Surprise Medical Billing: What the No Surprises Act Still Doesn’t Protect You From

Fact-checked by the Smart Insurance 101 editorial team

The No Surprises Act (NSA) was a landmark federal law designed to end the practice of surprise medical billing, where patients receive unexpected charges from out-of-network providers. If you’ve ever been hit with a bill from an anesthesiologist you didn’t choose or a radiology service you didn’t know was out-of-network, the NSA was supposed to have your back. Yet, the law still leaves critical loopholes that can expose you to thousands of dollars in unexpected costs. According to the U.S. Department of Labor, the Act does not apply to non-emergency services provided by an out-of-network provider at an out-of-network facility, and it doesn’t cover every high medical bill, services not covered by your plan, for instance, remain your responsibility.

Even with the NSA in place, surprise medical billing hasn’t disappeared. Narrow networks, aggressive cost-shifting, and a surge in independent dispute resolution (IDR) filings all point to a system still under strain. Understanding what the law actually protects, and what it doesn’t, is the only way to avoid a financial ambush after you’ve received care.

What Surprise Medical Billing Does the No Surprises Act Actually Stop?

The NSA specifically blocks balance billing, the practice of charging you the difference between what your insurer pays and what an out-of-network provider charges, in three scenarios: most emergency services, certain non-emergency services from out-of-network providers at in-network facilities, and out-of-network air ambulance services. In these situations, you’re only responsible for your in-network cost-sharing, and the provider and insurer must resolve payment disputes through a federal IDR process without involving you.

Emergency care is broadly protected. If you go to a hospital emergency department, even if the hospital or the doctors treating you are out-of-network, you can’t be balanced billed for the emergency services. The same protection extends to any post-stabilization care you receive until you can safely travel to an in-network facility. For non-emergency care, the NSA covers out-of-network services delivered at in-network hospitals, hospital outpatient departments, and ambulatory surgical centers. That means if you schedule surgery at an in-network hospital, you shouldn’t get a surprise bill from the anesthesiologist, pathologist, or radiologist, even if they’re not in your plan’s network.

Air ambulance rides are a standout success of the NSA. Before the law, a single air ambulance trip could cost patients $40,000 or more, with no out-of-network cap. Now, under the NSA, you’re protected from balance billing for air ambulance services, and your cost-sharing is limited to the in-network amount. However, as the South Carolina Department of Insurance notes, the law does not cover ground ambulances, a major exclusion that we’ll explore next.

Ground Ambulance Rides: Why Are They Still the Biggest Loophole?

Ground ambulance rides are the single largest remaining source of surprise medical billing that the NSA does not address. When the law was drafted, Congress explicitly excluded ground ambulance services, citing the fragmented nature of the industry and the need for further study. An advisory committee was formed, but, no federal protections have been enacted. That means a five-mile ambulance trip to the emergency room can still generate a balance bill of $1,200 or more, with patients often having no control over which ambulance company responds to a 911 call.

State-level efforts are filling the void in some places, but the patchwork is far from complete. In 2026, bills to ban ground ambulance balance billing are under consideration in Alabama, Georgia, Illinois, and several other states, following the lead of early adopters like Colorado and Maryland. However, a majority of states still permit ground ambulance balance billing. If you live in a state without a ban, and your employer’s plan is self-funded, which is true for 65% of covered workers, state laws may not apply at all because of federal preemption under ERISA, leaving you with no protection against a surprise ambulance bill.

Notice-and-Consent Waivers: When You Can Still Lose Protections

The NSA contains a carefully designed exception that allows out-of-network providers to ask you to waive your balance billing protections, but only under strict conditions. For non-emergency services where you are not in immediate danger, a provider can give you a written notice at least 72 hours before the service, clearly stating that the provider is out-of-network, listing in-network alternatives, and providing a good-faith estimate of the potential charges. If you sign that notice and consent form, you agree to be balance billed for the service.

The catch is that these waivers are not permitted in emergencies or for ancillary services, radiology, anesthesiology, pathology, neonatology, or hospitalist services, even if you’re at an in-network facility. So, you can never be asked to waive protections for an out-of-network anesthesiologist during surgery. However, for a scheduled surgery with an out-of-network surgeon at an in-network hospital, you might be presented with a waiver. Many patients, eager to get the procedure done, sign without fully understanding the financial consequences. A 2025 analysis by the Center on Health Insurance Reforms found that this waiver process is one of the most common ways consumers still face unexpected bills, particularly when the notice is confusing or provided under time pressure.

