The No Surprises Act: A Plain-English Guide

What Is The No Surprises Act?

This post is a simple guide to the No Surprises Act (NSA) that shows what is covered, what is not, how to use Good Faith Estimates (GFEs) and Patient-Provider Dispute Resolution (PPDR), what to do with air and ground ambulance bills, how Independent Dispute Resolution (IDR) works, and easy scripts you can use today.

The No Surprises Act

The No Surprises Act (NSA) limits surprise medical bills for most people with private insurance. In emergencies, and for certain non-emergency services at in-network hospitals and Ambulatory Surgery Centers (ASCs), you pay only in-network cost-sharing. The rest is a dispute between the plan and the provider, not you.

Government oversight comes from the U.S. Department of Health and Human Services (HHS), the U.S. Department of Labor (DOL), the U.S. Department of the Treasury (Treasury), and the Office of Personnel Management (OPM). Consumers get help through the Centers for Medicare & Medicaid Services (CMS).

What the NSA means for you

You are protected in these common situations:

• Emergency care, including the Emergency Department (ED) visit and stabilizing care afterward.
• Non-emergency care at an in-network hospital or ASC, even if some clinicians are out of network.
• Air ambulance rides.

You are not protected in these situations:

• Routine visits at out-of-network offices or clinics that are not hospitals or ASCs.
• Ground ambulance rides at the federal level. Check your state rules.

Programs where the NSA does not apply

• Medicare
• Medicare Advantage (MA)
• Medicaid
• Indian Health Service (IHS)
• TRICARE

These programs have their own billing protections. The NSA mainly protects people with job-based or individual market coverage.

Your cost-sharing must be treated as in-network

• Your copay and coinsurance must count toward your in-network deductible and your in-network Out-of-Pocket (OOP) maximum.

How the price is set behind the scenes

Plans calculate a benchmark called the Qualifying Payment Amount (QPA). It is usually the plan’s median in-network rate from 2019, updated by the Consumer Price Index for All Urban Consumers (CPI-U). The QPA helps set your cost-sharing and informs arbitration in Independent Dispute Resolution (IDR), but it does not automatically control the outcome.

If you are uninsured or paying yourself

Ask for a Good Faith Estimate (GFE) before being treated. Keep it.

If your final bill is at least 400 dollars more than your Good Faith Estimate (GFE), you can start Patient-Provider Dispute Resolution (PPDR) by paying a small administrative fee. An independent reviewer can lower the bill.

20 import parts of the NSA that most people never hear about

1. “Visit” covers the whole episode. Pre-operative, post-operative, imaging, labs, and related services are tied to the same encounter count.
2. Post-stabilization is part of the emergency. Protections can continue after the ED once you are stabilized, if conditions are met.
3. Many waivers are not allowed. You cannot waive protections for most ancillary services like anesthesia, pathology, radiology, and neonatology.
4. Only certain facilities trigger non-emergency protections. These are hospitals, hospital outpatient departments, critical access hospitals, and ASCs.
5. The QPA matters but does not rule. Arbitrators in IDR look at all required factors, not only the QPA.
6. Air ambulance is covered. The NSA does not cover ground ambulances. Know your state law.
7. Required notice to patients. Providers must post an official NSA rights notice online and on-site.
8. Notice-and-consent has strict rules. Correct form, clear itemized estimates, real in-network options, and proper timing are essential.
9. Provider directories must be accurate. Plans must be verified every 90 days, and errors must be fixed within two business days. Bad listings can bind the plan.
10. Continuity of care can keep you in-network. If your provider drops out mid-treatment, transitional protections may apply.
11. Facility-based clinicians you never meet are covered. Surprise bills from those services at in-network sites are usually unlawful.
12. Your plan must act on time. Plans must quickly provide an initial payment or a denial, which starts the negotiation clock.
13. State law can set the math. A Specified State Law (SSL) can control payment for fully insured plans. Employee Retirement Income Security Act of 1974 (ERISA) self-funded plans usually follow federal rules unless they opt in.
14. IDR is “baseball style.” Each side submits one final number. A certified entity picks one. Fees are now standardized.
15. Advanced Explanation of Benefits (AEOB) is still coming. You may not get one yet, and that can be normal.
16. Mental-health emergencies qualify. Network status should not be used to upcharge crisis care.
17. Directory screenshots help. Save proof of what you relied on when choosing a provider.
18. Bad timing equals bad waiver. Forms handed to you on a gurney or right before anesthesia are suspect.
19. Collections are not the final word. Dispute in writing, cite the NSA, and contact CMS if needed.
20. Documentation wins. Keep forms, bills, messages, call notes, and names. Organization is leverage.

Do this if a surprise bill shows up

1. Compare the bill to your Explanation of Benefits (EOB).
2. If the NSA should cover the service, send a short letter to the provider and the plan:

“The No Surprises Act protects this service. Reprocess the claim with in-network cost-sharing and send a corrected bill and EOB.”

1. Attach proof: the facility was in-network, copies of forms you signed, and any directory screenshots.
2. If no fix, file a complaint with CMS and keep copies of everything.

Keep a simple folder on your phone

• Facility name and whether it was in-network
• Photos of any forms you signed, with dates and times
• Your GFE and the final bill
• Directory screenshots or pre-visit confirmations
• The EOB and any plan messages
• Call notes with names, dates, and promises

Fast answers

Does the NSA apply to Medicare, Medicare Advantage, Medicaid, Indian Health Service, or TRICARE?

No. The NSA does not apply to Medicare, Medicare Advantage (MA), Medicaid, the Indian Health Service (IHS), or TRICARE. These programs have their own billing rules and protections.

What about ground ambulance bills?
The NSA does not cover ground ambulance at the federal level. Check state protections, request itemization, and negotiate early.

Acronyms used

• NSA: No Surprises Act
• CMS: Centers for Medicare & Medicaid Services
• GFE: Good Faith Estimate
• PPDR: Patient-Provider Dispute Resolution
• IDR: Independent Dispute Resolution
• QPA: Qualifying Payment Amount
• CPI-U: Consumer Price Index for All Urban Consumers
• EOB: Explanation of Benefits
• OOP: Out-of-Pocket
• ED: Emergency Department
• ASC: Ambulatory Surgery Center
• SSL: Specified State Law
• ERISA: Employee Retirement Income Security Act of 1974
• HHS: U.S. Department of Health and Human Services
• DOL: U.S. Department of Labor
• OPM: Office of Personnel Management
• MA: Medicare Advantage
• IHS: Indian Health Service
• TRICARE: The Department of Defense health care program

Ethics and compliance notes for Ohio and Kentucky

Attorney Advertising. This page provides general information. It is not legal advice and does not create an attorney-client relationship. Every situation is fact-specific. Do not rely on this content without advice from a lawyer who knows your facts. Past results do not predict future results.

Responsible lawyer and office address: Frank M. Mungo Attorney at Law, 7310 Turfway Road, Suite 550, Florence, Kentucky 41042. Mr. Mungo is licensed in Kentucky and Ohio.