Health Insurance State Laws:
No Surprises Act and Surprise Billing

This chart indicates whether the federal or state process is used by each state for disputes related to medical billing under the federal No Surprises Act. Note that some states used a mixed system where the system used depends on the type of complaint. Use the links in the chart to be directed to the complaint system chosen by your state for consumer complaints. This chart summarizes surprise billing laws in different states. Check back often, as these charts are updated frequently.

If you have a self-funded plan, certain state laws may not apply. For information on how to determine if your plan is self-funded, see our blog post.

If you don't find what you're looking for, see our other Charts of Health Insurance State Laws:

For more health insurance information, visit our Health Insurance Materials & Resources. If you are looking for information on Medicare or Medicaid, return to the main state laws page.

StateSurprise Billing Resolution Process (Federal/State/Mixed)
District of ColumbiaFederal
New HampshireMixed
New JerseyMixed
New MexicoMixed
New YorkMixed
North CarolinaFederal
North DakotaFederal,and%20some%20non%2Demergency%20services.
Rhode IslandFederal
South CarolinaFederal,between%20providers%20and%20your%20insurer.
South DakotaFederal,other%20related%20items%20or%20services.
West VirginiaFederal,their%20own%20health%20plan's%20network.
U.S. Territories
American SamoaFederal
North Mariana IslandsFederal
Puerto RicoFederal
U.S. Virgin IslandsFederal
Last Updated2/2024
StateSummary of State Surprise Billing LawState InformationEligibility Requirements
ARIZONAPatients enrolled in certain kinds of insurance health plans who receive a surprise bill can challenge the bill with the Arizona Department of Insurance and Financial Institutions. They can do so: 1) when the bill was for emergency services at at an in-network facility; or 2) when the bill was for non-emergency care at an in-network facility (unless the patient was given written notice that the provider was out-of network AND the patient signed the notice). Program date of the health care service was less than one year ago (unless extended by the time a health care appeal was in progress). The patient is enrolled in a qualified health insurance plan, generally a PPO (HMOs, self-insured employer plans, out-of-state policies, and state/federal government employee plans are not included). The amount of the bill is greater than or equal to $1,000. The bill or services are not the subject of legal action.
CALIFORNIAA patient who received care from an out-of-network provider at an in-network facility is responsible for no more than if the provider was in-network. Patients with coverage for out-of-network benefits can be billed the out-of-network cost-sharing rate only when the patient consents in writing 24 hours in advance. Program was provided after July 1, 2017; Patient has a health insurance plan regulated by California's Department of Insurance or Department of Managed Health Care, and plan was issued, amended, or renewed on or after July 1, 2017; California's surprise billing law does not apply to Medi-Cal, Medicare, or self-insured plans; Patient has not provided written consent at least 24 hours before receiving care from an out-of-network provider.
COLORADOState law prohibits balance billing for 1) emergency services; 2) non-emergency services from an out-of-network provider at an in-network facility; 3) emergency services from a private ground ambulance provider (i.e., not from a government entity like a fire department); 4) services from an out-of-network air ambulance. Patients receiving non-emergency care from an out-of-network provider must receive a notice explaining that the care could be more expensive than with an in-network provider. Providers are prohibited from asking patients to waive surprise billing protections for certain types of services. Program has insurance 1) through an employer; 2) via Connect for Health Colorado (Colorado's exchange); or 3) purchased from an insurance company. Patient received 1) emergency services; 2) non-emergency services from an out-of-network provider at an in-network facility (e.g., an in-network hospital); 3) emergency services from a private, non-government ground ambulance provider; or 4) services from an out-of-network air-ambulance provider. Consent to Balance Billing may be obtained in limited circumstances with 72-hours advance notice. Providers cannot ask patients receiving the following services to waive balance billing protection rights: emergency medicine; anesthesiology; pathology; radiology; neonatology; services by assistant surgeons, hospitalists, intensivists; diagnostic services; services provided by out-of-network provider if no in-network provider can provide the service at the facility.
