The short version
The No Surprises Act (NSA) took effect on January 1, 2022. It protects people with private insurance — including employer-sponsored plans, marketplace plans, and some federal plans — from balance billing in three categories:
- Emergency services (ER visit, stabilisation, post-stabilisation care)
- Non-emergency services from an out-of-network provider at an in-network facility (anesthesia, radiology, pathology, hospitalist, etc.)
- Air ambulance services
In all three cases, you pay only the in-network cost-sharing you would have paid if the provider were in-network. Anything above that cannot be billed to you.
What “balance billing” means
When a provider is out-of-network, they charge whatever they want. The insurer pays their allowed amount; the provider “balances” the bill by sending the difference to the patient. Pre-NSA, this could run into tens of thousands of dollars for an emergency visit where the ER doctor happened to be out-of-network.
The big gap: ground ambulances
Ground ambulance services are not protected by the federal NSA at this time. Some states have their own ground-ambulance balance-billing laws; most do not. Congress has considered bills to close this gap — as of this writing, it remains open.
If you're uninsured — the Good Faith Estimate
If you are uninsured or paying out of pocket, the provider must give you a Good Faith Estimate (GFE) of the total expected charges for scheduled services, on request or when you book. If the final bill is more than $400 higher than the GFE, you can dispute it through the federal Patient-Provider Dispute Resolution (PPDR) process. The dispute costs $25 and pauses collections while it's open.
Your notice-and-consent exception
Out-of-network providers can ask you to waive NSA protections for certain non-emergency services, but they must give you a written notice and consent form at least 72 hours in advance (or 3 hours for same-day care). You never have to sign. If you do, the NSA no longer protects you for that specific visit. You cannot be asked to waive for emergency care, ancillary services (anesthesiologist, radiologist, etc.) at in-network facilities, or air ambulance.
How to file a No Surprises Act complaint
If you think a provider, facility, or plan has violated the NSA, file a complaint with CMS:
- Online: cms.gov/nosurprises/help-with-no-surprises
- Phone: 1-800-985-3059 (TTY 1-800-985-3059)
- Each violation can carry a civil penalty of up to $10,000
If you already paid a surprise bill
Ask for a refund. Send a written letter citing the NSA and the specific service, and cc your state insurance commissioner and CMS. Many providers will refund rather than face a regulatory complaint.
Decision-support reminder: Fix My Bill surfaces likely NSA violations for you to verify. It is not legal advice. For complex situations — especially large bills or threatened collections — consult a consumer attorney.