No Surprises Act: What It Covers and What to Do

Surprise medical bills often arrive after a patient did what the health plan seemed to require: used the nearest emergency room, chose an in-network hospital, or scheduled surgery at an approved facility. Unexpected charges come from a provider the patient never selected, such as an anesthesiologist, radiologist, or air ambulance service.

Congress designed the No Surprises Act in part for the gap between the facility a patient chose and the clinicians who became involved. It does not erase deductibles or make every out-of-network bill unlawful. Your practical challenge is identifying whether the law covers the specific service and then using the correct process to challenge the charge.

What Is a Surprise Medical Bill?

Surprise medical bills are an unexpected out-of-network charge that the patient could not reasonably avoid or did not know would occur. It often involves balance billing, which is the provider’s attempt to collect the difference between its charge and the amount paid or recognized by the health plan.

For example, an emergency physician may be out of network even though the hospital is in network. In planned care, a surgeon may be in network while the anesthesiologist or laboratory is not. Before federal protections took effect in 2022, the patient could be left in the middle of the payment disagreement.

Covered No Surprises Act cases generally remove the patient from the payment dispute between the plan and provider. Providers and health plan must resolve the remaining payment between themselves, while the patient is limited to the cost sharing that would apply in network.

Who Is Protected by the No Surprises Act?

Federal protections apply to most people using private health insurance, including coverage through an employer, the Federal Employees Health Benefits Program, the federal or a state Health Insurance Marketplace, or another individual-market health plan.

Medicare, Medicaid, the Indian Health Service, Veterans Affairs health care, and TRICARE have separate billing protections. Patients with one of those programs should use the program’s own complaint and appeal channels rather than assuming the private-insurance process applies.

These federal balance-billing protections generally do not apply to services covered only by:

• Short-term limited-duration insurance
• Health care sharing ministries
• Fixed indemnity or hospital indemnity coverage
• Standalone vision or dental plans, unless the benefit is part of a covered health plan

State surprise-billing laws may provide broader rights or may govern parts of a claim that federal rules do not. Complaints filed with the federal help desk can be referred to an appropriate state authority when necessary.

Which Medical Services Are Covered?

Most Emergency Services

If the health plan covers emergency care, protected emergency services must generally be treated at in-network cost-sharing rates without prior authorization even when the facility or clinicians are out of network.

Covered emergency settings can include a hospital emergency room, an independent freestanding emergency department, and hospital departments providing certain post-stabilization services.

Post-Stabilization Care in Many Situations

Protection often continues after the immediate emergency while the patient receives care needed to stabilize the condition. Out-of-network providers may be able to request notice and consent for some later services, but only when the patient is stable enough to make an informed decision and can travel to an available in-network provider without medical or emergency transportation.

Certain Nonemergency Care at an In-Network Facility

Federal law protects many out-of-network services connected to a visit at an in-network hospital, hospital outpatient department, or ambulatory surgical center. This addresses situations in which the facility is in network but one of the professionals involved is not.

Out-of-Network Air Ambulance Services

Air ambulance services are covered by federal surprise-billing protections. Patient cost sharing generally must be calculated using in-network rules when the service falls within the law.

What the Law Does Not Cover

Federal surprise-billing protections are not a general cap on all medical bills. A high deductible, coinsurance amount, or uncovered service can still create a large balance without violating the law.

Common limitations include:

• Ground ambulance bills: These are generally not covered by the federal balance-billing protections, although some states provide additional rights.
• Care at an out-of-network facility: Planned care at a facility outside the network generally does not receive the same protection as out-of-network clinicians at an in-network facility.
• Ordinary in-network cost sharing: A large deductible is not itself a surprise-billing violation.
• Services the health plan does not cover: The law does not require a plan to cover every medical service.
• Certain nonstandard coverage arrangements: Short-term plans, fixed indemnity benefits, and health care sharing ministries may fall outside the protections.

Medical bills can still be incorrect even when the No Surprises Act does not apply. Check whether insurance was billed correctly, whether payments and contractual adjustments were posted, and whether the service matches the medical record.

How Much Can a Protected Patient Be Charged?

