The No Surprises Act, in plain English

The No Surprises Act is a federal law that took effect for most health plans in 2022. It protects insured patients from “surprise” bills from out-of-network providers in situations where they could not reasonably choose an in-network one, and it moves the question of how much the out-of-network provider is paid to the provider and the health plan.

Where the law comes from

Congress passed it as part of the Consolidated Appropriations Act, 2021. The core rules for health plans are in the Public Health Service Act at 42 U.S.C. 300gg-111 (statute), the rules for providers and facilities at 300gg-131 and 300gg-132 (300gg-131), and the federal agencies’ implementing regulations at 45 CFR Part 149 (regulations). Parallel provisions apply to employer plans under ERISA and the tax code.

Who is protected

People enrolled in group health plans (including self-funded employer plans) and individual health insurance. Medicare, Medicaid, CHIP, TRICARE and other public programs have their own rules and are not part of this process (CMS applicability chart). People without insurance have separate protections, such as good faith estimates (CMS consumer page).

The three situations it covers

• Emergency services from an out-of-network provider or facility, including certain care after the patient is stabilized (45 CFR 149.110).
• Non-emergency services by out-of-network clinicians at in-network facilities, such as hospitals, hospital outpatient departments, critical access hospitals and ambulatory surgical centers (45 CFR 149.120).
• Air ambulance services from out-of-network providers (42 U.S.C. 300gg-112).

What changes for each party

Patients pay no more than their in-network cost sharing, figured on a “recognized amount” (often the QPA), and cannot be balance billed for the difference (45 CFR 149.410).

Health plans must send an initial payment or a notice of denial within 30 calendar days after receiving the bill (300gg-111).

Providers and facilities are paid an “out-of-network rate” set, in order, by a specified state law, an All-Payer Model Agreement, an amount the provider and plan agree on, or a decision in the Federal IDR process (45 CFR 149.30). See how Federal IDR works and state laws.

Notice and consent

For some non-emergency care at in-network facilities, an out-of-network provider can ask the patient to give up these protections in writing, with advance notice and a cost estimate. This exception cannot be used for certain ancillary services, such as emergency medicine, anesthesiology, pathology, radiology and neonatology (42 U.S.C. 300gg-132) (45 CFR 149.420). See coverage.

Common questions

Does the No Surprises Act set a payment rate?

No single federal rate. The out-of-network rate comes from a specified state law, an All-Payer Model Agreement, an agreement between the provider and the plan, or a Federal IDR decision (45 CFR 149.30).

When did it take effect?

For most provisions, for plan years (and, for individual coverage, policy years) beginning on or after January 1, 2022.

More in Learn: How Federal IDR works, step by step · What is the qualifying payment amount (QPA)? · Which services and specialties are covered? · State surprise billing laws and Federal IDR (including Texas) · Federal IDR glossary

General information, not legal advice. Rules change; check the cited sources. Last reviewed 2026-10-19.