Quick answer: the federal No Surprises Act, in effect since January 1, 2022, protects people with most types of health coverage from surprise “balance bills” for emergency care, for non-emergency care from out-of-network providers at in-network hospitals and surgery centers, and for out-of-network air ambulance services. In those cases you pay only your in-network cost sharing. Ground ambulances are not covered by the federal law. If you are uninsured or self-pay, you have the right to a Good Faith Estimate, and you can dispute a bill that is at least $400 more than that estimate. The federal No Surprises Help Desk is 1-800-985-3059.
Before 2022, millions of people received medical bills they had no way to see coming. You could go to an in-network hospital for surgery and later receive a large bill from an out-of-network anesthesiologist you never chose. Or you could be rushed to the nearest emergency room, which happened to be outside your plan’s network, and be billed the difference between the hospital’s charge and what your insurer paid.
The No Surprises Act was designed to stop those situations. This article explains what the law covers, what it does not, how notice-and-consent forms work, what uninsured patients are entitled to and what to do if you receive a bill you think is not allowed. For the basics of how plans, networks and costs fit together, see our full health insurance guide.
This is general information, not legal advice. Sources: Centers for Medicare and Medicaid Services (CMS) No Surprises Act consumer pages and the No Surprises Help Desk; the U.S. Departments of Health and Human Services, Labor and Treasury implementing rules. State laws may add protections. Checked October 2026. Questions about this article: hello@proinsuranceinfo.com.
What Is a Surprise Medical Bill?
A surprise medical bill is an unexpected bill from a health care provider or facility, usually because some part of your care was delivered by someone outside your health plan’s network.
Balance billing
The key problem is balance billing. When an out-of-network provider treats you, they have no contract with your insurer limiting what they can charge. After your plan pays its share, the provider may bill you for the remaining balance, which can be far more than your normal copay or coinsurance. In-network providers have agreed to accept the plan’s rate and cannot do this.
Why it happened so often
Patients usually control which hospital they choose for planned care, but not which anesthesiologist, radiologist, pathologist or assistant surgeon is assigned. In emergencies, patients often cannot choose a facility at all. Those gaps are exactly what the No Surprises Act targets.
What the No Surprises Act Protects You From
According to CMS, if you have health coverage through an employer (including a self-funded plan), the Health Insurance Marketplace or an individual plan bought directly from an insurer, the No Surprises Act protects you from surprise bills in three main situations.
1. Emergency services
If you get emergency care, you are protected from balance billing even if the facility or providers are out of network. Your plan must cover the emergency care without requiring prior authorization and must apply in-network cost sharing. Protections can continue for certain services after you are stabilized unless you give written consent to waive them.
2. Non-emergency care at in-network facilities
If you get care at an in-network hospital, hospital outpatient department or ambulatory surgical center, out-of-network providers working there generally cannot balance bill you. Your cost sharing is limited to what you would pay in network.
3. Air ambulance services
Out-of-network air ambulance providers cannot balance bill you, and your cost sharing is limited to in-network levels.
How your costs are calculated
In protected situations, you pay only your normal in-network cost sharing, such as copays, coinsurance and deductibles. Those payments must count toward your in-network deductible and out-of-pocket maximum. Our explainer on deductibles, copays, coinsurance and out-of-pocket maximums explains how those numbers work.
Which Health Plans the No Surprises Act Covers
The No Surprises Act applies to most private health plans, including:
- Employer group health plans, both fully insured plans sold by insurance companies and self-funded plans run by employers.
- Individual health insurance, including plans bought through the Health Insurance Marketplace at HealthCare.gov or a state marketplace.
- Federal Employees Health Benefits (FEHB) plans.
It generally does not apply to short-term limited-duration plans, which are not considered individual health insurance coverage, or to some other kinds of coverage that are not comprehensive health insurance. Government programs such as Medicare, Medicaid, TRICARE, the Veterans Health Administration and the Indian Health Service have their own rules that already protect patients from most balance billing.
How state surprise billing laws fit in
Many states passed surprise billing laws before the federal law took effect in 2022. For state-regulated health plans, a state’s law may set how out-of-network payments are calculated in place of the federal process, but you keep at least the federal protections. Self-funded employer plans are generally governed by the federal law. If you are not sure which rules apply to your insurance plan, call the number on your insurance card or your state insurance department.
