The No Surprises Act is a federal law that protects you from unexpected medical bills when you receive care from out-of-network providers in situations you didn’t choose or couldn’t control. Enacted in December 2020 and effective since January 1, 2022, the law prohibits out-of-network providers from billing you for the difference between what your insurance pays and what the provider charges, a practice known as balance billing. It covers three main scenarios: emergency services, certain non-emergency services at in-network facilities, and air ambulance transport.
The Three Situations the Law Covers
Before this law, you could end up with a massive bill simply because one doctor involved in your care happened to be out of network, even if the hospital itself was in network. The No Surprises Act closes that gap in three specific areas.
Emergency services: Any treatment you receive in a hospital emergency department or a freestanding emergency facility is protected, including mental health emergencies. This extends to care you receive after you’ve been stabilized, regardless of which department in the hospital you’re moved to. You don’t need prior authorization, and the protections apply automatically.
Non-emergency services at in-network facilities: If you go to an in-network hospital, outpatient department, or ambulatory surgical center, you’re protected from surprise bills sent by out-of-network providers who treat you there. This is especially important for ancillary services you don’t typically get to choose yourself: anesthesiology, pathology, radiology, neonatology, as well as services from assistant surgeons, hospitalists, and intensivists. These providers cannot balance bill you under the law.
Air ambulance services: If your health plan covers air ambulance transport, you’re protected even when the air ambulance company is out of network. Ground ambulance services, however, are not covered by the law at all. An out-of-network ground ambulance provider faces no restrictions on what it can bill you.
What You Actually Pay
The law doesn’t mean out-of-network care is free. You still owe your normal in-network cost-sharing amount: your copay, coinsurance, or deductible as if the provider had been in network. The difference is that the provider and your insurer settle the rest between themselves, and the provider can’t come after you for the gap.
In states that have their own surprise billing laws with methods for calculating out-of-network payments, those state formulas generally apply. In states without such laws, your cost sharing is based on the lesser of two amounts: the provider’s billed charge or the qualified payment amount, which is typically the median of your insurer’s contracted rates for that service in your area.
When a Provider Can Ask You to Waive Protections
In limited non-emergency situations, an out-of-network provider at an in-network facility can ask you to waive your surprise billing protections. This requires written notice and your written consent before you receive care. The notice must clearly explain that you’re giving up your right to pay only the in-network rate and what the estimated charges will be.
There are hard limits on when this consent process can be used. It can never be applied to ancillary services like anesthesiology, radiology, pathology, or neonatology. It cannot be used for emergency services before you’re stabilized. And it cannot apply to care that arises from unforeseen, urgent medical needs during your visit. If a complication develops mid-procedure, you can’t be asked to sign away your protections for the additional treatment that follows.
For post-stabilization services in an emergency, a provider can only seek a waiver if the attending physician determines you’re stable enough to travel to an available in-network facility within a reasonable distance and you’re in a condition to provide informed consent.
Protections for Uninsured and Self-Pay Patients
If you’re uninsured or paying out of pocket, the No Surprises Act gives you the right to a good faith estimate of expected charges before you receive scheduled care. Providers must inform you of this right on their website, in their office, and anywhere scheduling or cost questions happen. Even a casual conversation about potential costs counts as a request for an estimate.
The estimate must include not just the primary service but also related items and services you’d reasonably need, even from other providers. If you’re scheduling a surgery, for example, the estimate should cover the surgeon’s fee, anesthesia, lab work, and facility charges.
Timing rules are specific. If your appointment is at least three business days away, you must receive the estimate within one business day of scheduling. If it’s at least 10 business days out, the provider has up to three business days. If you simply request an estimate without scheduling, it must arrive within three business days.
If your final bill exceeds the good faith estimate by $400 or more, you can dispute the charge through a patient-provider dispute resolution process. You have 120 days from the date on your bill to file.
How Payment Disputes Work Between Providers and Insurers
When an out-of-network provider and your insurer can’t agree on what the provider should be paid, the law sets up a structured process to resolve the disagreement, which happens entirely behind the scenes without affecting you.
After the insurer sends an initial payment or denial (within 30 calendar days of receiving a clean claim), the provider has 30 business days to begin an open negotiation period. The two sides then have 30 business days to negotiate directly. If they can’t reach an agreement, either party can initiate the federal independent dispute resolution process within four business days.
An independent arbitrator then reviews the case. Both sides submit their payment offers within 10 business days of the arbitrator’s selection. The arbitrator picks one offer or the other, with no splitting the difference. A decision must come within 30 business days, and payment is due within 30 calendar days after that. Both parties pay administrative fees and arbitrator fees to participate.
How State and Federal Laws Work Together
The No Surprises Act supplements state surprise billing laws rather than replacing them. If your state has its own protections that are at least as strong as the federal law, the state law generally applies. If your state law doesn’t cover a particular situation or only partially covers it, federal protections fill the gap.
Some states cover services the federal law doesn’t, or offer stronger protections in certain areas. The practical effect is that you get whichever law provides better protection for your specific situation. For the state law to apply, it must cover the type of health plan you have, the provider who treated you, and the specific services you received. If any of those pieces don’t line up, federal law steps in.
How to Report a Violation
If you believe a provider or insurer has violated the No Surprises Act, you can file a complaint through the No Surprises Help Desk by calling 1-800-985-3059 or submitting a complaint online through CMS. You’ll need to provide your contact information, details about the parties involved, a description of the issue, and any steps you’ve already taken to resolve it. You don’t need to have documentation ready before reaching out, though the Help Desk may request supporting materials like medical bills later. Complaints can be referred to the appropriate federal or state enforcement authority, which may require the provider or facility to adjust their charges.