The Federal No Surprises Act, effective January 1, 2022, protects patients from surprise medical bills when they receive emergency care or certain non-emergency care from out-of-network doctors at in-network facilities. The law applies to people with employer plans, Federal Employees Health Benefits, Marketplace coverage, and individual health insurance policies.
Table of Contents
- What does the No Surprises Act cover?
- How is your cost-sharing protected?
- Balance billing: what providers cannot charge you
- What happens when a provider disagrees with payment?
- Critical gap: ground ambulance services
- How to report a surprise bill
- Frequently Asked Questions
What does the No Surprises Act cover?
According to the Centers for Medicare & Medicaid Services, the law protects you in three situations: emergency services regardless of whether the provider is in-network, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance providers. For example, if you go to an emergency room at your in-network hospital and the treating ER doctor is out-of-network, the No Surprises Act applies.
Similarly, if you have surgery at an in-network surgery center but an out-of-network anesthesiologist is assigned to your care, you're protected. The law does not cover all medical situations. Planned procedures at out-of-network facilities, elective surgeries, or routine care scheduled in advance are not automatically covered by the act's protections.
How is your cost-sharing protected?
When the No surprises act applies, you pay only your plan's in-network cost-sharing amount—your copay, coinsurance, or deductible, whichever applies. The health plan then pays the out-of-network provider directly for any additional costs, so you won't receive a separate bill later for the difference.
The payment to the out-of-network provider is calculated using the Qualified Payment Amount (QPA), which represents your plan's median contracted rate for the same or similar services by similar providers in your geographic area, adjusted for inflation. The provider cannot balance bill you for the remaining amount beyond what you owe in-network cost-sharing.
Balance billing: what providers cannot charge you
Providers are banned from balance billing—charging you beyond your in-network cost-sharing amounts—for emergency services, post-stabilization care, and non-emergency services at in-network facilities. If a provider tries to balance bill you anyway, they're violating federal law. Healthcare providers must publicly disclose your rights regarding balance billing and provide contact information for federal and state agencies where you can report violations.
What happens when a provider disagrees with payment?
When a provider believes a plan's payment was too low, they don't automatically get to bill you the difference. Either the provider or the plan can request a 30-day open negotiation period to resolve the disagreement. If negotiation doesn't work, either party can initiate independent dispute resolution (IDR), where a neutral third party determines the appropriate payment rate. You're not involved in this process—the provider and plan resolve it directly.
Critical gap: ground ambulance services
Air ambulance services are protected by the No Surprises Act. However, according to Commonwealth Fund research, ground ambulance services are explicitly excluded from the law's protections, leaving an estimated 28% of ground ambulance rides vulnerable to surprise bills. If you're transported by ground ambulance, ask your insurance plan about coverage before transport when possible, or request an itemized bill afterward to verify there are no unexpected charges.
How to report a surprise bill
If you receive a surprise bill despite the No Surprises Act, take these steps: Keep copies of the original bill, your EOB, and any correspondence with the provider or insurer.
- Contact your health insurance company and request an explanation of benefits (EOB) showing all charges and what the plan paid
- File a complaint with your state's insurance commissioner (contact information is usually on your state insurance regulator's website)
- Report violations to the Centers for Medicare & Medicaid Services or the U.S. Department of Labor's Employee Benefits Security Administration
Frequently Asked Questions
Does the No Surprises Act apply if I chose to see an out-of-network doctor?
No. The protection applies only when you don't have a choice (emergency care) or when the out-of-network provider works at your in-network facility. Planned out-of-network care is not covered.
What is a Qualified Payment Amount?
The QPA is your insurance plan's median contracted rate for the same service by similar providers in your area. Out-of-network providers are paid based on the QPA, not their usual charge.
Can a provider still ask me to sign a waiver before treatment?
Not for emergency services or non-emergency services at in-network facilities. Balance billing waivers are not enforceable under the No Surprises Act in these situations.