No Surprises Act
Learn about new rights and protections to end surprise bills, better understand costs before getting health care, and minimize payment disagreements.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 can 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.
State Specific Rules
Arizona law protects patients from surprise medical bills for:
- Emergency services and health care services directly related to the emergency services provided during an inpatient admission by an out-of-network provider at an in-network facility; and
- Non-emergency health care services provided by an out-of-network provider at an in-network facility, if the out-of-network provider did not provide the patient or his or her authorized representative a written disclosure prior to the health care service or the patient or his or her representative chose not to sign the referenced disclosure.
The law applies to patients with coverage through a disability insurer, group disability insurer, blanket disability insurer, hospital service corporation or medical service corporation that provides health insurance in AZ. This law does not apply to any health plans that do not include coverage for out-of-network health care services.
Additionally, AZ law prohibits hospitals or providers from charging patients with coverage through a health maintenance organization (HMO) more than the amount a hospital or provider agreed to accept from the HMO.
Arizona Department of Insurance and Financial Institutions
Address: 100 N. 15th Ave. Ste. 261, Phoenix, AZ 85007-2630
Phone: (602) 364-3100
California law protects enrollees in state regulated plans from surprise medical bills when the following occur:
(a) an enrollee receives emergency services from a doctor or hospital that is not contracted with the patient's health plan or medical group; or
(b) an enrollee receives scheduled care at an in-network facility such as a hospital, lab, or imaging center, but services are delivered by an out-of-network provider.
In covered circumstances, providers cannot bill consumers more than their in-network cost sharing. Further, for uninsured individuals, hospitals must provide the patient with a written estimate of the amount the hospital will require for the expected services at the time of service.
California Department of Insurance
website: https://www.insurance.ca.gov/01-consumers/110-health/60-resources/NoSupriseBills.cfm or http://www.insurance.ca.gov/01-consumers/101-help/index.cfm
Colorado protects patients covered by state-regulated insurance plans from surprise medical bills for health care services provided at an in-network facility by an out-of-network provider. Colorado also protects patients from surprise medical bills for emergency services, even if the emergency services are out-of-network or provided by an out-of-network provider. Colorado law requires that patients pay only their in-network cost sharing amounts.
Colorado law does not protect patients from surprise medical bills when the patient intentionally uses an out-of-network provider.
Colorado Department of Regulatory Agencies, Division of Insurance, Consumer Services Division
Office of the Attorney General
Address: 1300 Broadway, 10th Floor, Denver, CO 80203
Telephone: (720) 508-6000
Connecticut passed its own law in 2015 to address balance billing. The law applies to health plans regulated by Connecticut's Department of Insurance and has similar protections to those provided under the federal No Surprises Act. For more information, please see Conn. Gen. Stat. §§ 38a-477aa and 20-7f.
The Connecticut Department of Insurance
Consumer Helpline: (800) 203-3447 or (860) 297-3900
The State of Connecticut Office of the Healthcare Advocate
Delaware protects patients from balance billing for: (i) any covered medically necessary services performed by an out-of-network provider, when the medically necessary service is not available through in-network providers in a reasonable amount of time, provided the patient has a referral; and (ii) emergency services from an out-of-network provider.
Additionally, Delaware also protects patients for: (i) covered non-emergency services provided at an in-patient or ambulatory facility by an out-of-network provider and/or at out-of-network facility; and (ii) covered non-emergency services provided by an out-of-network provider, unless the patient received and consented to a written disclosure. This protection allows patients to be billed for in-network cost-sharing amounts. These protections apply to patients with coverage through any policy or contract for health insurance delivered or issued in Delaware.
Delaware Department of Insurance
Phone: 1-800-282-8611 (In Delaware Only) Or (302) 674-7310
In the state of Florida, there are comprehensive balance billing protections in addition to those provided by the federal No Surprises Act. Florida law states that insurance companies are not allowed to bill you for amounts beyond your plan’s in-network cost-sharing amount. That protection applies to HMO and PPO insurance plans for emergency services by out-of-network providers and facilities, as well as non-emergency services provided by out-of-network providers at in-network facilities. For PPOs, the state payment standard applies to emergency services and non-emergency services provided by out-of-network providers at in-network facilities. For HMOs, the state payment standard only applies to emergency services but the state also has a claim dispute resolution program in place. Under Florida law, these protections do not apply to ground ambulance services for PPO insurance plans, patients enrolled in PPO insurance plans who consent to non-emergency out-of-network services, and patients with self-funded insurance plans. The laws put in place by the state of Florida work together with the requirements of the No Surprises Act to ensure that you are protected from surprise medical bills.
