Out-of-Network and Surprise Bills After the No Surprises Act

CareCostIndex

Since January 1, 2022, the federal No Surprises Act has made certain out-of-network balance bills illegal. The law closed some of the most egregious billing surprises, but it did not close all of them. Here is what is protected, what is not, and what to do if you get billed anyway.

What the No Surprises Act actually bans

The law applies to people with commercial insurance (ACA marketplace, employer, individual, short-term limited duration is generally excluded). It prohibits balance billing — charging the patient the difference between the provider’s billed amount and what the insurer paid — in three specific situations:

Emergency care at any facility. If you go to any emergency department (in-network or out), you can only be charged in-network cost-sharing. This includes post-stabilization services until the patient can safely be transferred.
Non-emergency care at in-network facilities by out-of-network providers. If your hospital is in-network but the anesthesiologist, pathologist, radiologist, assistant surgeon, hospitalist, or neonatologist who treats you is out-of-network, they cannot balance bill you. Applies unless you gave prior written consent and received a separate estimate at least 72 hours in advance.
Air ambulance transport. Always protected, regardless of network status.

What is still allowed

These situations are not covered by the NSA, and balance billing can still occur:

Ground ambulance transport. A notable gap. Ground ambulances are one of the most common sources of surprise bills and remain unregulated at the federal level. Some states (California, New York, Maryland, Florida, Illinois, Ohio among others) have passed state-level protections.
Elective out-of-network care you knowingly chose. If you deliberately choose an out-of-network surgeon, you can still be billed the difference.
Out-of-network care at out-of-network facilities. The facility has to be in-network for the NSA’s ancillary-provider protection to apply.
Services you consented to in writing. Providers can ask you to waive NSA protections for scheduled non-emergency care via a “Notice and Consent” form. You are not required to sign it, and you generally should not.
Medicare and Medicaid beneficiaries. Those programs already have their own balance-billing protections; the NSA doesn’t apply.

How the protection actually works

When you receive protected care:

You pay your in-network cost-sharing (deductible, coinsurance, copay) — and nothing more.
The provider and the insurer have 30 days to negotiate the out-of-network payment amount. If they don’t agree, either side can invoke Independent Dispute Resolution (IDR), a binding arbitration process. You are not a party to IDR — it happens entirely between the insurer and the provider.
Whatever they settle on, you still owe only in-network cost-sharing.

This is worth emphasizing: you should never receive a bill for the “balance” of a protected service. If you do, something is wrong.

If you receive a balance bill you should not have

Do not pay it immediately. Paying a disputed bill can complicate the refund process.
Cross-check with the Explanation of Benefits (EOB) from your insurer. The EOB should show the adjusted amount and your cost-share. If the provider is billing you more, they are out of compliance.
Call the provider’s billing office and state: “This appears to be a balance bill for a service protected by the No Surprises Act. Please re-submit a compliant bill for in-network cost-sharing only.” Keep written records (email is ideal).
Call your insurer and ask them to confirm the service was NSA-protected and that they paid the provider. Ask them to contact the provider if necessary.
File a federal complaint if the provider won’t correct. Complaints go to the CMS No Surprises Help Desk at 1-800-985-3059 or via cms.gov/nosurprises. There is a formal complaint form; average resolution time is reportedly about 60 days.
Don’t let the bill go to collections in the meantime. If the provider threatens collections while the dispute is active, that can itself be a violation. Document and report.

For some scheduled non-emergency services, an out-of-network provider can legally ask you to waive NSA protection via a written notice and consent form, given at least 72 hours before care. Signing it means they can balance-bill you.

Important: this form cannot be used for emergency care, ancillary services (anesthesiology, pathology, radiology, etc.), urgent care during an out-of-network stay, or any situation where the patient reasonably can’t choose an in-network provider.

Read anything handed to you at check-in. If a clinic tries to present a notice-and-consent form at 8 a.m. on the day of surgery, the 72-hour rule is not being met — you can refuse to sign and the protection stays intact.

Self-pay patients: the parallel protection

If you are uninsured or electing not to use insurance, you are entitled to a Good Faith Estimate under a separate section of the NSA. If the final bill exceeds the Good Faith Estimate by more than $400, you can invoke the Patient-Provider Dispute Resolution process. See our dedicated Good Faith Estimates guide.

State laws still matter

Several states have protections that are stronger than the federal NSA — notably in the ground-ambulance category, or in including plan types (like short-term limited duration) the federal law excludes. When the state law is more protective, it applies. Check your state insurance department’s website if your specific situation seems to fall through the federal cracks.

Bottom line

The No Surprises Act transformed the U.S. billing landscape for emergency and in-network-facility ancillary services. It did not make all surprise bills go away, but it did make the most common types illegal — and it gave you a free, federal complaint process to enforce your rights. Use it.

Reviewed by CareCostIndex Editorial Team · Last reviewed: 2026-04-16