The No Surprises Act Explained: What It Covers and What It Doesn't
What is the No Surprises Act?
The No Surprises Act is part of the Consolidated Appropriations Act, 2021 (Division BB, Title I, Pub. L. 116-260). It limits what out-of-network providers can charge patients in specific situations where the patient had little or no real choice of provider.
Before the law, you could go to an in-network hospital and still receive a large bill from an out-of-network doctor you never chose. The act aims to keep your cost sharing at in-network levels in the situations it covers.
Which situations are covered?
Two main situations matter for most people. Emergency services from out-of-network providers or facilities are protected from balance billing, and cost sharing is generally limited to in-network levels (42 U.S.C. § 300gg-111).
Non-emergency care at an in-network facility, delivered by an out-of-network provider, is also protected unless you gave proper notice and consent under the law (42 U.S.C. § 300gg-112). Anesthesiology, radiology, pathology and assistant surgeons at an in-network hospital are typical examples.
- Emergency room care at an out-of-network hospital
- Out-of-network anesthesiologist during an in-network surgery
- Out-of-network radiologist or pathologist at an in-network hospital
- Air ambulance services
What is not covered?
Ground ambulance services are not covered by the federal act. State law and your plan terms may help, so check both. The act also does not apply to Medicare, Medicaid, TRICARE, VA or Indian Health Service coverage, which have their own rules.
It does not make every out-of-network bill unlawful. If you knowingly choose an out-of-network provider, or sign a valid notice and consent for non-emergency care, different rules may apply.
How do you use the law when you get a bill?
Start by matching the bill to your EOB. Check whether the provider is listed as out-of-network and whether the care was an emergency or took place at an in-network facility. If it fits, call billing, say that you believe the No Surprises Act applies, and ask for a corrected bill in writing.
Also notify your insurer, since the plan has to process the claim correctly. Keep dates and names of every call.
- Gather the bill, the EOB and any forms you signed
- Ask whether you signed a notice and consent form, and request a copy
- Write down the network status shown on your EOB
- Send a written dispute and ask the provider to hold the account
Where can you get help?
The CMS No Surprises Help Desk can be reached at 1-800-985-3059, and CMS posts a patient rights summary at cms.gov/medical-bill-rights. Your state insurance department may also take complaints about insurer processing. For uninsured and self-pay patients, a separate good faith estimate process exists under 42 U.S.C. § 300gg-136.
Medical Bill Dispute Pro can include the applicable No Surprises Act citations in a dispute letter based on your answers, but it is not a law firm and cannot promise outcomes.
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Frequently asked questions
Does the No Surprises Act apply to me if I have employer insurance?
It applies to people with most private health plans, including employer and marketplace plans. Some details depend on how your plan is funded and regulated, so check your plan documents or ask the CMS help desk if you are unsure.
Does it cover ground ambulance rides?
No. Ground ambulance services are not covered by the federal act, though air ambulance services are. Some states have their own protections, and your plan may cover part of the bill. Appeal through your plan and check your state regulator's website.
Can I waive my protections?
For certain non-emergency services, a provider may ask you to sign notice and consent. The law sets requirements for how this must be done, and you can ask for a copy of what you signed. Emergency services generally cannot be handled this way.
What if I am uninsured?
Uninsured and self-pay patients are entitled to a good faith estimate before scheduled care. If the final bill is $400 or more above the estimate from that provider or facility, you may start the federal patient-provider dispute resolution process. Check the CMS website for the current filing window.
Who enforces the law?
Enforcement is shared among federal agencies and states. In practice, you can start with the CMS No Surprises Help Desk, your insurer, and your state insurance department. Keep your documents together when you file.
Sources and further reading
- CMS: No Surprises Act
- CMS: Medical bill rights
- 42 U.S.C. § 300gg-111
- 42 U.S.C. § 300gg-112
- 42 U.S.C. § 300gg-136
Related guides
Not legal or medical advice. Medical Bill Dispute Pro is a software tool that helps you prepare billing dispute letters. It is not a law firm, does not provide legal advice, and cannot guarantee any outcome. Laws and rules change and vary by plan and state; verify important details with the sources linked above, your insurer, or a qualified professional.