The No Surprises Act: What It Actually Covers

Updated August 3, 2026. Quick answer: if you went to an emergency room, or you had a procedure at an in-network hospital and an out-of-network anaesthetist or radiologist was involved, you cannot lawfully be balance-billed. You owe your normal in-network cost sharing and nothing more. And for those specialties, you cannot be asked to sign the protection away.

Emergency care

the emergency department of a hospital or independent freestanding emergency department shall not bill, and shall not hold liable, the participant, beneficiary, or enrollee for a payment amount for such emergency services so furnished that is more than the cost-sharing requirement

— 42 U.S.C. § 300gg-131(a)(1); related plan-payment provision 42 U.S.C. § 300gg-111(a)(1)(C)

It applies whether or not the facility is in your network, and it covers the emergency department of a hospital and independent freestanding emergency departments. You still owe your in-network deductible, copay or coinsurance — and that amount counts toward your in-network deductible and out-of-pocket maximum.

The out-of-network provider at the in-network hospital

This is the situation that generated the law: you check the hospital is in network, and then receive a separate bill from a doctor you never chose and never met.

items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether or not provided by a physician or non-physician practitioner, and items and services provided by assistant surgeons, hospitalists, and intensivists

— 42 U.S.C. § 300gg-132(a) (ban) and § 300gg-132(b)(2)(A)-(B) (ancillary-service definition excluded from the notice-and-consent exception in subsection (d))

Those specialties cannot obtain your consent to waive the protection. Some other out-of-network specialists at an in-network facility may ask you to sign a notice and consent form that allows balance billing — but emergency medicine, anaesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists and intensivists may not.

So if you are handed a consent form on admission naming one of those specialties, signing it does not make the bill lawful. That single fact resolves a large share of surprise bills.

If you are uninsured or paying cash

Substantially in excess means, with respect to the total billed charges by a provider or facility, an amount that is at least $400 more than the total amount of expected charges listed on the good faith estimate for the provider or facility.

— 45 CFR § 149.620 (definition of ‘substantially in excess’); GFE and PPDR statutory basis at 42 U.S.C. §§ 300gg-136 and 300gg-137

You are entitled to a good faith estimate of expected charges before scheduled care. If the final bill comes in at least $400 above that estimate — the threshold set in the 2022 regulation and unchanged in the text we read — you can start the federal patient-provider dispute resolution process. Ask for the estimate in writing and keep it — without it there is nothing to compare the bill against.

What we could not confirm. CMS.gov returned 403 to every request this session, including its own homepage, so CMS’s consumer explanations could not be read. The statutory text above comes from the U.S. Code via Cornell LII and the 2022 $400 threshold from the eCFR API (the standard eCFR pages served a verification wall). The notice-and-consent mechanics for non-ancillary specialties were read in summary rather than quoted, so treat the exclusion list as the firm part.

What to do with a surprise bill

1. Work out which category it is — emergency, or out-of-network provider at an in-network facility. Both are protected.
2. Check what your plan says it paid and what it says you owe. The bill and the explanation of benefits often disagree.
3. Say the law’s name when you dispute it. A bill that should not exist is frequently withdrawn once someone in billing understands you know that.
4. Do not pay it to make it go away. Getting money back is much harder than not sending it.

Related: auditing the bill · charity care.

General information drawn from the Internal Revenue Code, federal regulations, CMS and Medicare materials, not legal, financial or medical advice. Hospital financial-assistance policies are set by each hospital within federal rules, so eligibility bands differ between hospitals in the same city. Billing rules and figures change and every figure here is year-labelled with its source named. We sell nothing on these pages: no debt settlement, no negotiation service, no advocacy.