Balance Billing & the No Surprises Act: Know Your Rights in 2026

Your 2026 Balance Billing Checklist

Before reading the detailed explanations below, run your bill through this checklist. If any item applies to your situation, keep reading — you likely have grounds to dispute or reduce the charge.

1. Identify whether the bill is a balance bill. A balance bill charges you the gap between what your insurer paid and the provider's full charge. If your insurer's Explanation of Benefits (EOB) shows a payment and you're being billed for the remainder by an out-of-network provider, that's a balance bill.
2. Check if the service falls under No Surprises Act protection. Emergency care, non-emergency ancillary services (like anesthesia or radiology) at an in-network hospital, and air ambulance services are covered. Ground ambulance is not.
3. Confirm your plan type is covered. Private employer-sponsored plans, Marketplace plans, and individual health insurance are covered. Medicare, Medicaid, TRICARE, and short-term limited-duration insurance are not (they have separate or no protections).
4. Look for a signed notice-and-consent waiver. In limited circumstances, providers can ask you to waive your balance billing protections for certain non-emergency, non-ancillary services. If you signed one, your rights in that specific situation are reduced — but only if the consent process followed strict federal rules.
5. Request an itemized bill. You can't evaluate a balance bill without knowing what was billed. Ask for an itemized statement showing each service, CPT code, and charge. Our guide on how to spot upcoding and wrong billing codes on a hospital bill walks you through reading that statement line by line.
6. File a complaint or initiate dispute resolution. Insured patients file with CMS. Uninsured or self-pay patients use the federal patient-provider dispute resolution process if the bill is $400+ over the Good Faith Estimate.

What Balance Billing Is — and Why It Was So Common

Before the No Surprises Act, if you received care from an out-of-network provider or facility — even unknowingly — your health plan might not have covered the entire out-of-network cost, leaving you with higher charges than if you'd gotten care in-network. On top of any out-of-network cost-sharing you owed, the out-of-network provider could bill you for the difference between their billed charge and the amount your health plan paid, unless banned by state law. This practice is called "balance billing," and an unexpected balance bill from an out-of-network provider is also called a surprise medical bill.

Researchers estimate that 1 in every 6 emergency room visits and inpatient hospital stays involve care from at least one out-of-network provider, resulting in surprise medical bills. The problem was particularly acute in emergencies — situations where patients had no ability to shop for in-network care. According to the GAO, the median price charged by air ambulance providers ranged from $36,400 to more than $40,000, and over 70% of these transports were furnished out-of-network, meaning most or all costs fell to the insured individual alone.

What the No Surprises Act Actually Covers (and Doesn't)

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. The core cost-sharing rule is found at 45 CFR § 149.110: when the No Surprises Act applies, the consumer's cost-sharing requirement for out-of-network items or services cannot be greater than the requirement that would apply if the item or service was provided in-network. For example, a consumer's costs for the out-of-network service would be determined using in-network copay amounts or coinsurance percentages.

Knowing what's excluded is just as important. Air ambulance service providers — but not ground ambulance service providers — are banned from balance billing under the No Surprises Act. As such, no restrictions are placed on the amount a ground ambulance provider can bill an individual under the No Surprises Act. The protections also don't apply to Medicare, Medicaid, Indian Health Service, Veterans Affairs health care, or TRICARE — these programs have other protections. The No Surprises Act protections also don't apply to short-term limited-duration insurance (STLDI) or excepted benefits.

State law can be stronger than the federal floor. The No Surprises Act supplements state surprise billing laws — it does not supplant them. It creates a "floor" for consumer protections against surprise bills. As a general matter, as long as a state's surprise billing law provides at least the same level of consumer protections as the No Surprises Act and its implementing regulations, the state law generally will apply.

The Notice-and-Consent Exception: When Providers Can Still Balance Bill

In limited situations, the No Surprises Act allows some out-of-network providers and facilities to seek written consent from individuals to voluntarily waive their protection against balance billing for post-stabilization services and non-ancillary, non-emergency services. These are referred to as "notice and consent exceptions." This is the primary way a provider can legally send you a balance bill even when the NSA would otherwise prohibit it.

Providers must follow strict requirements for the process and timing of obtaining consent from consumers. This includes the requirement to use the Standard Notice and Consent documents provided by CMS to secure consumer consent to waive No Surprises Act balance billing protections. If the provider used its own informal document, made you sign at the point of care during an emergency, or didn't give you a real choice, the waiver may be invalid. The consent requirements for non-emergency services are detailed at 45 CFR § 149.420. Ancillary services like anesthesiology, radiology, pathology, neonatology, and laboratory services are never eligible for the notice-and-consent exception — you cannot waive your protections for those.

