What is the No Surprises Act and How Does It Protect You

Have you ever received a shocking medical bill after visiting an in-network hospital, only to find out an out-of-network doctor treated you without your knowledge? The No Surprises Act, which took effect January 1, 2022, was designed to protect you from exactly this scenario. Here's everything you need to know about your rights under this landmark federal law.

What is the No Surprises Act?

The No Surprises Act is a federal law included in the Consolidated Appropriations Act of 2021. It received strong bipartisan support and was signed into law in December 2020. The law creates new protections against "surprise" medical bills—those unexpected charges that occur when patients unknowingly receive care from out-of-network providers.

Before this law, patients could receive bills for thousands of dollars simply because an anesthesiologist, radiologist, or other specialist at their in-network hospital happened to be out-of-network. Patients had no way to know this in advance and no way to avoid these charges.

Key Takeaway: The No Surprises Act protects you from being billed more than in-network rates when you receive emergency care or when out-of-network providers treat you at in-network facilities without your consent.

Who Does the No Surprises Act Protect?

The law protects people who have:

Employer-sponsored health insurance (group health plans)
Individual health insurance purchased through the marketplace or directly from insurers
Federal Employees Health Benefits (FEHB) program coverage

Additionally, the law provides important protections for uninsured patients and those who choose to self-pay, including the right to receive Good Faith Estimates before receiving care.

Note: Medicare, Medicaid, Indian Health Services, Veterans Affairs, and TRICARE have their own protections and are not covered by the No Surprises Act. However, these programs already have similar protections in place.

The Three Main Protections

1. Emergency Services Protection

When you receive emergency care, you're protected regardless of whether the facility or providers are in your insurance network. This includes:

Emergency room visits
Emergency services at freestanding emergency departments
Post-stabilization care until you can safely be transferred

What this means for you: You can only be charged your in-network cost-sharing amount (copay, coinsurance, or deductible) for emergency services, even if the hospital or doctors are out-of-network.

2. Non-Emergency Services at In-Network Facilities

When you schedule a procedure at an in-network hospital or surgical center, you're protected from surprise bills from out-of-network providers who treat you there, including:

Anesthesiologists
Radiologists
Pathologists
Assistant surgeons
Hospitalists
Intensivists
Neonatologists

These providers cannot bill you more than your in-network cost-sharing amount, regardless of their network status.

3. Air Ambulance Services

Air ambulance bills have been notoriously expensive, often exceeding $40,000. Under the No Surprises Act:

You can only be charged your in-network cost-sharing amount
Out-of-network air ambulance providers cannot balance bill you
The protection applies to both emergency and non-emergency air ambulance transport

Important Exception: Ground ambulance services are NOT covered by the No Surprises Act. This remains a gap in federal protections, though some states have their own ground ambulance billing laws.

Your Cost-Sharing Under the No Surprises Act

According to CMS guidance, when the No Surprises Act applies:

Your cost-sharing (deductible, copay, coinsurance) is calculated as if the provider were in-network
These payments count toward your in-network deductible and out-of-pocket maximum
Providers cannot bill you for the difference between their charges and what insurance pays (no "balance billing")

Example

You have surgery at an in-network hospital. Your insurance has a $500 deductible and 20% coinsurance for in-network care. An out-of-network anesthesiologist treats you and charges $5,000.

Before the No Surprises Act: You might have owed the entire $5,000 or a large portion of it.

After the No Surprises Act: You only owe your in-network cost-sharing—perhaps $500 toward your deductible plus 20% of the remaining amount. The anesthesiologist cannot bill you for the rest.

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Good Faith Estimates for Uninsured Patients

The No Surprises Act created important new protections for people without insurance or those who choose to self-pay. Healthcare providers must give you a Good Faith Estimate of expected charges before you receive scheduled care.

What Must Be Included

A list of each item or service expected to be provided
The diagnosis codes (if known)
The service codes (CPT/HCPCS codes)
The expected charges for each item or service
The name, NPI, and Tax ID of each provider
A disclaimer that actual charges may differ

When You Must Receive It

Scheduled services (3+ days in advance): You must receive the estimate at least 1 business day before your appointment
Scheduled services (less than 3 days): You must receive the estimate within 3 business days after scheduling
Upon request: You can request a Good Faith Estimate at any time

The $400 Rule

If your final bill exceeds the Good Faith Estimate by $400 or more, you have the right to dispute the charges through the Patient-Provider Dispute Resolution process.

The Notice and Consent Exception

There is one important exception to the No Surprises Act protections. For non-emergency servicesat in-network facilities, an out-of-network provider can ask you to waive your protections, but only if:

They give you written notice at least 72 hours before the service (or same day for appointments made less than 72 hours in advance)
The notice clearly states the provider is out-of-network
The notice includes a good faith estimate of charges
You sign a consent form agreeing to waive your protections
An in-network alternative is available (in most cases)

Protect Yourself: You are NEVER required to sign this waiver. If you feel pressured to sign, or if the notice is given too late, your protections still apply. Also, consent waivers cannot be used for emergency services, ancillary services (like anesthesiology), or when there's no in-network alternative.

