By Chris Myers
Introduction
Health insurance is supposed to be your safety net — the thing that keeps a health crisis from becoming a financial catastrophe. Yet three years after the No Surprises Act (NSA) was signed into law to end balance billing for most emergency and in-network hospital care, many patients are still getting blindsided by staggering medical bills.
While the NSA has reduced patient out-of-pocket expenses by more than 16%—roughly $600 per person on average—it hasn’t eliminated surprise bills altogether.
The problem isn’t that the law doesn’t work — it’s that it doesn’t go far enough.
Where the No Surprises Act Stops Short
The NSA protects you if you have federally regulated insurance and receive:
- Emergency care (including mental health emergencies)
- Non-emergency care from an out-of-network provider at an in-network facility
- Services from out-of-network air ambulances
But here’s where patients fall through the cracks:
- Ground ambulance services
- Completely exempt from the NSA
- Often out-of-network and can leave patients with four- or five-figure bills
- Certain plan types — the NSA does not apply to:
- Short-term, limited-duration plans
- Standalone dental or vision plans
- Retiree-only plans
- Certain account-based group health plans
- State-regulated plans without matching protections
- If your plan is regulated at the state level and your state hasn’t passed its own surprise billing protections, you may not be covered at all
Karim Hachem of Suade Health notes that the average American still gets hit with at least one surprise bill a year. And as Joe Saad of the College of American Pathologists explains, this patchwork oversight means your protections depend on where you live — and what type of plan you have.
Why It Matters
Surprise bills can be financially devastating. Most insurance plans cap out-of-network reimbursement based on the Centers for Medicare & Medicaid Services (CMS) fee schedule — which is far below market rates. The rest becomes your responsibility.
Patients often do everything “right”: they go to an in-network hospital, only to learn weeks later that their anesthesiologist, radiologist, or ambulance wasn’t covered — and now they owe thousands.
Jeremy Gurewitz of Solace Health calls it “disorienting, financially jarring — and let’s be honest, unfair.”
How to Protect Yourself (For Now)
Until the law catches up, your best defense is vigilance:
- Ask specifically if every provider, not just the facility, is in-network
- Request a written estimate — many facilities are required to provide this by law
- Appeal any surprise bill — patients have successfully had charges dismissed when providers couldn’t show they gave a “good faith” estimate
- Understand your plan’s scope — especially if you have a short-term, retiree-only, or state-regulated plan
What Needs to Change
The No Surprises Act was a crucial step, but it leaves too many Americans exposed. Policymakers must:
- Add ground ambulance services to federal protections
- Require all plan types — including short-term and retiree plans — to comply
- Close state-level gaps by tying federal funding to adoption of similar protections
- Crack down on narrow networks that push patients toward out-of-network care even inside “in-network” facilities
Closing Thoughts
The intent of the No Surprises Act was simple: no one should face financial ruin because they got care they couldn’t possibly avoid or control. Yet for too many Americans, that promise still rings hollow.
Closing these gaps isn’t just about protecting patients from unexpected bills — it’s about restoring trust in a healthcare system that too often feels rigged against them. Until lawmakers expand the law’s reach, “surprise” will remain a predictable part of the patient experience — and that should surprise us all.
