The No Surprises Act: How Federal Law Protects You From Surprise Medical Bills

Before 2022, a patient could go to an in-network hospital, do everything right, and still receive a bill for thousands of dollars from an out-of-network anesthesiologist, radiologist, or emergency physician they never chose. The No Surprises Act, a federal law that took effect January 1, 2022, bans many of these surprise bills. It is one of the most important consumer protections in American health care, yet many patients do not know how it works. This guide explains what the law covers, its limits, and the steps to take if you receive a bill you think is prohibited.

What balance billing is

When you see an out-of-network provider, your insurer may pay part of the bill, and the provider may bill you for the difference between their charge and what the insurer paid. This is balance billing. Surprise bills are balance bills for care you did not knowingly choose from an out-of-network provider, such as in an emergency or from a provider assigned to you at an in-network facility.

What the No Surprises Act covers

The law applies to most private health plans, including employer plans, self-funded plans, and individual market plans. It protects you in three main situations.

1. Emergency services

For emergency care, including at out-of-network hospitals and freestanding emergency departments:

Your plan must cover the services without requiring prior authorization.
You pay no more than your in-network cost-sharing, such as your in-network copay, coinsurance, and deductible.
The provider cannot balance bill you.
These protections generally continue after you are stabilized until you can safely travel to an in-network facility and give informed consent to out-of-network care.

Your plan decides whether a condition qualifies as an emergency based on your symptoms, not just the final diagnosis, under the prudent layperson standard.

2. Non-emergency care at in-network facilities

When you receive care at an in-network hospital, hospital outpatient department, or ambulatory surgery center, out-of-network providers there cannot balance bill you for certain services. This includes ancillary services such as anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeons, hospitalists, and intensivists. You pay only in-network cost-sharing.

For some other services, out-of-network providers can ask you to waive your protections, but only if they give you written notice and obtain your consent at least 72 hours before the service, or three hours for same-day appointments. You are never required to sign, and you cannot be asked to waive protections for emergency care or ancillary services.

3. Air ambulances

Out-of-network air ambulance providers cannot balance bill patients with covered plans. You pay in-network cost-sharing. Ground ambulances are not covered by the federal law, although a growing number of states have passed their own ground ambulance protections. A federal advisory committee has recommended options for ground ambulance protections, but as of now federal law does not cover them.

Who resolves the payment dispute

Under the law, out-of-network providers and insurers negotiate payment between themselves. If they cannot agree, either side can use the federal independent dispute resolution (IDR) process, in which an arbiter chooses one party’s offer. The patient is not part of this dispute and is not responsible for any amount beyond in-network cost-sharing.

Good faith estimates for uninsured and self-pay patients

If you are uninsured, or you choose not to use insurance, 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. The estimate must include expected charges for the primary service and items or services reasonably expected to be provided with it.

If you receive a bill that 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. You generally must file within 120 calendar days of receiving the bill, and a small administrative fee applies. An independent reviewer decides what you owe. While the dispute is pending, the provider cannot send the bill to collections.

The law also calls for advanced explanations of benefits for insured patients, which would give estimates before scheduled care, but federal agencies have delayed enforcement while they develop technical standards.

Protections the law does not provide

The No Surprises Act is broad, but it does not cover everything:

Ground ambulances, as noted above, unless your state has its own law.
Care you knowingly choose out of network at an out-of-network facility for non-emergency services.
Medicare and Medicaid, which already have separate rules that largely prohibit balance billing for enrolled providers.
Short-term limited-duration plans and some other non-ACA coverage, which may not be subject to the law.
Your normal in-network cost-sharing, which you still owe.

Many states had surprise billing laws before 2022, and some offer additional protections, such as for ground ambulances or state-regulated plans. The federal law sets a floor, and stronger state laws can apply where relevant.

What to do if you get a surprise bill

Compare the bill with your explanation of benefits (EOB). Your EOB should show whether the claim was processed under No Surprises Act protections and what cost-sharing applies.
Look for signs of a protected service, such as an emergency room visit or an out-of-network anesthesiologist at an in-network hospital.
Call the provider’s billing office. Explain that you believe the service is protected and ask them to correct the bill. Many errors are resolved at this stage.
Call your insurer to confirm how the claim was processed and ask them to reprocess it if necessary.
File a complaint with the federal No Surprises Help Desk at 1-800-985-3059 or through the CMS website. You can also contact your state insurance department or attorney general.
Do not ignore the bill while it is being resolved. Ask the provider to hold collections while you dispute it.

Tips for avoiding surprise bills in the first place

Check that the hospital or surgery center is in network before scheduled care.
Ask whether your surgeon, anesthesiologist, and other providers will be in network.
Read any consent forms carefully and decline to waive protections if you are unsure.
For planned care, request a cost estimate from your insurer and provider.
Keep copies of all notices, estimates, and EOBs.

Price transparency tools

Separate federal rules require hospitals to post their prices online, including negotiated rates with insurers, and require most health plans to provide online price comparison tools for covered items and services. Using these tools before scheduled care can help you avoid unexpected costs and choose lower-cost settings.

Understanding your EOB

The explanation of benefits your insurer sends after a claim is not a bill, but it is your best tool for spotting errors. Look at the provider name, date of service, billed amount, allowed amount, what the plan paid, and the amount you may owe. For claims protected by the No Surprises Act, the EOB should state that the claim was processed under federal protections and show your cost-sharing at the in-network level. If the amount the provider later bills you is higher than the patient responsibility shown on the EOB, that difference is a red flag worth questioning. Keep EOBs together with matching provider bills so you can compare them quickly, and remember that most insurers make EOBs available in their online portals.

Frequently Asked Questions

Does the No Surprises Act apply if I have Medicare?

Medicare already has strong rules limiting balance billing, so the No Surprises Act mainly protects people with private insurance and uninsured patients through good faith estimates.

Can an emergency room bill me after I am admitted?

Protections continue for post-stabilization services unless you are able to travel and you consent in writing to out-of-network care.

Do I still have to pay my deductible?

Yes. The law limits you to in-network cost-sharing, which can include your deductible, copays, and coinsurance.

This article is for general informational purposes only and is not legal, medical, tax, or financial advice. Rules vary by state and change over time; confirm details with the relevant agency or a licensed professional.