Balance Billing: State Laws and the Federal Ban

Balance billing is when a health care provider bills you for the difference between its full charge and what your health plan paid, on top of your normal copay, coinsurance and deductible. Federal law bans it for most private health plans in three situations: emergency care, non-emergency care from out-of-network clinicians at an in-network hospital or surgery center, and air ambulance rides (45 CFR 149.410, 149.420, 149.440).

Outside those three, the answer depends on your state and your plan. Ground ambulance bills are the biggest gap: the federal law does not cover them, and only some states do. The table below shows every state's surprise-billing and ground ambulance rules, drawn from the same data as our medical bill checker.

Information last verified on October 20, 2026. This article has not been reviewed by a licensed lawyer.

Jurisdiction scope: This article covers the federal balance-billing ban in the No Surprises Act rules (45 CFR Part 149) for private health coverage, and the surprise-billing and ground ambulance laws of every state and D.C. It does not cover provider-insurer payment disputes or the good faith estimate for uninsured patients, and it treats Medicare, Medicaid and other government programs only briefly.

Surprise bill check

Your state’s surprise billing and ground ambulance rules, next to the federal law.

State where you got the careChoose oneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Federal law: for emergency care, air ambulance, and out-of-network clinicians at in-network hospitals and surgery centers, people in job-based, individual and Marketplace plans generally owe only in-network cost-sharing. Ground ambulance is not covered. No Surprises Help Desk: 1-800-985-3059.

Source: 45 CFR 149.410; CMS No Surprises Act consumer advocates toolkit

Open the full medical bill checker

What balance billing is

A balance bill is the leftover part of a provider's charge after your plan pays. Composite example for illustration, not a real case: an out-of-network anesthesiologist charges $3,000 for a procedure, and your plan pays $1,200 toward it. Your copay, coinsurance or deductible is one part of what remains. A bill for the rest of the $3,000 is a balance bill.

The federal rules describe exactly what is banned. Where the ban applies, the provider "must not bill, and must not hold liable" the patient for more than "the cost-sharing amount" (45 CFR 149.440, air ambulances; 149.410 uses the same words for emergency care). A balance bill you did not expect, because you did not choose the provider or had no chance to, is what people usually call a surprise bill.

Where federal law bans balance billing

The No Surprises Act protects people with private health coverage, including plans from an employer, the Federal Employees Health Benefits Program and the Health Insurance Marketplace. It bans balance billing in three situations:

• Emergency care at a hospital emergency department or an independent freestanding emergency department, including care after you are stabilized, unless a narrow notice-and-consent exception is met (45 CFR 149.410).
• Non-emergency care from an out-of-network clinician at an in-network facility. The facility must be a hospital, a hospital outpatient department, a critical access hospital or an ambulatory surgical center (45 CFR 149.30).
• Air ambulances, helicopter or airplane (45 CFR 149.440).

In those situations your cost sharing is figured as if the care had been in network, and what you pay counts toward your in-network deductible and out-of-pocket maximum (45 CFR 149.110, 149.120, 149.130). The No Surprises Act guide covers each situation in more depth.

The consent exception

For some scheduled care at an in-network facility, an out-of-network provider can ask you to sign away the protection. The written notice must reach you at least 72 hours before the care, on the day you book if you book within 72 hours, or at least 3 hours ahead for same-day care (45 CFR 149.420). CMS states: "A consumer does not have to sign this consent form."

The form can never be used for emergency medicine, anesthesiology, pathology, radiology or neonatology; for assistant surgeons, hospitalists or intensivists; for diagnostic services, including radiology and laboratory services; when no in-network provider can furnish the service at the facility; or for care because of an unforeseen, urgent medical need that arises at the time of care (45 CFR 149.420).

Watch out: A consent form signed for your surgeon does not reach the anesthesiologist, the radiologist or the lab. A balance bill from one of them is still covered by the federal ban.

Where balance billing is still allowed under federal law

The federal ban has edges, and a balance bill outside them is limited only where a state law steps in.

• Ground ambulances. CMS states: "Ground ambulance services are not covered under the No Surprises Act, but some consumers may have protections for ground ambulance surprise bills under state law."
• Doctor's offices and clinics. CMS states that the surprise-billing provisions "generally would not apply to non-emergency services provided in a community health clinic or doctor's office."
• A facility you chose that is out of network. The protection for planned care depends on the facility being in network.
• Some other plan types. Health care sharing ministries, farm bureau plans and short-term, limited duration insurance are not subject to the surprise-billing protections.

Government programs sit outside the No Surprises Act and "generally have separate protections against balance billing," in CMS's words. Medicaid providers must accept the Medicaid payment, plus any cost sharing the state plan allows, "as payment in full" (42 CFR 447.15). And CMS reminds providers that "since 1997, federal law has prohibited Medicare providers from collecting Medicare Part A and Part B coinsurance, copayments, and deductibles from QMBs," meaning Qualified Medicare Beneficiaries, including those in Medicare Advantage.

