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Federal Consumer Protection

The No Surprises Act: Your Complete Guide to Protection from Surprise Medical Bills

Since January 2022, federal law protects you from most surprise out-of-network bills. Here is exactly what is covered, what is not, and how to fight back.

~10M

Americans protected per year

$9.36B

Estimated patient savings

Jan 2022

Effective date

What the No Surprises Act Covers

Protected Under the Act

Emergency Services

All emergency care at any hospital, whether in-network or out-of-network. This includes ER visits, emergency surgery, and stabilization care.

Out-of-Network Providers at In-Network Facilities

When you receive care from an out-of-network anesthesiologist, radiologist, pathologist, neonatologist, or assistant surgeon at an in-network hospital or surgical center.

Air Ambulance Services

Emergency air ambulance transportation from out-of-network providers. You only pay in-network cost-sharing for air ambulance services.

In-Network Cost-Sharing Only

For all protected services, you pay only your in-network deductible, copay, and coinsurance amounts. The provider must accept this as payment in full.

No Prior Authorization for Emergencies

Insurance companies cannot require prior authorization for emergency services and must cover them at in-network rates.

NOT Protected Under the Act

Ground ambulance services (excluded from the Act)

Ground ambulances remain the largest gap in surprise billing protections. Some states have their own ground ambulance protections.

Post-stabilization care IF you give written consent to out-of-network treatment

After you are stabilized, a provider may ask you to consent to out-of-network care. You can refuse and request a transfer to an in-network facility.

Non-emergency services at out-of-network facilities (you chose to go there)

If you voluntarily choose an out-of-network facility for a scheduled procedure, the No Surprises Act does not apply.

Workers' compensation or federal programs

Separate rules apply to workers' comp, TRICARE, VA, and Indian Health Service.

How It Works -- Step by Step

1

You Receive Care

You receive emergency care or scheduled care at an in-network facility. An out-of-network provider (such as an anesthesiologist or radiologist) treats you, often without your knowledge.

2

Old System vs. New System

Under the old system, you would receive a "surprise bill" for thousands of dollars from the out-of-network provider. Under the No Surprises Act, you are protected from this.

3

You Pay Only In-Network Rates

You pay only your in-network cost-sharing amount: your copay, coinsurance, and deductible. The out-of-network charge counts toward your in-network deductible and out-of-pocket max.

4

Provider and Insurer Negotiate

The provider and your insurance company negotiate the payment directly. If they cannot agree, either party can initiate the Independent Dispute Resolution (IDR) process.

5

You Are Removed from the Middle

The dispute is between the provider and your insurer. You are not responsible for any amount beyond your in-network cost-sharing, regardless of the IDR outcome.

Good Faith Estimate (For Uninsured and Self-Pay Patients)

What Is a Good Faith Estimate?

Healthcare providers and facilities must give you an estimate of expected charges before you receive scheduled (non-emergency) services when you are uninsured or choosing to self-pay.

When you are entitled: Any non-emergency service when you are uninsured or choose to self-pay (even if you have insurance)

Timeline: Must be provided within 1 business day for services scheduled 3+ days ahead, or within 3 business days for services scheduled 10+ days ahead

What it includes: Expected charges for the primary service and any reasonably expected additional items/services (labs, anesthesia, imaging)

If actual bill exceeds GFE by $400+: You can initiate the patient-provider dispute resolution process

How to Request a Good Faith Estimate

You can request a GFE from any healthcare provider. Use this template language:

"I am requesting a Good Faith Estimate of expected charges under the No Surprises Act (Public Health Service Act Section 2799B-6). I am [uninsured / choosing to self-pay] for the following service: [describe service]. Please provide the estimate within the timeframe required by federal law, including charges for the primary service and any reasonably anticipated additional items or services."

Keep your GFE. If the final bill is $400+ higher than the estimate, you need the original GFE to file a dispute. Save it in a safe place.

