The No Surprises Act: What It Bans, and the Gap Texas Law Fills

The No Surprises Act took effect in 2022 and it bans surprise bills in three named situations: most emergency services, non-emergency services from out-of-network providers at in-network facilities, and out-of-network air ambulance services. Ground ambulance is not on that list, and this is the point at which most articles stop and most Texans get bad advice, because Texas law fills that federal gap for plans the Texas Department of Insurance regulates, for trips provided on or after 1 January 2024¹² (both checked 30 July 2026).

I write the billing pages here as a Certified Application Counselor, and the sentence above is one I have had to say slowly to people who arrived already convinced of the opposite. The pattern is always the same. Somebody calls their insurer about a bill, is told correctly that the federal surprise billing law does not cover ground ambulance, hears that as “there is no protection”, and puts the statement in a drawer. Nobody in that conversation was lying. The insurer answered the question it was asked, about federal law, and the answer that mattered was a state one nobody raised. That is why this page opens with both halves and why it hands the ambulance question straight over to a page of its own.

Nothing here is legal advice, and this site is not the Texas Department of Insurance or the Centers for Medicare and Medicaid Services. Every figure and date below carries the day it was checked.

What does the No Surprises Act ban?

Balance billing above your in-network cost sharing in three named situations, plus an arbitration process between plans and providers to settle the money without the patient in the middle. In the CMS description, the 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”, and it creates an independent dispute resolution process between plans and providers¹ (CMS fact sheet dated 3 January 2022, checked 30 July 2026).

The structural idea is worth understanding, because it explains what the law does and does not fix. A surprise bill is the gap between what an out-of-network provider charges and what your plan pays. Before the Act, that gap was yours. After it, in the protected situations, the gap is argued out between the provider and the plan and you owe only the cost sharing you would have owed in network.

One word in that CMS sentence deserves attention: “most”. The emergency protection is broad but not universal, and this site publishes no list of the exceptions, because no verified list is in its figure set as at 30 July 2026 and an incomplete list here would be worse than none. The practical version is to ask your plan in writing which category it says your bill falls into, and to get the answer as a document rather than as a phone call.

Which plans does it reach, and who decides

Your insurance card decides, and this is the highest-consequence question in Texas medical billing. Two laws sit on top of each other here and they cover different plans, so people routinely complain to the wrong body and lose weeks doing it.

The Texas Department of Insurance states the split in its own words: “Texas law applies to health plans regulated by TDI”, and “federal law applies to health plans not regulated by TDI and air ambulance services”² (TDI page last updated 21 July 2026, checked 30 July 2026).

TDI’s consumer test for the state side is whether the card carries DOI or TDI, plus ERS plans including HealthSelect, TRS plans including TRS ActiveCare and TRS-Care Standard for non-Medicare retirees, and Texas Farm Bureau or an employer plan that has opted in, whose card “might have TXI on it”³ (TDI page last updated 23 July 2026, checked 30 July 2026). A self-funded employer plan that has not opted in sits outside the Texas law and inside the federal one.

Two habits follow from this and both are cheap. Photograph the front and back of the card before you need it. And write down which law you concluded applies, and why, because that conclusion decides who you write to, and re-deriving it three phone calls later is how people give up. The state side is worked through in full in Texas balance billing law.

The right almost no uninsured Texan uses

If you have no coverage, the No Surprises Act does something completely different for you, and it is the most under-used right on this site: a good faith estimate of expected charges before a scheduled service. For uninsured and self-pay patients, the Act creates that estimate right, and a patient-provider dispute resolution process for when the final bill comes in substantially greater than the estimate¹ (checked 30 July 2026).

That matters more in Texas than almost anywhere, because there are more people it applies to. 16.7% of Texans were uninsured in 2024 against 8.2% nationally, the highest rate in the country, roughly one in six people and about 5.2 million of us⁴ (2024 data, checked 30 July 2026). A right held by one in six people and exercised by almost none of them is a strange thing to leave sitting there.

Four questions turn the estimate from a piece of paper into a usable document, and the second is the one that decides most disputes:

1. Ask for it in writing when you schedule, not on the day, and keep it with the date you received it.
2. Ask whether it covers every provider who will bill you, or only the entity issuing it. A facility estimate that silently omits the anesthesia group, the radiologist or the pathologist is not an estimate of what you will be asked to pay.
3. Ask what happens if the plan of care changes during the procedure, and what the facility will do about the estimate if it does.
4. Ask for the self-pay or cash price in the same conversation, because it is frequently below the billed charge and it is a different number from the estimate.

The last of those is its own subject: cash prices and self-pay discounts. And the estimate is strongest when it is read against the hospital’s published prices, which is why the two rights are worth using together.

Using the estimate with the published price file

Hospitals have had to publish their prices online since 1 January 2021, and the combination of that file with the good faith estimate is the strongest position an uninsured patient has ever had for anything planned. The requirement is for a comprehensive machine-readable file of all items and services and a consumer-friendly display of shoppable services; CMS audits a sample of hospitals, investigates complaints, and can impose civil monetary penalties; and enforcement of the updated requirements finalized in the CY 2026 OPPS and ASC final rule started 1 April 2026⁵ (checked 30 July 2026).

