The No Surprises Act, which took effect January 1, 2022, was supposed to end surprise medical bills once and for all. As of 2026, it has made a real difference for millions of patients, but it is not a complete shield. Several enforcement questions remain unsettled, key gaps still expose patients to large bills, and the rule governing how much insurers must pay out-of-network providers is in a state of legal flux that will not be resolved until at least August 2026.
Quick Answer: The No Surprises Act protects you from balance billing for emergency care, most out-of-network services at in-network facilities, and air ambulance transport. Ground ambulance rides, out-of-network care you choose and consent to, and non-emergency care at out-of-network facilities are not covered. In 2026, enforcement of how insurers calculate what they owe providers is still operating under a temporary framework, but your patient cost-sharing protections remain fully in effect.
What the No Surprises Act Covers in 2026
The law applies to most private health insurance plans, including employer-sponsored coverage, plans bought on the ACA marketplace through healthcare.gov, and individual market plans. It does not apply to short-term health plans, grandfathered plans, or federal programs like Medicare and Medicaid (which have their own billing protections).
Emergency Care at Any Facility
If you have an emergency and end up at an out-of-network emergency room or hospital, you cannot be billed more than your plan's in-network cost sharing. That means your normal in-network copay, deductible, and coinsurance apply, even if every provider treating you is out of network. The facility and providers cannot send you a balance bill for the difference between what they charge and what your insurer paid.
This protection applies regardless of whether you chose the facility or were transported there by ambulance. You cannot be asked to waive these protections before receiving emergency care.
Out-of-Network Providers at In-Network Facilities
This is the scenario the law was most directly designed to fix. You schedule a procedure at an in-network hospital. You go through in-network pre-authorization. Then you receive a separate bill from an anesthesiologist, assistant surgeon, radiologist, or pathologist who was brought in and is out of network. Under the No Surprises Act, these ancillary providers cannot balance bill you.
Covered provider types at in-network facilities include:
- Emergency medicine physicians
- Anesthesiologists
- Pathologists
- Radiologists
- Neonatologists
- Assistant surgeons
- Hospitalists
- Intensivists
Your cost sharing for these services is capped at your plan's in-network rate. If they try to bill you more, that is a violation of the law.
Air Ambulance Transport
Air ambulance was one of the most aggressive sources of surprise billing before 2022, with bills routinely exceeding $30,000 for a single flight. The No Surprises Act now covers air ambulance transport from out-of-network providers. Your cost sharing is capped at your in-network amount. Air ambulance companies cannot ask you to waive these protections under any circumstances.
Good Faith Estimates for Uninsured and Self-Pay Patients
If you are uninsured or paying out of pocket (for example, if your plan has a very high deductible and you are self-paying to avoid a claim), providers must give you a Good Faith Estimate (GFE) before scheduled services. The GFE must list expected charges for the primary service and any related items such as labs or imaging.
If your final bill is $400 or more above the GFE total, you have the right to dispute it through the federal Patient-Provider Dispute Resolution (PPDR) process. You have 120 days from receipt of the bill to request review. You can reach the CMS No Surprises Help Desk at 1-800-985-3059 (8 a.m. to 8 p.m. ET weekdays, 10 a.m. to 6 p.m. ET weekends) or submit a complaint at cms.gov/nosurprises.
What the No Surprises Act Does NOT Cover in 2026
Understanding the gaps is just as important as knowing the protections. Assuming you are covered when you are not can leave you with a five-figure bill and no legal recourse.
Ground Ambulance Transport
This is the biggest gap in the law. Congress explicitly excluded ground ambulance services from the No Surprises Act. If you are transported by a ground ambulance that is out of network with your insurance plan, the ambulance company can send you a balance bill for the full difference between their charge and what your insurer pays.
As of 2026, 22 states have enacted their own ground ambulance balance billing protections for people in fully insured plans. If you live in one of those states, your state law may protect you. Self-insured employer plans (the majority of large-employer coverage) are governed by federal ERISA rules and are generally exempt from state laws. Check with your state insurance commissioner to understand your local rules.
