The No Surprises Act: Coverage, Costs, and Your Rights

The No Surprises Act caps what you pay when you get emergency care from an out-of-network provider, non-emergency care from an out-of-network clinician at an in-network facility, or transport by an out-of-network air ambulance: your share is limited to your plan’s in-network cost sharing, and the provider cannot bill you for the difference. The protections took effect on January 1, 2022, and apply to group and individual health plans nationwide, including employer-sponsored and marketplace coverage.1Centers for Medicare & Medicaid Services. State Surprise Billing Laws and the No Surprises Act

Situations the Law Protects

Emergency Care

Federal protections cover emergency services regardless of whether the emergency room, the treating physician, or both are out of network. Your insurer must cover the care and limit your cost sharing to the in-network amount, from arrival through stabilization.2Office of the Law Revision Counsel. 42 USC 300gg-111 – Preventing Surprise Medical Bills Prior authorization is not required for emergency services, and your plan cannot charge more just because the provider is out of network.

After you’re stabilized, the rules shift. At an in-network facility, an out-of-network provider who wants to continue treating you can ask you to waive your protections, but only by following strict notice and consent requirements. At an out-of-network facility, protections continue through post-stabilization care until you can safely be transferred.3Centers for Medicare & Medicaid Services. Standard Notice and Consent Documents Under the No Surprises Act

Non-Emergency Care at an In-Network Facility

If you schedule a procedure at an in-network hospital or ambulatory surgical center and an out-of-network clinician ends up involved, the law protects you from balance billing for that clinician’s services. This most often shows up with anesthesiologists, radiologists, and pathologists, who commonly work at a facility without being in your plan’s network. You pay only the in-network share.2Office of the Law Revision Counsel. 42 USC 300gg-111 – Preventing Surprise Medical Bills

Air Ambulance

If you’re transported by an out-of-network air ambulance, your cost sharing is capped at the in-network rate for that service.4Office of the Law Revision Counsel. 42 USC 300gg-112 – Ending Surprise Air Ambulance Bills Ground ambulance is not covered. If you get a ground ambulance bill, your state’s laws are your only recourse, and many states do not regulate ground transport.5Centers for Medicare & Medicaid Services. Advisory Committee on Ground Ambulance and Patient Billing

Which Plans Are Covered

The Act applies to group health plans and individual health insurance coverage. That includes most employer-sponsored plans, Federal Employees Health Benefits plans, and plans bought through the Health Insurance Marketplace or directly from an insurer.1Centers for Medicare & Medicaid Services. State Surprise Billing Laws and the No Surprises Act It also reaches self-funded employer plans, which state surprise billing laws generally cannot regulate. If your employer self-insures, the federal law may be your only source of surprise billing protection.

If you have Medicare, Medicaid, TRICARE, or receive care through the Veterans Health Administration or Indian Health Service, you already have surprise billing protections under those programs, and the Act does not change your coverage.6Centers for Medicare & Medicaid Services. No Surprises – Understand Your Rights Against Surprise Medical Bills

Several kinds of coverage are excluded entirely:7Centers for Medicare & Medicaid Services. No Surprises Act – Overview of Key Consumer Protections

  • Short-term, limited-duration insurance, which falls outside the federal definition of individual health insurance coverage.8Federal Register. Short-Term, Limited-Duration Insurance and Independent, Noncoordinated Excepted Benefits Coverage
  • Standalone dental and vision plans. If dental or vision benefits are built into your major medical plan, the protections apply; if they’re a separate policy, they’re not covered.
  • Excepted benefit plans, including hospital indemnity, accident-only, disease-specific coverage like cancer-only plans, retiree-only plans, and account-based plans such as health reimbursement arrangements.

If one of these is your only coverage, you are in the same position as an uninsured patient for surprise billing purposes. The good faith estimate rules below become your main safeguard.

What You Actually Pay

When you receive a protected service from an out-of-network provider, your insurer calculates your copay or coinsurance from the qualifying payment amount (QPA), which is the median rate your plan has contracted for the same type of service, in the same specialty, in the same geographic area.2Office of the Law Revision Counsel. 42 USC 300gg-111 – Preventing Surprise Medical Bills In practice, you pay roughly what you would have paid if the provider had been in network.

