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The No Surprises Act: Your Rights Against Surprise Medical Bills

Updated October 21, 2026 · By the VeriAdvisor editors

Before 2022, you could go to an in-network hospital, be treated by an anesthesiologist you never chose, and later receive a bill for thousands of dollars because that doctor was out of network. The federal No Surprises Act, which took effect on January 1, 2022, was written to end many of those "surprise" bills. It does not make all medical care cheap, and it has important gaps. This guide explains what it covers, how to tell whether a bill violates it, what steps to take, and how state laws in California, New York, Texas and Florida fit alongside it. It is general information, not legal advice.

What is balance billing?

When you see an out-of-network provider, your health plan typically pays part of the charge and the provider may bill you for the rest, called balance billing. If the provider charges $2,000 and the plan's allowed amount is $600, the plan pays some portion of the $600 and the provider may bill you for the $1,400 difference, plus your cost sharing. The No Surprises Act bans balance billing in several specific situations where you had little or no real choice.

What the Act protects (for insured patients)

• Emergency services. You cannot be balance billed for emergency care at a hospital or freestanding emergency department, even if the facility or doctor is out of network, and prior authorization cannot be required. Your cost sharing must be calculated as if the provider were in network, and counts toward your in-network deductible and out-of-pocket maximum. This also covers post-stabilization care in many cases (42 U.S.C. 300gg-111).
• Non-emergency care at in-network facilities. If you go to an in-network hospital or surgery center, out-of-network providers there, such as anesthesiologists, radiologists, pathologists and assistant surgeons, generally cannot balance bill you (42 U.S.C. 300gg-132).
• Air ambulances. Out-of-network air ambulance services are protected from balance billing (300gg-112).

The protections apply to most private health plans, including employer plans (self-funded and insured) and marketplace plans, and to certain federal employee plans. Medicare, Medicaid and TRICARE already have their own balance billing limits.

What it does not cover

• Ground ambulances. The federal Act does not protect against ground ambulance balance billing, and this is a frequent source of large bills. Some states have their own rules.
• Providers who meet notice and consent rules. A non-emergency out-of-network provider can ask you to waive protections by giving written notice and getting your signed consent at least 72 hours before the service, with a good faith estimate, but this exception is not allowed for ancillary services such as anesthesiology, radiology and pathology, or when there is no in-network option for a service at that facility. You are never required to sign.
• Out-of-network care you choose, such as seeing an out-of-network surgeon at your own initiative.
• Ordinary in-network cost sharing. Deductibles, copays and coinsurance still apply, and the Act does not limit what the in-network provider's contract allows.
• Bills that are simply wrong. Coding errors, duplicate charges and services you did not receive are different problems, addressed below.

Uninsured and self-pay patients: the good faith estimate

If you are uninsured or choose not to use insurance, providers and facilities must give you a written "good faith estimate" of the expected charges for scheduled services (45 CFR 149.610). It must be provided in writing: within one business day after scheduling if the service is scheduled at least 3 business days ahead but fewer than 10, and within 3 business days if the service is scheduled at least 10 business days ahead. You can also request an estimate before scheduling and the provider must give it within 3 business days of your request. Each provider, such as the surgeon, anesthesiologist and facility, may give a separate estimate, or one provider may coordinate them.

Patient-provider dispute resolution

If the final bill is at least $400 more than the good faith estimate from that provider or facility, you can start the federal patient-provider dispute resolution process. CMS says you must start it within 120 days of receiving the bill, and you pay a small administrative fee (CMS has set it at $25 for prior years; check the current amount on the CMS page before filing). An independent reviewer, called a selected dispute resolution entity, decides: if the reviewer agrees with the patient, you pay the estimated amount, and if the reviewer agrees with the provider, you pay the bill amount. Collection activity on the disputed bill must pause while the dispute is pending. This is separate from insurer-provider disputes, which happen out of your sight.

