Surprise bills and the No Surprises Act

The federal No Surprises Act may limit what you owe if you had emergency care, if an out-of-network clinician treated you at an in-network hospital or surgery center, or if an out-of-network air ambulance took you. It covers job-based, Marketplace and other individual plans. It does not cover every bill, so the first step is to check whether yours falls in a protected group.

A surprise bill is a bill from an out-of-network provider that you did not choose or could not avoid. Use the surprise bill checker to see whether the Act may apply to you. It is not a ruling on your bill.

What this means

Who is protected. People with employer coverage (including the Federal Employees Health Benefits program), Marketplace coverage and other individual coverage, including grandfathered plans.

Who is not. Short-term limited-duration plans, health care sharing ministries, fixed indemnity plans and, generally, stand-alone dental or vision plans.

What is protected. Where the Act applies, you owe only your in-network cost sharing in these cases. For emergency services and for a wrong provider directory, it also counts toward your in-network deductible and out-of-pocket maximum. For the other two cases, ask the plan whether it counts.

• Emergency services. If your plan covers emergency department services at all, it must cover emergency services without prior authorization, in or out of network.
• Care by out-of-network clinicians at in-network facilities. An out-of-network clinician at an in-network hospital, hospital outpatient department or ambulatory surgical center may not bill you more than in-network cost sharing, unless you signed a valid notice-and-consent waiver.
• Air ambulance. An out-of-network air ambulance provider may not bill you more than in-network cost sharing.
• A wrong provider directory. If the plan’s directory said a provider was in network and that was wrong, the plan may not impose more than in-network cost sharing.

What is not protected. Ground ambulance services are not covered by the Act. See the ambulance bills guide. Also, a waiver can apply to some scheduled non-emergency services.

The waiver. A valid waiver needs written notice at least 72 hours before a service scheduled 72 or more hours ahead (otherwise on the day of scheduling and at least 3 hours before the service), a good faith estimate of charges, and a statement that consent is optional and you may choose an in-network provider instead. A waiver can never be used for emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists, diagnostic services (including radiology and laboratory), situations where no in-network provider is available at the facility, or unforeseen urgent needs.

The plan and the provider. For protected services, the plan must decide whether the services are covered and send the provider an initial payment or a notice of denial within 30 calendar days after it has the information it needs. If the plan and the provider disagree on the payment, they resolve it between themselves in a federal process. You are not a party and you owe only in-network cost sharing.

What to do

1. Do not ignore the bill, and do not pay yet. Ask the provider in writing to hold the bill while you check. Use the surprise bill letter to the provider, or call first with the billing office phone script. If the bill has a due date, call the billing office before that date and ask for a hold in writing. A hold is a request, not a legal right, so the office can say no. A bill left unanswered can be sent to collections. If a collection notice arrives, answer it in writing and keep a copy: use the debt validation request letter and read medical debt in collections. (You.)
2. Read the explanation of benefits. Compare it with the bill. Check whether the plan processed the claim as out of network. (You.)
3. Use the surprise bill checker. It asks where you got care, whether the provider was in network and what you signed. It points to whether the Act may apply. It is not a ruling on your bill. (You.)
4. Ask the plan to reprocess the claim at in-network cost sharing. Say which protection applies. Ask for the answer in writing. The surprise bill letter to your plan sets it out. (You.)
5. Tell the provider in writing that you believe the Act bars the extra billing. Ask for a corrected bill. The surprise bill letter to the provider does this. (You.)
6. Complain if it continues. Call the No Surprises Help Desk at 1-800-985-3059, or use the online complaint form at the Centers for Medicare & Medicaid Services website. The agency says help is available in English, Spanish and more than 350 other languages. We could not confirm the Help Desk’s hours, so ask when you call. The no surprises complaint letter helps you set out the facts. (You.)
7. If the plan denies the protection, appeal. A denial or higher cost sharing that turns on whether the Act’s protections apply can go to external review, including under a grandfathered plan. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial to appeal, and at least four months for external review. Check the date on your notice, which controls.

What the plan or provider may say, and what to say back

“I signed a consent form.” Ask for a copy. Check the date and the estimate. A waiver is valid only if the notice came in time with a good faith estimate, and it can never be used for emergency, anesthesia, pathology, radiology, diagnostic or other listed services.

“The doctor is not in our network.” If the doctor treated you at an in-network hospital or surgery center, in an emergency, or after the plan’s directory said the doctor was in network, the Act may apply. Ask the plan to say in writing why it does not.

The rule

An out-of-network provider covered by the Act may not bill you more than in-network cost sharing for emergency services, for non-emergency services by out-of-network clinicians at in-network facilities (unless you validly waive), and for air ambulance services. 45 Code of Federal Regulations (CFR) 149.410

Watch for

• Self-pay and uninsured patients. A different process lets uninsured or self-pay patients get a good faith estimate and dispute a bill when the provider’s total billed charges are at least $400 more than the estimate. You must start it within 120 calendar days of the initial bill, and the fee is $25 as of 11 November 2026 (check the Centers for Medicare & Medicaid Services page for the current amount). While it is pending, the provider must not move the bill into collection. Insured patients cannot use this process. The matching rule for insured patients has not yet been put into effect.
• State laws. Some states add their own surprise billing protections for insured plans. See Colorado, Texas and Washington for examples. State laws generally do not reach self-funded employer plans.
• Other coverage. This guide covers job-based and individual plans. For Medicare, Medicaid and other coverage, see the coverage pages.
• Keep records. Keep the bill, the explanation of benefits, the consent form and your call log.

What next

• Ambulance bills: air and ground ambulance differ.
• Emergency room claim denied: if the plan denied emergency care.
• The bill while you appeal: how to protect yourself while you dispute a bill.
• Out-of-network underpayment: when the plan paid too little.