Anything you pay toward a covered out-of-network service counts toward your in-network deductible and out-of-pocket maximum, just as if the provider were in your plan’s network.2Office of the Law Revision Counsel. 42 USC 300gg-111 – Preventing Surprise Medical Bills Without this rule, those payments could accumulate separately and never bring you closer to your annual cap.

Behind the scenes, the provider and your insurer resolve the rest of the bill between themselves. If they can’t agree, either side can push the dispute into a federal Independent Dispute Resolution process where a neutral entity picks one of the two payment offers.9Centers for Medicare & Medicaid Services. About Independent Dispute Resolution You owe nothing beyond your in-network cost sharing regardless of how it comes out.

When You Can Be Asked to Waive Protections

In some non-emergency situations, an out-of-network provider at an in-network facility can ask you to waive your surprise billing protections and agree to pay full charges. Before you can sign, the provider must give you a written notice on a standard form that shows the estimated cost and clearly states you have the right to refuse.10Office of the Law Revision Counsel. 42 USC 300gg-131 et seq. – Health Care Provider Requirements

The timing is strict. For services scheduled at least 72 hours ahead, you must get the notice at least 72 hours before the appointment. For services scheduled with less lead time, including post-stabilization care in an emergency, you must get it at least 3 hours before the service. A provider representative must be available in person or by phone to explain the documents, and providers must arrange translation or a qualified interpreter for patients with limited English proficiency.3Centers for Medicare & Medicaid Services. Standard Notice and Consent Documents Under the No Surprises Act

You cannot be asked to waive protections at all for certain services where patients rarely get to choose the provider:11Centers for Medicare & Medicaid Services. Frequently Asked Questions for Providers About the No Surprises Rules

  • Emergency medicine, anesthesiology, pathology, radiology, and neonatology
  • Assistant surgeons, hospitalists, and intensivists
  • Diagnostic services, including lab work and imaging
  • Any service where no in-network provider is available at the facility to perform it

If a provider skips the notice requirements or tries to get a waiver for a protected service, the waiver is invalid, and you cannot legally be billed beyond your in-network cost-sharing amount.

If You’re Uninsured or Paying Out of Pocket

If you don’t have insurance or choose to self-pay, you’re entitled to a written good faith estimate before receiving scheduled care. The estimate must itemize expected charges for the primary service and reasonably related costs such as lab work, imaging, and facility fees, and it must cover every provider and facility that will bill separately.12Office of the Law Revision Counsel. 42 USC 300gg-136 – Provision of Information Upon Request and for Scheduled Appointments

The delivery deadline depends on lead time:

  • Scheduled 10 or more business days ahead: within 3 business days of scheduling, or within 3 business days of your request.
  • Scheduled 3 to 9 business days ahead: within 1 business day of scheduling.
  • Scheduled fewer than 3 business days ahead: no estimate is required by law.

If your final bill comes in at least $400 more than the estimate, you can challenge it through the federal Patient-Provider Dispute Resolution process. You must file within 120 calendar days of receiving the initial bill, and an administrative fee is required to start the process; the fee was $25 as of 2024 and may be adjusted annually.13Centers for Medicare & Medicaid Services. No Surprises Act Good Faith Estimate and Patient-Provider Dispute Resolution Requirements A dispute resolution entity reviews the evidence and issues a binding determination on what you owe. While the review is pending, the provider cannot send the bill to collections or threaten legal action. Below the $400 threshold, your only option is to negotiate directly with the provider.

If You Get a Surprise Bill Anyway

If a provider or insurer balance bills you for a protected service, fails to provide a good faith estimate, or ignores the notice and consent requirements, file a complaint with the federal No Surprises Help Desk. The Help Desk investigates compliance and refers cases to other federal or state enforcement authorities when appropriate.14Centers for Medicare & Medicaid Services. Submit a Complaint

You can submit a complaint online at cms.gov or call 1-800-985-3059. Assistance is available in English, Spanish, and more than 350 other languages.14Centers for Medicare & Medicaid Services. Submit a Complaint Providers who violate the Act face civil monetary penalties of up to $10,000 per violation. Filing a complaint is worth doing even if you also plan to dispute the bill directly.