Out-of-Network Care You Choose and Consent To
The law allows providers to ask for your written consent to waive balance billing protections in certain non-emergency situations. If you want to see a specific out-of-network specialist at an in-network facility for a non-emergency service, and there is an in-network alternative available, the provider can ask you to sign a notice-and-consent form agreeing to be balance billed. If you sign it, you lose the protection for that visit.
You cannot waive protections for:
- Emergency services
- Ancillary services (anesthesia, lab, radiology, etc.) required during your procedure
- Services when no in-network provider is available at the facility
Read any consent forms carefully before signing. If a form asks you to accept financial responsibility beyond your in-network cost sharing, ask specifically which protections you are being asked to waive.
Non-Emergency Care at Fully Out-of-Network Facilities
If you choose to go to an out-of-network hospital or surgical center for a scheduled, non-emergency procedure, the law does not cap what that facility can charge you. The surprise billing protections apply to out-of-network providers working inside in-network facilities, not to out-of-network facilities themselves. Always verify facility network status before any planned procedure.
Short-Term and Grandfathered Health Plans
Plans sold before the Affordable Care Act that have maintained grandfathered status, and short-term health plans (sold as temporary coverage, often lasting under 12 months), are not covered by the No Surprises Act. If you have one of these plan types, you have no federal surprise billing protections. This is a critical reason to verify your plan type before assuming you are covered.
The QPA Situation: What Patients Need to Know
The Qualifying Payment Amount (QPA) is the benchmark that determines how much your insurer pays an out-of-network provider in a covered NSA situation. It also determines your cost sharing. When the QPA is calculated lower, your cost sharing is lower. When it is calculated higher, your cost sharing may be higher.
Since August 2023, the QPA calculation methodology has been in legal dispute. A federal court vacated the original calculation rules in the Texas Medical Association v. HHS case, and federal agencies have been operating under enforcement discretion, meaning they have not strictly enforced which QPA methodology plans must use. This enforcement discretion has been extended multiple times and is currently expected to remain in place through August 1, 2026. Agencies have indicated they do not expect to extend it further, but will reassess.
What this means for patients right now: your cost sharing caps still apply. You still cannot be balance billed. The legal dispute affects how insurers and providers settle payment between themselves through the Independent Dispute Resolution (IDR) process, not your out-of-pocket liability. If your plan calculated your cost sharing based on a QPA that differs from what a different methodology would produce, the difference is generally small for individual cost-sharing purposes.
If enforcement discretion ends in August 2026 as expected, expect increased audit activity and potential QPA recalculations. The final IDR Operations Rule, which would standardize claim codes, batching, and timelines for insurer-provider disputes, is still pending as of mid-2026.
How to Use the CoveredUSA Bill Analyzer to Spot Violations
If you receive a medical bill after an emergency, a hospital stay, or an outpatient procedure at an in-network facility, you should check it line by line against what the No Surprises Act allows. This is where the CoveredUSA Bill Analyzer can help. The CoveredUSA Bill Analyzer compares each charge on your bill to expected rates, flags items that may exceed your in-network cost sharing cap, and identifies common billing errors and overcharges that appear on hospital bills.
Upload your hospital bill to the free CoveredUSA Bill Analyzer to find errors, overcharges, and charity care options in 30 seconds.
How to Dispute a Surprise Bill
If you receive a bill you believe violates the No Surprises Act, here is what to do.
Step 1: Gather your documents. Collect your Explanation of Benefits (EOB) from your insurer, the itemized bill from the provider, and any Good Faith Estimate you received before the service.
Step 2: Contact your insurer first. Call the member services number on your insurance card. Explain that you believe you were billed in violation of the No Surprises Act and ask them to review the claim. Get the name of the representative and a case or reference number.
Step 3: Contact the provider's billing department. Tell them you are covered under the No Surprises Act for this service and that your cost sharing should not exceed your in-network amounts. Ask them to rebill using your in-network cost sharing.
Step 4: File a complaint with CMS. If the insurer and provider do not resolve it, file at cms.gov/nosurprises or call 1-800-985-3059. CMS can investigate and take enforcement action against plans and providers who violate the law.