For protected services, the patient generally owes no more than the in-network cost-sharing amount. Cost sharing may include a copayment, deductible, or coinsurance based on the amount recognized under the applicable rules.

Protected patients should not be billed for the difference between the provider’s out-of-network charge and the amount paid by the plan. Provider-plan payment disputes are separate from the patient’s responsibility.

A useful comparison is between the medical bill and the explanation of benefits:

• Does the EOB process the service at an in-network cost-sharing level?
• Does the provider bill match the EOB patient responsibility?
• Has the provider posted the insurance payment and required adjustment?
• Did the patient already pay a copay or deposit that is missing from the account?

When a Notice and Consent Form Matters

Some planned nonemergency or post-stabilization services, an out-of-network provider may ask the patient to sign a notice and consent form. Signing means the patient agrees to receive out-of-network care and gives up surprise-billing protections for the identified services.

Valid forms should:

• Be separate from other registration and medical consent paperwork
• Explain the patient’s protections in plain language
• Estimate what the out-of-network care may cost
• Be provided in advance under the applicable timing rules
• Be available in an appropriate language or with interpreter access
• Give the patient a genuine choice whether to proceed out of network

Waivers cannot be required to waive protections for emergency services before stabilization. Notice and consent also cannot be used for several ancillary services, including emergency medicine, anesthesiology, pathology, radiology, neonatology, diagnostic services such as laboratory work, and services from assistant surgeons, hospitalists, or intensivists.

Providers also should not use notice and consent when no in-network provider at the facility can perform the needed nonemergency service.

What to Do When a Surprise Bill Arrives

1. Do Not Pay the Disputed Amount Immediately

Paying may make the account harder to unwind. Avoid ignoring the bill, but first determine whether it represents allowed in-network cost sharing, a claim-processing error, or an unlawful balance bill.

2. Gather the Core Documents

Collect the medical bill, all related EOBs, insurance card, itemized statement, notice and consent form, receipts, and correspondence. Organize records by provider and date of service if the account contains several providers.

3. Identify the Protected Setting

Write down whether the care involved an emergency room, an in-network hospital, hospital outpatient department, ambulatory surgical center, or air ambulance. Verify the facility’s network status for the date of care.

4. Contact the Health Plan

Ask the health plan whether the claim was processed under the No Surprises Act and why the EOB assigned the stated amount to you. If the plan treated protected care as out of network or denied the claim, request appeal instructions.

5. Contact the Provider

Explain that the bill appears to exceed the permitted in-network patient responsibility. Request that the provider correct the account, issue a revised bill, and pause collection of the disputed amount during review.

6. Escalate Through the Correct Channel

Insured patients may need a health plan appeal, a CMS complaint, or both. Uninsured or self-pay patients with a qualifying good faith estimate dispute uses a separate process.

How Insured Patients Can Appeal or File a Complaint

If the health plan denied all or part of the claim or used out-of-network cost sharing when the law may require in-network treatment, follow the internal appeal instructions in the plan documents and denial notice. Appeal deadlines vary, so use the date printed on the specific EOB or denial letter.

File a complaint with the No Surprises Help Desk is appropriate when a provider, facility, or health plan may not be following federal surprise-billing rules. Help Desk staff can review the matter, investigate compliance within federal jurisdiction, or refer it to another federal or state authority.

Helpful complaint documents include:

• The medical bill
• The insurance card
• The explanation of benefits
• Any signed notice and consent form
• Provider and health-plan correspondence
• Appeal decisions
• Relevant evidence of plan coverage

Federal No Surprises Help Desk staff can be reached at 1-800-985-3059. Save the complaint confirmation number and copies of everything submitted.

Complaints and an insurance appeal serve different purposes. Appeals challenge claim decisions, while complaints address possible rule violations, while the appeal challenges the health plan’s claim decision. Depending on the problem, both may be necessary.

Rights for Uninsured and Self-Pay Patients

Patients who are uninsured or choose not to use insurance generally have the right to receive a good faith estimate for scheduled care or upon request. Good faith estimates should describe the expected charges for the anticipated items and services.

