Last reviewed: 2 October 2026

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Surprise out-of-network medical bills: what the No Surprises Act says it covers

The short answer: CMS says the No Surprises Act, in effect since January 1, 2022, protects people with most types of health insurance from unexpected out-of-network bills for emergency room visits, certain non-emergency care at in-network facilities, and air ambulance services.^[2] The statute text we read says emergency services must be covered without prior authorization, with in-network-level cost-sharing.^[3]

What CMS says the law covers

CMS describes the No Surprises Act as a federal law that went into effect on January 1, 2022, applies to most types of health insurance, and protects people from unexpected out-of-network medical bills from three situations: emergency room visits; non-emergency care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center; and air ambulance services.^[2]

What the statute says about emergency services

Section 300gg-111(a)(1) applies to a group health plan or insurer that covers emergency-department benefits. The text, summarized, says the plan or insurer must cover emergency services:^[3]

• without any prior authorization requirement, and whether or not the provider or facility is in the plan's network;
• with no coverage limitation more restrictive than applies to in-network emergency services;
• with cost-sharing no greater than if the services were in-network, calculated as if the total charge were the "recognized amount" the statute defines;
• with an initial payment or notice of denial sent to the provider or facility within 30 calendar days after the bill is transmitted, and a total plan payment made directly to the provider or facility equal to the out-of-network rate minus the cost-sharing amount; and
• with the patient's cost-sharing payments counted toward in-network deductibles and out-of-pocket maximums as if made to an in-network provider.^[3]

The statute defines an "emergency medical condition" using a "prudent layperson" test: acute symptoms, including severe pain, such that a person with average knowledge of health and medicine could reasonably expect that without immediate medical attention the result would be one of the serious outcomes listed in a cross-referenced Social Security Act provision.^[3] "Emergency services" include a medical screening examination and further examination and treatment required to stabilize the patient.^[3] It also says emergency services include certain items and services furnished by an out-of-network provider after the patient is stabilized, as part of an outpatient observation or an inpatient or outpatient stay, unless every one of listed conditions is met; those conditions include that the provider satisfies the notice and consent criteria of section 300gg-132(d).^[3] The statute also defines "independent freestanding emergency department" as a health care facility that is geographically separate from and separately licensed from a hospital and provides emergency services.^[3]

The statute also calls for an audit process for how plans apply the "qualifying payment amount," and sets out how that amount is defined.^[3] We do not reproduce those formulas here.

If you do not use insurance

CMS says that usually, if you do not have or do not use health insurance, providers must give you a good faith estimate of what care will cost; on its good faith estimate page it says you get one when you schedule care at least 3 business days in advance or if you ask for one, and that you may be able to dispute a bill that is at least $400 more than the estimate.^[2]

Disputes and complaints

CMS describes an independent dispute resolution (IDR) process for out-of-network payment disputes, with an "IDR Gateway" for submitting and processing disputes, and describes the consumer protections as removing consumers from payment disagreements between their providers, health care facilities and health plans.^[1] CMS says you can submit a complaint if you believe your facility, provider or insurer is not following these rules, and lists a phone line, 1-800-985-3059, available seven days a week.^[2]

How to verify this yourself

Read the CMS consumer page and the statute text in the references, and look at the explanation of benefits and bill you received. If a bill looks inconsistent with what those sources describe, CMS's listed phone line is the route it names for questions and complaints.^[2] CMS pages are updated; check their dates.

What this page does not cover

We did not read the statute text for the non-emergency-services provisions or for the dispute-resolution process, so we describe those only as CMS does.^[1][2] We do not cover state surprise-billing laws, which the sources we read do not address, or plans and services CMS may treat differently. This is general information, not legal or insurance advice and not a determination about any bill. For your own bill, ask CMS, your insurer or your state insurance regulator. See also our guide to internal appeals and external review.

Related checks

Our standard says how we check an agent's license and disciplinary history, and Check an agent reports our findings at category level. Neither is a review of any insurer, plan or health-care provider, and neither replaces asking the regulator or program named above.

When we will update this page

We re-read the sources when they change. If something here is out of date, tell us; corrections are dated on the page.

References

1. [1] Centers for Medicare & Medicaid Services, "No Surprise Billing", read 2 October 2026 — www.cms.gov/nosurprises
2. [2] Centers for Medicare & Medicaid Services, "Medical bill rights" (consumer page), read 2 October 2026 — www.cms.gov/nosurprises/consumers
3. [3] Legal Information Institute (Cornell), 42 U.S.C. § 300gg-111, Preventing certain cases of balance billing (unofficial text), read 2 October 2026 — www.law.cornell.edu/uscode/text/42/300gg-111