The No Surprises Act Explained: Your Protection Against Surprise Bills

The No Surprises Act (NSA), which took effect January 1, 2022, is the most significant federal patient protection law since the Affordable Care Act. It eliminates most surprise medical bills and gives you powerful tools to dispute out-of-network charges you did not agree to.

What the No Surprises Act Covers

The NSA protects you from surprise out-of-network charges in three key situations:

1. Emergency Services

If you go to any emergency room, you cannot be billed more than your in-network cost-sharing amount (copay, coinsurance, deductible), regardless of whether the ER or any treating physician is in your network. This applies to the ER visit, any stabilization care, and post-stabilization services until you can safely be transferred to an in-network facility.

2. Out-of-Network Providers at In-Network Facilities

If you have surgery at an in-network hospital but the anesthesiologist, assistant surgeon, radiologist, or pathologist is out-of-network, you are protected. You pay only your in-network cost-sharing amount. The provider and insurer must resolve the payment difference between themselves.

3. Air Ambulance Services

If you are transported by an out-of-network air ambulance, you pay only your in-network cost-sharing amount. Ground ambulance services are not yet covered by the NSA, though separate legislation is being considered.

Your Right to a Good Faith Estimate

If you are uninsured or paying out of pocket, the NSA requires healthcare providers to give you a "Good Faith Estimate" of costs before treatment. If the final bill exceeds the estimate by more than $400, you can dispute the bill through a federal patient-provider dispute resolution process. This applies to all scheduled healthcare services, not just emergency care.

What the No Surprises Act Does NOT Cover

Understanding the limitations is equally important:

• Ground ambulance: Not covered by the NSA. Ground ambulance balance billing remains legal in most states.
• Non-emergency out-of-network care you chose: If you knowingly choose an out-of-network provider for a scheduled procedure, the NSA does not apply. However, the provider must give you a written notice and you must sign a consent form at least 72 hours in advance.
• Medicare and Medicaid: The NSA primarily protects people with private insurance. Medicare and Medicaid have their own balance billing protections.
• Short-term health plans: Some short-term or limited-benefit plans may not be covered.

How to Use the No Surprises Act

1. Know when you are protected. Emergency care and out-of-network providers at in-network facilities are automatically protected. You do not need to do anything in advance.
2. Check your bills. If you receive a surprise bill that you believe violates the NSA, do not pay it. Contact your insurer and the provider to dispute it.
3. File a complaint. You can report potential NSA violations to CMS at 1-800-985-3059 or through the No Surprises Help Desk at cms.gov.
4. Request IDR if needed. If there is a payment dispute between the provider and your insurer, either party can initiate Independent Dispute Resolution (IDR). As a patient, your cost-sharing is fixed regardless of the IDR outcome.

State Laws That Add Extra Protection

Many states enacted surprise billing laws before the federal NSA, and some provide broader protection. States like California, New York, Texas, Florida, and Colorado have laws that may cover ground ambulance, additional provider types, or provide stronger enforcement mechanisms. When both federal and state law apply, the law that provides stronger patient protection takes precedence.