CONNECTICUTOut-of-Network providers are not allowed to bill for more than the in-network allowed amount if a patient is seeking emergency services. Similarly, for non-emergency services, patients only pay the in-network costs for an out-of-network provider at an in-network facility unless the patient knowingly opts out. Patients will also only pay the in-network rate for lab work when an out-of-network lab performed services on referral from an in-network provider. Program Care: Patient treated by out-of-network provider, or at an out-of-network center. Non-emergency Care: 1) Patient received care from out-of-network provider at in-network facility, during a service/procedure performed by an in-netwrok provider, or during a service/procedure that the insurance provider previously approaved, and patient did not knowingly opt for the out-of-network provider. 2) Patient received services from a clinical lab that is out-of-network on referral of an in-network provider.
DELAWAREBefore balance billing, facility or healthcare provider must provide disclosure and get signed consent form from patient. Program protection entered into effect 10 days after publication of final regulations on February 1, 2017.
FLORIDAFor emergency care, patients pay the same IN rate regardless of whether provider is in-network or out-of-network. For nonemergency care, patients pay the IN rate for care provided by an OON provider at an IN facility, or when the patient did not have the ability and opportunity to choose an IN provider at the facility. is covered under an individual or group health insurance policy by an insurer who is authorized to transact in Florida; Patient received emergency care, or received nonemergency care at 1) an in-network facility from an out-of-network provider and 2) patient did not have the ability and opportunity to choose an in-network provider at the facility. State law protection effective July 1, 2016.
GEORGIAPatients who receive emergency care from an out-of-network provider are responsible for no more than the in-network out-of-pocket costs. Patients who receive a surprise bill for nonemergency care at an out-of-network facility or from an out-of-network provider are held to the in-network costs dictated by their policies. Note, however, that the bill must be a surprise bill - patients who provide written acknowledgment that they wish to receive nonemergency medical services from an out-of-pocket providers may not have reduced financial responsibilities resulting from that care. Program is enrolled in a plan that qualifies them for protection - e.g., Medicare, plans subject to ERISA jurisdiction are subject to different protections. State law protection provision effective January 1, 2021.
ILLINOISPatients only pay in-network out-of-pocket expenses for emergency care from out-of-network providers or at out-of-network facilities. Patients receiving nonemergency care at an in-network facility who receive certain "ancillary" services (for example, anesthesiology; radiology; many laboratory services/tests) are also held to in-network out-of-pocket expenses. Providers must provide notice and receive consent to bill the patient more than in-network costs when the care is provided by an out-of-network provider at an in-network facility.'s insurer must be licensed to do business in Illinois and be subject to Illinois state law regulating insurance; For patients who received nonemergency care, the services must have been provided at an in-network facility. If the nonemergency services did not fall into the "ancillary services" described by the law, then the out-of-network provider, or the in-network facility (acting on the provider's behalf) must satisfy notice and consent criteria; Most of the Illinois surprise billing law took effect on July 1, 2022 (some provisions regarding disclosure requirements for insurance companies (not care providers) took effect on January 1, 2023).
INDIANAA patient receiving care at an in-network facility from an out-of-network practitioner only pays the rate established by the patient's "network plan" unless the provider provides the patient with a form at least 5 days in advance of the scheduled appointment advising the patient that they can be balance-billed, includes an estimate of the services, and the patient provides written consent. Program,at%20an%20in%2Dnetwork%20facility.Provision effective as of July 1, 2020
IOWAInsurance carriers are responsible for meeting costs of emergency care, whether it occurs in- or out-of-network. Program effective as of January 1, 2000. "Carriers" defined by Iowa Code Sec. 513B.2 - entity subject to Iowa's insurance laws and regulations, and jurisdiction of Iowa's insurance commissioner. Includes HMOs, nonprofit health service corporation, and any other entity offering health insurance, benefits, or services.
LOUISIANAOut-of-pocket expenses billed by OON ambulance provider are held to in-network level. has health insurance from a provider licensed in Louisiana, and regulated by Louisiana state law; Effective August 1, 2023.
