Most brokers know the No Surprises Act exists. Fewer know exactly which services it covers, which plans it applies to, and what clients should expect when a surprise bill arrives anyway. The law went into effect on January 1, 2022, and by now most clients covered by ACA-compliant plans are under it. The gaps still catch people.
Key Takeaways
- The No Surprises Act took effect January 1, 2022. It prohibits balance billing for emergency services at out-of-network facilities and for certain non-emergency services at in-network facilities where the provider is out-of-network.
- Cost-sharing for a protected surprise bill is capped at in-network rates. The client pays their in-network deductible, copay, and coinsurance. The provider cannot bill the difference.
- The law applies to most ACA-compliant individual and group market plans. It does not apply to short-term limited duration plans, grandfathered health plans, or excepted benefit plans.
- An independent dispute resolution (IDR) process governs billing disputes between providers and insurers. The broker's job is to explain the client's cost-sharing obligations, not the IDR mechanics.
- Providers must give uninsured and self-pay patients a good faith estimate of expected costs before a scheduled service. Insured patients have separate protections.
What the law actually prohibits
The No Surprises Act prohibits balance billing in two main scenarios. The first is emergency services at any facility. If a client goes to an out-of-network emergency room, the plan must apply in-network cost-sharing. The ER provider cannot bill the difference between what the insurer pays and what the provider charges. This applies from the point of emergency service through discharge and stabilization.
The second scenario is non-emergency services at an in-network facility where the provider is out-of-network. This is the situation that surprised the most people before the law: a client has surgery at an in-network hospital, the surgeon is in-network, but the anesthesiologist or the radiologist reading the post-op imaging is not. Those ancillary providers cannot balance bill at an in-network surgical facility. They are paid through the insurer's process and the client pays in-network cost-sharing only.
One important carve-out: for some non-emergency services (not the ancillary categories listed above), a provider at an in-network facility may ask the client to sign a consent form waiving surprise billing protections. The consent must be given at least 72 hours before the scheduled service and may not be used for anesthesiology, radiology, pathology, neonatology, or assistant surgeon services at in-network facilities.
What the law covers and what it does not
| Service category | Protected? | Notes |
|---|---|---|
| Emergency services at any facility | Yes | Cost-sharing capped at in-network rates regardless of whether the ER is in-network. Applies to stabilization services through discharge. |
| Non-emergency services at in-network facility with out-of-network provider | Yes, with notice exception | If the client signs a consent form at least 72 hours in advance waiving surprise billing protections for non-ancillary services, the provider may balance bill. This exception does not apply to anesthesiology, radiology, pathology, neonatology, or assistant surgeons at in-network surgical facilities. |
| Air ambulance services from participating providers | Yes | Protections apply to air ambulance companies that participate in the federal independent dispute resolution process. Ground ambulance is not yet covered under the federal rule. |
| Planned out-of-network care at out-of-network facility | No | If the client knowingly chooses an out-of-network provider at an out-of-network facility for non-emergency care, standard out-of-network cost-sharing applies. |
| Short-term limited duration plans | No | Short-term plans are not ACA-compliant and are not subject to No Surprises Act protections. Clients on these plans retain full balance billing exposure. |
Based on No Surprises Act provisions effective January 1, 2022. Ground ambulance is not currently subject to federal surprise billing protections; state laws vary. Verify current guidance at cms.gov.
Which plans are subject to the law
The No Surprises Act applies to ACA-compliant individual and small group market plans, both on and off the Marketplace. It also applies to most large and small employer-sponsored plans regulated under ERISA. The law is implemented jointly by HHS, the Department of Labor, and the Department of the Treasury.
Plans exempt from the law include short-term limited duration plans, grandfathered health plans (those in existence before March 23, 2010, that have not made certain changes), and excepted benefit plans such as standalone dental and vision coverage. This is a significant gap that brokers should communicate clearly when a client is considering a short-term plan as an alternative to Marketplace coverage. The absence of surprise billing protections is one of several meaningful differences. For a full breakdown of what ACA-compliant plans must cover versus what short-term plans are permitted to exclude, see essential health benefits: what every ACA plan must cover.
The cost-sharing mechanics
When a protected surprise bill situation occurs, the client pays their in-network deductible, copay, and coinsurance. The insurer pays the remainder at whatever amount it negotiates with the out-of-network provider through the dispute resolution process. The provider can dispute the payment through the federal Independent Dispute Resolution (IDR) process, but that dispute is between the insurer and the provider. The client is not part of it and cannot be held responsible for any amount above their in-network cost-sharing obligation.