What the Law Does Not Cover
The No Surprises Act is broad but not complete.
| Situation | Federal protection? |
|---|---|
| Emergency room care, in or out of network | Yes |
| Out-of-network anesthesiologist at an in-network hospital | Yes |
| Out-of-network air ambulance | Yes |
| Ground ambulance | No (some states have their own laws) |
| Choosing an out-of-network doctor’s office for routine care | No |
| Services your plan does not cover at all | No |
| Care after you knowingly signed a valid waiver | No |
Ground ambulances
Ground ambulance bills are one of the biggest remaining gaps. The federal law does not include ground ambulance services, although an advisory committee created by the law studied the issue and recommended protections. A number of states have passed their own ground ambulance balance billing laws, so check with your state insurance department.
Medicare and Medicaid
People with Medicare, Medicaid, TRICARE, VA care and Indian Health Service coverage already have separate protections against balance billing in most situations, so the No Surprises Act’s main protections are aimed at private coverage.
Notice and Consent: When You Can Waive Your Protections
In limited situations, an out-of-network provider can ask you to give up your No Surprises Act protections. This is called notice and consent.
The rules
- It applies only to non-emergency care, or post-stabilization care in certain cases.
- The provider must give you a written notice with a good faith estimate of costs and a list of in-network alternatives.
- For appointments scheduled at least 72 hours in advance, the notice must be given at least 72 hours before the service. For care scheduled within 72 hours, notice must be given at least three hours before.
- You can refuse to sign. Signing is always voluntary.
Providers who cannot ask you to waive
Certain providers can never use notice and consent, because patients typically do not choose them. According to CMS, these include providers of ancillary services such as emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists and intensivists, as well as diagnostic services like lab work and imaging. They also cannot ask you to waive protections if no in-network provider is available at the facility.
Should you sign?
In most cases, there is no reason to sign a waiver. If you are asked, ask for an in-network provider instead, or confirm the expected cost in writing before deciding.
Good Faith Estimates for Uninsured and Self-Pay Patients
The No Surprises Act also helps people without insurance and people who choose not to use their insurance for a service.
Your right to an estimate
If you are uninsured or self-pay, providers and facilities must give you a Good Faith Estimate of expected charges when you schedule care at least three business days in advance, or when you ask for one. The estimate should list items and services you are reasonably expected to receive, with expected charges.
Disputing a bill
If your final bill is at least $400 more than the Good Faith Estimate for any provider or facility, you can start the federal patient-provider dispute resolution process. CMS says you generally must start the dispute within 120 calendar days of the date on the original bill. There is a small administrative fee. An independent dispute resolution entity decides what you owe.
Keep a copy of every Good Faith Estimate you receive. Without it, a dispute is much harder. For a sense of how high costs can run without coverage, see our guide to the cost of surgery without insurance.
What to Do If You Get a Surprise Medical Bill
Step 1: Compare the bill to your explanation of benefits
Your insurer sends an explanation of benefits (EOB) for each claim. Check whether the provider was out of network, how the claim was processed and what the EOB says you owe. In a protected situation, you should owe only in-network cost sharing.
Step 2: Call the provider’s billing office
Explain that you believe the bill violates the No Surprises Act. Ask them to review it and resubmit to your insurer if needed. Write down the date, the name of the person you spoke with and what they said.
Step 3: Call your insurer
Ask whether the claim was processed under No Surprises Act protections. If not, ask them to reprocess it.
Ask your insurer to reprocess the claim under No Surprises Act rules if it was paid as out-of-network. Insurance companies must apply in-network cost sharing to emergency services and to covered non-emergency services from out-of-network providers at in-network facilities, and the amount you owe should count toward your in-network deductible and out-of-pocket maximum.
Step 4: Contact the No Surprises Help Desk
If the issue is not resolved, call the federal No Surprises Help Desk at 1-800-985-3059 or submit a complaint through the CMS No Surprises website. CMS can investigate and refer complaints to the right federal or state agency.
Step 5: Contact your state
Your state insurance department or attorney general may also have authority, especially for state-regulated plans and state balance billing laws.
Do not ignore the bill
While you dispute, keep records and ask the provider to pause collection. Unpaid medical bills can eventually be sent to collections, so stay in contact and keep notes. Our article on how long providers have to bill insurance explains billing timelines.