MAINEPatient who receives services (including emergency care) from an out-of-network provider at an in-network facility, or during a procedure performed by an in-network provider or when the insurance company previously authorized the procedure, is only required to pay out-of-pocket expenses that would have applied if the out-of-pocket provider was in-network. But these protections do not apply if the patient had the opportunity to go to an in-network provider but chose the out-of-network provider instead. Program must have received care from an OON provider at: 1) an IN facility; 2) as part of a procedure performed by an IN provider; or 3) during a procedure previously authorized by the insurance company. Patients must not have opted for the out-of-network provider when an in-network provider was available. Effective March 18, 2020.
MARYLANDPatients with HMO plans: Cannot be balance-billed for services covered by their plans. Patients with PPO or EPO plans: Cannot be balance billed by hospital-based or on-call physicians paid directly by the insurance plan, and they cannot ask patients to waive protections against balance billing. Ground ambulance providers operated by local governments who accept benefits from plans governed by Maryland state law cannot balance bill. As of January 2023, if a patient is approved to see an out-of-network specialist for mental health or substance abuse disorder, the patient cannot be balance-billed.,to%20receive%20the%20benefits%20forState Program is enrolled in an HMO, PPO, or EPO plan (plans like Medicaid, Medicare, and TRICARE have different protections and are governed by federal law). IF HMO: Service is covered by patient's plan. If PPO/EPO: Patient was treated by hospital-based or on-call physician who was paid directly by the insurance company. Protections for participants in preferred-provider plans effective July 1, 2011.
MASSACHUSETTSUpon scheduling an appointment, or at the patient's request, care providers have to tell the patient whether they are in-network with the patient's insurance plan. Patients have the right to request information about the costs of their care, and providers must provide the information. For non-emergency care, if an out-of-network provider fails to notify a patient in advance that the provider is out-of-network, the provider may not bill the patient for more than the out-of-pocket costs would be for an in-network provider. entered into effect on January 1, 2021. Effective January 1, 2025 there will be a penalty for no more than $2500 in each instance.
MICHIGANPatients who receive emergency care are held to in-network out-of-pocket expenses, regardless of whether the care takes place at an in-network or out-of-network facility. Patients who receive non-emergency care only pay in-network out-of-pocket expenses for care by an out-of-network provider if they receive the care at an in-network facility. That protection also applies to patients who are admitted to an in-network hospital within 72 hours of receiving care in the hospital's emergency room and receive care from an out-of-network provider during that time in the hospital. Michigan also requires providers to make disclosures to patients about the possibility of balance billing. If the providers fail to make those disclosures, patients may not be required to pay out-of-pocket at out-of-network rates. Program Cases: Patient's insurance plan is regulated by Michigan's Department of Insurance and Financial Services. Emergency Patient: Care is 1) provided to an emergency patient; 2) covered by the emergency patient's health insurance; and 3) is provided by an out-of-network provider at either an in-network or out-of-network facility. Non-Emergency Patient: Care is 1) provided to non-emergency patient; 2) covered by the patient's health insurance; 3) provided by out-of-network provider at in-network facility, and either a) the non-emergency patient did not have the ability or opportunity to choose an in-network provider or b) the non-emergency patient did not receive a disclosure from the provider that the care was out-of-network. Special Case: Patients Admitted Shortly After ER Visits: Care is 1) provided by out-of network provider; 2) at an in-network hospital; 3) to an emergency patient; 4) who was admitted to the hospital within 72 hours after receiving care in the hospital's emergency room. Michigan state law protections took effect October 22, 2020.
MINNESOTAMinnesota requires care providers to receive informed consent from patients before balance billing in the following circumstances: 1) a patient receives care from an out-of-network provider at an in-network hospital or ambulatory surgical center; 2) an in-network provider sends a specimen to an out-of-network lab or other testing facility; 3) an out-of-network provider or facility provides emergency services to a patient. Program1) Patient did not provide informed consent to balance billing; and 2) Patient received emergency care, or 3) Patient received nonemergency care from an out-of-network provider at an in-network facility; or an in-network provider sent a specimen to an out-of-network lab. State statutory protections effective July 1, 2023.
MISSISSIPPICare providers who accept assignment of benefits from patients and receive payment for a claim from an insurance company cannot then bill patients for more than the patient's deductible, copay, coinsurance, or other standard out-of-pocket fees. Program statute effective since at least 2014.