How to File a Complaint

If you believe a provider has violated the No Surprises Act, you can take action:

Step 1: Contact the Provider

Start by contacting the provider's billing department. Explain that you believe the bill violates the No Surprises Act and request a corrected bill. Many billing errors are resolved at this stage.

Step 2: Contact Your Insurance

If the provider won't correct the bill, contact your insurance company. They have a vested interest in ensuring providers follow the law and may intervene on your behalf.

Step 3: Use the No Surprises Help Desk

CMS operates a dedicated help desk for No Surprises Act questions and complaints:

Phone: 1-800-985-3059
Online: Submit a complaint at CMS Medical Bill Rights

Step 4: File a Formal Complaint

You can file complaints with:

Your state insurance department (for insurance-related issues)
Your state attorney general (for provider violations)
The federal government through CMS

The Independent Dispute Resolution (IDR) Process

The No Surprises Act created a new process called Independent Dispute Resolution (IDR) for payment disputes between insurance companies and providers. While this process primarily affects providers and insurers, it benefits you because:

You're removed from the middle of payment disputes
You pay only your in-network cost-sharing while the dispute is resolved
Neither party can bill you additional amounts during or after the dispute

Patient-Provider Dispute Resolution

For uninsured or self-pay patients, there's a separate dispute resolution process when bills exceed Good Faith Estimates by $400 or more:

Initiate the dispute within 120 days of receiving the bill
Pay a small administrative fee (currently $25)
The provider must participate in the process
A third-party reviewer will determine a fair payment amount
The decision is binding on the provider

State Laws and the No Surprises Act

The No Surprises Act creates a "floor" of protections, but states can provide additional protections. Many states had surprise billing laws before the federal law, and those laws may offer broader protections. The federal law applies when:

The state has no surprise billing law
The state law provides weaker protections than federal law
The services aren't covered by state law (e.g., self-insured employer plans)

States with Strong Protections

Several states have comprehensive surprise billing laws that may provide additional protections:

California - Extensive protections since 2017
New York - Strong patient protections since 2015
Texas - Mediation process for surprise bills
Florida - Protections for emergency and non-emergency services
Colorado - Comprehensive surprise billing law

What the No Surprises Act Doesn't Cover

Understanding the limitations of the law is important:

Ground ambulance services - A significant gap in coverage
Out-of-network care you knowingly choose - If you choose an out-of-network provider with full knowledge, you're not protected
Services you consent to waive protections for - If you sign a valid waiver
Short-term, limited-duration insurance - These plans aren't required to comply
Health care sharing ministries - Not considered insurance under the law

How to Protect Yourself

Before Receiving Care

Ask if all providers involved in your care are in-network
If scheduling a procedure, request a list of all providers who may treat you
If uninsured, request a Good Faith Estimate in writing
Don't sign consent waivers unless you fully understand the costs and have no other option

After Receiving Care

Review your bills carefully for any out-of-network charges
Compare bills to any Good Faith Estimates you received
If you see surprise charges, contact the provider immediately
Know your rights and don't pay surprise bills without disputing them first

Frequently Asked Questions

Does the No Surprises Act apply to dental and vision care?

Only if dental or vision services are covered under your health insurance plan. Standalone dental or vision plans are not covered by the law.

What if I receive a surprise bill from before 2022?

The No Surprises Act only applies to services received on or after January 1, 2022. For earlier bills, you may have protections under state law.

Can providers refuse to treat me if I don't sign a consent waiver?

For emergency services, providers cannot condition treatment on signing a waiver. For non-emergency services, if you refuse to sign and no in-network alternative exists, the provider must treat you under the No Surprises Act protections.

How long do I have to dispute a surprise bill?

For the Patient-Provider Dispute Resolution process (uninsured/self-pay), you have 120 calendar days from the date you receive the bill. Don't wait—start the process as soon as you identify a problem.

Do I still need to pay my deductible and copay?

Yes. The No Surprises Act protects you from balance billing but doesn't eliminate your normal cost-sharing responsibilities. You still owe your in-network deductible, copay, or coinsurance.

How Health Bill Central Helps

Health Bill Central can help you understand and exercise your No Surprises Act rights by:

Analyzing your bills to identify potential No Surprises Act violations
Comparing your charges to Good Faith Estimates
Generating dispute letters that cite your legal protections
Helping you understand what you should and shouldn't owe
Providing guidance on the dispute resolution process

If you believe you've been balance billed illegally, read our in-depth balance billing guide for step-by-step dispute instructions. You may also qualify for hospital financial assistance to reduce your remaining costs.

The Bottom Line

The No Surprises Act represents the most significant federal protection against unfair medical billing in decades. While it doesn't solve every problem with healthcare costs, it does eliminate one of the most frustrating experiences patients face: receiving a massive bill for care they had no way to avoid or anticipate.

Remember your key rights:

Emergency care is protected regardless of network status
Out-of-network providers at in-network facilities cannot balance bill you
Air ambulance services are protected
Uninsured patients have the right to Good Faith Estimates
You can dispute bills that exceed estimates by $400 or more
You never have to sign a consent waiver for emergency care

Don't pay a surprise bill without understanding your rights. If something doesn't look right, question it, dispute it, and if necessary, file a complaint. The law is on your side.