Surprise Medical Bills: What the No Surprises Act Protects You From
Which out-of-network bills the No Surprises Act blocks, what it leaves out, how Good Faith Estimates and bill disputes work, and how to report a violation.
If you have most kinds of private health insurance, the No Surprises Act shields you from out-of-network bills in three situations: emergency care, treatment by an out-of-network provider during a visit to an in-network hospital or surgery center, and air ambulance flights. In those situations your cost is capped at your plan's in-network cost sharing, and the provider cannot bill you for the remainder.
The law, in effect since January 1, 2022, also gives people who are uninsured or not using insurance the right to a Good Faith Estimate for scheduled care and a way to dispute a bill that comes in well above it. Ground ambulance rides are generally left out.
Key takeaways
- For emergency care, your plan cannot require prior authorization, and out-of-network providers cannot charge you more than in-network cost sharing.
- Out-of-network doctors, labs and anesthesiologists at an in-network hospital or surgery center generally cannot balance bill you.
- Ground ambulance bills are not covered by the federal protections, though a state law may help.
- If you are uninsured or paying yourself, ask for a Good Faith Estimate. In 2026, a bill at least $400 above the estimate can be disputed; filing costs a $25 non-refundable fee.
- Report a violation to the No Surprises Help Desk at 1-800-985-3059 or online.
What counts as a surprise bill
A balance bill is a provider asking you to pay whatever is left of its charge after your plan has paid. It becomes a surprise bill when it comes from an out-of-network provider or facility you did not expect, or when it asks for more cost sharing than an in-network visit would cost. The Centers for Medicare & Medicaid Services (CMS), the federal agency that runs the No Surprises Help Desk, says the risk is highest when you cannot pick an in-network provider ahead of time, an emergency being the obvious case.
Where the law applies, you still pay your usual in-network share. That can mean an unmet deductible (the amount you pay each year before the plan starts sharing costs), a copay or coinsurance.
Who the law covers
| Protected by the No Surprises Act | Not covered by its billing protections |
|---|---|
| Job-based plans, both fully insured and self-funded | Medicare, including Medicare Advantage |
| Individual plans bought on or off HealthCare.gov or a state marketplace | Medicaid, CHIP, Indian Health Service, VA health care and TRICARE |
| Federal Employees Health Benefits plans | Short-term limited-duration insurance and health care sharing ministries |
| State and local government plans and church plans | Hospital indemnity, accident-only and disease-specific policies |
| Fully insured student health plans | Stand-alone dental and vision plans |
CMS notes that those government programs already have some protections against balance billing of their own. The table is not a complete list: retiree-only plans and account-based plans such as health reimbursement arrangements are also outside the billing protections. Dental or vision benefits inside a major medical plan can still be protected.
The three situations the law protects
Emergency care
If your plan covers emergency care, it must cover it at an out-of-network emergency room or freestanding emergency department, without prior authorization. Whether it was an emergency is judged by your symptoms under a "prudent layperson" standard: would a person with typical knowledge of health and medicine believe the symptoms needed immediate care to avoid serious harm? The plan cannot decide based only on the final diagnosis code.
The hospital, the doctors who treat you and an air ambulance company are all limited to your in-network cost sharing. The protection also covers care after you are stabilized, unless you validly waive it in writing, as explained below. For emergency care, federal rules require your plan to count what you pay toward your in-network deductible and in-network out-of-pocket maximum.
Non-emergency care at an in-network facility
The second protection applies when the facility is in your network but someone who treats you there is not. Four kinds of in-network facility qualify: hospitals, hospital outpatient departments, critical access hospitals and ambulatory surgical centers. Out-of-network anesthesiologists, radiologists, pathologists, labs, assistant surgeons, hospitalists and intensivists are typical examples, and a service linked to the visit, such as a lab test run off site, can count too. Federal rules again require your payments to count toward your in-network deductible and out-of-pocket maximum.