MISSOURIPatients who receive unexpected out-of-network care at an in-network facility are limited to the in-network deductible and out-of-pocket cost-sharing requirements. Program was treated at an in-network facility by an out-of network provider; The patient initially presented with an emergency medical condition; The care took place any time up to the patient's discharge from the facility. State law protections enacted in 2019.
NEBRASKAA patient who receives emergency care at either an in-network or out-of-network facility only pays the same amount out-of-pocket that they would pay for covered, in-network care. patient who receives emergency care is eligible for protection under Nebraska's state-law protections. Nebraska's state-law surprise billing protections became operative on Jan. 1, 2021.
NEVADAPatients who receive emergency care at an OON facility are only responsible for the out-of-pocket costs that they would have incurred if the facility had been in-network. Health plans not otherwise subject to Nevada's protection are free to opt-in to it. Program's insurance was sold inside Nevada; Healthcare was provided less than 24 hours after notification that patient was stabilized - within 24 hours of the patient's condition stabilizing, the OON facility is supposed to notify the patient's insurer, who is supposed to arrange for transfer to an in-network facility; Patient was treated at a hospital certified as a critical access hospital by the Secretary of Health and Human Services; The patient's health insurance provider falls within the scope of Nevada's state protections. For example, Nevada's state law protection does not include the Nevada plan for Medicaid. State protections effective January 1, 2020.
NEW HAMPSHIREPatients who go to an in-network facility for treatment cannot be billed above the in-network rate for out-of-pocket costs for certain types of care and services: anesthesiology, radiology, emergency medicine, and pathology. Program must have a managed care plan. State protections took effect on July 1, 2018.
NEW JERSEYPatients who receive "inadvertent out-of-network services" are only responsible for the out-of-pocket costs they would have if the care was prvided in-network. "Inadvertent out-of-network services" include care from an out-of-network provider at an in-network facility, lab tests ordered by an in-network provider but performed by an out-of-network lab, or any type of emergency or urgent care. Program,%2C%20copayments%2C%20or%20coinsurance).Patient has qualifying health insurance issued in New Jersey. NJ state protections effective as of Aug. 30, 2018.
NEW MEXICOPatients who receive emergency care from an OON provider only have to pay up to their in-network out-of-pocket limits. Patients who receive non-emergency care only pay in-network rates if treated by an out-of-network provider when: 1) the patient was at an in-network facility but was unable to choose an in-network provider; or 2) "medically necessary" care was unavailable within the insurance plan's network; or 3) the out-of-network provider provided "unforeseen" services; or 4) the patient did not give specific consent for an out-of-network provider to provide the services. has qualifying health insurance (i.e., not TRICARE, Medicare, Medicaid); New Mexico's state protections are effective as of Jan. 1, 2020.
NEW YORKEmergency Services: patients who receive emergency care are only responsible for the level of out-of-pocket costs that they would have been paid if the care was in-network. State protection includes bills from doctors and hospitals, but as of January 2022, protection extended to any other providers of emergency care. Non-emergency care protections in 3 scenarios: 1) Patient receives services from an out-of-network provider at in-network hospital or ambulatory surgical center; 2) Patient receives care from out-of-network provider after being referred by in-network physician to out-of-network provider; 3) Uninsured patient is treated at a hospital or ambulatory surgical center but did not receive certain disclosures. ProgramPatient's health insurance is subject to New York law (if insurance ID card says "fully insured," the plan is covered by NY law.) Scenario 1: Out-of-network provider at an in-network hospital: a) in-network provider was unavailable; or b) out-of-network provider provided services without patient's knowledge; or c) unforeseen services arise at time when health care services are provided. If an IN provider was available and a patient opted for an OON provider, it's not a surprise bill. Scenario 2: Out-network care on referral from in-network physician: patient did not provide written consent acknowledging that the referral was to an OON provider and the referral might result in costs not covered by insurance. Scenario 3: Uninsured patient did not receive disclosures: Section 24 of the Public Health Law requires doctors and other healthcare professionals to make certain disclosures to patients. An uninsured patient who did not receive these disclosures may be protected from a surprise bill. State law protections at NY FIN SERV Ch. 18-a, Art. 6 effective April 9, 2022.