Independent Dispute Resolution (IDR) Process

1

Receive a Surprise Bill

Day 1

You receive a bill that you believe violates the No Surprises Act. This could be a balance bill for emergency care or out-of-network care at an in-network facility.

2

Contact Your Insurer and Provider

Days 1-14

Call your insurance company and the provider's billing department. Explain that the bill violates the No Surprises Act. Request an Explanation of Benefits (EOB) showing in-network processing.

3

File a Complaint with CMS

Days 14-30

If the issue is not resolved, file a complaint with CMS at cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.

4

Patient-Provider Dispute Resolution (GFE Issues)

Within 120 days

For Good Faith Estimate disputes (uninsured/self-pay patients where the bill exceeds the estimate by $400+), file within 120 days of receiving the bill.

5

Open Negotiation Period

30 business days

For balance billing disputes, your insurer and the provider enter a 30-business-day open negotiation period to reach agreement.

6

IDR Entity Decision

30 business days

If negotiations fail, an independent IDR entity makes a binding decision within 30 business days. The entity considers the qualifying payment amount, provider experience, and market conditions.

How to File a Complaint

Surprise Bill from Emergency Care

1

Call your insurer -- ask them to reprocess the claim at in-network rates under the No Surprises Act

2

Contact the provider billing department -- inform them the bill violates the No Surprises Act

3

File with CMS No Surprises Help Desk: 1-800-985-3059 (8am-8pm ET, Mon-Sat)

4

File online at cms.gov/nosurprises

Balance Bill from Out-of-Network Provider at In-Network Facility

1

Contact your insurer -- request the claim be processed at in-network cost-sharing

2

Inform the out-of-network provider that you did not consent to waive your No Surprises Act protections

3

Your insurer handles the IDR process with the provider on your behalf

4

File a complaint with CMS if the insurer or provider does not comply

Good Faith Estimate Exceeded by $400+

1

Gather your original Good Faith Estimate and final bill

2

File a patient-provider dispute at cms.gov/nosurprises

3

You must file within 120 days of receiving the bill

4

Filing fee is $25. It is not refunded, but if you win, an amount equal to it comes off your bill. SDR entity decides within 30 business days

Insurance Company Not Following the Law

1

File an internal appeal with your insurance company

2

Request an external review by an independent review organization

3

File a complaint with your state insurance department (find yours at naic.org)

4

File a federal complaint at cms.gov/nosurprises or call 1-800-985-3059

State Balance Billing Laws

Many states had balance billing protections before the federal No Surprises Act. In some cases, state law provides stronger protections. When both apply, the law that is more protective to the patient takes effect.

State	Law	Key Differences from Federal
New York	Surprise Bill Law (2015)	One of the first states to ban surprise billing. Covers more provider types than federal law.
California	AB 72 (2017)	Bans balance billing for out-of-network providers at in-network facilities. Uses payment standard based on average contracted rate.
Colorado	HB 19-1174	Comprehensive balance billing protections with arbitration process. Covers ground ambulances.
Connecticut	PA 15-146	Surprise billing protections for emergency and non-emergency care at in-network facilities.
Florida	SB 1278 (2016)	Balance billing protections for emergency services and surgical procedures.
Georgia	SB 359 (2019)	Surprise Billing Consumer Protection Act covers emergency and in-network facility settings.
Illinois	SB 1905	Network Adequacy and Transparency Act includes surprise billing protections.
Maryland	HB 1122	Strong balance billing protections; regulated all-payer rate-setting system.
Oregon	HB 2339	Balance billing protections for emergency and in-network facility care.
Texas	SB 1264 (2019)	Comprehensive surprise billing law covering most settings. Uses baseball-style arbitration.
Washington	SB 6505 (2019)	Balance Billing Protection Act covers emergency, in-network facilities, and some ground ambulance.

When State Law Applies vs Federal Law: If your state has its own surprise billing law, the law that provides more protection to the patient applies. For fully insured plans, state law takes precedence if it is stronger. For self-insured employer plans (ERISA plans), federal law applies because states cannot regulate self-insured plans.