The No Surprises Act: What Protections You Have, Where They End, and Why Ground Ambulance Is Still the Biggest Gap

The No Surprises Act took effect January 1, 2022. For specific categories of care, it ended a genuinely harmful practice: patients receiving out-of-network bills for emergency care or for out-of-network providers at in-network facilities where they had no ability to choose. KFF data shows the share of privately insured adults reporting unexpected out-of-network bills declined between 2021 and 2023. The law worked in the categories it covered. For one major category, ground ambulance, it explicitly did nothing, and that gap remains one of the most common sources of large unexpected medical bills in the country.

What the Law Covers

The NSA covers three categories. Emergency services: if you receive emergency care anywhere, in-network or out-of-network facility, the insurer processes it at in-network cost-sharing rates and providers cannot balance bill you beyond that amount. Non-emergency care at in-network facilities from out-of-network providers: if you're admitted to an in-network hospital and an out-of-network anesthesiologist, radiologist, or assistant surgeon treats you as part of that care, their bill is subject to in-network cost-sharing. Air ambulance: surprise bills from air transport providers are prohibited. These protections apply to most private insurance plans, including employer-sponsored coverage.

Ground Ambulance: Explicitly Excluded

Ground ambulance was excluded from the No Surprises Act after lobbying by municipal ambulance services arguing federal rate-setting would destabilize local emergency response funding. The CFPB has found ground ambulance balance billing is among the most common sources of large unexpected medical bills, median out-of-network ground ambulance charges exceeding $900 above insurance payment in many markets, with some balance bills reaching $2,000 to $5,000 for a single transport.

A small number of states have enacted their own ground ambulance balance billing protections: California, New York, and several others, but in most states, a patient transported by an out-of-network ground ambulance can be billed the full difference between the provider's charge and what the insurer paid. This hasn't changed and isn't likely to change soon at the federal level.

The Consent-to-Waive Form

For non-emergency out-of-network services, the NSA allows providers to ask patients to waive their balance billing protections by signing a consent form and receiving a Good Faith Estimate. If you sign it, you give up in-network cost-sharing for that provider. The law requires the consent to be informed and voluntary, providers cannot make it a condition of receiving care, and it cannot apply to emergency situations. Some providers have presented waiver forms as standard intake paperwork. Read everything before signing. If any form includes language about out-of-network billing or cost-sharing, ask specifically what it covers before agreeing.

The IDR Backlog and What It Means for Patients

When providers and insurers dispute what the insurer owes under the NSA, they use an independent dispute resolution (IDR) arbitration system. More than 300,000 disputes were submitted in 2024, far exceeding system capacity. GAO data shows providers win approximately 80% of arbitration cases. These disputes run between insurers and providers, patients aren't directly involved in IDR proceedings. But the system's backlog explains why some NSA-related billing disputes take months to resolve and why some insurers have become more conservative in paying initial NSA claims while awaiting arbitration results.

Filing a Complaint If the Law Wasn't Followed

If you received a balance bill that appears to violate No Surprises Act protections, you can file a complaint at cms.gov/nosurprises. CMS maintains a complaint portal and has authority to investigate and impose penalties on providers and insurers who violate the law. Before filing, document the billing sequence: when you received care, the facility's network status, which providers were involved, what you were billed, and what the insurer paid. The more specific the documentation, the more actionable the complaint.

Compass Health Consultants® can help you review your coverage and understand what No Surprises Act protections apply to your specific plan. Get in touch with us here: https://www.chcquotes.com/getyourquote