The short answer
The No Surprises Act, in force for health plan years beginning on or after January 1, 2022, protects people in job-based and individual health plans from most surprise out-of-network bills. It covers three situations: emergency care, including at an out-of-network hospital; non-emergency care from out-of-network providers at an in-network hospital or surgery center; and air ambulance services. In each, you owe only your plan's in-network cost sharing, and that amount counts toward your in-network deductible and out-of-pocket maximum. The out-of-network provider cannot bill you for the rest; it settles the difference with your plan. Ground ambulances are not covered by the federal law. If you are uninsured or paying yourself, you can ask for a good faith estimate, and if the bill is at least $400 above it, you can dispute it within 120 days. The federal No Surprises Help Desk is 1-800-985-3059.
The problem the law was written for
Health plans pay in-network providers an agreed rate, and those providers cannot charge you more than your share of it. Out-of-network providers had no such agreement, so they could bill you for the difference between their price and what your plan paid. That practice is called balance billing.
The trouble was that patients often had no say in who treated them. You might pick an in-network hospital for surgery and still be seen by an out-of-network anesthesiologist, or arrive by ambulance at whatever emergency room was closest. The No Surprises Act stops balance billing in the situations where you could not reasonably choose.
Three situations the law covers
- Emergency care. Emergency services at any hospital emergency department or independent freestanding emergency department, in network or not, along with certain care after you are stabilized. Ancillary services available to the emergency department, such as a radiologist reading your scan, are included.
- Non-emergency care at an in-network facility. Services from out-of-network providers at an in-network hospital, hospital outpatient department or ambulatory surgical center.
- Air ambulances. Air ambulance services from out-of-network providers, for plans that cover air ambulance care.
The protections apply to people covered by group health plans, including most job-based coverage, and by individual plans, including those bought on the Marketplace. Many states also have their own surprise billing laws, which can add protection where they apply.
What you can be charged
In a covered situation, your share is limited to what you would have paid an in-network provider: your plan's in-network deductible, copayment or coinsurance. The provider cannot send you a bill for the rest. That payment also counts toward your in-network deductible and out-of-pocket maximum, so it moves you toward the point where your plan pays everything. Your share is figured from an amount set under the law's rules, generally your plan's typical in-network rate for the service, not from the price the out-of-network provider would have charged.
The rest is between the provider and your plan. They negotiate, and if they cannot agree they use a federal independent dispute resolution process. You are not part of that dispute, and its outcome does not change what you owe.
Take a common case. You have knee surgery at a hospital in your plan's network, with an in-network surgeon, but the anesthesiologist on duty that day is out of network, which you learn only when a claim appears on your plan's explanation of benefits. Because anesthesiology at an in-network facility is protected, you owe only your plan's in-network coinsurance for the anesthesia, and it counts toward your in-network deductible. A bill from the anesthesiologist for anything more is not allowed.
When you can be asked to give up the protection
For some planned, non-emergency care, an out-of-network provider at an in-network facility may give you a notice and ask you to sign a consent form waiving your protections. You never have to sign it, and you can choose an in-network provider instead.
The law limits when that request is allowed. You cannot be asked to waive protections for emergency care before you are stabilized, for air ambulance services, for ancillary services such as anesthesiology and radiology, or for unforeseen, urgent medical needs that come up during care. A consent form signed for one of those is not valid, and the protections still apply.
What the law does not cover
Ground ambulances are the biggest gap: the federal protections do not reach them, though some states have their own rules. The law also does not change what you pay if you choose to see an out-of-network provider at an out-of-network facility for planned care; your plan's usual out-of-network rules apply there.
And it does not set your plan's cost sharing. A high deductible is still a high deductible; the law only keeps an out-of-network bill from costing you more than an in-network one would have. If cost sharing itself is the problem, our guide to Marketplace subsidies explains the help available on plans bought there, and the ACA calculator estimates it.
Common cases at a glance
Swipe sideways to see the whole table.
| Situation | Protected by federal law? | What you owe |
|---|---|---|
| Emergency room visit at an out-of-network hospital | Yes | Your in-network cost sharing |
| Out-of-network anesthesiologist during surgery at an in-network hospital | Yes | Your in-network cost sharing |
| Air ambulance from an out-of-network provider | Yes, if your plan covers air ambulance care | Your in-network cost sharing |
| Ground ambulance to the emergency room | No | Your plan's usual rules, unless state law protects you |
| Planned visit to an out-of-network doctor at an out-of-network clinic | No | Your plan's out-of-network cost sharing |
| Uninsured or self-pay patient booking a procedure | Good faith estimate rules apply | The bill, with a dispute right if it is $400 or more above the estimate |
Without insurance: the good faith estimate
If you are uninsured, or you choose not to bill your insurance, providers must give you a good faith estimate of the expected charges when you schedule care at least three business days ahead, and you can ask for one when shopping for care. These estimate rules do not apply to people enrolled in Medicare or Medicaid.
If the final bill from any one provider or facility is at least $400 more than its estimate, you can start the patient-provider dispute resolution process. You must start it within 120 calendar days of receiving the bill, and there is a $25 administrative fee. An independent reviewer then decides what you pay, which can be the estimate, the billed amount or something in between. Keep every estimate you receive; the dispute depends on it.
People without coverage may also qualify for help paying for it. Our guide to Medicaid eligibility explains who qualifies by income.
If a surprise bill arrives anyway
- Compare the bill with your plan's explanation of benefits. If your plan processed the claim as in-network cost sharing, the provider should not bill you more than that amount.
- Check whether the care fits a protected situation: emergency care, an out-of-network provider at an in-network facility, or an air ambulance.
- Call the provider's billing office and your plan. Ask them to confirm the claim was handled under the No Surprises Act, and write down the date and the name of each person you speak to.
- Do not ignore the bill while it is in question. Ask the provider to hold it while the claim is reviewed.
- Pay the part you do owe, your in-network cost sharing, once the amount is confirmed.
- Contact the No Surprises Help Desk at 1-800-985-3059 or submit a complaint through CMS if the bill is not corrected.
Common questions
Does the No Surprises Act cover ground ambulances?
No. The federal protections cover air ambulances but not ground ambulances. Some states have their own rules for ground ambulance bills, so check with your state's insurance department.
Do I have to sign a consent form before surgery?
No. You never have to sign a form giving up your protections, and the form is not valid at all for emergency care, air ambulances, ancillary services such as anesthesiology and radiology, or unforeseen urgent needs.
How long do I have to dispute a bill that is higher than my estimate?
If you were uninsured or paid yourself, you must start the dispute within 120 calendar days of receiving the bill, and the bill must be at least $400 more than that provider's good faith estimate.
Official sources
Keep the paperwork that proves your case
Most surprise bills are settled on paper: the explanation of benefits, the bill itself, any consent form you were asked to sign, and any good faith estimate. Keep all of them together, check each bill against the three protected situations before you pay, and call the Help Desk if a provider will not correct one. If the bigger worry is the coverage itself, our guide to special enrollment periods explains when you can change plans outside open enrollment.