NORTH CAROLINAInsurers cannot charge out-of-network costs unless there are in-network providers who can meet the patient's needs without "unreasonable delay." Patients who are enrolled in North Carolina's State Health Plan for Teachers and State Employees and who receive treatment from an in-network provider who is not connected to North Carolina's Health Information Exchange network cannot be billed more than if the provider was connected to the Health Information Exchange network. Program "unreasonable delay" prevents the patient from seeing an IN provider, or patient is enrolled in NC State Health Plan for Teachers and State Employees, patient went to an in-network provider, and provider is not connected to Health Information Exchange network. Provision took effect as of March 1, 2002.
OHIOPatients who receive unanticipated out-of-network care (including lab services) at an in-network facility cannot be balance-billed by providers for the difference between what their insurer will pay and what the care provider charges. Patients who receive emergency services at an out-of-network emergency facility in Ohio cannot be balance billed by the facility or out-of-network provider for the difference between what their insurer will pay and the facility or provider's charges for the service. A similar rule applies to OON ambulance services. Program Patient is not covered by Medicare supplement, Medicaid, Federal Employee Benefit Program; or care issued under Title 10, Chapter 55 (military healthcare programs); 2) Patient received emergency care, or if the care was not emergency care, patient did not have the ability to request care be provided from an in-network provider. State law protections effective as of January 12, 2022.
OREGONA patient who receives out-of-network services (emergency or nonemergency) at an in-network facility may not be balance billed unless the patient opts for out-of-network care, and an out-of-network provider must inform the patient of out-of-pocket costs if the patient chooses an out-of-network provider. Program balance billing protections and provider obligation to inform became effective for provider-patient interactions on or after March 1, 2018.
RHODE ISLANDAny cost-sharing for out-of-network emergency services cannot exceed cost-sharing if the services were provided in-network; however, the patient may be required to pay, in addition to the in-network cost sharing, the excess of the amount the out-of-network provider charges over the amount the plan is required to pay
TEXASOut-of-pocket costs for emergency care are limited to the amount "initially determined payable" by their insurance company (which can change, depending on the insurance company's appeal process); out-of-pocket costs for nonemergency care provided at in-network facilities by out-of-network providers are held to the same limits, unless the patient provides written consent to the out-of-network provider and receives certain written disclosures. Out-of-pocket costs for imaging and lab services provided by out-of-pocket providers are also held to in-network limits. Program's insurance is regulated by Texas Department of Insurance (this includes the Employees Retirement system of Texas, the Teacher Retirement System of Texas, and plans where patient's insurance card has DOI or TDI printed on them), After Jan. 1, 2022 the law applies to anyone with any type of insurance except Medicare. The patient received care on or after January 1, 2020.
VERMONTMedicare and General Assistance enrollees can only be balance billed if 1) they received Social Security benefits that were subject to federal income tax in the calendar year prior to treatment (or if they would have); 2) if the enrollee declines to sign a certain statement; or 3) the care in question is an office or home visit. is a Medicare or General Assistance Beneficiary. Provision enacted in 1987.
VIRGINIAPatients who receive emergency services, or nonemergency surgical or ancillary services (for example, surgery, anesthesiology, pathology, radiology, hospitalist services, and laboratory services) from an out-of-network provider at an in-network facility are only responsible for in-network out-of-pocket costs. Program's%20new%20balance%20billing%20law,or%20other%20health%20care%20facility.The patient has a health insurance plan regulated by Virginia, purchased via in Virginia or through Virginia's marketplace; or has a Virginia state employee health plan; Virginia state law provision took effect January 1, 2021;
WASHINGTONPatients only pay in-network out-of-pocket expenses for emergency care (including behavioral health emergency services) and for nonemergency services from out-of-network providers at in-network facilities. Providers cannot ask patients to waive these protections. Washington also protects against balance billing for air ambulance services (as does the federal No Surprises Act). Program either received emergency care, or nonemergency care from an OON provider at an IN facility; Patient has an insurance plan that is regulated by Washington State, or a state/school employee benefit plan, or a self-funded group health plan. Washington State balance billing protections took effect on January 1, 2020.
Last Updated3/24