotia used to be based at funeral homes and were used for basic transportation in a medical emergency. Today, they are staffed by highly qualified paramedics. "I'm not suggesting that it's an easy issue to fix, but from a public point of view and from a patient point of view, it would make a great deal of sense to me for us to figure out how to get the [ambulance] user fees off the table and come up with a different funding model altogether," Hampton said.She urged people to contact their member of Parliament about rewriting legislation to make ambulances an essential service.Chris Hood, the former president of the Paramedics Association of Canada, agrees. Back in 2015, he told CBC's Marketplace, "You don't pay for a police officer to come to your house when you've got somebody breaking into it. You don't pay for the fire department to come and put your fire out. Why is paramedic service or ambulance service any different? It's the same thing." In an interview last week, Hood said that question remains valid today.Are fees a deterrent to use?Michael Nickerson, president of the union that represents Nova Scotia paramedics, said he hopes fees don't deter anyone from calling an ambulance if they need one."Anecdotally, we've heard from paramedics and patients alike that have concerns around the cost of an ambulance, and that some people have waited and not called at all or drove themselves to the hospital while experiencing a medical emergency," Nickerson said.He worries someone driving to hospital while having a heart attack, for example, could have an accident, injuring themselves further and perhaps others on the road — or worse."There's a danger of losing your life if you're having a heart attack and you're not being treated promptly," Nickerson said. He noted Nova Scotia paramedics are highly trained and the province is one of the few jurisdictions that allows paramedics to administer a medication specifically for heart attacks.The Nova Scotia government said in 2018 there were 1,649 ambulance bills, for a total of about $1.2 million. It said 44 bills were written off, for a total amount of $31,554.80.In an email to CBC News, a spokesperson for the province said the government has no immediate plans to review the fees.Will McAleer, executive director of the Travel Health Insurance Association of Canada, said travel health insurance is easy to purchase and affordable, but many people don't realize they need it until they have an out-of-province emergency and are facing a big bill. "When you're looking at an interprovincial or within-Canada policy, you can purchase that for a dollar, maybe two dollars, a day," McAleer said. He emphasized the importance of discussing your needs with the insurance provider and identifying any pre-existing conditions prior to buying insurance to ensure you get the coverage you need. Payment options availableAs for MacNeill and her $12,800 ambulance bill, a small portion of it is covered by her work insurance.Most provinces offer an appeal process for those who feel they are unable to pay their ambulance bills, but it varies from province to province. According to government information online, the Nova Scotia Ambulance Fee Assistance Program will use your net household income as the primary eligibility test to determine whether you qualify to have the debt written off. MacNeill said she's been told the appeal criteria in Nova Scotia are very limited and that fees would only be waived if there's a paramedic error. In this case, there was not."The paramedics were very kind and helpful," MacNeill said.