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The No Surprises Act, explained

Since January 1, 2022, a federal law protects most people from surprise medical bills. Here is what it covers, what it doesn't, and what to do if you get a bill that looks like one.

Updated October 2026

What a “surprise bill” is

A surprise bill, also called balance billing, happens when a doctor or hospital outside your insurance network bills you for the difference between its full price and what your plan paid. Before 2022, it often happened in situations you couldn't control: an ambulance took you to the nearest hospital, or the anesthesiologist at your in-network hospital wasn't in your network.

What the law protects

If you have private health insurance (through work, the marketplace or on your own), the No Surprises Act protects you from balance billing for:

• Emergency care, even at an out-of-network hospital or freestanding emergency room, including care after you are stabilized in most cases.
• Non-emergency care from out-of-network clinicians at an in-network facility: a hospital, a hospital outpatient department or an ambulatory surgical center.
• Air ambulance flights from out-of-network providers.

In these cases you can be asked to pay only your in-network cost sharing: the copay, coinsurance and deductible you would have paid if the provider were in network. The provider and your plan settle the rest between themselves.

Who can never ask you to give up these protections

Some out-of-network providers may ask you to sign a notice giving up your protections for scheduled, non-emergency care. But these clinicians can never ask, because you rarely choose them:

• emergency medicine, anesthesiology, pathology, radiology and neonatology;
• assistant surgeons, hospitalists and intensivists;
• diagnostic services, including radiology and lab work;
• any out-of-network clinician when no in-network one at that facility could provide the service.

And no one may ask you to give up your protections for emergency care.

What is not covered

• Ground ambulances are not covered by the federal law. Some states have their own rules.
• Care at an out-of-network facility that you chose for scheduled, non-emergency care.
• Cases where you validly agreed in writing, in advance, to out-of-network care from a provider allowed to ask.

Good Faith Estimates for uninsured and self-pay patients

If you don't have insurance, or you choose not to use it, providers must give you a Good Faith Estimate: a written estimate of the expected charges, before scheduled care and whenever you ask.

If your final bill is at least $400 more than a provider's or facility's own estimate, you can start the patient-provider dispute resolution process:

1. Start within 120 calendar days of receiving the bill.
2. Pay the $25 fee. If the decision goes your way, it is taken off what you owe.
3. An independent reviewer decides what you should pay.

While the dispute is open, the provider must not send the bill to collections (and must stop collections already started), and must not charge late fees. Keep your estimate and your bill together; you'll need both.

What to do if you get a surprise bill

1. Compare the bill with your Explanation of Benefits. If your plan processed the claim as protected, the EOB shows your in-network cost sharing. The bill shouldn't ask for more.
2. Call the provider's billing office. Say you believe the bill is protected by the No Surprises Act, ask them to correct it to your in-network cost sharing, and ask for a billing hold.
3. Put it in writing, and keep a copy.
4. Call your insurer if the claim was processed as out of network.
5. Call the No Surprises Help Desk at 1-800-985-3059 if it isn't fixed. It takes complaints and can tell you which protections apply.

For the general process, see how to dispute a medical bill. If the bill is correct but too big to pay, read about hospital financial assistance.

Common questions

What does the No Surprises Act protect against?

Surprise bills for emergency care, including at out-of-network hospitals, for out-of-network clinicians at in-network hospitals, hospital outpatient departments and ambulatory surgical centers, and for air ambulances. In those cases you can be asked to pay only your in-network cost sharing.

Does the No Surprises Act cover ground ambulances?

No. Ground ambulance bills are not covered by the federal law, though some states have their own protections.

What is a Good Faith Estimate?

If you are uninsured or paying for care yourself, providers must give you a written estimate of the expected charges before scheduled care, and on request. If your bill is at least $400 more than a provider's estimate, you can start a patient-provider dispute within 120 days of receiving the bill.

Who do I call about a surprise bill?

The No Surprises Help Desk at 1-800-985-3059. You can also start at cms.gov/nosurprises.

Sources

• CMS: No Surprises, your rights and protections
• CMS: Dispute a bill (uninsured or self-pay)
• eCFR: 45 CFR 149.420, notice and consent exceptions
• eCFR: 45 CFR 149.620, patient-provider dispute resolution

Billcheck is a medical bill review tool, not a law firm. This guide is general information, not legal or medical advice. Rules vary by state and by health plan.