Federal law now bans surprise medical bills for emergency care and certain non-emergency services through the No Surprises Act, which took effect on January 1, 2022. The law protects patients from unexpected balance bills when out-of-network providers treat them at in-network facilities or in emergencies, limiting cost-sharing to in-network levels.
The No Surprises Act covers a surprisingly narrow set of scenarios. Most protections apply to emergency care and to specialists who work inside in-network hospitals without patient consent to balance bill. But the law leaves critical gaps—most notably for ground ambulances—that can still trigger substantial debts.
Table of Contents
- What the Federal Law Protects
- The Major Gap: Ground Ambulances
- When You Can Be Asked to Waive Your Protection
- Who Enforces These Rules
- What to Do If You Receive a Surprise Bill
What the Federal Law Protects
The law prevents balance billing for emergency department care, regardless of whether the provider is in your insurance network. According to CMS, out-of-network specialists including radiologists, anesthesiologists, pathologists, neonatalists, assistant surgeons, hospitalists, and intensivists cannot send you surprise bills when they work at in-network facilities.
Your cost-sharing for these specialists is limited to your plan's in-network copay and deductible levels even though they practice outside your network. Air ambulance services also receive federal protection. If an out-of-network air ambulance transports you, the provider cannot balance bill you, and your cost-sharing remains at in-network levels.
The Major Gap: Ground Ambulances
Ground ambulance transport is conspicuously absent from federal No Surprises Act protections. According to Commonwealth Fund research, patients regularly receive surprise bills averaging around $450 from out-of-network ground ambulance services, with no federal limit on what providers can demand. Ten states have created their own ground ambulance protections: Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont, and West Virginia. However, even these state protections apply only to fully insured health plans, not to self-funded employee benefits plans, which cover roughly half of American workers.
When You Can Be Asked to Waive Your Protection
Providers must obtain advance written consent before they can ask you to waive No Surprises Act protections. If a hospital or specialist does not obtain this consent in advance, the provider cannot later claim you agreed to bypass federal protections. This requirement applies to all covered scenarios, including emergency care.
In practice, a provider might present a consent form when you arrive for a scheduled procedure or in advance of planned out-of-network care. Signing means you accept the risk of surprise billing for that specific service. You are never required to sign—refusing does not prevent treatment in most settings—but declining means the provider cannot balance bill you.
Who Enforces These Rules
Enforcement depends on your plan type. State insurance regulators enforce the law against fully insured health plans (plans where the insurer pays claims from its own reserves). The federal government—HHS and CMS—enforce against self-funded plans (plans where the employer takes on the financial risk). This split matters because it determines where you file a complaint.
For fully insured plans, contact your state insurance commissioner's office. For self-funded plans, file a complaint with CMS or the Department of Labor. Federal enforcement discretion protecting providers using 2021 calculation methods for payment rates remains extended through August 1, 2026, addressing ongoing disputes between providers and insurers over what constitutes a reasonable rate.
What to Do If You Receive a Surprise Bill
If you receive a surprise balance bill for emergency care, a specialist at an in-network facility, or air ambulance transport: The law is now four years old, and provider knowledge is uneven. A clear citation of the No Surprises Act in your dispute often resolves the matter without escalation.
- Check whether the bill arrived from an out-of-network provider for a No Surprises Act-covered service.
- Verify you did not sign an advance written consent to waive protections.
- Contact your health insurance company and dispute the bill as a violation of federal balance billing protections.
- If the insurer does not respond satisfactorily, file a complaint with your state insurance commissioner (for fully insured plans) or CMS (for self-funded plans).