Good Faith Estimates: The Protection for Uninsured and Self-Pay Patients

Beginning January 1, 2022, health care providers and facilities must provide an estimate of expected charges to individuals who do not have health coverage (or those who lack coverage for a particular item or service) and to individuals who have certain health coverage but who are not seeking to have claims submitted to their insurance. This estimate is known as a "Good Faith Estimate" (GFE). The requirements are codified at 45 CFR § 149.610.

The GFE has real teeth. If the final bill for a provider or facility is at least $400 higher than the GFE, the uninsured or self-pay patient can initiate the federal patient-provider dispute resolution process under 45 CFR § 149.620. A self-pay patient can initiate the dispute resolution process by submitting notice and an administrative fee within 120 days after receiving the disputed bill. The determination is generally binding on the parties absent fraud. Timing matters: if you miss the 120-day window, you lose this right. Before your scheduled procedure, also check whether you're getting a hospital price transparency-compliant estimate — these are separate but related obligations.

How to Dispute an Illegal Balance Bill: Step by Step

Don't pay a balance bill before verifying whether you owe it. Here is the concrete sequence to follow:

1. Pull your Explanation of Benefits (EOB). Your insurer sends this after processing a claim. It shows what was billed, what the insurer paid, and what you owe. If your EOB shows in-network cost-sharing but you received a separate bill for more, that's a red flag.
2. Request an itemized bill from the provider. Get every line item with CPT codes. Compare it to your EOB. See our guide on how hospitals inflate bills and how to spot it for help reading the codes.
3. Send a written dispute to the provider. State in writing that you believe the charge violates the No Surprises Act (cite 45 CFR § 149.110) and request that the provider bill only your in-network cost-sharing amount. Keep a copy.
4. File a complaint with CMS. Contact the No Surprises Help Desk at 1-800-985-3059 or submit a complaint online at cms.gov/medical-bill-rights/help/submit-a-complaint. You should submit a complaint if you received care on or after January 1, 2022, and you received an out-of-network bill for a visit to the emergency room or an in-network facility, you already paid more than in-network rates, or your provider didn't follow the rules around notice and consent.
5. Appeal through your insurer. If you think your insurer's decision to deny part or all of a claim violates the No Surprises Act, appeal the bill by following the process described in your plan's documents and denial notices.
6. File a parallel state complaint. Many states have stronger protections than the federal floor. File with your state insurance commissioner as well. Providers found in violation face civil monetary penalties of up to $10,000 per violation.

For insured patients, the federal Independent Dispute Resolution (IDR) process is a back-end mechanism between providers and insurers — it doesn't directly involve you as the patient. What it does affect is how much your insurer ultimately pays the provider, which in turn determines what you legitimately owe. Read our detailed breakdown of what the federal IDR process actually means for your medical bill if your insurer and provider are in an active payment dispute.

What's Changing in 2026: Regulatory Gaps to Know

As the No Surprises Act enters 2026, federal agencies are expected to focus on three key issues: finalizing delayed rulemaking, issuing guidance to address operational challenges in the IDR process, and managing enforcement discretion amid ongoing litigation. Several statutory provisions remain unimplemented, creating regulatory uncertainty for health plans, providers, and other stakeholders.

One active area of uncertainty affects how your insurer calculates its in-network benchmark, called the Qualified Payment Amount (QPA). The QPA is the benchmark amount used in IDR to value out-of-network payment disputes. It is generally defined as the median in-network rate for a given code in a geographic area. The federal departments said they would continue the use of enforcement discretion for plans that calculate QPAs using the 2021 methodology, amid ongoing litigation in Texas Medical Association v. HHS. Practically, this means the formula used to set your in-network cost-sharing benchmark is still in legal flux — another reason to scrutinize your EOB carefully rather than assuming the insurer's calculation is correct.

The Trump administration still has a long regulatory to-do list for 2026, including continued implementation of the No Surprises Act. Advanced Explanation of Benefits (AEOB) requirements — rules that would require plans to provide detailed pre-service cost and coverage information to insured individuals — remain unimplemented despite their statutory deadlines. Until AEOBs are fully in force, insured patients won't automatically receive upfront cost breakdowns before a procedure, making self-advocacy at billing time even more important.

About VerifyDoc: We help patients identify errors and overcharges on medical bills. We publish guides on hospital billing, the No Surprises Act, and disputing medical charges, updated as federal and state rules change.