Your state might protect you more than the federal law does -- or it might leave you fully exposed. As of 2026, the answer depends heavily on where you live, what kind of insurance you have, and whether you got to an out-of-network provider by ambulance.
Quick Answer: The federal No Surprises Act (effective January 1, 2022) protects most privately insured patients from balance billing for emergency services and many non-emergency services at in-network facilities. But it has real gaps -- most notably ground ambulances. About 22 states have added their own protections that either fill those gaps or go further than the federal floor. Several states, including California, New York, Illinois, Colorado, and Texas, have some of the strongest combined protections in the country as of 2026.
What the Federal No Surprises Act Actually Does
The No Surprises Act established a nationwide floor of protections for people with private insurance (not Medicare, Medicaid, or TRICARE -- those programs have separate rules). Under the federal law:
- Emergency services at any hospital or emergency department must be billed at in-network cost-sharing rates, regardless of whether the facility or provider is in your network.
- Non-emergency services at in-network facilities -- including anesthesiology, radiology, pathology, lab work, and assistant surgeon fees -- cannot result in a surprise balance bill if an in-network provider was not available.
- Air ambulance services from out-of-network providers are covered under the law's protections.
- Uninsured patients are entitled to a good faith cost estimate before scheduled services.
The law requires providers to bill you only your normal in-network cost-sharing (deductible, copay, coinsurance). The insurer and provider work out the difference without pulling you in the middle.
What it does not cover is a long list.
The Federal Gaps: Where You Can Still Get Surprised
Ground ambulances are the biggest hole. You can call 911 in a medical emergency and receive a bill for $2,000 to $20,000+ from an out-of-network ambulance company -- and the No Surprises Act does nothing to stop it. The law explicitly excluded ground ambulances from its provisions.
Other gaps include:
- Certain facility types. The law applies to hospitals, emergency departments, and ambulatory surgical centers. Stand-alone clinics and some urgent care centers are not fully covered.
- Self-funded employer plans in some situations. If your employer sponsors a self-funded plan, federal law applies -- but enforcement can be more complex than for fully insured plans regulated by states.
- Waived protections. In non-emergency situations at in-network facilities, a provider can ask you to sign a written consent form waiving your surprise billing protections. This is allowed under the federal law, though some states prohibit it.
- Ongoing implementation issues. As of 2026, the independent dispute resolution (IDR) process has been tied up in legal challenges. Several regulatory provisions of the law remain unfinished or not yet fully implemented.
When a gap exists at the federal level, state law is what determines whether you are protected.
How State Laws Interact With Federal Protections
The No Surprises Act sets a minimum floor. Where state law is more protective, state law applies to fully insured plans. Where state law is weaker or nonexistent, federal law steps in.
The catch: this only covers state-regulated fully insured plans. Self-funded employer plans are governed by ERISA, a federal law, and are largely exempt from state insurance rules. If you get health insurance through a large employer, you may be in a self-funded plan without knowing it -- and your only protection is the federal law, no matter how strong your state's law is.
Before the No Surprises Act passed in 2021, 33 states had enacted some form of balance billing protection. Many of those laws still matter, particularly for ground ambulances and state-specific coverage categories.
State-by-State Breakdown (As of 2026)
States With Comprehensive Protections (Strong Laws + Federal Floor)
These states have their own laws that extend protections beyond what the federal law requires. They typically cover ground ambulances, apply to a broader range of provider types, or include additional dispute resolution mechanisms.
| State | Emergency Care | Non-Emergency | Ground Ambulance | Notes |
|---|
| California | Full protection | Full protection | State law covers | Charity care mandate up to 400% FPL; 150-day collection limit |
| New York | Full protection | Full protection | Partial state law | 240-day collection limit; strong balance billing ban |
| Illinois | Full protection | Full protection | Limited state law | Charity care mandate up to 600% FPL; 240-day collection limit |
| Colorado | Full protection | Full protection | State law covers | One of the earliest state-level surprise billing laws |
| Connecticut | Full protection | Full protection | Partial state law | Comprehensive dispute resolution process |
| Maryland | Full protection | Full protection | Partial state law | Physician bill protections predate federal law |
| Florida | Full protection | Full protection | Partial state law | Covers most outpatient surgical and emergency settings |
| Texas | Full protection | Full protection | State law covers | 365-day collection limit; independent dispute resolution |
| New Mexico | Full protection | Full protection | State law covers | Broad provider coverage categories |
| Washington | Full protection | Full protection | State law covers | Extended to behavioral health providers; post-stabilization coverage |
States With Partial Protections (Federal Floor Only or Limited State Law)
These states rely primarily on the No Surprises Act and have limited or no state-level additions. Ground ambulance billing remains unregulated in most of them.