How state balance billing laws work

State laws add to the federal ban; they do not replace it. CMS puts it this way: "The No Surprises Act supplements state surprise billing laws; it does not replace them."

The scope limit matters more than any other detail. A state law reaches state-regulated plans, which include most individual plans and fully insured employer plans. If you are covered by a self-insured group health plan, CMS explains, "a state will not be able to enforce its surprise billing protections unless the plan has opted into the state's surprise billing law." Your plan documents or your employer's benefits office can tell you which kind of plan you have.

State laws fall into three broad patterns.

Broad state bans. Some states bar balance billing for both emergency care and surprise bills at in-network facilities. In Texas, for state-regulated HMO, PPO and EPO plans, an out-of-network provider may not bill more than your copay, coinsurance and deductible for emergency care, for facility-based care at an in-network facility, or for imaging or lab work tied to care from an in-network provider (Tex. Ins. Code 1271.155, 1271.157, 1301.155, 1301.164, 1301.165). In Colorado, out-of-network providers and facilities may not bill beyond your cost sharing for emergency care or covered non-emergency care at an in-network facility, though the rule does not apply when you voluntarily choose an out-of-network provider (C.R.S. 10-16-704(3)(d), (5.5)). Washington's law also covers air ambulances and extends to self-funded plans that opt in (RCW 48.49.020).

Narrower rules. Other states cover only part of the ground:

• Arizona offers arbitration, not a ban. Members of state-regulated plans may arbitrate a surprise out-of-network bill of at least $1,000 (after cost sharing and the insurer's payment) from a provider at an in-network facility, within one year of the service, after any insurer appeal finishes (A.R.S. 20-3111 to 20-3118).
• Delaware, Nebraska, Nevada and Vermont limit balance bills for emergency care only (18 Del. C. 3349; Neb. Rev. Stat. 44-6848; NRS 439B.745, 439B.757; Vt. DFR Reg. H-2009-03).
• Indiana covers non-emergency care at in-network facilities, but an out-of-network practitioner may charge more than the network rate if it gave you a written estimate at least 5 business days ahead and you signed consent (Ind. Code 25-1-9-23).
• Mississippi treats an insurer's direct payment to a provider as payment in full, apart from your cost sharing, when you directed the insurer in writing to pay the provider (Miss. Code 83-9-5(1)(i)).

Insurer rules without a provider ban. In some states the law tells the insurer what to charge you but does not stop the provider from billing the rest. North Carolina, for example, requires state-regulated insurers to charge in-network cost sharing for out-of-network emergency care, but no state law bars the provider from balance billing (N.C. Gen. Stat. 58-3-190(d)). Rhode Island limits your cost sharing for out-of-network emergency care, and the same section allows you to be billed the amount above what the plan must pay (R.I. Gen. Laws 27-18-76(d)).

Many other states, such as Kansas, South Carolina and Wyoming, have no surprise-billing or ambulance billing law of their own, so the federal ban is the only one that applies there.

Ground ambulance balance billing

Ground ambulances are where state law fills the largest gap in the federal ban, and where the state rules differ most. Even among states that limit these bills, the details change what you can be charged:

• Who is covered. Colorado's rule covers private emergency ambulance services but not ambulances run by publicly funded fire agencies (Colo. Ins. Reg. 4-2-66). Maryland's covers public or publicly contracted ambulance services paid directly by your plan, not other private companies (Md. Code, Ins. 15-138). Indiana excludes ambulances run by health systems (Ind. Code 27-1-2.3-8.1, 8.2).
• Emergencies only. New York's rule covers emergency ambulance care, not scheduled, non-emergency transport (N.Y. Ins. Law 3216(i)(24)). Ohio's also covers emergency services only (Ohio Rev. Code 3902.51(C)(3)).
• Conditions on the payment. In Pennsylvania, an out-of-network EMS agency may not bill you beyond your cost sharing for a 911-dispatched emergency only if your insurer paid it the in-network rate (Insurance Company Law of 1921, s. 635.7). Mississippi treats a set minimum payment as payment in full apart from your cost sharing, but does not limit that cost sharing to in-network levels (Miss. Code 83-9-373).
• Extra protections. California, for plans issued, amended or renewed from 2024, limits an out-of-network ground ambulance to your in-network cost sharing, bars it from reporting you to credit bureaus or suing within 12 months, and bars wage garnishment and liens on your primary home (Cal. Health & Safety Code 1371.56). See the California medical bill rules.
• Rules with an end date. Texas's ground ambulance rule expires September 1, 2027 (Tex. Ins. Code 1301.166, 1271.159). Mississippi's expires June 30, 2028, and Alabama's, in effect since October 1, 2026, repeals June 1, 2029 (Ala. Code 27-65-3).
• Rules not yet in force. Starting January 1, 2027, Illinois limits out-of-network emergency or urgent ground ambulance providers to in-network cost sharing for state-regulated insured plans (215 ILCS 5/356z.3a(b-10)). West Virginia's rule starts with health insurance policies issued on or after January 1, 2027 (W. Va. Code 33-15-24 and related sections).

