The No Surprises Act: What It Covers, What It Doesn't, and What to Do If a Bill Breaks It

The No Surprises Act is a federal law, in force since January 1, 2022, that stops many surprise medical bills. It covers three situations: emergency care, care from an out-of-network provider you did not choose at an in-network hospital or surgery center, and air ambulance rides. In those cases you owe only your in-network share, and a bill for more than that can be disputed in writing and reported to the federal government.

A surprise bill is a bill you had no way to avoid. You went to the emergency room. Or you went to a hospital in your plan's network, and a doctor you never met turned out to be outside it. Then a bill came for the difference between what the doctor charged and what your insurance paid.

The No Surprises Act is the federal law written for that bill. This page explains what it covers, what it leaves out, and the letter to send when a bill breaks it.

What does the No Surprises Act cover?

Two words first. In-network means your insurance company has a contract with the provider. Out-of-network means it does not. Your cost-sharing is the part you pay under your plan: the copay, the coinsurance, or the deductible.

The law covers three situations. In each one, an out-of-network provider may charge you only your in-network cost-sharing. Billing you for the rest is called balance billing, and the law forbids it here.

1. Emergency care

Any emergency care, at any emergency room, in or out of network. This includes the care that stabilizes you. The provider or facility "shall not bill, and shall not hold liable" you for more than your in-network share (42 U.S.C. § 300gg-131; 45 C.F.R. § 149.410).

2. An out-of-network provider at an in-network facility

You chose an in-network hospital, hospital outpatient department, or surgery center. A provider there, one you did not pick, was out of network. The anesthesiologist, the radiologist who read your scan, the pathologist who read your biopsy. That provider may charge only your in-network share (42 U.S.C. § 300gg-132; 45 C.F.R. § 149.420).

3. Air ambulance

An out-of-network air ambulance may charge only your in-network share (42 U.S.C. § 300gg-135).

For a longer walkthrough of the first two cases, see Balance billing: what it is and how to fight it.

What does the No Surprises Act not cover?

Ground ambulances. Congress wrote air ambulances into the law and left ground ambulances out. A bill from the truck that drove you to the hospital is not covered by the federal law. Some states have their own rules. Read Congress protected the helicopter and left out the ambulance.

Care you chose out of network. If you picked an out-of-network doctor for a non-emergency visit, the law does not step in.

Non-emergency care outside the listed facility types. For non-emergency care, the protection reaches a hospital, a hospital outpatient department, a critical access hospital, and an ambulatory surgical center. A freestanding imaging center, an independent lab, or an urgent care clinic is not on that list.

Your own cost-sharing. The law does not make care free. You still owe your in-network copay, coinsurance, or deductible.

People covered by Medicare or Medicaid. Those programs have their own rules against balance billing. The No Surprises Act is written for insurance through a job and insurance you buy yourself.

Can I sign away my protection?

For some care, yes. For some care, never.

A provider can ask you to sign a notice and consent form. If the form is valid, the provider may bill you above your in-network share. The rules are strict (45 C.F.R. § 149.420(c)–(d)):

• The notice must come at least 72 hours before a scheduled service. If the service was scheduled inside 72 hours, it must come no later than 3 hours before.
• It must be a separate paper, not a page inside your admission packet.
• It must include a good faith estimate of what the provider may charge you.

For a whole group of services, the form does not work at all (45 C.F.R. § 149.420(b)): emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, diagnostic services including lab work, and any service where no in-network provider was available at that facility. If you signed something and then got a balance bill from the anesthesiologist, that signature did not make the bill legal.

Read The clipboard trap: the one form that cancels your surprise-bill protection.

What if I have no insurance or pay cash?

The law gives you a different tool. Before scheduled care, a provider must give you a written Good Faith Estimate of what the care will cost (42 U.S.C. § 300gg-136; 45 C.F.R. § 149.610). If you ask for one, it must arrive within 3 business days.

If the final bill from that provider is at least $400 more than the estimate, you can ask the federal government to send the bill to an independent reviewer. You must start the dispute within 120 calendar days of receiving the bill (45 C.F.R. § 149.620). Read The $400 rule.

How do I know if my bill breaks the law?

Put the bill next to your Explanation of Benefits, the EOB. The EOB is the statement your insurance company sends that shows what it paid and what your share is. How to read your EOB.

Then ask three questions:

1. Was this emergency care? If yes, the law covers it.
2. Was the facility in network, and was this a provider I did not choose? If yes, the law covers it, unless you signed a valid consent form for a service that allows one.
3. Does the bill ask for more than the EOB says is my share? If yes, and the answer to 1 or 2 was yes, the bill is very likely one the law forbids.

What should I do if a bill breaks the No Surprises Act?

Step 1: Ask in writing first

A letter has a date on it, and a copy stays in your folder. A phone call does not. The letter should:

• Name the account number and the date of service
• Name the No Surprises Act and say which situation applies to you
• Ask the provider to correct the bill to your in-network cost-sharing
• Ask that the account be held out of collections while they review it
• Ask for the answer in writing

BillFighter's Dispute Letter asks for exactly this. You read it, sign it, and mail it. Read a made-up example: Medical bill dispute letter sample.

Step 2: Check what your insurance paid

Under the law, your insurance company must process the claim as if the provider were in network. If the EOB shows an out-of-network share, the insurer may have made its own mistake. BillFighter's Insurance Appeal letter asks the plan to reprocess the claim.

Step 3: Report it

File a complaint with:

• The federal No Surprises Help Desk: 1-800-985-3059, or online at cms.gov/medical-bill-rights/help/submit-a-complaint
• Your state insurance department, which enforces state surprise-billing rules. Your state's protections

Step 4: Follow up

If your date passes with no answer, BillFighter's Follow-Up Letter refers to the first letter and the date it was sent, and asks again for a written reply.

Keep every paper: the bill, the EOB, your letter, and the mail receipt.

What BillFighter does here

Upload the bill and, if you have it, the EOB. BillFighter reads them and flags a charge that shows the signs of a surprise bill: an out-of-network emergency charge, an out-of-network anesthesiologist or radiologist at an in-network hospital, a balance above the insurer's allowed amount. Checking a bill is free, and the free check includes a complete sample letter so you can see how the dispute reads.

A letter written for your own bill is part of the Fight Kit. You review every draft, you sign it, and you send it. With In Your Corner, BillFighter mails up to two of your approved letters by certified mail and tracks delivery. BillFighter does not call the other side, and it is not a law firm. Check my bill, free →