This protection does not reach other settings, such as a doctor's office that is not a hospital outpatient department, or a visit to an out-of-network facility. Network checks still matter when you pick a 2027 plan, and the guide to HMO, PPO, EPO and POS network types explains how each type handles out-of-network care.
Air ambulance
Out-of-network air ambulance providers, by helicopter or airplane, cannot charge you more than in-network cost sharing for covered services, and those payments count toward your in-network limits. If your plan covers air ambulance only in emergencies, the law does not make it cover a non-emergency flight.
How your share is calculated
When neither a state law nor a state All-Payer Model Agreement sets the amount, your plan starts from the lower of the provider's billed amount and the qualifying payment amount. That amount is generally based on the median rate the plan has agreed to pay in-network providers in the same area. For air ambulance services, this federal method always applies. The plan then applies your in-network deductible, copay or coinsurance. So if a plan's coinsurance is 10% in network and 40% out of network, a protected patient pays the 10%.
The provider and your plan settle the rest through negotiation or a federal process called independent dispute resolution. You are not part of it, and your plan cannot raise your cost sharing because of its outcome.
Example: In 2026, Sam has knee surgery at an in-network ambulatory surgical center. The anesthesiologist is out of network and bills $2,400. Sam has already met his deductible, and his plan charges 20% coinsurance for in-network surgery. The plan's qualifying payment amount for the anesthesia is $1,500. All of these numbers are illustrative.
The plan uses the lower figure, $1,500, and applies the in-network rate: 20% of $1,500 is $300. Sam owes $300, and that amount counts toward his in-network out-of-pocket maximum. The anesthesiologist cannot bill him the other $2,100.
When you can be asked to give up your protections
In limited cases, an out-of-network provider may hand you a notice-and-consent form. Signing it means you accept out-of-network care and give up your surprise-billing protections, so you will likely pay more. Signing is your choice, but if you refuse, the provider may decline non-emergency care or care after an emergency.
The form must be separate from other paperwork, include a cost estimate, and be given in advance. It cannot be used at all:
- for emergency care before you are stabilized, or in the emergency room;
- by providers of emergency medicine, anesthesiology, pathology, radiology, neonatology or diagnostic services such as labs and imaging;
- by assistant surgeons, hospitalists or intensivists;
- when no in-network provider at the facility can provide the service.
After an emergency, consent can be sought only when two things are true: you are well enough to reach a nearby in-network provider without an ambulance or other medical transport, and you are in a condition to make an informed decision. If a form arrives and an in-network option exists, ask for the in-network provider before you sign, and call the help desk if you are unsure.
What the law does not cover
- Ground ambulances. These are generally outside the federal protections and may charge out-of-network rates unless a state law says otherwise. Ask your state insurance department about state rules.
- Services your plan does not cover. The law limits cost sharing for covered care; it does not make your plan cover a service it excludes.
- Your normal share. CMS says a bill for an unmet deductible is not a No Surprises Act violation.
Two related protections can help. If your plan's directory wrongly listed a provider as in network and you used that provider because of it, you cannot be charged more than in-network cost sharing, and the provider must refund anything you paid above that amount, with interest. And if your doctor or hospital leaves your plan's network while you are in the middle of certain treatment, such as care for a pregnancy or a serious and complex condition, you can choose to keep the same plan terms with that provider for up to 90 days. Federal guidance calls this being a "continuing care patient." CMS says regulations for both protections have not been issued yet; until they are, plans and providers are expected to follow a reasonable, good-faith reading of the law.
Good Faith Estimates if you are uninsured or paying yourself
If you have no insurance, or have private insurance but choose not to use it for a service, providers usually must give you a Good Faith Estimate: an itemized list of the charges they expect. You get one when you book care at least 3 business days ahead, or when you ask for one. Tell the provider before care that you are not using insurance, because the dispute process described below requires it. People enrolled in federal programs such as Medicare, Medicaid, CHIP, TRICARE or VA health care are not eligible for a Good Faith Estimate.
| When the care is scheduled | When you get the estimate |
|---|---|
| 0 to 2 business days ahead | No estimate is required |
| 3 to 9 business days ahead | Within 1 business day |
| 10 or more business days ahead | Within 3 business days |
| You ask before scheduling | Within 3 business days |
An estimate covers a single provider or facility, so an operation can mean separate estimates from the surgeon and from the hospital. Keep every estimate, because you cannot dispute a bill without one.