Florida Department of Financial Services, Division of Consumer Services
Georgia law generally contains balance billing protections similar to those under the No Surprises Act (as described in this Notice), for individuals enrolled in fully funded commercial plans, such as preferred provider (“PPO”) plans, and health maintenance organization (“HMO”) plans. If you have one of these plans, Georgia also extends the balance billing protections to covered emergency and non-emergency medical services provided by nonparticipating providers in participating birthing centers, diagnostic and treatment centers, hospices or similar institutions.
If you have a Georgia PPO or HMO plan and think you’ve been wrongly billed by your health care provider, you may file a complaint with the Georgia Consumer Protection Division by calling (404) 651-8600 or visiting https://consumer.georgia.gov/resolve-your-dispute/how-do-i-file-complaint
If you believe you have received an improper bill from your health plan, you may file a complaint with the Office of Commissioner of Insurance and Safety Fire by emailing email@example.com or visiting https://oci.georgia.gov/file-consumer-insurance-complaint.
Illinois protects patients from balance billing for: (i) covered medical services at an in-network hospital or ambulatory surgical center provided by an out-of-network facility-based provider, if (a) the patient has agreed in writing to assign their benefits to the out-of-network provider, (b) an in-network facility-based provider is unavailable and (c) the patient did not willfully choose the out-of-network provider; and (ii) covered emergency services at an out-of-network facility or provided by an out of network provider. This protection does not prohibit the imposition of in-network cost-sharing amounts. This protection applies to all insurers providing accident and health insurance, including health maintenance organizations (“HMOs”).
Illinois law also protects patients from surprise medical bills for patients that have made a good faith effort to utilize in-network providers, but it is determined that the insurer does not have the appropriate in-network providers. In this case, the insurer must ensure that the beneficiary will be provided the covered service at no greater cost than if the service had been provided by an in-network provider.
Illinois Department of Insurance, Office of Consumer Health Insurance
Indiana law protects patients from balance billing for non-emergency services provided by out-of-network providers at in-network facilities. This protection does not apply if a patient has received advanced notice from an out-of-network provider and consents to the pricing of the healthcare services. This protection limits the financial liability of patients to the rate paid to the out-of-network provider by the covered individual’s network plan plus any in-network cost-sharing amounts. This prohibition applies to all patients with coverage through a network plan.
Indiana also protects patients with coverage through an HMO from balance billing for: emergency services received from an out-of-network provider or at an out-of-network facility and any covered services performed by an out-of-network provider when the covered service is not available through in-network providers, provided the patient has a referral. Indiana law requires the patient to pay only in-network expenses.
Indiana Department of Insurance
800-622-4461 or 317-232-2395
Iowa law requires state regulated insurance plans and public employee plans to cover all emergency services, including emergency services provided by out-of-network providers.
Iowa Insurance Division
Maine law protects patients from balance billing for "surprise bills" and for covered emergency services rendered by an out-of-network provider. A surprise bill is a bill for health care services received by an enrollee for covered services rendered by an out-of-network provider when the services were rendered at a network provider, during a service or procedure performed by a network provider, or during a service or procedure previously approved or authorized by the insurance carrier and the enrollee did not knowingly elect to obtain such services from that out-of-network provider. Such patients are only required to pay the applicable coinsurance, copayment, deductible, or other out-of-pocket expense that would be imposed for the health care services if the services were rendered by a network provider.
Maine Bureau of Insurance
207-624-8475 or 800-300-5000https://www.maine.gov/pfr/insurance/contact_us.html
If you are in a Health Maintenance Organization (HMO) governed by Maryland law, you may not be balance billed for services covered by your plan. If you are in a PPO or EPO governed by Maryland law, hospital-based or on-call physicians paid directly by your PPO or EPO (assignment of benefits) may not balance bill you for services covered under your plan and can’t ask you to waive your balance billing protections.