Step 5: Contact your state insurance commissioner. For fully insured plans, your state insurance department may also have jurisdiction. They can investigate violations under state law that mirror the federal protections.
Step 6: Consult a patient advocate. Nonprofit patient advocacy organizations and hospital billing advocates can assist with complex disputes at no cost.
What to Do Before Your Next Medical Appointment
Knowing your rights is most useful before a bill arrives, not after. These steps can prevent a surprise bill from happening.
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Verify network status for every provider, not just the facility. Search your insurer's online directory for the hospital and for any specialist you expect to see. Call the provider's office directly to confirm their in-network status with your specific plan.
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Request a Good Faith Estimate for any scheduled service. Under the No Surprises Act, providers must give you one when you ask. This establishes the baseline against which your final bill can be disputed.
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Ask about ancillary providers. Before any procedure, ask whether the anesthesiologist, surgical assistant, or any other ancillary provider is in network. If not, they should be covered under the law, but document that you asked.
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Read consent forms before signing. Never sign a notice-and-consent form waiving balance billing protections without understanding exactly which services and providers it covers.
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Check your EOB within 30 days of receiving care. Your insurer's EOB will show what was billed, what they paid, and what they say you owe. Compare this to the bill from your provider.
Frequently Asked Questions
Does the No Surprises Act apply to Medicare or Medicaid patients?
No. The No Surprises Act applies to private insurance plans, including employer-sponsored and ACA marketplace coverage. Medicare and Medicaid have separate billing protections under their own program rules. Medicare patients are protected from balance billing for Medicare-covered services under Medicare assignment rules. Medicaid generally prohibits providers who accept Medicaid from balance billing Medicaid patients.
Can a hospital charge me more than my in-network deductible after an emergency?
Not for covered services under the No Surprises Act. Your cost sharing for out-of-network emergency care at an out-of-network facility must be limited to your plan's in-network deductible, copay, and coinsurance amounts. You cannot be billed the difference between the provider's charge and what your insurer paid.
Is the No Surprises Act still in effect in 2026 despite the court cases?
Yes. The patient protections, including cost-sharing caps and balance billing prohibitions, remain fully in effect in 2026. The ongoing litigation involves how insurers and providers resolve payment disputes between themselves through the IDR process, not whether patients can be balance billed. Your protections have not been paused or reduced.
What is the QPA and why does it matter to me?
The Qualifying Payment Amount (QPA) is the median in-network rate your insurer uses as a benchmark for out-of-network claims. It determines your cost sharing. The methodology for calculating it has been in legal dispute since 2023, and agencies have been using enforcement discretion on how plans calculate it. As of 2026, enforcement discretion is expected to end around August 2026. This primarily affects insurer-provider payment disputes, not your right to be free from balance billing.
What if I got a ground ambulance bill?
Ground ambulance transport is not covered under the No Surprises Act. Your options depend on your state. If you are in one of the 22 states with ground ambulance balance billing laws and you have a fully insured plan, state law may protect you. If you have a self-insured employer plan, state laws generally do not apply. You can also negotiate directly with the ambulance company, ask your insurer to negotiate on your behalf, or ask the ambulance company about financial assistance programs. The CoveredUSA Bill Analyzer can help identify whether there are charity care options or billing errors regardless of insurance status.
Can I be asked to waive my surprise billing rights before emergency care?
No. Consent waivers are never allowed for emergency services, ancillary services during a procedure, or services where no in-network option exists at the facility. If a provider presents you with a waiver before emergency care, do not sign it and report it to CMS.
How do I know if my plan is covered by the No Surprises Act?
Most private insurance plans are covered, including individual and family plans, employer-sponsored plans, and ACA marketplace plans. Short-term plans and grandfathered plans are not covered. Check your plan documents or call your insurer's member services line and ask specifically whether your plan is subject to the No Surprises Act protections.
Where can I file a complaint about a surprise bill?
File a complaint with CMS online at cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059 (8 a.m. to 8 p.m. ET weekdays, 10 a.m. to 6 p.m. ET weekends). Your state insurance commissioner is also an option for fully insured plans. For employer self-insured plans, contact the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) at dol.gov/agencies/ebsa.