| State | Emergency Care | Ground Ambulance | Status |
|---|
| Ohio | Federal floor | Not protected | No state balance billing law |
| Georgia | Partial (anesthesia, radiology, ER docs) | Not protected | Georgia Surprise Billing Consumer Protection Act covers specific specialties only |
| Minnesota | Federal floor + some state law | Limited | State law covers certain non-emergency out-of-network situations |
| Pennsylvania | Federal floor | Ground ambulance protected | PA Act 135 covers ground ambulance balance billing |
| Wisconsin | Federal floor | Not protected | No state balance billing protections under current law |
| Arizona | Federal floor | Partial | Some state rules on emergency billing |
| Iowa | Federal floor | Not protected | Limited state-level protections |
Recent State Action on Ground Ambulances (2025-2026)
As of 2026, roughly 22 states have some form of ground ambulance billing protection. Recent additions:
- New Hampshire: Balance billing for ground ambulances prohibited starting January 1, 2026.
- Utah: Insurers must pay a state fee-schedule rate, protecting patients from balance bills.
- North Dakota: Limits ground ambulance charges to 250% of the Medicare rate.
- Texas: Added ground ambulance protections to its existing balance billing law.
- West Virginia: SB 645 enacted April 1, 2026.
States considering ground ambulance legislation in 2026 include Alabama, Georgia, Illinois, Kentucky, Massachusetts, North Carolina, South Dakota, Tennessee, and Virginia.
How to Know Which Rules Apply to Your Specific Bill
Three things determine which rules cover your bill:
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Your insurance type. Medicare, Medicaid, TRICARE, and VA each have separate rules. The No Surprises Act covers private insurance -- employer plans, ACA marketplace plans, or plans bought directly from an insurer.
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Self-funded vs. fully insured employer plan. Self-funded plans are exempt from state insurance law. Call your HR department and ask. This one fact changes which protections you have.
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Your state of residence. If you're in a fully insured plan, your state's laws stack on top of the federal floor.
What to Do If You Receive a Surprise Bill
Step 1: Request an itemized bill. Ask for every line item, procedure code (CPT code), and diagnosis code (ICD-10 code). Surprise bills often contain errors on top of the out-of-network issue.
Step 2: Check whether the federal or state law applies. Call your insurer and ask if this service was subject to the No Surprises Act. If it was, the provider cannot legally collect more than your in-network cost-sharing amount from you.
Step 3: File a complaint. If a provider is balance billing you in violation of the No Surprises Act, you can file a complaint at cms.gov/nosurprises. If a state law applies, file with your state's insurance commissioner.
Step 4: Check your bill for errors. Research suggests 30% to 80% of medical bills contain at least one mistake -- duplicate charges, upcoded procedures, or services billed for work not performed. The CoveredUSA Bill Analyzer compares each line item against the Medicare rate to flag overcharges, errors, and potential charity care eligibility at no cost.
Step 5: Negotiate. Hospitals and providers will often settle for less, especially on large bills. If you cannot pay the full amount, ask about financial hardship programs, charity care, or a payment plan. Most nonprofit hospitals are legally required to offer charity care if your income is below a certain threshold.
Step 6: Request Independent Dispute Resolution (IDR). If a provider bills you improperly and your insurer is not resolving it, you can request an IDR proceeding where a neutral arbitrator determines a fair payment amount.
What If You Have No Insurance?
The No Surprises Act's good faith estimate provision applies to uninsured patients. If you schedule a service at least three business days in advance, the provider must give you a written estimate. If the final bill comes in $400 or more above that estimate, you can dispute it through the Patient-Provider Dispute Resolution process.
