No Surprises Act

Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or receive care, you may owe out-of-pocket costs like a copayment, coinsurance, or deductible. If you get care from a provider or facility that isn’t in your health plan’s network, you may be billed for the difference between what your plan pays and what the provider charges. This is called balance billing, and it’s often higher than in-network costs.

Surprise billing happens when you’re unexpectedly treated by an out-of-network provider—such as during an emergency or at an in-network hospital—without knowing the provider isn’t in your plan’s network.

Note: These protections do not apply to ground ambulance services in most cases.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

  • You are only responsible for your in-network cost-sharing amounts (like copayments, coinsurance, or deductibles).
  • Your health plan pays out-of-network providers and facilities directly.
  • Your health plan generally must:
  • Cover emergency services without prior authorization.
  • Cover emergency care provided by out-of-network providers.
  • Base your share of the cost on what it would pay an in-network provider and show that on your explanation of benefits.
  • Count what you pay toward your deductible and out-of-pocket maximum.

If You Disagree with a Bill

If you believe you’ve been wrongly billed, you can:

  • Contact the U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227)
  • Reach out to Broadlawns Financial Counseling at (515) 282-2246
  • Learn more about your rights at cms.gov/nosurprises

Updated 2025 Notice: The administrative fee for filing an independent dispute (IDR) under the No Surprises Act is now $150 per party, effective January 1, 2025. Enforcement of certain payment standards is under review and will continue under extended federal oversight through August 1, 2025.