The No Surprises Act: What It Protects and How to Use It

Since 2022, a federal law called the No Surprises Act has made surprise medical bills illegal in most emergency situations and at in network hospitals. Many people never use the protection because they do not know how strong it is. This guide explains in plain language what the law covers, what it leaves out, how to tell whether your bill breaks the rules, and exactly what to do if it does.

What the No Surprises Act protects

The No Surprises Act targets the classic surprise medical bill, the one that arrives after you did everything right and still got charged out of network rates you never agreed to. In the situations it covers, an out of network provider cannot balance bill you, which means you owe only the in network cost sharing you would have owed anyway, such as your normal copay, coinsurance, or deductible. Three situations are covered.

Emergency care

If you have an emergency, you are protected no matter which hospital you go to or whether the providers are in your network. The law bans balance billing for out of network emergency services at hospital emergency rooms and freestanding emergency facilities. The protection also extends to the care you receive right after you are stabilized, until you can safely be moved to an in network facility and are able to agree to it. Because emergencies leave no time to shop, this is the heart of the law.

Out of network providers at an in network facility

You can choose an in network hospital and still be treated by an individual provider who is out of network, often without ever meeting them. An anesthesiologist, a radiologist who reads a scan, a pathologist, or an assistant surgeon may bill separately and be outside your network. The No Surprises Act protects you from these surprise bills for care at an in network hospital, surgical center, or similar facility, so a provider you did not choose cannot balance bill you.

Air ambulance

Air ambulances are covered. If you are insured and were flown by an out of network air ambulance, the provider generally cannot bill you beyond your in network cost sharing. This matters because air transport bills can reach tens of thousands of dollars, and you almost never get to pick the company.

What the No Surprises Act does not protect

The law is powerful, but it has real gaps, and knowing them keeps you from assuming a protection that is not there.

Ground ambulance and the No Surprises Act

Ground ambulances were left out of the law. In most of the country a ground ambulance can still balance bill you for an out of network transport, even though air ambulances are covered. A growing number of states have passed their own protections, so it is worth checking yours. Because these bills are common and often large, we cover them in detail in our guide to how to negotiate an ambulance bill.

Non emergency care you chose to get out of network

If you knowingly decide to see an out of network provider for scheduled, non emergency care, the No Surprises Act generally does not protect you, because there is no surprise. You chose to go out of network, and the usual out of network cost sharing and balance billing apply. The law is built to protect you when you had no real choice, not when you picked an out of network provider on purpose.

Notice and consent waivers

There is one way to lose a protection you would otherwise have. For certain non emergency services, an out of network provider at an in network facility can ask you to sign a notice and consent form that waives your balance billing protection for that visit. If you sign it, you can be balance billed. These forms are supposed to be given in advance, generally at least 72 hours before a scheduled service, with an estimate of the cost.

The most important thing to know is that a waiver is never valid for emergency care, and it is never valid for certain ancillary services such as anesthesiology, radiology, pathology, neonatology, and assistant surgeons, or when no in network provider is available at the facility. In those cases you keep your protection even if you signed something. Still, the safe rule is simple. Do not sign a notice and consent form you do not fully understand, and do not feel pressured to sign one at check in. If you refuse, the facility should try to find you an in network provider.

What is balance billing and when is it illegal

Balance billing is when an out of network provider bills you for the difference between its full charge and the amount your insurance paid. If a provider charges 3,000 dollars, your plan pays 1,200 dollars, and the provider sends you a bill for the remaining 1,800 dollars, that 1,800 dollar bill is a balance bill. It is separate from and on top of your normal cost sharing.

Balance billing is not always illegal. It is illegal in the situations the No Surprises Act covers, meaning emergency care, out of network providers at in network facilities, and air ambulance transport. It is generally legal when you chose to go out of network for non emergency care, when you signed a valid notice and consent waiver, and for ground ambulances in states without their own protection. So the same out of network bill can be perfectly legal in one situation and against the law in another, which is why the details of how you got the care matter so much.

There is also a state law layer. Many states passed their own surprise billing and balance billing protections, some broader than the federal law, and these generally apply to state regulated insurance plans. If you have a self funded employer plan, which many large employers use, state protections may not reach it, and the federal No Surprises Act is your main shield. When in doubt, your state department of insurance can tell you what applies to your plan.

How to tell if your bill violates the No Surprises Act

You do not need to be a lawyer to spot a likely violation. Walk your situation through a few questions.

• Was it an emergency? If you were treated for an emergency at any emergency room, in network or not, you are almost certainly protected, and an out of network balance bill is likely a violation.
• Was the facility in network? If you went to an in network hospital or surgery center and a separate provider billed you at out of network rates, that surprise bill is likely covered, unless you signed a valid waiver.
• Did you sign a waiver? If no one had you sign a notice and consent form, you did not give up your protection. If you did sign one, check whether it was valid, since it cannot apply to emergency or ancillary services.
• What does your EOB say? Compare the bill to your explanation of benefits. If the provider is billing you far more than the patient responsibility your plan calculated, that gap is the balance bill. Our guide to reading an EOB shows how to find the number that should match.

If your answers point to a protected situation and you still got an out of network balance bill, the tool below can help you think it through, and the next section explains what to do about it.

What to do if you got an illegal surprise bill

If your bill looks like a violation, do not rush to pay it. Paying a bill you may not owe makes it harder to get your money back than it is to simply withhold payment on the disputed amount while you sort it out. Work through these steps.

1. Call your insurer. Point to the claim and say the No Surprises Act should apply, so you should owe only in network cost sharing. Ask them to reprocess the claim and confirm what you actually owe.
2. Call the provider's billing office. Tell them the charge appears to be a prohibited balance bill under the No Surprises Act and ask them to correct it. Put the request in writing as well, so there is a record.
3. File a federal complaint. If they will not fix it, you can report a suspected violation to the federal No Surprises Help Desk at 1-800-985-3059, open weekdays from 8:00 am to 8:00 pm and weekends from 10:00 am to 6:00 pm Eastern time, or through the online complaint form at cms.gov. The government can review whether the plan, provider, facility, or air ambulance followed the rules.
4. Contact your state department of insurance. If your plan is state regulated, the state may enforce its own surprise billing law and can take a complaint directly.

Keep a record of every call and letter, including the date, who you spoke with, and what was said. To put a clean dispute in writing, our guide to how to dispute a medical bill includes a free letter you can adapt. If the bill has already been handed to a collector, you keep the right to dispute it, and here is what to know about medical bills and collections.

Uninsured or self pay: Good Faith Estimates and the dispute process

The balance billing protections above are built around having insurance, so they work differently if you are uninsured or paying cash. The No Surprises Act gives you a different tool instead: the Good Faith Estimate. When you schedule care or ask about the price, a provider is supposed to give you a written estimate of what the care will cost.

That estimate has teeth. If your final bill comes in at least 400 dollars above the good faith estimate you were given, you can use the patient provider dispute resolution process, generally within 120 days of the bill, and an independent reviewer decides a fair amount. Keep your estimate, compare it to the final bill, and if the gap is 400 dollars or more, that is your opening. Even when the dispute process does not apply, the estimate is a strong anchor for negotiating the bill down.