What Is the No Surprises Act?
You went to an in-network hospital for a scheduled surgery. You checked. The facility was covered. You signed the paperwork, recovered at home, and then a bill arrived from an out-of-network anesthesiologist for $6,200 — a provider you never selected, spoke to, or even knew was involved. Before 2022, that bill might have been legally enforceable. Today, federal law says you should not pay it.
The No Surprises Act is a federal law signed in December 2020 that took effect on January 1, 2022. It was designed to protect patients from unexpected, often enormous medical bills that resulted from receiving care from out-of-network providers — usually in situations the patient had no ability to control or even anticipate.
Before this law, it was common for patients to receive care at an in-network hospital only to later discover that a particular surgeon, anesthesiologist, or radiologist was out of network. The patient would then be stuck with a massive bill for the difference between what the out-of-network provider charged and what their insurance paid. The No Surprises Act put significant limits on this practice.
What the No Surprises Act Covers
Emergency Services
For emergency medical care, the No Surprises Act prohibits out-of-network providers and facilities from billing you more than your in-network cost-sharing amounts — regardless of where you receive care and regardless of whether the hospital or provider is in your network.
This means if you are rushed to the closest ER in a life-threatening situation, you cannot be charged out-of-network rates for the emergency care you receive. You are responsible only for your plan’s in-network deductible, copay, and coinsurance.
Non-Emergency Services at In-Network Facilities
When you schedule a procedure at an in-network hospital or facility, an out-of-network provider may be involved — an assistant surgeon, the anesthesiologist, or a consulting specialist. Under the No Surprises Act, these providers cannot balance bill you unless:
- They provide you with advance written notice that they are out of network
- They give you a good faith estimate of their charges
- You sign a written consent form acknowledging you understand and agree to pay out-of-network rates
This consent must be given at least 72 hours before a scheduled procedure, or no less than 3 hours before for same-day scheduling. If you were not notified and did not consent, the out-of-network provider generally cannot balance bill you.
Air Ambulance Services
Air ambulance transport is notoriously expensive and frequently out of network. The No Surprises Act extends protections to air ambulance services, requiring that patients be charged only in-network cost-sharing amounts.
Note: Ground ambulance services are a significant gap in the law and remain largely unprotected at the federal level as of 2024.
How Claims Are Processed Under the No Surprises Act
Under the law, when an out-of-network provider is involved in a covered situation, the patient’s insurer and the provider must negotiate payment between themselves. The patient pays only their in-network cost-sharing amount, and the insurer pays the rest directly to the provider.
If the insurer and provider cannot agree on payment, they can use an Independent Dispute Resolution (IDR) process — a form of arbitration established by the law. The patient is not involved in this process and is not responsible for the outcome.
What the No Surprises Act Does NOT Cover
Understanding the law’s limits is just as important as knowing what it covers.
Ground ambulance services: Despite being one of the most common sources of surprise bills, ground ambulance is not covered by the federal law. States may have separate protections.
Out-of-network providers you knowingly choose: If you voluntarily seek care from an out-of-network provider and sign the required consent acknowledging this, the balance billing protections do not apply.
Grandfathered health plans: Health plans that existed before March 23, 2010 and have not made significant changes may be exempt from certain ACA and No Surprises Act requirements.
Short-term health plans and certain other coverage: The law applies to most employer-sponsored and individual market plans but may not apply to all types of coverage.
Your Right to a Good Faith Estimate
For uninsured or self-pay patients, the No Surprises Act requires providers to give you a Good Faith Estimate in writing before scheduled services. This document must list:
- The expected items and services
- The estimated cost for each
- Diagnoses, procedure codes, and expected dates of service
If you receive a bill that exceeds your Good Faith Estimate by more than $400, you have the right to dispute it through a Patient-Provider Dispute Resolution process.
How to Use the No Surprises Act if You Receive a Surprise Bill
If you believe you received a bill that violates the No Surprises Act, take these steps:
- Review your EOB from your insurer to see how the claim was processed. Our EOB decoder can help you understand the key sections.
- Contact your insurer and ask whether the claim was subject to No Surprises Act protections and whether they were applied.
- Ask your provider’s billing department to confirm whether you signed an advance consent form waiving your protections. If you did not, the balance may not be legally owed.
- File a dispute in writing. Use our dispute letter tool to generate a letter that references the specific protections under the Act.
- File a complaint with the federal No Surprises Act Help Desk at 1-800-985-3059 or cms.gov/nosurprises if the issue is not resolved.
State Laws and the No Surprises Act
Many states have their own surprise billing laws that predated or go beyond the federal law. In states where state law provides stronger consumer protections, those protections generally continue to apply. State insurance departments oversee compliance with both state and federal surprise billing protections for state-regulated plans.
For employer-sponsored plans governed by ERISA, the federal law applies and state enforcement is limited. Your employer’s HR department or plan administrator can tell you which rules apply to your coverage.
FAQ
Q: Does the No Surprises Act apply to Medicare and Medicaid? A: Medicare and Medicaid have their own long-standing protections against balance billing. The No Surprises Act primarily targets the private insurance market.
Q: What if an out-of-network provider sends me a bill anyway? A: Do not automatically pay it. Contact your insurer, confirm that No Surprises Act protections apply, and file a complaint if the provider continues to pursue the improper balance.
Q: Can I waive my No Surprises Act protections? A: For non-emergency care at in-network facilities, yes — but only if you sign a specific consent form and the provider meets the advance notice requirements. For emergency care, you cannot waive these protections.
Q: What is the Independent Dispute Resolution (IDR) process? A: IDR is the arbitration mechanism the law established for insurers and providers to resolve payment disputes. It happens between the insurer and the provider — patients are not participants and are not financially affected by the outcome.
Q: Where can I file a No Surprises Act complaint? A: Call 1-800-985-3059 or visit cms.gov/nosurprises. You can also file with your state insurance department, which may have additional enforcement jurisdiction depending on your plan type.