Real-World Examples
These simplified scenarios show how the protections apply. Exact costs depend on your plan.
Example 1: Emergency room out of network
You have a car accident and are taken to the nearest emergency room, which is outside your plan’s network. Under the No Surprises Act, the hospital and ER doctors can bill you only your in-network cost sharing, such as your ER copay and coinsurance after your deductible. They cannot send you a balance bill for the rest.
Example 2: Anesthesiologist at an in-network hospital
You schedule knee surgery at an in-network hospital with an in-network surgeon. The anesthesiologist turns out to be out of network. Because anesthesiology is an ancillary service, the anesthesiologist cannot balance bill you or ask you to waive your protections. You owe in-network cost sharing only.
Example 3: Ground ambulance
An ambulance takes you to the hospital by road, and the ambulance company is out of network. Federal law does not protect you here, so you may receive a balance bill. Check whether your state has a ground ambulance law, and call your insurer to ask about an appeal or negotiation.
Example 4: Self-pay imaging
You are uninsured and schedule an MRI a week in advance. The imaging center gives you a Good Faith Estimate of $900. Your final bill is $1,450. Because it is more than $400 above the estimate, you can start the patient-provider dispute resolution process within 120 days of the bill date.
How the Independent Dispute Resolution Process Settles Payment Disputes
When an out-of-network provider and an insurer disagree about payment for a protected service, the patient is no longer caught in the middle. Instead, they negotiate, and if they cannot agree, either side can start the federal independent dispute resolution (IDR) process. A certified IDR entity chooses between the two parties’ offers. The patient’s cost sharing stays at the in-network amount regardless of the outcome.
Tips to Avoid Surprise Billing Altogether
The law helps, but avoiding surprise bills in the first place is even better.
- Choose in-network facilities for planned care whenever possible.
- Ask who will be involved in a planned procedure, including anesthesia, and whether they are in network.
- Read anything you are asked to sign before non-emergency care, especially forms about out-of-network costs.
- Know your plan type. HMOs and EPOs generally do not cover out-of-network care except emergencies; our guide to HMO vs PPO vs EPO vs POS plans explains the differences.
- Request a Good Faith Estimate if you are paying yourself.
- Keep every EOB and bill until the claim is fully settled.
Frequently Asked Questions
What does the No Surprises Act cover?
It protects people with most private health coverage from balance billing for emergency services, non-emergency services from out-of-network providers at in-network hospitals and surgery centers, and out-of-network air ambulance services. You pay only in-network cost sharing in those cases.
Does the No Surprises Act cover ground ambulances?
No. Ground ambulance services are not included in the federal law, though several states have passed their own protections.
How do I report a surprise medical bill?
Contact the provider and your insurer first. If the problem is not resolved, call the federal No Surprises Help Desk at 1-800-985-3059 or submit a complaint through CMS, and contact your state insurance department.
What is a Good Faith Estimate?
It is a written estimate of expected charges that providers must give uninsured or self-pay patients when care is scheduled at least three business days in advance or when the patient asks. If the final bill is at least $400 higher, you can dispute it.
Can a provider make me sign away my No Surprises Act rights?
No provider can require it. Certain out-of-network providers can ask for consent for non-emergency care with advance written notice, but signing is voluntary, and ancillary providers like anesthesiologists and radiologists cannot ask at all.
Does the No Surprises Act apply to all health plans?
It applies to most private health plans, including employer plans and individual plans from the Health Insurance Marketplace. It generally does not apply to short-term health plans. Medicare, Medicaid, TRICARE, VA care and the Indian Health Service have separate protections against surprise billing.
What is the independent dispute resolution process?
It is the federal arbitration process insurers and out-of-network providers use to settle payment disagreements after an open negotiation period. Patients are not part of it; your costs stay at in-network levels while the insurer and provider resolve the payment.
Sources
- Centers for Medicare and Medicaid Services: No Surprises Act consumer protections; Ending Surprise Medical Bills; No Surprises Help Desk.
- CMS: Good Faith Estimates and the patient-provider dispute resolution process.
- U.S. Departments of Health and Human Services, Labor and Treasury: Requirements Related to Surprise Billing interim final rules (2021).
