No Surprises Act: What It Covers and How to Use It

The No Surprises Act is a federal law that limits surprise out-of-network bills in three situations: emergency care, non-emergency care from an out-of-network clinician at an in-network hospital, hospital outpatient department, critical access hospital or ambulatory surgical center, and air ambulance transport. When the rule applies, the out-of-network provider may not bill you more than your in-network cost-sharing (45 CFR 149.410, 149.420, 149.440).

It does not reach everything. Ground ambulances, care in a doctor's office or clinic, and scheduled care at a facility that is itself out of network fall outside it, and Medicare, Medicaid and other government programs run on their own rules. This page explains where the line sits, the signed-consent exception, and what to do with a bill that crosses it.

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

Jurisdiction scope: This article covers the federal No Surprises Act rules in 45 CFR Part 149 for private health coverage, with examples of state surprise-billing laws. It does not cover Medicare, Medicaid or other government-program billing rules in depth, provider-insurer payment disputes, or the good faith estimate for uninsured patients, which has its own page.

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

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What the No Surprises Act protects

The law protects people with private health coverage in three situations. In each one, an out-of-network provider or facility may not bill you more than the cost-sharing you would have paid in network. Your copay, coinsurance or deductible is figured as if the care had been in network.

Emergency care

For emergencies, the federal rule is direct. Under 45 CFR 149.410, an out-of-network emergency facility "must not bill, and must not hold liable" the patient for emergency services beyond "the cost-sharing requirement for such services."

The protection continues after you are stabilized, with one narrow exception. Post-stabilization care can be billed out of network only if all of these are true: the attending emergency physician or treating provider decides you can travel by nonmedical or nonemergency transport to an available in-network provider within a reasonable distance, you receive and sign the written notice-and-consent form, you are able to consent, and the provider meets any extra requirements of state law.

Non-emergency care at an in-network facility

The second protection covers the surprise that happens during planned care. You choose an in-network hospital or surgery center, and a clinician you did not choose, such as an anesthesiologist or a radiologist, turns out to be out of network.

The rule reaches four kinds of facilities only: a hospital, a hospital outpatient department, a critical access hospital, and an ambulatory surgical center (45 CFR 149.30). CMS states the limit plainly: the surprise-billing provisions "generally would not apply to non-emergency services provided in a community health clinic or doctor's office."

Air ambulance

Out-of-network air ambulance providers, whether helicopter or fixed-wing, "must not bill, and must not hold liable" the patient for more than the in-network cost-sharing amount (45 CFR 149.440).

What you owe instead

When the rule applies, you owe the same copay, coinsurance and deductible you would owe in network. Under 45 CFR 149.110, what you pay counts toward your in-network deductible and in-network out-of-pocket maximum, as if an in-network provider had treated you.

What the No Surprises Act does not cover

Many surprise bills fall outside the federal rule. Knowing which side yours is on decides where you go next.

• 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." See the state section below and the balance billing laws by state.
• Doctor's offices and clinics. Non-emergency care in a community health clinic or a doctor's office generally falls outside the surprise-billing provisions.
• An out-of-network facility you chose. Non-emergency care at a facility that is out of network is not protected. The protection for planned care depends on the facility being in network.
• Government programs. Medicare (including Medicare Advantage), Medicaid, CHIP, the Indian Health Service, VA care and TRICARE are outside the No Surprises Act's balance-billing rules. CMS notes that these programs "generally have separate protections against balance billing."
• 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.

Two of those separate federal protections matter often. Medicaid providers must accept the Medicaid payment, plus any cost-sharing the state plan allows, "as payment in full" (42 CFR 447.15). And for people enrolled as Qualified Medicare Beneficiaries, CMS states that "since 1997, federal law has prohibited Medicare providers from collecting Medicare Part A and Part B coinsurance, copayments, and deductibles from QMBs, including those enrolled in Medicare Advantage."

Which private plans are covered

The federal rule covers group health plans, both insured and self-funded, and group and individual health insurance. CMS lists coverage "obtained through an employer, the Federal Employees Health Benefits Program, the Health Insurance Marketplace" among the plans protected.

If you have short-term, limited duration insurance, CMS treats you as uninsured for the good faith estimate and the patient-provider dispute process. That means you can ask for a good faith estimate before scheduled care.

The consent exception: when you can give up the protection

For some scheduled, non-emergency care, an out-of-network provider at an in-network facility can ask you to sign away the protection. The waiver works only if it follows strict timing and form rules (45 CFR 149.420).

The written notice must reach you:

• at least 72 hours before the care, if you booked the appointment 72 hours or more ahead;
• on the day you book, if you booked within 72 hours of the care;
• at least 3 hours before the care, if you get the notice on the day of the care.

You do not have to sign. CMS's wording: "A consumer does not have to sign this consent form. A provider or facility can refuse to treat an individual who does not consent to waive their balance billing protections if doing so is allowed under state law."

Services that can never be waived

The consent form cannot be used at all for these services (45 CFR 149.420):

• items and services related to emergency medicine, anesthesiology, pathology, radiology and neonatology;
• items and services from assistant surgeons, hospitalists and intensivists;
• diagnostic services, including radiology and laboratory services;
• items and services from an out-of-network provider when no in-network provider can furnish them at the facility;
• items or services furnished because of an unforeseen, urgent medical need that arises at the time of care.

