A network is a set of contracts. When a provider is in your plan's network, they have agreed to accept the plan's negotiated rate as payment in full, minus your share.
When a provider is out of network, no such agreement exists, and that single fact produces most of the shocking medical bills people receive.
What balance billing is
If an out-of-network provider charges more than your plan pays, the provider may bill you for the difference. That difference is called a balance bill, and when it arrives unexpectedly it is called a surprise bill.
It is distinct from ordinary cost sharing. Your deductible and coinsurance are amounts you agreed to when you chose the plan. A balance bill is the gap between a provider's charge and what your plan considered payable, and historically there was no ceiling on it.
Balance bills also tend not to count toward your out-of-pocket maximum, so they sit outside the protection people assume that number provides.
What the No Surprises Act bans
The federal No Surprises Act took effect January 1, 2022. It prohibits balance billing in the circumstances where surprise bills were most common, and limits your cost sharing in those situations to the in-network amount.
Emergency services. Out-of-network providers are banned from balance billing for emergency services for an emergency medical condition, even without prior authorization. Your cost sharing cannot exceed what an in-network provider would have cost. The protection applies at hospitals, hospital outpatient departments and independent freestanding emergency departments, and covers ancillary services used to evaluate whether an emergency condition exists, such as a radiologist reading an imaging study. Providers are not allowed to ask you to waive these protections for emergency care.
Out-of-network providers at an in-network facility. If you go to an in-network hospital or facility and an out-of-network clinician treats you as part of that visit, certain services cannot be balance billed. This covers the common case of an anesthesiologist, radiologist, pathologist or assistant surgeon who is not in your network even though the hospital is.
Air ambulance services. Air ambulance providers are banned from balance billing.
Post-stabilization care, until you are able to travel to an in-network provider without medical transport, subject to the notice and consent rules described below.
Your cost sharing for protected services must be calculated as if the care were in network, and it must count toward your in-network deductible and out-of-pocket maximum.
The notice and consent exception
There is a way to lose these protections, and it is by signing them away.
For certain scheduled non-emergency care and certain post-stabilization care, an out-of-network provider may ask you to sign a notice and consent form waiving your balance billing protections. Signing is voluntary.
The rules constrain how the request may be made. The form must be given separately from other paperwork and cannot be buried in or attached to other documents. It generally applies only where you could reasonably travel to a nearby in-network provider without needing medical transportation.
The practical guidance is simple: you do not have to sign it. If you are handed a form waiving surprise billing protections and you do not understand it, you can decline, ask for an in-network provider, or ask to speak with the facility's patient financial services office first. For emergency care, no such form is permitted at all.
What is not covered
The protections are specific, and the gaps are real.
- Ground ambulances. They are not covered by the federal balance billing protections. Some states have their own laws addressing ground ambulance billing, and this varies by state.
- Care you choose to receive out of network. If you knowingly select an out-of-network provider for non-emergency care outside the protected categories, ordinary out-of-network rules apply.
- Short-term limited-duration insurance and excepted benefit plans. These are not subject to the protections. That is one of several reasons those products are covered separately in deductible, copay, coinsurance and out-of-pocket max as something different from comprehensive coverage.
- Medicare, Medicaid, TRICARE, VA and Indian Health Service coverage, which have their own separate protections against high bills.
If you are uninsured or paying cash
Uninsured and self-pay patients have a distinct set of rights. Providers must give a good faith estimate of expected charges before scheduled care. If the final bill is substantially higher than that estimate, there is a federal patient-provider dispute resolution process available to challenge the charges.
State law sits underneath the federal floor
The No Surprises Act supplements state surprise billing laws rather than replacing them. It sets a floor. Where a state law provides at least the same level of protection, the state law generally governs the situation, and some states protect consumers in areas federal law does not reach.
Which rules apply to you depends on your state and on whether your plan is state regulated or a self-funded employer plan. Your state Department of Insurance can tell you which applies.
What to do when a surprise bill arrives
- Do not pay it immediately. Paying a bill you may not owe complicates getting the money back.
- Get the explanation of benefits from your plan and compare it line by line against the provider's bill. They are different documents and they frequently disagree.
- Ask the provider whether the service falls under the No Surprises Act. Billing offices deal with this daily.
- Call your plan and ask how the claim was processed and whether the surprise billing protections were applied.
- Appeal if the plan denied or underpaid the claim. The process is covered in appealing a denied health insurance claim.
- File a complaint with the federal No Surprises Help Desk or your state Department of Insurance if you believe your rights were violated.
Keep dates, names and reference numbers for every call. As with any claim, a written record is what makes a dispute resolvable later.
Prevention is mostly a scheduling problem
For non-emergency care, the network question is answerable in advance and worth the phone calls.
Confirm the network status of the facility, the surgeon or treating physician, and the ancillary clinicians separately, because each contracts independently. Ask the scheduler directly whether every provider involved in the procedure is in network with your specific plan, and ask for the answer in writing where you can get it. For emergencies, none of this applies and none of it needs to; the protections exist precisely because emergencies do not permit shopping.
Coverage, network composition and state protections vary by insurer and by state. For your own situation, your plan documents, the insurer, a licensed agent, or your state Department of Insurance are the sources that can answer definitively. You can also request health insurance quotes to get connected with licensed carriers and agents offering plans in your area.