US Healthcare · Bills & Rights
The No Surprises Act
What the No Surprises Act covers — emergency protections, out-of-network charges at in-network facilities, good-faith estimates for the uninsured, and the dispute process.
Anyone who has received an unexpected out-of-network bill, is scheduled for care at an in-network facility, or wants to understand federal surprise billing protections.
Before 2022, patients in the US frequently received large, unexpected bills from out-of-network providers who had treated them at in-network facilities — often without the patient’s knowledge that the provider was out-of-network. These “surprise bills” could amount to thousands of dollars for a single encounter. The No Surprises Act, which took effect on January 1, 2022, established federal protections against the most common forms of surprise billing.
What the No Surprises Act prohibits
The core prohibition of the No Surprises Act is that out-of-network providers and facilities cannot bill patients more than in-network cost-sharing amounts in two main situations:
Emergency services at any facility. When you receive emergency services at a hospital emergency department or other freestanding emergency facility, your cost-sharing is limited to in-network amounts — regardless of whether the facility or the treating physicians are in your network. This applies even if you are taken to an out-of-network ER by ambulance. The insurer pays the out-of-network provider based on a median in-network rate (or through the independent dispute resolution process), and the provider cannot bill you for the difference beyond your in-network cost-sharing.
Non-emergency services at in-network facilities. When you receive non-emergency services at an in-network hospital, ambulatory surgery center, or other facility, and an out-of-network provider participates in your care without your knowledge or meaningful consent, that provider cannot balance bill you. Common examples include:
- An out-of-network anesthesiologist or surgical assistant who works with your in-network surgeon
- An out-of-network radiologist who reads an imaging study ordered by your in-network doctor
- An out-of-network laboratory that processes samples from an in-network facility
- An out-of-network hospitalist or intensivist assigned during an inpatient stay
When you can waive your protections
There is an exception: a non-emergency, non-ancillary service by an out-of-network provider at an in-network facility. If an out-of-network specialist is available and you are given the choice, the provider can ask you to sign a consent form acknowledging you are choosing the out-of-network provider and waiving your balance billing protections. This consent must be voluntary, given in writing, provided at least a defined number of days before the service, and accompanied by a good-faith cost estimate.
Providers cannot ask you to waive your protections for: emergency services, anesthesiology, radiology, pathology, neonatology, or any situation where no in-network provider is available.
Good-faith estimates for uninsured patients
The No Surprises Act also creates new protections for people who are uninsured or who choose to pay out of pocket for services. Before scheduling any service, providers and facilities must provide an uninsured or self-pay patient with a good-faith estimate of the expected costs. This estimate must:
- Itemize expected charges for the primary service and any reasonably expected ancillary services (anesthesia, labs, etc.)
- Be provided at least a defined number of business days before the service date
- Be clear about which providers and items are included
If your final bill exceeds the good-faith estimate by more than a defined threshold set by federal rule, you can use the Patient-Provider Dispute Resolution (PPDR) process to have an independent entity review the charges and determine a fair amount.
The independent dispute resolution process
When an insurer and an out-of-network provider cannot agree on payment for a surprise billing claim, either party can initiate the federal Independent Dispute Resolution (IDR) process. An IDR entity certified by the federal government reviews offers from both sides and selects one. The entity considers the median in-network rate, the complexity of the services, the provider’s training, and other factors.
As a patient, you are not a party to this process — you pay only in-network cost-sharing and are shielded from whatever payment dispute is happening between the insurer and the provider. This is a key consumer protection: your bill is not held hostage to the payment dispute.
How to respond to a potential surprise bill
If you receive a bill that appears to violate the No Surprises Act:
- Request an itemized bill from the provider to understand exactly what was charged.
- Compare the bill to your Explanation of Benefits (EOB) — check what your insurer paid and what it says you owe.
- Contact your insurer’s member services — they can help determine whether the No Surprises Act applies and may intervene with the provider directly.
- If the issue is not resolved, file a complaint at the federal No Surprises Help Desk (cms.gov/nosurprises) or with your state insurance commissioner’s office.
Key terms
| Term | Plain meaning | Glossary |
|---|---|---|
| Surprise bill | An unexpected bill from an out-of-network provider for care received at an in-network facility | → |
| Balance billing | When a provider bills you for the gap between their charge and what your insurer paid | → |
| In-network | A provider or facility contracted with your insurer at negotiated rates | → |
| Out-of-network | A provider without a contract with your insurer; costs are typically higher | → |
| Emergency room | Hospital-based department treating severe conditions, where surprise bill protections apply | → |
Common questions
- Does the No Surprises Act apply to all health insurance plans?
- The No Surprises Act applies to most job-based and individual/family health plans, including Marketplace plans. It does not apply to short-term limited duration plans, excepted benefit plans (like dental or vision-only plans), or health care sharing ministries. Grandfathered plans have limited applicability.
- What if I voluntarily chose an out-of-network provider?
- The No Surprises Act's balance billing protections generally do not apply when you voluntarily choose an out-of-network provider for non-emergency services at an out-of-network facility. However, if you are at an in-network facility and do not have a choice about which providers treat you, protections apply even if you are not aware the provider is out-of-network.
- What is a good-faith estimate?
- Providers are required to give uninsured and self-pay patients a good-faith estimate of expected costs before scheduled services. The estimate must itemize expected costs for the primary service and reasonably expected ancillary services. If your final bill exceeds the estimate by more than a defined threshold, you can use the patient-provider dispute resolution process to contest it.
- How does the independent dispute resolution process work?
- When an insurer and an out-of-network provider disagree on the payment amount for a surprise bill claim, either party can initiate Independent Dispute Resolution (IDR). An independent IDR entity reviews both offers and selects one. The losing party pays the IDR entity's fee. As a patient, you are generally shielded from the dispute and pay only in-network cost-sharing.
- Where do I file a complaint if I receive a surprise bill?
- If you believe you received a surprise bill that violates the No Surprises Act, you can file a complaint with the federal No Surprises Help Desk, your state insurance commissioner (if your state has additional laws), or the insurer. The help desk contact information is on cms.gov.
Sources
Last reviewed: September 2026