Disputing a bill that exceeds the estimate
Under the rules in effect in 2026, you can use the federal patient-provider dispute process if all of these are true: you got the care on or after January 1, 2022 without using insurance; you told the provider beforehand that you were not using insurance; you have the provider's estimate; and one provider or facility billed you at least $400 more than its own estimate, on a first bill dated within the last 120 calendar days. Filing costs a $25 non-refundable fee; if the independent reviewer decides in your favor, the $25 is taken off what you owe the provider. CMS says your costs will not go up because you disputed. While the dispute is open, the provider cannot send the bill to collections and must stop collecting on a bill already there.
Example: In 2026, Rosa books an outpatient procedure three weeks ahead, tells the facility she will not use insurance, and receives its Good Faith Estimate of $1,800. The facility's bill arrives at $2,300. All of these numbers are illustrative. The bill is $500 over the estimate ($2,300 minus $1,800), which clears the $400 threshold, so Rosa can start a dispute as long as she files within 120 calendar days of the date on that first bill.
How to report a violation or get help
- Check your Explanation of Benefits first. It should show your share figured at in-network rates. The guide to reading an Explanation of Benefits shows what to compare.
- Call the provider's billing office. If the bill asks for more than your in-network share, ask for a corrected bill, and note who you spoke with and when.
- Contact the No Surprises Help Desk. Call 1-800-985-3059, seven days a week, or use the online complaint form. Have your bill, insurance card, Explanation of Benefits and any consent form or estimate ready. CMS says it will contact you within 60 days if it needs more information.
- Appeal if your plan got it wrong. If your plan denied or underpaid a claim, appeal it. The law also lets you ask an independent reviewer to decide whether a denial complied with the No Surprises Act. Federal Employees Health Benefits plans use the Office of Personnel Management's disputed claims process instead. The guide to appealing a denied claim covers the deadlines.
Frequently asked questions
Does the No Surprises Act apply to Medicare?
No. Medicare, including Medicare Advantage, and Medicaid already have some protections against balance billing, and they are outside this law's billing protections. CMS offers a separate action plan for billing problems with these programs.
Are you protected from a surprise ground ambulance bill?
Not by federal law. The federal protections generally exclude ground ambulances, so they can still bill out-of-network rates unless a state law says otherwise. Air ambulances are covered.
Can you get a Good Faith Estimate if you have insurance?
With private insurance, only if you tell the provider before care that you will not use your insurance for that service. CMS says the estimate rules for people who do use their insurance have not been put into effect yet. People in Medicare, Medicaid and other federal programs are not eligible. If you use your plan, your protections come from the surprise-billing rules and your plan's appeal process.
What if you already paid a surprise bill?
File a complaint with the No Surprises Help Desk. CMS lists paying more than in-network rates for an emergency room visit or a visit to an in-network facility as one of the reasons to complain. If you paid more than in-network cost sharing because your plan's provider directory was wrong, the provider must refund the excess, with interest.
Sources
- Know your medical bill rights (CMS)
- Know your medical bill rights when using insurance (CMS)
- No Surprises Act: Overview of Key Consumer Protections (CMS, revised June 2026)
- 45 CFR 149.110, Preventing surprise medical bills for emergency services (U.S. Government Publishing Office, 2025 edition)
- 45 CFR 149.120 and 149.130, Non-emergency and air ambulance surprise bills (U.S. Government Publishing Office, 2025 edition)
- What is a good faith health insurance estimate? (CMS)
- Dispute a medical bill (CMS)
- Submit a provider or insurer complaint (CMS)