Out-of-network billing: what the No Surprises Act covers in 2026

Quick answer: The No Surprises Act (effective January 2022) prohibits balance billing in two main situations: (1) emergency care at any facility regardless of network status, and (2) non-emergency care at an in-network facility where you had no meaningful choice about which provider performed the service (e.g., an anesthesiologist assigned without your input). In both cases, you pay only your in-network cost-sharing. Any bill for more than that is not legally your responsibility.

Before the No Surprises Act, patients routinely received bills for thousands of dollars from out-of-network providers they never chose -- a surgeon was in-network but the assistant they brought in was not. The Act closed most of these situations, but significant gaps remain.

What the No Surprises Act protects

Emergency care at any facility: If you go to an emergency room -- even one entirely outside your network -- you pay only your in-network deductible, copay, and coinsurance. The out-of-network facility and physicians can only bill you at in-network rates. Post-stabilization care is also covered if you couldn't reasonably consent to transfer.

Non-emergency care by out-of-network providers at in-network facilities: This covers situations like:

• An out-of-network assistant surgeon performing part of your in-network surgery
• An out-of-network anesthesiologist assigned to your procedure
• An out-of-network radiologist reading your in-network facility's imaging
• An out-of-network laboratory processing samples from an in-network visit
• An out-of-network hospitalist seeing you during an in-network hospital stay

In all of these, you pay in-network cost-sharing only. The provider disputes with the insurer directly through a federal Independent Dispute Resolution (IDR) process -- you're not involved.

Air ambulance: Out-of-network air ambulance services are covered by the Act. You pay in-network cost-sharing.

What the No Surprises Act does NOT cover

Scheduled out-of-network care with consent: If you knowingly choose an out-of-network provider for scheduled (non-emergency) care and sign a written consent acknowledging out-of-network status and estimated costs, you're responsible for the higher charges. The consent must be provided at least 72 hours before scheduled care, and you must have had a reasonable in-network alternative available.

Ground ambulance: Ground ambulance services are explicitly excluded from the No Surprises Act and remain a source of large surprise bills. Several states have their own ground ambulance billing protections; federal legislation has been proposed but not passed as of 2026.

Services at out-of-network facilities: If you choose an out-of-network hospital or outpatient center for scheduled care without a required referral, the full out-of-network rates apply. The Act only covers in-network facilities.

How to identify and dispute a violation

If you receive a bill that appears to violate the No Surprises Act:

Step 1: Check your Explanation of Benefits (EOB). Your insurer sends an EOB showing what was billed, the allowed amount, what insurance paid, and what you owe. If the patient responsibility amount on the EOB exceeds your in-network cost-sharing, that's a potential violation.

Step 2: Identify the service type. Was this an emergency? Was this an elective visit to an out-of-network facility? Was this a provider at an in-network facility you didn't choose?

Step 3: Contact your insurer. If you believe the service is covered by the No Surprises Act, call your insurer and reference the Act. Ask them to confirm your in-network cost-sharing obligation.

Step 4: Contact the provider. Send a written dispute to the provider's billing department, citing the No Surprises Act (or your state's equivalent) and stating that you are not responsible for amounts beyond your in-network cost-sharing.

Step 5: File a federal complaint. At cms.gov/nosurprises or by calling 1-800-985-3059. The provider faces civil monetary penalties for violations.

Consent forms: when they're legitimate and when they're not

Providers may ask you to sign a consent form acknowledging out-of-network status before scheduled procedures. This is legitimate for voluntary out-of-network care. It is NOT legitimate if:

• You were not given the form at least 72 hours before scheduled care (or 3 hours for same-day scheduling)
• There was no in-network alternative available
• You were in an emergency situation
• The form was presented in a context where you couldn't reasonably refuse (e.g., already in the pre-op area)

A signed consent form obtained under pressure or without the required advance notice is not enforceable as a waiver of No Surprises Act protections.

State law may provide additional protections

The No Surprises Act establishes a federal floor. Many states have stronger protections:

• Several states extend surprise bill protections to ground ambulance
• Some states have lower balance billing limits than federal law
• Some states cover all insured patients (vs. the federal law's focus on ACA-compliant plans)

State laws can be more protective but never less protective than the federal Act.

Out-of-network cost estimating

For planned out-of-network care, request a Good Faith Estimate. Under the Act, uninsured patients and those paying out-of-pocket are entitled to a written cost estimate for scheduled services at least 3 days before the appointment. Insured patients have separate cost estimate rights under the ACA's price transparency rules.

For understanding how your deductible and out-of-pocket maximum interact with network costs, see health insurance deductible vs out of pocket and what does my insurance cover.

Frequently asked questions

What if I signed a consent form agreeing to out-of-network charges in the ER?

Consent forms for out-of-network charges signed in emergency situations are not enforceable under the No Surprises Act. Emergency care protections apply regardless of what you signed. Dispute the charge, citing the Act.

Does the No Surprises Act apply to self-funded employer health plans?

Yes. The Act applies to most group health plans, including self-funded employer plans. ERISA plans are covered.

What if my insurer says I owe more than my in-network cost-sharing?

If your insurer's EOB shows cost-sharing higher than your in-network rates for a protected service, the insurer may be misclassifying the claim. Request an appeal and reference the No Surprises Act. If the appeal fails, file a complaint with the Department of Labor (for employer plans) or your state insurance commissioner (for individual/marketplace plans).

Are telehealth visits covered by the No Surprises Act?

Yes. Telehealth providers who are out-of-network but providing services at in-network facility rates are covered. Purely out-of-network telehealth for scheduled care follows the standard rules (consent-based).

How do I know if a provider is in-network before a visit?

Call the provider's office and ask them to verify in-network status with your specific plan. Don't rely solely on the online directory, which can be outdated. Get the confirmation in writing (email or letter) for planned procedures, and keep that documentation.

Use ReadMyPolicy to review your health insurance policy's out-of-network provisions and understand exactly what protections apply to your coverage.