Surprise Medical Bill Protection Laws by State 2026 — What the No Surprises Act Actually Covers

Kevin went to the nearest in-network emergency room with chest pains. The ER was in-network. His cardiologist was in-network. The anesthesiologist who put him under for the procedure — not in-network. Kevin never chose that anesthesiologist. He never knew his name until the $4,800 bill arrived six weeks later.

Before 2022, that bill was entirely legal. Kevin would have owed it in full. After the No Surprises Act, that bill is illegal. The anesthesiologist cannot bill Kevin more than his in-network cost-sharing amount.

Kevin filed a complaint. The bill was reduced to his $250 in-network copay. The $4,550 difference disappeared because Kevin knew the law existed.

In New Jersey — which had its own surprise billing law before the federal one — I have followed these cases closely. The federal law is stronger than what most states had. But it still has gaps that state laws can fill. Whether those gaps are filled depends entirely on where you live.

What the No Surprises Act Actually Covers

Emergency care — covered everywhere. If you receive emergency care at any hospital emergency department or freestanding emergency facility, you cannot be billed out-of-network rates regardless of whether the facility or any provider there is in your network. Your cost-sharing is capped at your in-network level. This applies even if you are uninsured — the facility must give you a good-faith cost estimate before non-emergency services.

Surprise bills from non-emergency care at in-network facilities — covered. If you go to an in-network hospital for a scheduled procedure and an out-of-network provider treats you without your informed consent, that provider cannot balance-bill you. This covers situations like the anesthesiologist, the assistant surgeon, or the radiologist you never met who read your scans.

Air ambulance services — covered. Air ambulance (helicopter and fixed-wing) is covered under the No Surprises Act. Your cost-sharing for air ambulance is capped at your in-network level even if the service is out-of-network.

Ground ambulance — NOT covered. This is the biggest gap. Ground ambulance services are explicitly excluded from the No Surprises Act. Some states fill this gap. Most do not. Ground ambulance surprise bills remain one of the most common and expensive surprise billing situations patients face.

Surprise Medical Bill Protections — All 50 States 2026

The Ground Ambulance Gap — The Biggest Surprise Bill Still Legal in Most States

Ground ambulance is explicitly excluded from the No Surprises Act. This was not an oversight — it was a deliberate carve-out while Congress studied the ground ambulance market. As of 2026, federal legislation to address ground ambulance surprise billing has been introduced but not enacted.

Ground ambulance bills are among the largest surprise bills patients receive. A single ground ambulance transport can cost $2,000 to $4,000 or more. If the ambulance service is out-of-network — which is common, because patients in emergencies do not choose their ambulance provider — the full balance may fall to the patient.

States addressing this gap: Texas, Minnesota, and a small number of others have enacted state-level ground ambulance surprise billing protections. Most states have not. Check your state insurance department’s website for the most current status — this is an actively evolving area of law.

What Actually Happened to Kevin in Ohio

Kevin’s chest pain story from the opening ended well — but only because he knew to file a complaint. Here is what that process looked like.

He received the $4,800 anesthesiologist bill. He called the billing department and was told it was a legitimate out-of-network charge. He did not accept that answer. He filed a complaint with Ohio’s Department of Insurance and simultaneously submitted a complaint through the federal No Surprises Act complaint portal at cms.gov.

Ohio’s DOI opened an investigation. The anesthesiology group was contacted. Within 30 days of the complaint, Kevin received a revised bill showing his in-network cost-sharing only — $250. The $4,550 difference was written off as required by the No Surprises Act.

The complaint took Kevin 25 minutes to file online. It saved him $4,550. Filing a complaint is always the right next step when a surprise bill arrives.

How to Fight a Surprise Medical Bill — Step by Step

Step 1 — Identify whether the No Surprises Act covers your situation. Was it emergency care? Was it at an in-network facility from a provider you did not choose? Was it air ambulance? If yes to any — the law protects you.

Step 2 — Send a written dispute to the billing provider. State clearly that the bill violates the No Surprises Act. Reference the specific protection that applies. Request that your bill be revised to reflect your in-network cost-sharing only.

Step 3 — File a complaint with CMS. Go to cms.gov and file a No Surprises Act complaint. CMS investigates and can refer violations to the Department of Health and Human Services Office of Inspector General. This complaint is free and takes under 30 minutes.

Step 4 — File a complaint with your state insurance department. Even if your state only has federal protections, state insurance departments track complaint patterns and often accelerate resolution when you file formally.

Step 5 — Request Independent Dispute Resolution if billing disputes persist. The No Surprises Act includes a federal IDR process — an independent arbitrator reviews disputed out-of-network bills. This process exists specifically to resolve disagreements between providers and insurers — but patients can initiate the process through their insurer.

Questions People Ask About Surprise Medical Bill Protections

Does the No Surprises Act apply to self-funded employer health plans?

Yes — this is one of the most important aspects of the federal law. Self-funded employer plans (common at large employers) are governed by federal law, not state insurance law. The No Surprises Act applies to self-funded plans directly. State surprise billing laws often do not. This means the federal law actually extended protection to workers who previously had none because their employer’s self-funded plan was not subject to state regulation.

What if I was told about the out-of-network provider and signed a consent form?

If you were given proper written notice that a provider was out-of-network, given a good-faith cost estimate, and signed an explicit consent to pay out-of-network rates — the provider may legally bill you at out-of-network rates. The key word is proper consent. Burying it in a general admission form does not count. The notice must be specific, in plain language, and given with enough time for you to choose an in-network alternative if one exists.

Can I be balance-billed by a freestanding emergency room?

Freestanding emergency departments are covered under the No Surprises Act for emergency services — meaning you cannot be balance-billed for emergency care there at out-of-network rates. However, the definition of “emergency” matters, and follow-up care at the same facility may not be covered. Check the specific facts of your visit.

What if I have no insurance and receive a surprise bill?

The No Surprises Act also has good faith estimate requirements for uninsured patients — providers must give you a cost estimate before scheduled services. If the actual bill exceeds the estimate by $400 or more, you have the right to initiate a patient-provider dispute resolution process. This is separate from the insured surprise billing protections but provides meaningful recourse for uninsured patients facing unexpectedly large bills.