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Since January 2022, the No Surprises Act has protected people who use most types of private health insurance from unexpected out-of-network bills for emergency room visits, air ambulance flights, and non-emergency care at in-network hospitals. Before the federal ban took effect, an analysis of claims data from a large issuer found out-of-network bills in over 20 percent of elective surgeries from 2012 to 2017 where the hospital and primary surgeon were in network.
For patients with private insurance, the law leaves two main exceptions: ground ambulance services are not covered, and some out-of-network doctors at in-network hospitals can ask patients to sign a written waiver before planned care.
Enrollees in Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE already have protections against some unexpected out-of-network bills through those programs. Patients who pay without insurance must get a good faith estimate before scheduled care and can challenge a final bill that far beats the estimate.
Which Bills the Law Covers and Excludes
Balance billing happens when an out-of-network provider bills an insured patient for charges above what the health plan pays, as federal auditors note in their report. Federal law bars surprise balance bills in three main settings:
- Emergency visits: An out-of-network emergency room or doctor cannot bill an enrollee above the plan’s in-network cost-sharing limit.
- In-network hospitals: Out-of-network doctors at a participating hospital or surgical center cannot bill enrollees above in-network cost-sharing without notice and consent.
- Air ambulances: Health plans must apply in-network cost-sharing to air ambulance rides and count those payments toward the in-network deductible and out-of-pocket limit.
These billing protections generally do not apply to vision-only and dental-only plans, short-term limited duration plans, fixed indemnity plans, retiree-only plans, or health care sharing ministries.
When a doctor or hospital leaves a plan’s network during care, continuing care patients can keep in-network rates for up to 90 days. That 90-day rule covers patients treated for a serious and complex illness, getting inpatient care, scheduled to get non-elective surgery, pregnant, or terminally ill.
For some planned care or care after an emergency patient is stable, an out-of-network doctor may ask for a written notice and consent waiver. If care is booked at least 72 hours ahead, the doctor must give the written notice at least 72 hours before the visit. For shorter bookings, the notice is due on the scheduling day and at least 3 hours before care.
Support (“ancillary”) doctors at an in-network facility can never ask a patient to waive surprise billing rights, including doctors in emergency medicine, anesthesiology, pathology, radiology, and neonatology, plus assistant surgeons, hospitalists, intensivists, and diagnostic or lab providers. Waivers are also barred when no in-network doctor is at the facility or when urgent medical needs arise during care.
How the Cost Cap Works in Practice
Unless a state law or state model sets the pay amount, the July 2021 federal rule bases cost-sharing on the lesser of the billed charge or the qualifying payment amount (QPA). By statute, the QPA is the plan’s median contracted rate on January 31, 2019, for the same or a similar service in that area, adjusted each year for consumer price index inflation.
Suppose a health plan has three in-network contracts for the same service in one area paying $475, $490, and $510. The middle amount of $490 is the median contracted rate. If a fourth contract pays $515, the plan averages the two middle rates ($490 and $510) to get a $500 median contracted rate. The plan indexes that rate for inflation to set the QPA and applies the patient’s coinsurance to the QPA.
For people without insurance, federal law sets delivery deadlines for a written good faith estimate. A provider has 1 business day when a visit is scheduled at least 3 business days ahead, or 3 business days when scheduled 10 or more business days out.
Suppose an uninsured patient receives a good faith estimate of $450 for scheduled care and later gets a bill for $875. Because the $875 bill beats the $450 estimate by at least $400, the patient can pay a $25 administrative fee within 120 calendar days to start a federal dispute. Unless the doctor proves unforeseen medical needs, the reviewer sets the price at $450 and subtracts the $25 fee.
How Federal Billing Rules Compare
| Medical Care Setting | Federal Billing Rule | What the Patient Pays | Waiver or Dispute Rule |
|---|---|---|---|
| Hospital or freestanding emergency room | Bars out-of-network balance bills for emergency care | In-network deductible, copayment, or coinsurance | No notice and consent form allowed for emergency care |
| Support (“ancillary”) doctors at in-network hospitals | Bars out-of-network balance bills at participating hospitals | In-network deductible, copayment, or coinsurance | Waivers prohibited for support specialties (July 2021 rule) |
| Other planned care from out-of-network doctors at in-network hospitals | Bars out-of-network providers from billing enrollees above in-network cost-sharing without notice and consent | In-network share without consent, or full charge with consent | Notice due 72 hours ahead if booked 72+ hours out (or 3 hours same-day) |
| Out-of-network air ambulance flights | Bars out-of-network balance bills for air transport | In-network cost-sharing counted toward deductible | No notice and consent waiver allowed (July 2021 rule) |
| Out-of-network ground ambulance rides | Excluded from the federal billing ban under the No Surprises Act | Out-of-network charges unless state law caps them | State or local billing rules apply |
| Uninsured or self-pay scheduled care | Requires written good faith estimates before scheduled care | Estimated charge, or amount set by reviewer | Federal dispute within 120 calendar days if bill beats estimate by $400 |
Why Doctors and Insurers Clash Over Pay
When an out-of-network doctor and a health plan disagree on pay, the June 2026 federal dispute rule requires a 30-business-day open talk period first. If talks fail, either side has 4 business days to start federal dispute resolution, where each side submits one final pay offer and a reviewer picks one binding offer. Providers and insurers filed 489,000 disputes in year one, about 22 times the agencies’ forecast of about 22,200 anticipated disputes, and total filings passed 5.1 million by early 2026.
Texas Medical Association and air ambulance provider LifeNet filed separate suits over how reviewers weigh the QPA, and a Texas federal district court vacated the 2021 rules that treated the QPA as the default benchmark. In 2023, the Texas district court vacated more payment, QPA, batching, and fee rules in later Texas Medical Association suits. The Fifth Circuit affirmed the payment-rule vacatur in August 2024 and partly reversed the QPA vacatur in October 2024, then vacated its October 2024 opinion in May 2025 for full-court rehearing, leaving the 2023 vacatur in place.
Because of those rulings, reviewers now weigh the QPA alongside training, experience, and case complexity without a presumption. In rulemaking comments, supporters of starting with the QPA contended that tying pay to median in-network rates protects families from rising insurance premiums and brings more doctors into plan networks. Opposing commenters countered that emphasizing the QPA favors health plans and lowers provider pay rates, warning that lower payments could hurt network adequacy and physician practices.
In February 2026, a federal audit of provider networks examined claims from 2019 through 2023 across emergency medicine, radiology, anesthesiology, and air ambulance care. The share of in-network claims rose for three of the four specialties after the law took effect, which auditors noted may indicate higher network participation, while provider groups told auditors participation stayed about the same or fell. Over the same period, inflation-adjusted payments largely followed pre-2022 trends, rising for hospital emergency claims while falling for physician emergency claims.
How to Challenge a Surprise Medical Bill
Patients who get an unexpected out-of-network bill or a charge far above a written estimate can take four practical steps:
- Compare your bill with plan records: Insured patients should check their provider bill against their explanation of benefits to verify that covered care matches in-network cost-sharing.
- Check whether any waiver was valid: A notice and consent form must stay separate from other documents, meet the 72-hour or 3-hour deadline, and cannot come from an emergency or support (“ancillary”) doctor.
- Start a good faith estimate dispute: Uninsured or self-pay patients can start a dispute online or by mail within 120 calendar days, which pauses collections and late fees.
- Call the federal help desks: Patients can call the No Surprises Help Desk at 1-800-985-3059 for billing help, or contact the Consumer Financial Protection Bureau at 1-855-411-2372 over medical debt collection.
