The No Surprises Act is your legal shield against one of the most expensive surprises in healthcare: getting billed by an out-of-network provider you never chose. Since January 1, 2022, this federal law has protected millions of patients, but only if you know how to invoke it.
Quick answer
A federal law in force since 1 January 2022 that caps what you pay when an out-of-network provider you did not choose treats you. It covers emergency care and out-of-network clinicians working at in-network facilities, and in both cases you owe only your normal in-network cost-sharing. Ground ambulances are not covered.
Here's what you need to know: what the law actually covers, what it doesn't, and exactly how to use it if you receive a surprise bill.
What the No Surprises Act is
The No Surprises Act, which took effect January 1, 2022, is a federal law designed to protect patients from unexpectedly large medical bills. It limits what you can be charged in certain situations where you receive care from an out-of-network provider, especially when you don't have a meaningful choice in the matter.
The law applies to both health insurance plans and self-insured employers. It doesn't eliminate out-of-network billing entirely, but it does cap what you can be asked to pay.
What it covers
Out-of-network care at in-network facilities
This is the most common scenario. If you go to an in-network hospital or surgical center, but a doctor, anesthesiologist, pathologist, or radiologist who treats you is out-of-network, the No Surprises Act protects you. You'll pay no more than your in-network cost-sharing amount (your copay, coinsurance, or deductible), and the provider can't balance bill you for the difference between their charge and what your insurer paid.
Emergency care
If you receive emergency services from an out-of-network provider or facility, you're protected. You'll pay your in-network cost-sharing amount, regardless of the provider's network status. This includes emergency department visits, stabilization, and post-stabilization care.
Air ambulance
If you need an air ambulance to reach an emergency facility, the No Surprises Act applies. You'll pay in-network rates. (Ground ambulances are not covered, see below.)
Good Faith Estimates
Healthcare providers are now required to give you a Good Faith Estimate (GFE) in writing before you receive non-emergency care. If the bill you receive is more than $400 above the estimate, you have the right to dispute it.
The next step is a phone call, a hold queue, and a supervisor who has heard it before. That part we do for you, and only charge if the bill comes down.
Let us make the callWhat it doesn't cover
The No Surprises Act is broad, but it has real gaps. Knowing what's excluded protects you from expecting protection you don't have. Here are the complete exclusions:
Ground ambulances
Unlike air ambulances, ground ambulance services are explicitly excluded from the No Surprises Act. Ground ambulances are not covered by the law, so you could still receive a surprise bill. For guidance on negotiating ambulance bills, see our detailed guide. And if the ride followed a crash, an ambulance bill after a car accident plays by its own rules, since auto insurance may pay before health insurance does. If you're transported by ambulance, always clarify whether it's ground or air, the law treats them completely differently.
Non-emergency care at out-of-network facilities you chose
If you intentionally went to an out-of-network facility for non-emergency care, the No Surprises Act doesn't protect you. You made the choice, so you're responsible for out-of-network rates. The law protects you only when you didn't have a meaningful choice, not when you deliberately selected an out-of-network provider.
Dental and vision care
The No Surprises Act does not cover dental or vision care. If you receive surprise bills from dental or vision providers, you'll need to handle those separately. This exclusion exists because dental and vision coverage operate under different regulatory frameworks. Surprise dental bills and vision bills require their own negotiation approach.
Out-of-network pharmacies
If you fill a prescription at an out-of-network pharmacy, the No Surprises Act doesn't apply. You'll pay out-of-network rates. Always ask if a pharmacy is in-network before filling a prescription, especially for expensive medications.
Medical equipment and supplies at out-of-network vendors
Durable medical equipment (wheelchairs, oxygen, CPAP machines) and supplies purchased from out-of-network vendors are not covered. Check whether equipment providers are in-network before you purchase.
Medically unnecessary care deemed by insurance
If your insurance deems that a service was not medically necessary, the No Surprises Act may not apply. Insurance companies still make coverage decisions, and if they reject a service as unnecessary, the law doesn't protect you from the bill, even if it came from an out-of-network provider.
Elective and cosmetic procedures
If you choose an elective or cosmetic procedure, the No Surprises Act doesn't cover surprise bills. The law assumes you chose the procedure with knowledge of costs.
How to use it if you receive a surprise bill
Step 1: Confirm you're eligible
Check that your situation fits one of the covered categories above. If you received emergency care or non-emergency care from an out-of-network provider at an in-network facility, you're likely protected.
Step 2: Contact the provider
Call the billing department of the provider who billed you out-of-network. Say:“I received this bill for out-of-network services provided at [facility name] on [date]. Under the No Surprises Act, I should only be responsible for my in-network cost-sharing. Can you recalculate my bill?”
Step 3: Request a corrected bill
Ask the provider to issue a corrected bill reflecting your in-network cost-sharing amount. Request this in writing if possible, and keep a record of your communication.
The dispute process
If the provider refuses to adjust the bill or argues that the No Surprises Act doesn't apply, you have options:
Contact your insurance company
File a complaint with your health insurance plan. Explain that the bill violates the No Surprises Act. Most insurers have processes to handle these disputes.
File a complaint with HHS
If your insurance company doesn't resolve it, file a complaint with the U.S. Department of Health and Human Services. Visit NoSurprises.cms.gov to submit a complaint. The government takes these seriously.
Contact your state insurance commissioner
Your state's insurance regulator also has authority over this. You can file a complaint with your state insurance commissioner's office if federal channels aren't moving quickly.
Enforcement and updates in 2025-2026
Since its 2022 launch, the No Surprises Act has been refined through court battles and regulatory updates. The Independent Dispute Resolution (IDR) process for providers and insurers to resolve billing disputes faced a significant setback in 2023 when the 5th Circuit Court struck down key provisions. CMS has spent 2024 and 2025 revising the IDR rules, and as of 2026, the process is operational again but with considerably higher administrative fees for providers.
The practical effect: higher IDR fees mean fewer providers file disputes for smaller bill amounts, which can leave patients vulnerable to surprise bills under $5,000. This underscores why you must actively dispute bills yourself rather than waiting for the provider and insurer to resolve it.
On the positive side, the CFPB and CMS issued joint guidance in 2025 clarifying that good faith estimates must be provided within one business day of scheduling non-emergency services. If you get a final bill more than $400 above the estimate, you have clear grounds to dispute it. Ground ambulance services remain the biggest gap in the law. Congress has introduced legislation multiple times to extend No Surprises Act protections to ground ambulances, but as of early 2026, no bill has passed. If you receive a ground ambulance bill, it falls entirely outside the law's protections, though negotiation tactics still apply.
When to get help
If you're facing a large surprise bill and the provider is resistant, or if you're unsure whether the No Surprises Act applies to your situation, it might be time to bring in reinforcement. Don't wait, the first 48 hours are critical. For situations involving out-of-network bills, we have a comprehensive action plan.
And if you need to dispute a bill with your insurance company, we've got a comprehensive guide on the appeals process.
Sources
- CMS, No Surprises Act
The federal surprise billing protections, and the independent dispute resolution process for out-of-network payment disagreements.
- CMS, Understanding costs in advance (good faith estimates)
Uninsured and self-pay patients are entitled to a good faith estimate, and may dispute a final bill that exceeds it by $400 or more.
- CMS, Know your rights when using insurance
States that ground ambulance services are generally not covered by the No Surprises Act billing protections unless state law says otherwise, and may still charge out-of-network rates.
Sources last checked 27 July 2026. Medical billing rules change, so if you spot something out of date, tell us and we will correct it.
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