For large bills, the most important step is asking about the hospital's charity care program. Most nonprofit hospitals are required to provide free or reduced-cost care to patients below a certain income level and do not advertise it prominently.
The Medical Bill Analyzer: A Fast Way to Spot Problems
Hospital bills are hard to read by design. Procedure codes, revenue codes, and facility fees are not consumer-friendly. A $450 charge might be correct or it might be a duplicate -- and you usually cannot tell without comparing against a benchmark.
The CoveredUSA Bill Analyzer does that comparison automatically. Upload your bill and within about 30 seconds you can see which charges exceed typical rates, spot potential duplicates, and check whether the hospital's charity care threshold applies to your income.
Upload your hospital bill to the free CoveredUSA Bill Analyzer to find errors, overcharges, and charity care options in 30 seconds.
Frequently Asked Questions
Does the No Surprises Act apply to Medicare and Medicaid patients?
No. The No Surprises Act applies to private health insurance plans. Medicare, Medicaid, TRICARE, VA health care, and Indian Health Service each have their own separate protections. Medicare, for example, already bans balance billing by providers who accept Medicare assignment. If you have Medicare and receive a surprise bill, the issue is usually provider fraud or billing error, not a gap in the law.
Can a provider ask me to waive my surprise billing protections?
Under the federal No Surprises Act, a provider can ask you to sign a consent form waiving your protections in some non-emergency situations. However, they cannot ask you to waive protections for emergency services, ancillary services at in-network facilities, or services in situations where you had no practical choice of provider. Some states prohibit waivers entirely. If a provider asks you to sign something waiving your billing rights before a scheduled procedure, review it carefully or push back.
What is balance billing and how is it different from a surprise bill?
Balance billing happens when an out-of-network provider charges you the difference between what they billed and what your insurer paid. A surprise bill is a specific kind of balance bill that happens without your knowledge or choice -- you went to an in-network hospital but an out-of-network doctor treated you, or you had an emergency with no ability to select providers. The No Surprises Act bans balance billing in those specific surprise-bill scenarios.
My employer provides my health insurance. Does state law protect me?
Possibly not. If your employer's plan is self-funded (meaning the employer pays claims directly and just uses an insurer for administration), your plan is governed by ERISA federal law, not state insurance regulation. Self-funded plans are largely exempt from state-level balance billing laws. The federal No Surprises Act still applies to self-funded employer plans, but if you were hoping for stronger state-level protections, they may not reach you. Ask your HR department whether your plan is self-funded.
I got a huge bill from a ground ambulance. What are my options?
This is one of the worst gaps in the current law. The No Surprises Act does not cover ground ambulances. Your options depend on your state. If you're in a state with ground ambulance billing protections (Pennsylvania, California, Washington, New Hampshire, Utah, Oregon, North Dakota, Texas, and others), you may have a legal claim. If not, your options are negotiation, financial hardship applications, and filing complaints with your state insurance commissioner. Check whether the ambulance service is government-operated -- many are, and some have different billing practices than private ambulance companies.
How do I dispute a surprise bill if the provider refuses to correct it?
File a complaint at cms.gov/nosurprises or call 1-800-985-3059 (the federal No Surprises Help Desk). If your state has its own surprise billing law, also file with your state's insurance commissioner. If you believe the provider is violating the law, you can also submit to the independent dispute resolution process. Keep records of everything: the bill, your Explanation of Benefits from your insurer, and any communications with the provider.
What is the independent dispute resolution (IDR) process?
When a provider and insurer cannot agree on payment for a service covered under the No Surprises Act, either party can request IDR. A neutral certified arbitrator reviews the dispute and sets a payment amount. The losing party pays the arbitrator's fee. Patients are not directly involved -- it happens between the provider and insurer. The IDR process has faced ongoing legal challenges since 2022, with courts ruling on how arbitrators should weigh different factors in their decisions.
How do I find out if my hospital has a charity care program?
Ask the billing department directly for their "financial assistance policy." Nonprofit hospitals are required by IRS rules to have one. Most will reduce or eliminate bills for patients below 200% to 400% of the federal poverty level -- some states like Illinois mandate thresholds up to 600% FPL. You can also upload your bill to the CoveredUSA Bill Analyzer to check charity care eligibility as part of the review.