Almost nobody uses either. The reason, in my experience, is not laziness but sequencing: both rights operate before the service, and the moment people become motivated to learn about medical billing is the moment the bill arrives, which is weeks too late for either. If there is one thing to take from this page for a planned procedure, it is that the useful work happens in the week you book, not the week you are billed. See hospital price transparency.

Ground ambulance: the gap, and the half of it that is filled

Federal law does not protect you from a balance bill for a ground ambulance trip. In Texas, state law does, for TDI-regulated plans, for trips provided on or after 1 January 2024. Both sentences are true at once, and quoting only the first is how a Texan gets told to give up a protection they have.

The federal position, in TDI’s framing of it: “As of January 1, 2022, federal law prohibits health care providers and facilities and air ambulance service providers from balance billing for certain items and services”² (checked 30 July 2026). Air is named. Ground is not.

The Texas position, verbatim from the same TDI page: Texas laws ban balance billing for “Emergency medical services (EMS) and trips provided by a ground ambulance on or after January 1, 2024”, and where it applies, “health plans have to pay an amount set by Texas law for EMS care and ground ambulance trips. You don’t have to pay more than your deductible, copay, or coinsurance”² (checked 30 July 2026).

And the mirror image completes the picture: Texas law does not reach air ambulance. TDI says so directly². So the two laws are complementary rather than overlapping. Federal covers air. Texas covers ground.

Which means an ambulance bill is never a yes or a no. It is an ordered test: ground or air, then what the card says, then the date of the trip. Work it in that order and in full at ambulance bills in Texas, because an insurer telling a Texan with a TDI-regulated plan that the surprise billing law does not cover a 2024 or later ground ambulance trip is wrong, and that is a complaint rather than an outcome.

What the Act does not do

It is not a cap on what health care costs, it is not a rule about bills you agreed to in advance, and it does not reach the reason most Texans get large bills, which is having no coverage at all.

Three limits worth holding on to.

• It is a protection against a specific mechanism, the balance bill, in specific situations. A large in-network bill built from a deductible and coinsurance is not a surprise bill, and the Act does nothing about it.
• It does not decide whether the care was necessary or the coding was right. That is the itemized bill’s territory: reading an itemized bill.
• It is not the reason to hesitate in an emergency. Under EMTALA a Medicare-participating hospital that offers emergency services must provide a medical screening examination and stabilizing treatment “regardless of an individual’s ability to pay”⁶ (CMS page last modified 10 March 2026, checked 30 July 2026), with all three limits in the same breath: it is not free care and a bill follows, it reaches those hospitals rather than clinics, urgent care or physician offices, and it covers screening and stabilization rather than the ongoing treatment the emergency reveals you need. Read EMTALA and the emergency room on a day when you have time, and go anyway on a day when you do not.

The scale underneath all of this has not moved much. People in the United States owe at least $220 billion in medical debt, with about 14 million adults (6%) owing more than $1,000 and about 3 million adults (1%) owing more than $10,000⁷ (KFF analysis of the 2021 Survey of Income and Program Participation, 2021 data, checked 30 July 2026). Surprise billing was never the whole of that. It was the most obviously unfair slice of it.

How to work a bill you think breaks the law

Establish which law applies, then request the documents, then write once, properly, to the body with authority. In that order, because a complaint sent before the documents exist tends to be closed for want of evidence.

1. Check the card and conclude which law reaches the plan².
2. Request the fully itemized bill in writing and note the date you asked.
3. Get the explanation of benefits from the plan for the same dates of service, and read the two against each other.
4. Ask the hospital for its financial assistance policy in the same call, because that runs in parallel and does not wait for the dispute: hospital charity care in Texas. A nonprofit hospital should refrain from extraordinary collection actions for at least 120 days from the first post-discharge billing statement, which is working time you can use⁸ (checked 30 July 2026).
5. Write to the right body, once, with dates, names and copies.

Do not agree a payment plan while any of this is outstanding. A plan is an acknowledgement that the full amount is owed, which is exactly the question you are disputing: payment plans and what to avoid. If the account has already moved to an agency, that changes who is calling rather than what is owed: medical bill collections in Texas.

Where the complaint goes

To the body with authority over the party in the wrong, which is decided by the card test rather than by who upset you.

• A balance bill or a plan decision, where TDI regulates the plan: the Texas Department of Insurance consumer help line is 800-252-3439 toll free, or 512-676-6000 in Austin, “8 a.m. to 5 p.m. Central time, Monday through Friday”⁹ (checked 30 July 2026). How to file so it lands is in complaining to the Texas Department of Insurance.
• A plan federal law reaches: the federal No Surprises Act process rather than TDI, because TDI has no authority over a plan it does not regulate.
• A hospital that has not published its prices: CMS accepts complaints under the price transparency requirements⁵.
• A billing error or a refused financial assistance application: the hospital’s billing office, then its patient advocate or ombudsman, in writing, keeping the dates.

The order of operations for the whole bill, from the first statement to a closed account, is in medical bills in Texas. For where the bill came from in the first place, health coverage in Texas, and for the position of a Texan whom no coverage route reaches at all, the Texas coverage gap and getting care without insurance in Texas.

This site is published independently. It is not part of the State of Texas, the Texas Health and Human Services Commission, the Texas Department of Insurance or the Centers for Medicare and Medicaid Services, it cannot decide a dispute, and nothing on it is legal advice. The current text of the federal rights described here lives with CMS, and the current Texas position lives with TDI.