Skip to content

No Surprises Act (NSA)

What is the No Surprises Act (NSA) 2022? 

The No Surprises Act (NSA) establishes new federal protections against surprise medical bills that take effect in 2022. Surprise medical bills arise when insured patients inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose. 

Here are five things to know about the first regulation implementing the No Surprises Act: 

  1. The regulation bans surprise billing for emergency services – patients must be treated on an in-network basis without prior authorization. 
  2. Out-of-network ancillary care at an in-network facility – patients must be treated as an in-network service unless the law’s notice and consent requirements are met. 
  3. Health care providers and facilities must use clear understandable language to obtain patient approval before providing and billing for out of network care. 
  4. The regulations don’t prevent patients from receiving care from their preferred providers – may consent to be billed at a higher “out of network” rate for care. 
  5. These changes took effect on January 1, 2022.

Providers and Plans Responsibilities 

  • Providers and plans must notify consumers of their surprise medical bill protections.  
  • Providers and health care facilities must publicly disclose patient protections against balance billing. 
  • This notice must be provided no later than the date when payment is requested, though the regulation specifies it is not required to be included with the bill, itself.  
  • Health plans are required to provide patients the disclosure notice with explanation of benefits that includes a claim for surprise medical bills. 
  • Implement workflow to ensure patients are billed for the correct in-network amounts. 
  • Develop workflow for consent on non-emergent and certain emergent out-of-network services 


  • An exception to federal surprise billing protections is allowed if patients give prior written consent to waive their rights under the NSA and be billed more by out-of-network providers.  
  • Providers are never allowed to ask patients to waive their rights for emergency services or for certain other non-emergency services or situations described above.  
  • Consent must be given voluntarily and cannot be coerced, although providers can refuse care if consent is denied. 
  • The law requires that consent must be given at least 72-hours in advance or, if the patient schedules a service less than 72-hours in advance, no later than the day the appointment is made.  
  • For same day scheduled services, regulations permit consent to be given at least 3 hours in advance. 

Uninsured Individuals 

  • For people who do not have health insurance or pay for care on their own (also known as “self-paying”), the rules that took effect January 1, 2022 require most providers to give a “good faith estimate” of costs before providing non-emergency care. 
  • The good faith estimate must include expected charges for the primary item or service, as well as any other items or services that would reasonably be expected.  
  • For an uninsured or self-pay consumer getting surgery, for example, the estimate would include the cost of the surgery, as well as any labs, other tests, and anesthesia that might be used during the procedure. 
  • Uninsured or self-pay consumers who receive a final bill that exceeds the good faith estimate by $400 or more can dispute the final charges.

For more information about the No Surprise Rule, please review the FAQs for Providers About the No Surprise Rule [PDF]