Out-of-Network Facilities and Non-Covered Services: Where the NSA Draws a Hard Line

The NSA does not cover non-emergency care you receive at an out-of-network facility. If you choose to have a procedure at an out-of-network hospital or visit a standalone outpatient clinic that isn’t in your plan’s network, the law provides no protection against balance billing. Similarly, services that your health plan simply does not cover, such as certain elective procedures, treatments deemed experimental, or services excluded by your plan’s design, remain your financial responsibility regardless of the NSA.

For uninsured or self-pay patients, the law offers a different safeguard: the good-faith estimate requirement. Starting in 2022, providers and facilities must give you a written estimate of expected charges at least three business days before a scheduled service, or upon request. If the final bill exceeds the estimate by more than $400, you can dispute the charges through a patient-provider dispute resolution process. This is a meaningful protection, but it doesn’t eliminate surprise billing for the uninsured, it merely gives you a tool to challenge it. If you’re in a plan that uses a narrow network, like an HMO, you may face more situations where you’re inadvertently steered to an out-of-network facility, and the NSA won’t help.

IDR Disputes and Enforcement: What to Do When the System Fails

Even when the NSA clearly applies, the protection is only as strong as its enforcement. The law created a federal IDR process to resolve payment disputes between providers and insurers, but in practice, the system has been overwhelmed. In the first six months of 2025, 1.2 million new disputes were filed, according to a CHIR analysis. Providers won in over 80% of resolved cases, yet a 2024 survey by the Emergency Department Practice Management Association found that nearly one in four respondents reported IDR awards were unpaid or paid incorrectly within the statutory 30 business days. This noncompliance erodes trust and, critically, can lead to providers dropping out of networks, which ultimately harms patients.

For consumers, the IDR process is not the direct path to dispute a bill, that’s handled through your insurer’s internal appeals process and, if necessary, external review. However, if you receive a bill you believe violates the NSA, you should first contact your insurer and the provider to confirm the claim’s status. If the bill is for a service that should be protected (such as emergency care or an ancillary provider at an in-network facility), file a complaint with the No Surprises Help Desk at CMS. The federal government can investigate and impose penalties on noncompliant providers. If you have a self-funded employer plan governed by ERISA, you may need to navigate a different set of rules, state protections often don’t apply, and the federal Department of Labor becomes your primary recourse. With medical coverage shrinking, knowing your plan type is more important than ever when navigating these disputes.

Frequently Asked Questions

What is surprise medical billing and how does it happen?

Surprise medical billing occurs when you receive care from a provider who is outside your health insurance network, often without your knowledge or meaningful choice, and are then billed for the difference between the provider’s full charges and what your insurer pays. This most commonly happens in emergency situations where you have no time to check network status, or during planned procedures where an out-of-network specialist such as an anesthesiologist or radiologist is brought in by an in-network facility without your awareness. The result can be thousands of dollars in unexpected charges that arrive weeks or months after your care.

Does the No Surprises Act cover all types of medical bills?

No. The No Surprises Act targets a specific subset of surprise medical billing situations: emergency services at any facility, non-emergency care from out-of-network ancillary providers at in-network facilities, and air ambulance rides. It does not cover non-emergency care at out-of-network facilities, ground ambulance rides, services your health plan doesn’t cover at all, or situations where you voluntarily signed a notice-and-consent waiver agreeing to out-of-network charges. If any of these scenarios applies to your bill, the NSA’s balance billing protections will not help you.

Why are ground ambulance rides not covered by the No Surprises Act?

Congress deliberately excluded ground ambulance services from the NSA when it was passed in 2020, acknowledging that the ground ambulance industry is uniquely complex, it is heavily fragmented, often municipally operated, and deeply intertwined with local government funding structures. Lawmakers determined that further study was needed before a federal solution could be crafted. A federal advisory committee was established to examine the issue, but as of mid-2026, no federal legislation has passed to close this gap. Until federal action occurs, protection from ground ambulance balance billing depends entirely on whether your state has enacted its own law, and whether your health plan is subject to state regulation at all.

Can a provider legally make me sign away my No Surprises Act protections?