How to check your own bill

1. Get the paperwork together. You need the itemized bill (not just a statement), and the Explanation of Benefits (EOB) from your plan. Look at the date of service, the provider names, the billing codes and the amounts billed, allowed and owed.
2. Find out the network status of each provider on the date of service. Check whether the facility was in network and whether the person billing you was an anesthesiologist, radiologist, pathologist, assistant surgeon or emergency physician.
3. Compare what you owe with your plan's in-network cost sharing. For protected services, you should owe only your in-network deductible, copay or coinsurance, not the difference between the billed and allowed charge. Our No Surprises Act checker and the out-of-network bill calculator walk through the comparison.
4. Look for coding errors. Duplicate lines, services after discharge, or higher-level codes than the visit warrants. Our itemized hospital bill dispute generator can help prepare a request.

A simple example with invented figures: You have a scheduled surgery at an in-network hospital. The anesthesiologist is out of network and bills $3,200. Your plan allows $900, pays $720 and says your 20 percent share is $180. If the protections apply, the most you owe is $180, computed as if the anesthesiologist were in network. A bill for $2,480 ($3,200 - $720) is the kind of balance bill the Act prohibits.

What to do if you receive a prohibited bill

1. Don't pay it yet. Ask the provider for an itemized bill and ask in writing whether it believes the No Surprises Act applies.
2. Call your health plan. Tell them it is a claim for protected services, and ask them to reprocess it at in-network cost sharing. Ask for a written explanation if they refuse.
3. Send a written dispute to the provider and billing company citing the No Surprises Act, with your EOB attached. Use certified mail and keep a copy.
4. File a complaint through the CMS No Surprises Help Desk (cms.gov/nosurprises, phone 1-800-985-3059). CMS and the Department of Labor, HHS and Treasury enforce the rules, and state insurance regulators handle many cases too.
5. Watch for collections. If a provider sends your account to a collector, the debt collection protections in our guide to debt collector rights apply and you can dispute the debt in writing within the validation period.

If you are also dealing with a credit card charge for the bill, you may have separate rights; see our guide on credit card billing disputes.

State laws: where they add protection

State laws can still matter, especially for plans regulated by the state (fully insured plans) and for services the federal law does not cover. Self-funded employer plans, which cover many workers, are regulated by federal ERISA law and generally are not subject to state balance billing laws, although the federal Act applies to them.

• California. AB 72 (Health and Safety Code 1371.9 and Insurance Code 10112.8) protected patients from out-of-network bills at in-network facilities before the federal law, and still applies to state-regulated plans. Check with the California Department of Managed Health Care or the Department of Insurance.
• New York. The Financial Services Law, Article 6, creates an independent dispute resolution process for surprise bills and protects patients in several circumstances; the Department of Financial Services runs the process.
• Texas. Insurance Code Chapter 1467 provides mediation and arbitration for out-of-network disputes for state-regulated plans, with the Texas Department of Insurance overseeing it, and Texas has statutes that cover balance billing for emergency services.
• Florida. Florida statutes, such as Fla. Stat. 627.64194 and 641.513, restrict balance billing for emergency services and certain facility-based care by state-regulated plans.

When state and federal protections overlap, the one that gives you more generally controls. If you are not sure which agency regulates your plan, look at your insurance card or plan documents and call the number listed.

Other options if you cannot pay

• Financial assistance. Nonprofit hospitals must have written financial assistance policies under Internal Revenue Code 501(r), so ask for the application and income cutoffs.
• Payment plans. Many hospitals offer interest-free plans. Ask for the terms in writing.
• Negotiation. Providers often accept less than the billed amount, especially for self-pay bills.
• Time limits. Medical debt is still subject to the statute of limitations in your state; see our guide on limitation periods.

When to get help

For bills over a few thousand dollars, repeated denials, or a threat of a lawsuit, contact your state insurance department, a patient advocate (many hospitals have one), or a consumer or health law attorney. Legal aid organizations assist with medical debt. This article is general information and not legal advice.

Sources

• CMS, Medical Bill Rights
• CMS, Dispute a medical bill
• 42 U.S.C. 300gg-111, Preventing surprise medical bills (emergency services)
• 42 U.S.C. 300gg-132, Out-of-network providers at in-network facilities
• 45 CFR 149.610, Good faith estimates for uninsured or self-pay individuals
• CMS, No Surprises Act resources

General legal information, not legal advice. Laws differ by state and change often. Check the official sources linked above, and talk to a licensed attorney or your local legal aid office before you act. Spotted a mistake? Email huhuwen09@gmail.com with the page address and we will check and correct it.