If you believe you’ve been wrongly billed, you may contact the Health Education and Advocacy Unit (HEAU) of Maryland’s Consumer Protection Division:
Health Education and Advocacy Unit
Office of the Attorney General
200 St. Paul Place, 16th Floor
Baltimore, Maryland 21202
Phone: 410-528-1840 or toll-free -877-261-8807
En espanol: 410-576-6571
If you believe your health plan processed your claim incorrectly, you may contact the Maryland Insurance Administration:
Maryland Insurance Administration
Life and Health Complaints Unit
200 St. Paul Place, Suite 2700
Baltimore, Maryland 21202
Phone 410-468-2000 or toll free 1-800-492-6115
Massachusetts protects patients from balance billing when patients receive (i) covered non-emergency services from an out-of-network provider when patients did not receive notice that the provider was out-of-network; (ii) covered medically necessary services from an out-of-network provider when such services are not available in-network,; (iii) covered medically necessary services from an out of network provider at an in-network facility, if patients did not have a reasonable opportunity to choose an in-network provider. These protections apply to patients with coverage through insurers licensed to transact accident or health insurance, a nonprofit hospital service corporation, a nonprofit medical service corporation, a health maintenance organization (“HMO”), and preferred provider organization (“PPO”). These protections only require patients to pay the amount required for in-network services.
Massachusetts also protects patients with coverage through a PPO from balance billing when patients receive emergency services and cannot reasonably reach a preferred provider. Additionally, Massachusetts protects patients with coverage through an HMO from balance billing when patients receive emergency services.
Massachusetts Division of Insurance, Consumer Service Unit
Health and Human Services of the Commonwealth of Massachusetts
Address: 1 Ashburton Place, 11th Floor Boston, Massachusetts 02108
Telephone: (617) 573-1600
Michigan law protects patients from balance billing and requires that the patient pay only their in-network cost sharing amounts for: (i) covered emergency services provided by an out-of-network provider at an in-network facility or out-of-network facility; (ii) covered nonemergency services provided by an out-of-network provider at an in-network facility if the patient does not have the ability or opportunity to choose an in-network provider; and (iii) any healthcare services provided at an in-network facility from an out-of-network provider within 72 hours of a patient receiving services from that facility’s emergency room.
Additionally, Michigan law states if the patient consents to receive non-emergency care from an out-of-network provider, the balance billing prohibition does not apply. These protections apply to any patient covered by a Michigan health benefit plan and a self-funded plan established or maintained by the state or local unit of government for its employees.
Michigan Department of Insurance and Financial Services
In addition to federal law, Minnesota law provides Minnesota residents with similar rights and protections against surprise medical bills for emergency services and unauthorized provider services provided by out-of-network health care providers. Minnesota balance billing statutes protect against:
Emergency services provided at out-of-network hospitals or other emergency facilities. See 62Q.55 EMERGENCY SERVICES.
Out-of-network services provided at in-network facilities. See 62Q.556 UNAUTHORIZED PROVIDER SERVICES.
In-network provider discounts. See 62K.11 BALANCE BILLING PROHIBITED.
Minnesota Department of Commerce
(651) 539-1600 or (800) 657-3602
In addition to the protections under federal law, Mississippi law prohibits balance billing for emergency care from facilities or providers that are out-of-network for those patients with state-regulated health plans.
Mississippi law states that if a healthcare provider accepts a patient’s insurance assignment from a state-regulated health plan, then the plan will pay the provider directly for the patient’s treatment. That payment is considered payment in full to the healthcare provider – this means the provider cannot bill the patient later for any amount more than the payment received from the plan, other than normal deductibles or co-pays.
Mississippi Insurance Department
Missouri protects patients from surprise medical bills for health care services provided at an in-network facility from an out-of-network provider from the time the patient presents with an emergency medical condition until the patient is discharged. Additionally, Missouri law requires that patients pay only their in-network cost-sharing amounts. These protections apply to any patient covered by a state-regulated insurance plan but does not apply to a liability insurance policy, workers’ compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy.
Missouri Department of Insurance
File a complaint at https://insurance.mo.gov/consumers/complaints/index.php
Visit https://insurance.mo.gov/ for more information about your rights under Missouri laws
In accordance with the Nebraska Out-of-Network Emergency Medical Care Act, if you receive emergency services from any health care providers, such providers are not permitted to bill you in excess of any deductible, copayment, or coinsurance amount applicable to in-network providers’ emergency services pursuant to your health benefits plan. Your insurer is obligated to make sure you do not incur out-of-pocket costs greater than the out-of-pocket costs you would have incurred had you received emergency services from an in-network health care provider.
