The No Surprises Act Explained: What It Covers and Who It Protects

The No Surprises Act (NSA) is a federal law that protects you from most unexpected out-of-network medical bills when you receive emergency care or are treated by an out-of-network provider at an in-network facility. It went into effect on January 1, 2022 (Public Law 116-260, Title I). If you receive a surprise bill for a service covered by the NSA, you are only required to pay your in-network cost-sharing amount.

This guide explains exactly which situations the NSA covers, which it does not, and what to do if you receive a bill that violates the law. For help reading your EOB to identify potential NSA violations, see the how to read an EOB guide. For specific appeal deadlines based on your state and plan type, see the appeal deadlines by state guide.

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What the No Surprises Act Covers

Emergency Services

The NSA covers all emergency services received at an out-of-network facility or from an out-of-network provider — without prior authorization. This includes:

• Emergency department visits at out-of-network hospitals
• Emergency services provided by out-of-network doctors (e.g., an out-of-network ER physician at an in-network hospital)
• Ambulance services (ground and air) for emergency transport

Under the NSA, you can only be charged your in-network copay, deductible, and coinsurance for emergency services. The provider cannot balance-bill you for the difference between their charge and what your plan paid.

Non-Emergency Services at In-Network Facilities

If you receive non-emergency care at an in-network hospital or facility, and an out-of-network provider treats you there (e.g., an out-of-network anesthesiologist at an in-network surgical center), the NSA prohibits surprise billing for:

• Radiology and lab services
• Anesthesiology
• Pathology
• Assistant surgeon services
• Hospitalist and intensivist services
• Neonatology services

You must receive a plain-language consent notice before an out-of-network provider can bill you more than in-network rates for non-emergency services.

Air Ambulance Services

The NSA covers air ambulance services, but not ground ambulance (this is a significant gap — ground ambulance billing is regulated at the state level and varies widely).

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What the No Surprises Act Does NOT Cover

| Situation | Not Covered By NSA | Why | |---|---|---| | Ground ambulance | Yes | Excluded from the law; state laws vary | | Out-of-network providers you choose | Yes | NSA only protects against unexpected out-of-network charges | | Non-emergency care at out-of-network facilities | Yes | NSA does not apply if you knowingly chose an out-of-network facility | | Services not covered by your plan | Yes | NSA applies to cost-sharing amounts, not to benefit exclusions | | Balance billing in states with stronger laws | Varies | State law may apply if state protections are stronger than NSA |

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Your Rights Under the NSA

If you receive a bill that violates the NSA:

1. You only owe your in-network cost-sharing amount — copay, deductible, and coinsurance as if the provider were in-network
2. You cannot be balance-billed for the difference between the billed charge and what your plan paid
3. You have a 120-day dispute window to challenge the bill under NSA independent dispute resolution (IDR)

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What to Do If You Receive a Surprise Bill

Step 1: Determine if the NSA applies

Ask yourself:

• Was this an emergency service? → NSA applies
• Was this non-emergency care at an in-network facility? → NSA may apply
• Did I sign a consent waiver for out-of-network billing? → NSA may not apply

Step 2: Check your EOB

Your Explanation of Benefits will show how the claim was processed. If the patient responsibility amount reflects out-of-network charges for a service that should be protected, the provider may be billing in violation of the NSA.

Step 3: Contact your insurer

Ask your insurer to reprocess the claim under NSA protections. If they refuse, request a written explanation of why the NSA does not apply.

Step 4: Contact the provider

If the provider sends you a bill for more than your in-network cost-sharing amount, call their billing office and cite the No Surprises Act. Many billing errors are resolved at this step.

Step 5: File a complaint

If the provider continues to pursue the balance bill, you can file a complaint with:

• CMS — online at cms.gov/nosurprises
• Your state insurance department — state-level enforcement may be faster
• Department of Health and Human Services — for violations of federal NSA provisions

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How Hedical Can Help

Upload your EOB or denial letter to the Medical Bill & Denial Navigator. Our AI will check whether the NSA applies to your situation, flag potential violations, and help you draft a letter to the provider or insurer citing your rights.

Try the Bill & Denial Navigator — free for basic analysis.

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Sources

• Public Law 116-260, Title I — No Surprises Act (2020)
• 45 CFR §149 — NSA implementing regulations (CMS)
• 45 CFR §147.136 — External review standards
• CMS, "No Surprises Act: Consumer Protections" — cms.gov/nosurprises
• National Academy for State Health Policy, "State Surprise Billing Laws" tracking