In limited circumstances, yes. Providers can ask you to sign a notice-and-consent waiver for certain non-emergency, non-ancillary out-of-network services, but only if they give you written notice at least 72 hours before the scheduled service, include a list of in-network alternatives, and provide a good-faith cost estimate. Critically, waivers are completely prohibited for emergency services and for ancillary providers such as anesthesiologists, radiologists, pathologists, neonatologists, and hospitalists, even when you are at an in-network facility. If you are ever asked to sign such a waiver in an emergency or for an ancillary service, you have the right to refuse and to file a complaint with the No Surprises Help Desk.

What should I do if I receive a surprise medical bill that I believe violates the No Surprises Act?

Start by contacting both your insurer and the billing provider to verify how the claim was processed and whether the service should have been covered under NSA protections. Request an itemized bill so you can identify each charge individually. If you confirm the bill appears to violate the law, file a complaint with the federal No Surprises Help Desk operated by CMS at 1-800-985-3059 or online at cms.gov/nosurprises. If your plan is a self-funded employer plan, also contact the U.S. Department of Labor’s Employee Benefits Security Administration, since state insurance regulators may not have jurisdiction over your plan. Keep copies of all correspondence and document every phone call with dates and representative names.

Are self-pay and uninsured patients protected from surprise medical billing?

Uninsured and self-pay patients are not protected from balance billing in the same way insured patients are, but the NSA does give them one important tool: the right to a good-faith estimate. Before any scheduled service, providers must give uninsured patients a written estimate of expected charges at least three business days in advance, or upon request for non-scheduled services. If the final bill exceeds that estimate by more than $400, you can initiate a patient-provider dispute resolution process to challenge the difference. This is a meaningful right, but it requires you to act, the dispute resolution process is not automatic, and you must formally request it within 120 days of receiving the bill.

Does the No Surprises Act apply to all health insurance plans?

The NSA applies broadly to most private health insurance plans, including those offered through employers, individual and family plans purchased on or off the ACA marketplace, and non-grandfathered health plans. However, there are important exceptions. Grandfathered health plans, those that existed before the ACA and have not made significant changes, are exempt. Short-term limited-duration health plans are also not covered. Federal programs like Medicare, Medicaid, CHIP, and TRICARE have their own separate billing protections. If you have a self-funded employer plan, state-level protections don’t apply, but the federal NSA rules still do, meaning your primary recourse is through federal agencies rather than your state insurance department.

How does the independent dispute resolution (IDR) process affect patients?

The IDR process is a mechanism for providers and insurers to resolve payment disputes without involving the patient directly, in theory, keeping you out of the middle of billing conflicts. When a provider believes an insurer has underpaid for an NSA-protected service, they can initiate IDR, and a certified arbitrator determines the appropriate payment. While this process is meant to protect patients from being balance billed, its volume has become a serious problem. Over 1.2 million disputes were filed in just the first half of 2025, straining the system’s capacity and causing long delays. For consumers, the key practical impact is that IDR backlogs can lead some providers to drop out of insurer networks entirely, potentially narrowing your access to in-network care over time.

What steps can I take before a medical procedure to avoid surprise medical billing?

Prevention is the most powerful tool you have. Before any scheduled procedure, call your insurer to verify that every provider involved, including the facility, surgeon, anesthesiologist, assistant surgeon, and any lab or pathology services, is in-network. Ask the facility directly whether any providers they work with are out-of-network and, if so, request an in-network alternative. Request a good-faith estimate in writing before your procedure date. If you are presented with a notice-and-consent waiver, read it carefully and understand that signing it means you agree to potential balance billing; you are not required to sign, and you can seek an in-network provider instead. For emergency situations, you generally cannot plan ahead, but knowing your rights after the fact, including the right to file a complaint, is equally important.

Will the No Surprises Act gaps ever be fixed, and what reforms are being discussed?

Legislative efforts to close the remaining gaps in the NSA are ongoing but slow-moving. The most significant pending issue is ground ambulance billing, where federal advisory committee recommendations have been made but not yet enacted into law. Several states are advancing their own ground ambulance balance billing bans, and federal bills have been introduced in Congress to extend NSA protections to ground ambulances, though none had passed as of mid-2026. Other reform discussions include tightening the notice-and-consent waiver process to prevent abuse, increasing penalties for noncompliant providers and insurers, and improving the capacity and efficiency of the federal IDR system. Staying informed through resources like the CMS No Surprises Act page and patient advocacy organizations is the best way to track changes that may affect your rights.

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