No Surprises Act: Out-of-Network Balance Bills and How to Fight Them
The No Surprises Act (NSA) of 2022 ended most surprise balance billing for emergency services and out-of-network providers at in-network facilities. What's protected, what isn't, and how to dispute a bill that violates the NSA.
The No Surprises Act, effective January 1, 2022, ended most surprise balance billing for emergency services and out-of-network providers at in-network facilities (e.g., the anesthesiologist you didn't choose). If you receive a balance bill in violation: (1) file a complaint with the federal NSA line (1-800-985-3059); (2) refuse to pay and dispute through your insurer. Patient cost-sharing for protected services is limited to your in-network cost-share. Notable carve-out: ground ambulance is NOT covered.
The NSA covers three main scenarios: emergency services (any provider, any facility), non-emergency services at in-network facilities provided by out-of-network ancillary providers, and out-of-network air ambulance. Ground ambulance is NOT covered (some states fill the gap).
What the NSA protects
(1) Emergency services: cost-share at in-network rate; provider cannot balance-bill above that. Applies at any emergency department, urgent care delivering emergency services, or post-stabilization care. (2) Non-emergency at in-network facilities: if you're treated by an out-of-network provider you didn't choose (anesthesiologist, radiologist, pathologist, etc.), cost-share is in-network rate. Exceptions: written NSA waiver, but waiver CANNOT be requested for emergency or ancillary services. (3) Air ambulance: NSA caps your cost-share at in-network rate.
What the NSA does NOT protect
Ground ambulance (biggest carve-out — still subject to balance billing in most states), services you knowingly chose out-of-network with signed acknowledgment, self-pay/uninsured (different rules — Good Faith Estimate), workers' compensation, auto insurance.
Step-by-step: how to dispute
- Get the Explanation of Benefits (EOB) from your insurer.
- Identify the protected category (emergency? ancillary? air ambulance?).
- File complaint with CMS: 1-800-985-3059 or cms.gov/nosurprises.
- Notify the provider in writing — refuse to pay the disputed balance, cite the NSA statute.
- If sent to collections: report as separate NSA violation to CMS, CFPB, and state AG.
State-law overlay
Some states have stronger surprise-billing protections than federal NSA. California AB 72 since 2017 (ground ambulance covered in some scenarios). New York Surprise Bill Protection Law since 2015 (comprehensive including ground ambulance). Texas SB 1264 (stronger arbitration; ground ambulance covered).
Frequently asked questions
Does the NSA apply if my plan is self-funded ERISA?
Yes. NSA applies to most group health plans including ERISA self-funded plans. Exceptions: grandfathered plans and short-term limited-duration insurance.
What if I'm on Medicare or Medicaid?
Medicare beneficiaries are protected from balance billing for most covered services under separate Medicare law. Medicaid beneficiaries similarly protected. NSA primarily applies to private/commercial insurance.
How long do I have to dispute an NSA violation?
Federal complaint to CMS has no strict deadline but file as soon as practical. State-law deadlines vary. File within 30-60 days of receiving the disputed bill.
Can the provider sue me for the balance?
A provider pursuing collection on an NSA-protected bill is violating federal law. If they sue, the NSA violation is a defense AND grounds for a counterclaim.
Will ground ambulance ever be covered?
Federal legislation has been introduced repeatedly but not passed as of 2026. Some states have filled the gap; check your state's specific law.
What if the insurer pays a low amount and the provider bills me the difference?
Classic NSA violation. Provider's recourse is to negotiate with the insurer or use IDR. Provider cannot balance-bill you above your in-network cost-share.
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