The No Surprises Act: what it actually stops, and where the loopholes remain

The No Surprises Act, in effect since 2022, protects patients from unexpected 'balance billing' — being billed the difference between what an out-of-network provider charges and what insurance pays — in two main scenarios: emergency care regardless of which facility it's received at, and non-emergency care received at an in-network facility from a provider who happens to be out-of-network, most commonly anesthesiologists, radiologists, and pathologists who a patient generally doesn't choose directly and may not even realize are out-of-network until the bill arrives.

In both covered scenarios, the law requires the patient to be billed only their normal in-network cost-sharing amount, with the dispute over the remaining payment resolved directly between the insurer and provider through an independent arbitration process — removing the patient from that financial dispute entirely, a genuine structural improvement over the previous system, where patients were frequently caught in the middle of insurer-provider payment disagreements.

The gaps that remain are specific and worth knowing in advance: ground ambulance transport is notably excluded from the law's protections, meaning surprise billing for ambulance rides — one of the most commonly reported sources of surprise medical bills before the law even passed — remains a real risk that federal protection doesn't currently address, an exclusion that's been the subject of ongoing advocacy for expanded coverage but hasn't yet been closed. Scheduled, non-emergency care where a patient knowingly chooses an out-of-network provider also generally falls outside the law's protection, since the protection is specifically built around situations where the patient didn't have a meaningful choice in provider selection.

For anyone receiving a bill that seems like it should be covered under No Surprises Act protections, disputing it directly with both the provider and insurer, referencing the law specifically, is worth doing — federal complaint processes exist specifically for suspected violations. For ground ambulance transport specifically, since it remains uncovered, asking in advance which ambulance services in your area are in-network with your insurance, where that information is available, is one of the few proactive steps that addresses this particular remaining gap.