Nebraska Department of Insurance
402-471-2201 or 1-877-564-7323
Visit www.doi.nebraska.gov for more information about your rights under Nebraska law.
Nevada law protects patients covered by health benefit plans regulated by the state, the Public Employees’ Benefits Program, and third parties that opt into the prohibition from balance billing for medically necessary emergency services provided by an out-of-network provider.
Additionally, Nevada law requires that the patient pay only their in-network cost-sharing amounts. This law does not apply to: (1) any patient who has coverage through an out of state insurance policy; (2) critical access hospitals or any medically necessary emergency services provided at such a hospital and (3) any out-of-network healthcare services provided 24 hours after notification that a patient has been stabilized.
Department of Business and Industry, Nevada Division of Insurance
Visit https://doi.nv.gov/Consumers/Health_and_Accident_Insurance/Balance_Billing_FAQs for more information about your rights under Nevada law.
New Hampshire state law protects you from having to pay more than your standard copays deductibles, or coinsurance for emergency services you get at an in-network hospital or surgical center, from anesthesiology, radiology, emergency medicine, or pathology service providers—even if those providers are not in-network for your insurance plan.
New Hampshire Department of Insurance
603-271-2261 or (800) 852-3416 [(800) 735-2964 (TYY/RDD Relay Services)]www.nh.gov/insurance
New Jersey law prohibits out-of-network providers and health care facilities in New Jersey from balance billing patients in excess of the patient’s deductible, copayment, or coinsurance amount applicable to in-network services for (i) emergency or urgent medically necessary services, and (ii) inadvertent out-of-network services. New Jersey law defines “inadvertent out-of-network services” as health care services (1) covered under a managed care health benefits plan that provides a network; and (2) provided by an out-of-network provider at an in-network health care facility when in-network services are unavailable at that facility. This protection applies to all carriers operating in New Jersey with regards to health benefits plans issued in New Jersey, including self-funded plans that opt-in.
Additionally, Nevada law requires that the patient pay only their in-network cost-sharing amounts. This law does not apply to: (1) any patient who has coverage through an out of state insurance policy; (2) critical access hospitals or any medically necessary emergency services provided at such a hospital and (3) any out-of-network health care services provided 24 hours after notification that a patient has been stabilized.
New Jersey Department of Banking and Insurance
New Mexico protects patients from balance billing when patients receive: (i) emergency services from an out-of-network provider or provided at an out-of-network facility; (ii) covered non-emergency services provided by an out-of-network provider at an in-network facility if the patient did not have the ability or opportunity to choose an in-network provider; and (iii) medically necessary care from an out-of-network provider when an in-network provider is unavailable within a patient’s network.
Additionally, New Mexico law states that if a patient chooses to receive non-emergency care from an out-of-network provider, the balance billing protection does not apply. These protections only require patients to pay their in-network cost-sharing amounts. This protection applies to any entity subject to New Mexico’s insurance laws.
New Mexico Office of Superintendent of Insurance, Managed Care Bureau
North Carolina law protects patients from surprise medical bills for emergency services to the extent necessary to screen and to stabilize the patient when provided by an out-of-network provider. Additionally, North Carolina law requires that patients pay only their in-network cost sharing amounts. This law applies to patients with coverage through insurance companies licensed by North Carolina, health maintenance organizations, service corporations, and multiple employer welfare arrangements.
North Carolina Department of Insurance
Visit www.ncdoi.gov for more information about your rights under North Carolina law.
Ohio law protects patients from balance billing and requires patients to pay their in-network cost sharing amounts for: (i) emergency services provided by an out-of-network provider or provided at an out-of-network emergency facility; and (ii) medical services provided by an out-of-network provider at an in-network facility if a patient did not have the ability to request an in-network provider. For services provided to a covered patient by an out-of-network provider at an in-network facility, a patient cannot be balance billed unless the patient is informed, provided with a good faith estimate of the cost of the healthcare services, and consents.
Additionally, the Ohio law applies to patients covered under state-regulated insurance plans and insurance plans subject to the jurisdiction of the superintendent of insurance.