The practical implication for brokers: when a client calls in January with a surprise medical bill from a December hospitalization, the first question is whether the service qualifies for protection. Emergency care at any ER qualifies. Non-emergency care at an in-network facility with an out-of-network ancillary provider qualifies. The client should contact their insurer and ask the plan to reprocess the claim under the No Surprises Act. CMS publishes a Help Desk for complaints at no cost to the client.
Good faith estimates for self-pay patients
The No Surprises Act also requires providers to give uninsured and self-pay patients a good faith estimate of expected charges before a scheduled service. The estimate must be provided at least 3 business days before a service scheduled at least 10 business days in advance. If the actual bill exceeds the good faith estimate by more than $400, the patient can dispute it through a patient-provider dispute resolution process.
This provision matters for brokers working with clients who are between coverage periods, especially those in the 60-day SEP window after losing employer coverage. A client who schedules a procedure while shopping for Marketplace plans is a self-pay patient for that period and should ask for a good faith estimate before the service date.
What this means for how brokers explain network choices
The No Surprises Act reduced but did not eliminate out-of-network exposure. Emergency care is now protected. Non-emergency care at in-network facilities is largely protected for ancillary services. But a client who deliberately chooses an out-of-network provider for a planned procedure at an out-of-network facility still faces standard out-of-network cost-sharing. EPO plans, which cover no out-of-network care at all for non-emergencies, still function as designed for planned out-of-network services.
The network conversation at enrollment remains as important as it was before the law. The difference is that brokers can now tell clients that if they end up at an out-of-network ER in an emergency, or if an out-of-network specialist sees them during surgery at their in-network hospital, the financial exposure is capped at their in-network cost-sharing. That is a meaningful assurance for clients who previously avoided lower-premium HMO and EPO plans because of network anxiety. For more on how plan network types affect the real-world care experience, see ACA network types: HMO, PPO, EPO, and POS explained.
Platforms like GetInsured AgentExpress surface plan network information during enrollment. QuoteTurbo surfaces live CMS Marketplace plan data including the plan type, allowing the broker to explain network implications before the client selects. The explanation at enrollment is what prevents the confusion later. Enrollment tools do not ask the questions; brokers do.
Competitor data verified: June 2026. Vendors update features and pricing without notice. Confirm directly before purchasing decisions. GetInsured is a trademark of its respective owner. QuoteTurbo is not affiliated with or endorsed by GetInsured.
FAQ
Questions brokers and clients ask about the No Surprises Act and surprise billing.
Does the No Surprises Act apply to all ACA Marketplace plans?
Yes. All ACA-compliant individual and small group market plans sold on or off the Marketplace are subject to the No Surprises Act. The law also applies to most employer-sponsored plans. It does not apply to short-term limited duration plans, grandfathered plans, or excepted benefit plans such as standalone dental or vision.
If a client receives a surprise bill after January 2022, what are their options?
The client can dispute the bill with the provider or insurer. If the bill exceeds the in-network cost-sharing amount for a protected service, the insurer must reprocess it at the in-network rate. If the dispute is not resolved, the client can file a complaint with the federal No Surprises Help Desk or the relevant state agency. CMS has published guidance on the complaint process at cms.gov.
What is the Independent Dispute Resolution process and does a broker need to explain it to clients?
The IDR process is a federal mechanism for resolving payment disputes between providers and insurers when they cannot agree on the payment amount for a surprise bill. Brokers generally do not need to explain IDR mechanics to clients. The client's obligation is their in-network cost-sharing amount. The payment dispute between the provider and insurer is handled outside the client's involvement.
Are clients required to sign consent forms to waive No Surprises Act protections?
Some providers may ask for a consent form waiving surprise billing protections for non-emergency services at an in-network facility. The consent must be given at least 72 hours before the scheduled service. This option is not available for certain ancillary services including anesthesiology, radiology, pathology, neonatology, and assistant surgeon services at in-network facilities, where protections apply regardless.
Does the No Surprises Act change how brokers should explain EPO and HMO network restrictions?
The No Surprises Act does not remove EPO or HMO network restrictions for planned care. If a client in an EPO goes to an out-of-network provider for a scheduled non-emergency procedure at an out-of-network facility, standard plan cost-sharing applies. The law protects against surprise bills in specific situations, not from ordinary out-of-network usage for planned care.