Watch out: A consent form signed for one clinician does not reach the anesthesiologist, the radiologist or the lab. If a bill from one of those arrives with charges above your in-network cost-sharing, the consent form is not a defense to the federal rule.

What to do with a surprise bill

Work through the bill in this order. 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. Read the EOB before you pay. The EOB from your plan shows what the plan treated as in network and what it says you owe. If the EOB shows in-network cost-sharing and the bill asks for more, the gap is what you are questioning.
2. Check which situation you were in. Emergency, in-network facility, or air ambulance points to the federal rule. Ground ambulance, office visit or an out-of-network facility points to state law, if any.
3. Ask the provider in writing to rebill. Say the care was an emergency (or at an in-network facility, or an air ambulance), that you signed no consent form (or that the service is one that cannot be waived), and ask for a corrected bill at your in-network cost-sharing. Ask for the itemized bill at the same time.
4. Call your plan if the EOB is wrong. If your plan processed the claim as out of network, use your plan's appeal process. 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."
5. Contact the No Surprises Help Desk. Call 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. Contact your state insurance department if your plan is state-regulated or the bill is for a service the state law covers. The medical bill checker names the agency for each state.

Act early. Your plan's appeal deadlines are set in your plan documents, and a bill left unanswered can move toward collections. If a bill has already gone to a collector, the debt collection laws explain your rights to dispute it.

State surprise-billing laws on top of the federal law

The No Surprises Act sets a floor, not a ceiling. CMS answers the question of whether it replaces state law in one word: "No. The No Surprises Act supplements state surprise billing laws; it does not replace them." State insurance departments enforce their own laws.

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

Some examples of what state laws add:

• 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, facility-based care at an in-network facility, or 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). See the Texas medical bill rules.
• New York. For state-regulated (fully insured) plans, an out-of-network provider may not bill you for emergency care, or for a surprise bill at an in-network hospital or surgery center, beyond your in-network cost-sharing (N.Y. Fin. Serv. Law 603, 606). See the New York medical bill rules.
• Arizona takes a different route: 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 (A.R.S. 20-3111 to 20-3118). Any insurer appeal must finish first.

Ground ambulance is where state law fills the largest gap in the federal rule:

• Colorado. For state-regulated plans, you owe an out-of-network private emergency ambulance service only your in-network deductible, coinsurance or copay. The rule does not cover ambulances run by publicly funded fire agencies (3 CCR 702-4, Colo. Ins. Reg. 4-2-66; C.R.S. 10-16-704(5.5)(d)). See the Colorado medical bill rules.
• New York. For emergency ambulance care covered by a comprehensive state-regulated policy, the ambulance service may not bill beyond your copay, coinsurance or deductible. Scheduled, non-emergency transport is not covered (N.Y. Ins. Law 3216(i)(24)).
• Illinois. Starting January 1, 2027, for state-regulated insured plans, an out-of-network emergency or urgent ground ambulance provider may charge no more than in-network cost-sharing (215 ILCS 5/356z.3a(b-10)).

Other states have no surprise-billing law of their own, so only the federal rule applies to emergency and in-network-facility care there. The balance billing laws by state page lists every state's surprise-billing and ground ambulance rules side by side.

Related pages

• Medical bills: your rights before you pay
• Balance billing laws by state
• Good faith estimate and the $400 dispute rule
• How to dispute a medical bill
• Medical bill checker

This article provides general legal information about federal and state surprise-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 does the No Surprises Act protect me from?

It limits out-of-network bills for emergency care, for non-emergency care by out-of-network clinicians at in-network hospitals, hospital outpatient departments, critical access hospitals and ambulatory surgical centers, and for air ambulances. In those cases the provider may not bill more than your in-network cost-sharing (45 CFR 149.410, 149.420, 149.440).

Does the No Surprises Act cover ground ambulances?

No. CMS states that ground ambulance services are not covered by the No Surprises Act. Some state laws cover them for state-regulated plans, such as Colorado and New York.

Does the No Surprises Act apply to Medicare or Medicaid?

No. Medicare, Medicaid, CHIP, the Indian Health Service, VA care and TRICARE are outside its balance-billing rules and generally have their own protections. Medicaid providers, for example, must accept the Medicaid payment as payment in full (42 CFR 447.15).

Can a doctor make me sign away my surprise billing protections?

Only for some scheduled care, with a written notice given at least 72 hours ahead (or the day you book, or 3 hours ahead for same-day care), or for care after an emergency once you are stable, and you do not have to sign. Anesthesia, radiology, pathology, lab, emergency medicine and several other services can never be waived (45 CFR 149.420).

Does the No Surprises Act apply to doctor's office visits?

Generally no. CMS states the surprise-billing provisions generally would not apply to non-emergency services in a community health clinic or a doctor's office.

Who do I call about a surprise medical bill?

The No Surprises Help Desk at 1-800-985-3059, open 8am-8pm ET on weekdays and 10am-6pm ET on weekends. You can also file a complaint online with CMS, and contact your state insurance department if your plan is state-regulated.

Does my state's surprise billing law apply to my employer plan?

It depends on the plan. State laws reach state-regulated plans; a self-insured employer plan follows the federal law, and a state can enforce its own law against it only if the plan opted in.