Surprise Medical Bills and the No Surprises Act: What Is Covered
What counts as a surprise medical bill?
Picture a scheduled surgery at an in-network hospital. Weeks later you receive a separate bill from an anesthesiologist who was out of network, for the portion your plan did not pay. You never picked that provider, and you had no chance to check the network. That is the classic surprise bill.
Emergency care produces them too, since you cannot choose a hospital while being rushed in for treatment.
What does the No Surprises Act protect?
The No Surprises Act is part of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). It applies to people with most private health plans, including employer and marketplace plans.
- Emergency services from out-of-network providers and facilities: balance billing is generally prohibited and cost sharing is generally limited to in-network levels (42 U.S.C. § 300gg-111)
- Non-emergency care from out-of-network providers such as anesthesiologists, radiologists, pathologists, or assistant surgeons at an in-network hospital: protected unless you gave proper notice and consent (42 U.S.C. § 300gg-112)
- Air ambulance services
What is not covered?
Ground ambulance services are not covered by the federal Act, so a surprise ground ambulance bill needs a different approach, such as your state's rules, plan terms, and negotiation. The Act also does not apply to Medicare, Medicaid, TRICARE, VA, or Indian Health Service coverage, which have their own rules.
If you were given the required notice and signed a valid consent for out-of-network care, the protection for non-emergency services may not apply. Look at what you signed, and when.
What are the first steps when a surprise bill arrives?
Hold off on payment until you have checked the facts. Collect your EOB, the bill, and any forms you signed at admission.
- Check the EOB for the allowed amount, what the plan paid, and your patient responsibility
- Write down whether the care was an emergency and whether the facility was in-network
- Ask the provider for an itemized bill and whether they believe the Act applies
- Call your insurer and ask how the claim was processed and whether in-network cost sharing was applied
- Keep a log of every call, with names, dates, and reference numbers
How do you dispute it?
Send the provider a written dispute stating that you believe the bill is covered by the No Surprises Act, giving the date of service, account number, and the amount in question. Ask that the bill be corrected to match your in-network cost sharing and that the account be held while the review is open.
If you do not get resolution, the CMS No Surprises Help Desk at 1-800-985-3059 can help with federal protections. Your state insurance department is another place to file a complaint, and state law may add protections beyond the federal Act.
How does Medical Bill Dispute Pro handle this?
The questions about emergency care and network status help the analysis flag when the Act may apply. The resulting letter cites the relevant rules in its regulations section, states what the provider is expected to do, and asks for a response in 10 business days. Please review it before you send it.
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Frequently asked questions
What is the No Surprises Act in simple terms?
It is a federal law that protects people with most private health plans from certain surprise out-of-network bills, mainly for emergency care and for out-of-network providers at in-network facilities. It generally limits what you owe to in-network cost sharing, and it also covers air ambulance services.
Does the No Surprises Act apply to Medicare or Medicaid?
No. It does not apply to Medicare, Medicaid, TRICARE, VA, or Indian Health Service coverage, which have their own billing rules. Medicaid providers generally may not bill beyond the Medicaid payment and any allowed copay, so contact your state Medicaid agency if you receive a bill.
Can I be billed for an emergency room visit at an out-of-network hospital?
If you have a covered private plan, the Act generally prevents out-of-network emergency providers and facilities from balance billing you and limits your cost sharing to in-network levels. You may still owe your normal deductible, copay, or coinsurance, so check the EOB to see what you owe.
What if I signed a consent form before my procedure?
Valid notice and consent can allow out-of-network billing for some non-emergency care, but the rules around it are specific. Ask for a copy of what you signed and the date, and ask the provider to show how it meets the law. If you are unsure, contact the CMS help desk.
Where do I file a complaint about a surprise bill?
For federal protections, call the CMS No Surprises Help Desk at 1-800-985-3059 or visit cms.gov/nosurprises. For complaints about insurers, contact your state insurance department, and for provider billing practices, your state attorney general may help. The NAIC state map can point you to your regulator.
Sources and further reading
- 42 U.S.C. § 300gg-111 (emergency services)
- 42 U.S.C. § 300gg-112 (out-of-network at in-network facilities)
- CMS: No Surprises Act
- CMS: Medical bill rights
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.