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Map: No Surprises Act Enforcement

The No Surprises Act, signed into law in 2020, went into effect for most consumers enrolled in individual and group health insurance plans on January 1, 2022. The new law addresses surprise bills for medical care in any of the following three circumstances: 

  • an enrollee receives emergency care at an out-of-network facility or from an out-of-network provider 

  • an enrollee requires emergency air-ambulance transportation (but not ground-ambulance services) 

  • an enrollee receives elective nonemergency care at an in-network facility but is inadvertently treated by an out-of-network health care provider. 


External review. A process for appealing an adverse insurer determination — that is, a coverage decision — that involves consideration of whether an insurer is complying with the No Surprises Act. 

Federal enforcement. The federal government has responsibility for enforcing the relevant provisions. 

Independent dispute resolution (IDR). Process for determining payments to out-of-network providers when providers challenge the amount paid by the insurer and when negotiations fail.

Patient–provider dispute resolution. A process for resolving disputes between patients and providers with regard to good-faith cost estimates. 

Provider. A facility covered under the No Surprises Act (hospital, critical access hospital, hospital outpatient department, or ambulatory surgery center), an individual physician or nonphysician provider, or an air ambulance provider.

Shared (collaborative enforcement). Enforcement is shared, and a collaborative enforcement agreement between the state and the federal government will be used to allocate responsibilities for at least some designated provisions. For example, for enforcement against providers, the state might investigate and issue voluntary enforcement letters and the federal government would impose civil monetary penalties as needed.

Shared enforcement. Some provisions are enforced by the state and some by the federal government.  

Specified state law. A state law that is recognized as having a specific mechanism to determine how much insurers should pay out-of-network providers. 

State enforcement. The state has responsibility for enforcing the provisions that apply to state-regulated insurers and/or providers. 

View the No Surprises Act Map below

In these scenarios, consumers are guaranteed that their costs are generally limited to in-network cost sharing, and providers are banned from sending balance bills for any amounts beyond cost sharing. The federal law builds on state laws enacted in 33 states, extending protections to consumers in self-funded plans that states cannot regulate and extending protections for air-ambulance services, where federal law restricted states’ ability to act. 

Implementation and enforcement of the No Surprises Act involve both federal and state governments. Generally, the law assigns enforcement to the states but calls for federal enforcement where states are unwilling or unable to take it on. Many states are sharing enforcement responsibility with the federal government, sometimes with a collaborative enforcement agreement. In addition, almost half of all states have specified state laws that will be used to determine payments from insurers (generally state-regulated insurers) to out-of-network providers in lieu of the federal independent dispute resolution system.  

This interactive map summarizes the roles of the federal and state governments on various aspects of the No Surprises Act, including enforcement, specified state laws for payment determination, the use of external review for surprise-billing cases, and the patient–provider dispute resolution process.  For more information about the impact of the No Surprises Act on consumers, including how to file complaints, please refer to the Centers for Medicaid and Medicaid Services’ No Surprises Act Consumer FAQ page. To contact state regulators regarding the No Surprises Act, please click here for agency websites.  

Hover over each state for more information. Use the drop-down menu to select different state actions. Zoom in on Washington, D.C., to view its data. 

Publication Details



Madeline O’Brien, Research Fellow, Center on Health Insurance Reforms, Georgetown University Health Policy Institute

[email protected]


Madeline O’Brien, “Map: No Surprises Act Enforcement,” Commonwealth Fund, Mar. 14, 2022.