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Federal protections

The No Surprises Act.

Since January 1, 2022, federal law has protected people with most types of health coverage from surprise bills after emergency care and from out-of-network providers they did not choose. Here is what that means in practice.

Balance billing is what happens when a provider who has no contract with your plan bills you for the difference between what they charged and what your plan paid. In an emergency, or when an out-of-network clinician turns up in the middle of a procedure at an in-network hospital, you have no realistic way to shop around first. The No Surprises Act removes you from that gap.

Who the law covers

The protections apply to most job-based plans, including self-funded plans, and to individual and family plans bought on or off a marketplace, including student health plans. They also apply if you have no insurance at all, through the good faith estimate rules described below.

People enrolled in Medicare, Medicaid, CHIP, TRICARE, the Indian Health Service, or the Veterans Health Administration were already protected from balance billing under the rules of those programs, so the No Surprises Act does not change their coverage. Short-term limited duration policies and other plans that are not comprehensive health coverage are generally outside the law.

Situations that are protected

  • Emergency care at any hospital or freestanding emergency department, in network or out, with no prior authorization required
  • Care you keep getting after you are stabilized in an emergency, until you can safely be moved or you knowingly agree in writing to out-of-network care
  • Treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center, such as an anesthesiologist, radiologist, pathologist, neonatologist, assistant surgeon, hospitalist, or intensivist
  • Air ambulance transport by an out-of-network provider
  • Out-of-network lab work or imaging ordered while you are being treated at an in-network facility

What you pay instead

In a protected situation, your bill is limited to the in-network cost sharing your plan would have applied to that service: your deductible, copay, or coinsurance figured as though the provider were in network. That amount has to count toward your in-network deductible and your out-of-pocket maximum. Your plan also has to cover emergency care without requiring prior authorization, even out of network.

What the federal law does not reach

  • Ground ambulance rides, which the federal law does not cover, though a number of states have passed their own protections
  • Care you deliberately choose from an out-of-network provider outside of these situations
  • Services your plan does not cover at all, which is a coverage question rather than a balance billing question
  • Bills from a provider you gave written consent to see out of network after receiving the required notice and estimate

If you are uninsured or paying without insurance

Providers and facilities have to give people who are uninsured or self-paying a written good faith estimate of expected charges before scheduled care, and on request at any time. The estimate should cover the primary service and the related items and services the provider can reasonably expect. If the final bill comes in substantially above the estimate, you can start a federal patient-provider dispute resolution process rather than negotiating alone.

How to raise a problem

Start with your insurer, using the number on your member ID card, and ask specifically whether the No Surprises Act applies to the claim. If you think a provider billed you in violation of the law, the federal No Surprises Help Desk takes complaints at 1-800-985-3059, and the full consumer guidance is published at cms.gov/nosurprises. Your state insurance department may also handle complaints, and in some states state law rather than the federal law sets what the plan owes the provider.

Read the federal guidance at cms.govFile a grievance or appeal

Shopping for coverage

Every Affordable Care Act plan carries these protections. Enter your ZIP code to see what is available where you live.

The short version

Four numbers worth remembering.

when the federal protections took effect
Jan 2022
the cost sharing you owe in a protected situation
In network
minimum notice before you can be asked to waive protection
72 hours
for a plan and provider to negotiate before dispute resolution
30 days

Good to know

Common questions about surprise bills.

What counts as a surprise medical bill?
A surprise bill arrives when you get care from a provider who is not in your plan network in a situation where you had little or no ability to choose. The classic examples are an emergency room visit and a scheduled surgery at an in-network hospital where the anesthesiologist turns out to be out of network. Before 2022, that provider could bill you for whatever your plan did not pay. Federal law now prohibits that in most of these situations.
What do I actually pay in a protected situation?
Only the in-network cost sharing your plan would have charged for that service: your deductible, copay, or coinsurance calculated as if the provider were in network. That amount also has to count toward your in-network deductible and your out-of-pocket maximum. Anything above it is worked out between the provider and the plan, not with you.
Can I be asked to waive these protections?
In limited situations, yes, and you never have to agree. For certain non-emergency services, an out-of-network provider may ask you to sign a written notice and consent form giving up the protection, and they have to give it to you along with a cost estimate at least 72 hours before the appointment, or three hours in advance if you schedule same day. That waiver can never be used for emergency care, and it can never be used for the ancillary services listed above, such as anesthesiology, radiology, pathology, or neonatology, at an in-network facility. If you decline to sign, the protection stays in place.
What is a good faith estimate?
If you are uninsured or you choose not to use your insurance, a provider or facility has to give you a written estimate of expected charges for scheduled care, including related services from other providers when they can be identified. Ask for it when you schedule, and you can request one any time you are shopping for care. If the final bill is substantially higher than the estimate, there is a federal patient-provider dispute resolution process you can use.
How do the provider and the plan settle the rest?
The plan pays the provider an amount set by state law where one applies, and otherwise the two sides can negotiate for 30 days. If they cannot agree, either side can start federal independent dispute resolution, where a certified third-party entity picks between the two offers. None of that changes what you owe, and you are not a party to it.
What should I do if I get a bill that looks wrong?
Do not pay it right away. Compare the bill against the explanation of benefits your insurer sent, then call the number on your member ID card and ask whether the No Surprises Act applies. If you believe a provider billed you in violation of the law, you can file a complaint with the federal No Surprises Help Desk at 1-800-985-3059 or through cms.gov/nosurprises, and your state insurance department may also take complaints.

Coverage that carries these protections

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