No Surprises Act: Your Federal Protections Against Surprise Medical Bills

Surprise medical bills — unexpected charges from out-of-network providers you didn't choose — have been one of the most common causes of financial hardship for insured Americans. The federal No Surprises Act, effective January 1, 2022, bans the most common forms of surprise billing. Here's what the law protects you from, when it applies, and what to do if you receive a surprise bill.

What Is a Surprise Bill?

A surprise bill occurs when you receive care from an out-of-network provider and are then billed for the difference between what your insurer paid and what the provider charged. This often happens when:

• You go to an in-network emergency room but are treated by an out-of-network physician (anesthesiologist, radiologist, hospitalist, ER doctor)
• You schedule a procedure at an in-network facility but an out-of-network assistant surgeon, anesthesiologist, or specialist participates without your knowledge
• You are transported by an air ambulance that is out-of-network
• You receive care during an emergency and had no ability to verify provider network status

Before the No Surprises Act, patients could be billed for the full out-of-network amount in these situations — often thousands or tens of thousands of dollars.

What the No Surprises Act Prohibits

For covered situations, the No Surprises Act:

1. Bans balance billing. Providers cannot bill you more than your in-network cost-sharing (deductible, copay, coinsurance) for covered surprise billing situations.

2. Limits cost-sharing. Your cost-sharing for surprise bill situations is calculated at the in-network rate, not the out-of-network rate.

3. Removes out-of-network charges from deductibles. Surprise bill situations cannot count separately toward an out-of-network deductible — they must count toward your in-network deductible.

4. Requires good faith cost estimates. Providers must give you a good faith cost estimate before scheduled services.

5. Establishes a dispute resolution process. Providers and insurers who dispute the payment amount go through an independent arbitration process — without involving the patient.

Situations Covered by the No Surprises Act

Emergency services: For emergency care at any facility (in-network or out-of-network), you cannot be billed more than your in-network cost-sharing — regardless of whether the facility, ER physician, anesthesiologist, radiologist, or other provider is in-network.

Non-emergency services at an in-network facility: If you receive scheduled non-emergency care at an in-network hospital or ambulatory surgical center and an out-of-network provider participates in your care without your knowledge, the surprise billing protections apply. This covers anesthesiologists, radiologists, pathologists, assistant surgeons, and other ancillary providers.

Air ambulance services: Out-of-network air ambulance services from participating providers are covered by the No Surprises Act. You pay only in-network cost-sharing.

What Is NOT Covered

The No Surprises Act has important limitations:

• Intentional out-of-network choices: If you knowingly and voluntarily choose an out-of-network provider for non-emergency scheduled care (and sign a consent form), the surprise billing protections do not apply.
• Ground ambulance services: Ground ambulances are specifically excluded from the federal law, though some states have enacted their own protections.
• Balance billing by your actual chosen out-of-network provider: If you deliberately chose an out-of-network surgeon for an elective procedure, any balance billing from that surgeon is not covered. The law focuses on ancillary providers you didn't choose.
• Exceeding the good faith estimate: The NSA's good faith estimate provisions cover uninsured/self-pay patients; insured patients have separate rights through their plan.
• Short-term health plans, grandfathered plans, STLDI plans: These plans may not be subject to NSA provisions.

Required Notice and Consent Process

For non-emergency situations at in-network facilities, providers who are out-of-network must provide you a written notice and obtain your written consent if they want to bill you out-of-network rates. This notice must:

• Explain that the provider is out-of-network and not subject to the surprise billing protections
• Include a good faith cost estimate of what you'll owe
• Give you a list of in-network alternatives
• Be provided at least 72 hours before the scheduled service (or at the time of scheduling if within 72 hours)

If you did not receive this notice and did not sign a consent form, you likely should not have been billed out-of-network rates, even for a scheduled procedure.

How to Dispute a Surprise Bill

Step 1: Verify the bill is a surprise bill situation. Review your EOB. Is the provider out-of-network? Was this an emergency, or were you at an in-network facility when the ancillary provider participated?

Step 2: Contact the provider. Call the provider's billing department and state: "This appears to be a surprise bill prohibited by the No Surprises Act. I was at an in-network [hospital/facility] and I did not receive notice that you were out-of-network or sign a consent form. Please adjust this bill to my in-network cost-sharing level."

Step 3: Contact your insurer. Call your insurer and report the surprise bill. Request that they process the claim at in-network cost-sharing as required by the No Surprises Act. Insurers are required to process surprise billing situations this way and to coordinate with providers.

Step 4: File a complaint with CMS. If the provider or insurer fails to comply, file a complaint at cms.gov/nosurprises or call 1-800-985-3059. CMS enforces the No Surprises Act and has issued substantial civil monetary penalties for violations.

Step 5: Contact your state insurance department. Most states have their own enforcement mechanisms and may have enacted additional protections beyond the federal law.

State Surprise Billing Protections

Many states enacted surprise billing protections before the federal law, and some provide stronger protections:

• California: The California Health & Safety Code prohibits balance billing by out-of-network providers in emergencies and in certain non-emergency situations.
• New York: New York has one of the strongest state surprise billing laws, covering a wider range of situations than the federal law.
• Texas: Texas enacted its own surprise billing dispute resolution law, which operates alongside the federal process.

When state law provides stronger protections than federal law, the state law generally applies to state-regulated plans.

Fight Back With ClaimBack

If you've received a surprise bill and your insurer or provider won't correct it, ClaimBack can help you craft a formal dispute letter citing the No Surprises Act and the specific regulatory provisions that protect you.

Start your appeal at ClaimBack

Related Reading

• Common Reasons Insurance Claims Are Denied
• How to File a Complaint With Your State Insurance Department
• Insurance Ombudsman Guide