Ohio Department of Insurance
Additionally, Oregon protects patients from balance billing for emergency services or other inpatient or outpatient services provided at an in-network facility. Additionally, Oregon law requires that patients pay only their in-network cost-sharing amounts for in-network facilities. This protection applies to any patient with coverage through any hospital expense, medical expense, or hospital/medical expense policy; subscriber contract of a health care service contractor; or multiple employer welfare arrangement plan. It does not apply to non-emergency services when patients choose to receive the services from an out-of-network provider.
Oregon Division of Financial Regulation
https://dfr.oregon.gov/help/complaints-licenses/Pages/file-complaint.aspx Visit https://dfr.oregon.gov/laws-rules/Documents/Bulletins/bulletin2018-02.pdf for more information about your rights under Oregon law.
Pennsylvania law provides that managed care plans, including health maintenance organizations and gatekeeper, preferred provider organizations, and subcontractors of managed care plans cannot deny any claim for emergency services on the basis that the patient did not receive permission, prior approval, or referral prior to seeking emergency service. A managed care plan that has no in-network providers available to provide covered services shall cover services provided by an out-of-network provider. The plan shall cover the out-of-network services at the same level of benefit as an in-network provider.
Pennsylvania Department of Insurance
Rhode Island requires insurers to hold enrollees harmless for amounts beyond the in-netwwork level of cost-sharing. This protection applies to HMO enrollees for (1) emergency services, and (2) non-emergency services provided by out-of-network professionals at in-network facilities. The state protection does not apply to PPO enrollees, ground ambulance services, or enrollees of self-funded plans.
Tennessee law prohibits healthcare facilities from collecting out-of-network charges from a patient, or the patient’s insurance in excess of the in-network cost-sharing amount unless the healthcare facility provided written notice to the patient prior to the provision of medical services and documented whether the patient signed the written notice. This law applies to any state-regulated insurance plan.
Tennessee Department of Commerce and Insurance
615-741-2218 or 1-800-342-4029
Texas law protects patients with state-regulated health insurance (about 16 percent of Texans) from surprise medical bills in emergencies or when they didn’t have a choice of doctors. The law bans doctors and providers from sending surprise medical bills to patients in those cases. Texas law also prohibits balance billing for any health care, medical service, or supply provided at an in-network facility by an out-of-network physician or other provider and for services by diagnostic imaging providers and laboratory service providers provided in connection with a health care service performed by a network physician or provider.
Texas Department of Insurance
Consumer Help Line: 1-800-252-3439
Visit https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills.html or https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html for more information about your rights under Texas law.
Utah law protects patients with coverage from a health insurance policy or managed care organization from balance billing for emergency services. Additionally, Utah law states that a patient receiving services at an in-network facility may not be held responsible for more than the in-network cost-sharing amount.
Utah Insurance Department, Health Insurance Consumer Service
Vermont law states that a physician who agrees to treat a Medicare or General Assistance beneficiary may not balance bill the beneficiary unless: (1) during the calendar year prior to treatment, the Medicare beneficiary (or his or her spouse with whom he or she lived at any time during that year) received Social Security benefits or railroad retirement benefits which were subject to federal income taxation or would've been if they received them; (2) the Medicare beneficiary refuses to sign the statement authorized by 33 V.S.A. § 6504; or (3) the service for which the beneficiary is to be billed is either an office or home visit.
Vermont Department of Health, State Board of Medical Practice
Phone (802) 657-4220
West Virginia requires insurers to provide coverage for emergency medical services--including prehospital services--to the extent necessary to screen and stabilize an emergency medical condition without requiring prior authorization for the screening services or stabilization of the emergency medical condition. Such coverage of emergency services is subject to coinsurance, copayments, and deductibles applicable under the health benefit plan. W. Va. Code Section 33-25A-8d(b)(3).
If you believe you’ve been wrongly billed, you may contact the West Virginia Offices of the Insurance Commissioner at https://www.wvinsurance.gov/Consumer_Services or by phone at 304-558-3386 or Tollfree in WV: 1-888-TRY-WVIC.
Visit https://www.wvinsurance.gov/HealthPolicy for more information about your rights under West Virginia law.
When balance billing isn’t allowed, you also have these protections:
- You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact 1-800-985-3059. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good FaithEstimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.