Patient-provider dispute resolution may be available when:

• The care was provided on or after January 1, 2022.
• The patient did not have or did not use insurance for the care.
• The provider supplied a qualifying good faith estimate.
• The initial bill is dated within the last 120 calendar days.
• At least one provider or facility billed $400 or more above its estimate.

An independent third party reviews the dispute to determine an appropriate payment. To start the dispute, patients must provide the estimate and bill and currently pay a $25 nonrefundable administrative fee. The $25 fee is deducted from the amount owed to the provider if the dispute is decided in the patient’s favor.

While the formal dispute is pending, the provider cannot move the bill into collections, threaten collection, collect existing late fees on the disputed bill, or retaliate because the patient filed the dispute. Collection activity must pause during the process if the bill is already in collections.

This process is not the standard remedy for a patient who used insurance. Insured patients generally use claim appeals and the No Surprises complaint process instead.

What If the Bill Has Already Gone to Collections?

Collection accounts do not make an unlawful charge valid. Current federal consumer guidance states that collecting or credit reporting medical amounts that exceed No Surprises Act limits may violate debt collection or credit reporting laws.

Request the collector’s validation notice and a detailed breakdown of the bill. Compare the amount with the EOB, provider records, and any complaint or appeal result. A careful review of the debt collection notice should identify the creditor, amount, and dispute deadline.

Send the collector copies of relevant records and state which part of the balance exceeds the amount legally owed. You may also submit a complaint to the CFPB when a collector attempts to collect an impermissible surprise bill or when such a charge appears on a credit report.

Credit-report treatment of medical collections involves additional rules and industry policies. Review how medical debt can affect credit rather than assuming a billing complaint automatically removes every collection entry.

What If the Bill Is Legal but Still Unaffordable?

Certain out-of-network charges are limited by the No Surprises Act, but legitimate deductibles, copays, coinsurance, and uncovered services can still apply. Once the account is accurate, ask the provider about financial assistance, discounts, or an interest-free payment plan.

Nonprofit hospitals must maintain a financial assistance policy, although eligibility and covered providers vary. The provider’s hospital financial assistance and charity care policy should explain how to request assistance and apply.

When assistance is unavailable, use the verified balance to negotiate a medical bill before collections. Avoid moving the balance to a high-interest credit card before insurance errors and assistance options have been exhausted.

Common Mistakes to Avoid

• Assuming every large bill violates the law: A deductible or noncovered service can still be expensive.
• Comparing the wrong EOB and bill: One visit can generate several providers and claims.
• Signing a waiver without reading it: A notice and consent form may give up valuable protections.
• Treating a plan appeal and CMS complaint as interchangeable: They address different parts of the problem.
• Using the self-pay dispute process after billing insurance: Insured claims generally follow a different route.
• Missing the 120-day self-pay deadline: Count from the date of the initial bill.
• Ignoring collection notices: Preserve the dispute deadline even while the provider or insurer reviews the bill.
• Paying with expensive credit too early: Verify the bill and request assistance before converting medical debt into credit card debt.

Ground ambulance transportation is a major exception to the federal rules, so an ambulance-specific balance requires a separate ground ambulance bill review. For any protected or unprotected bill with incorrect charges, follow the full process to dispute the medical bill. Preserve the federal complaint records and follow the validation steps for medical debt in collections if a collector has already contacted you.

Bills outside the No Surprises Act, the medical debt options and rights overview explains the remaining assistance, negotiation, and payment choices.

Summary

The No Surprises Act protects many privately insured patients from unexpected out-of-network charges for emergency care, certain services at in-network facilities, and air ambulance transportation. In a covered situation, the patient generally owes only the applicable in-network cost sharing.

Start with the setting, plan type, EOB, bill, and any notice and consent form. Insured patients may need to appeal the claim and submit a complaint to the No Surprises Help Desk. Uninsured or self-pay patients may qualify for federal dispute resolution when a bill is at least $400 above a good faith estimate and the initial bill is still within the 120-day filing period. Move next to financial assistance or negotiation rather than paying an unverified amount if the charge is lawful but unaffordable.