Part 15 · Chapter 2

The No Surprises Act

Law stated as of October 3, 2026 · Health Plan Parity, CAA, and Transparency

Scope and status

This chapter, written from the plan/plan-sponsor side, covers the No Surprises Act (CAA 2021, Division BB, Title I): the balance-billing protections and plan cost-sharing/payment rules, the QPA, the federal IDR process (including the June 2026 IDR operations final rule), the TMA litigation line (including the Fifth Circuit's August 11, 2026 en banc decision on the QPA-methodology rules), and the adjacent CAA patient-protection obligations (ID cards, continuity of care, provider directories, advanced EOBs). The IDR machinery and the QPA rules are actively moving — verify the operative rules and enforcement-discretion windows for any live dispute.

Citations are to primary authority (ERISA §§716–725 as added by the CAA 2021; Code §§9816–9817; PHSA §§2799A-1 et seq.; the July 2021 and October 2021 interim final rules; the August 2024 IDR-related guidance; the June 2026 operations final rule; and the TMA decisions). Related questions are treated elsewhere: claims/appeals and external-review mechanics in Part 4 (Reporting, Disclosure, Recordkeeping, and Claims); the self-insured applicability map in Part 13 (COBRA, HIPAA, and Welfare Benefits); and MHPAEA and the transparency/reporting deliverables in this Part's companion chapteri.

Threshold framing. For plans, the NSA is three obligations stacked: (1) cost-sharing for protected out-of-network services must be computed at the in-network level using the recognized amount (usually the QPA); (2) payment/denial within 30 calendar days after the bill is transmitted (the regulations key the clock to receipt of the information needed to decide the claim, except for air ambulance, where the TMA III district court vacated that trigger — a vacatur the en banc court did not separately address; confirm current status), then open negotiation and IDR if the provider disputes; and (3) prompt payment of any IDR award (30 days). Most plan-side failures are operational — QPA computation, deadline management, and IDR-award payment tracking, typically delegated to a TPA whose performance the plan fiduciary must monitor.

Sections

Part A is shown in full. The other sections are listed by title; their text is available to subscribers.

Part A — Scope and Protections

A1.Protected services

Part 15, ch. 2, § A1

The NSA protects participants against balance billing for: (1) emergency services (including post-stabilization services until transfer conditions are met) from out-of-network facilities/providers; (2) non-emergency services by out-of-network providers at in-network facilities — with an absolute protection for ancillary services (anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeons/hospitalists/intensivists, and services when no in-network provider is available) and a notice-and-consent waiver path only for non-ancillary services (the standardized notice/consent, given at least 72 hours before the service, or on the day of scheduling if the appointment is made less than 72 hours ahead, and no later than 3 hours before a same-day service; 45 C.F.R. §149.420(d)); and (3) out-of-network air ambulance services (ground ambulance is not covered — a federal advisory committee studied it; state laws may apply). Statute: ERISA §§716–717; Code §§9816–9817; PHSA §§2799A-1, -2; Final reg (IFR): 86 Fed. Reg. 36872 (July 13, 2021). The NSA applies to grandfathered and non-grandfathered, insured and self-insured group health plans; excepted benefits and retiree-only plans are out.

A2.Cost-sharing and the recognized amount

Part 15, ch. 2, § A2

Participant cost-sharing for protected services is computed on the recognized amount: a specified state law amount (insured coverage in states with balance-billing laws), an All-Payer Model Agreement amount (which takes priority where one applies), or — otherwise, and the usual case for self-insured ERISA plans that have not opted into a state law — the lesser of the qualifying payment amount (QPA) and the billed amount (29 C.F.R. §2590.716-3; 45 C.F.R. §149.30). Statute: ERISA §716(a)(3)(H); Final reg (IFR): 86 Fed. Reg. 36872. Self-insured plans may opt in to some state programs where the state permits.

Part E — Enforcement and the Plan Fiduciary Overlay

The first Part of each chapter is open to everyone. The remaining sections, with their authority and practice points, are available to subscribers and to clients of ERISA Benefits Law Group, PLLC whose engagement includes access.