Where no state rule exists, you may owe the ambulance's full charge less what your plan pays. Nevada's Division of Insurance, for example, says you may be responsible for out-of-network ground ambulance charges because federal law does not cover them. A few states regulate ambulance charges in other ways: Rhode Island caps a state-regulated plan's ground ambulance copayment at $50 for Rhode Island licensed ambulances (R.I. Gen. Laws 27-18-69), and D.C. caps what its Fire and EMS Department charges for pre-hospital care and transport at $2,000 per transport plus mileage (D.C. Code 5-416(d)).

Balance billing laws by state

Read every state rule below with one limit in mind: it reaches state-regulated plans only, which include most individual plans and fully insured employer plans. A self-funded employer plan follows the federal No Surprises Act, and a state law reaches it only if the plan opted in. The federal ban on emergency, in-network-facility and air ambulance balance bills applies in every state on top of these rules.

"Surprise billing" means state rules on out-of-network bills for emergency care and for care at in-network facilities. Each row's notes name the main limits; the medical bill checker gives each state's full rule and the agency that takes complaints.

What to do if you get a balance bill

Keep every paper as you go: the bill, the explanation of benefits (EOB) from your plan, any consent form you signed, and notes of each call with the date and the name of the person you spoke to.

1. Compare the bill with your EOB. The EOB shows what your plan treated as in network and what it says you owe. The gap between that amount and the bill is the balance bill.
2. Work out which rule fits. Emergency care, an out-of-network clinician at an in-network hospital or surgery center, or an air ambulance points to the federal ban. A ground ambulance, an office visit or an out-of-network facility points to your state's law, if it has one and it reaches your plan.
3. Ask the provider in writing to rebill. Say which protection applies and ask for a corrected bill at your in-network cost sharing. Ask for an itemized bill at the same time; the guide to disputing a medical bill walks through it.
4. Appeal to your plan if it processed the claim as out of network. The No Surprises Act "expands the right to an external review to include consideration of whether a plan's or issuer's adverse benefit determination was made in compliance with the No Surprises Act." Your plan documents set the appeal deadlines.
5. Call the No Surprises Help Desk at 1-800-985-3059. CMS states the Help Desk "is open from 8:00am-8:00pm Eastern Time (ET) on weekdays and 10:00am-6:00pm ET on weekends." You can also submit a complaint online.
6. Complain to your state insurance department if your plan is state-regulated or the bill falls under a state rule. The checker names the agency, as on the Texas and Colorado pages.

Do not let the bill sit while you sort this out; an unanswered bill can move toward collections. If it already has, the debt collection laws explain how to dispute it. If you are uninsured, the protection that fits is the good faith estimate and $400 dispute rule, and if the bill is correct but you cannot pay it, a hospital's charity care program may help.

Related pages

• Medical bills: your rights before you pay
• No Surprises Act: what it covers and how to use it
• How to dispute a medical bill
• Medical debt on your credit report
• Medical bill checker

This article provides general legal information about federal and state balance-billing rules in the United States as of October 20, 2026. It is not legal advice. For a specific bill, contact your health plan, the No Surprises Help Desk, your state insurance department, or a lawyer licensed in your state.

Last updated: October 20, 2026.

Frequently Asked Questions

What is balance billing?

Balance billing is when a provider bills you for the difference between its full charge and what your health plan paid, beyond your copay, coinsurance and deductible. Where the federal No Surprises Act applies, the provider may not bill you more than your in-network cost sharing (45 CFR 149.410, 149.440).

Is balance billing legal?

It depends on the situation. Federal law bans it for emergency care, for out-of-network clinicians at in-network hospitals and surgery centers, and for air ambulances. Outside those situations it is limited only where a state law reaches your plan.

Can a ground ambulance balance bill me?

The No Surprises Act does not cover ground ambulances. Some states limit ground ambulance bills for state-regulated plans, such as California, Colorado, New York and Texas; the table on this page shows each state.

Can a doctor balance bill me if I signed a consent form?

For some scheduled care, a signed notice-and-consent form given on time lets an out-of-network provider bill above in-network rates. The form can never cover anesthesia, radiology, pathology, lab work, emergency medicine and several other services, or care for an unforeseen urgent need (45 CFR 149.420).

Does my state's balance billing law cover my employer plan?

Only if your plan is state-regulated, or it is a self-funded plan that opted into the state law. Otherwise a self-funded employer plan follows the federal No Surprises Act. Your employer's benefits office can tell you which kind of plan you have.

Can a Medicaid provider balance bill me?

Medicaid providers must accept the Medicaid payment, plus any cost sharing the state plan allows, as payment in full (42 CFR 447.15). Providers also may not collect Medicare deductibles, coinsurance or copays from Qualified Medicare Beneficiaries.

Where do I report a balance bill?

Call the No Surprises Help Desk at 1-800-985-3059 or file a complaint online with CMS. If your plan is state-regulated or a state law covers the bill, you can also complain to your state insurance department.