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Which specific health care providers and facility types are statutorily exempt from the No Surprises Act?
Executive summary
Federal No Surprises Act protections generally bar balance billing for emergency services, air ambulance transport and certain out‑of‑network (OON) services provided at in‑network facilities, but several narrow provider and service categories are treated differently or explicitly excluded in statute and guidance (for example, ground ambulance transport and plans or providers outside federal jurisdiction); the statutory text and federal FAQs and analyses make clear that air ambulance, hospitals, clinicians, and many facility types are covered while some services (notably most ground ambulance and certain ERISA/state preemption situations) fall outside or are handled differently [1] [2] [3]. Coverage and enforcement details have evolved through agency FAQs and litigation, and available reporting shows ongoing disputes about which providers and facilities are exempt or carved out [4] [5].
1. What the statute targets — hospitals, clinicians, and air ambulance providers
Congress designed the law to stop “balance billing” when patients cannot choose their provider: it protects consumers for most emergency services, post‑stabilization care, and certain non‑emergency OON services furnished at in‑network facilities, and explicitly applies to providers including hospitals, facilities, individual practitioners and air ambulance providers in those contexts [1] [3]. The law therefore reaches many facility types (hospitals and in‑network facilities) and many clinician categories (anesthesiologists, radiologists, pathologists, etc.) when they deliver the enumerated services [6] [1].
2. Key statutory and regulatory exemptions you should know about
The statute and follow‑on guidance leave several areas outside the Act’s consumer protection rules. Ground ambulance services are a well‑known example: Congress excluded most ground ambulance transports from the federal surprise‑billing payment protections while signaling interest in revisiting the issue, so many state laws and varying private insurer rules govern ground ambulance billing instead [2] [7]. The Act also interacts with ERISA and state law in ways that can make applicability complex: self‑funded employer plans (ERISA) and state‑regulated plans have different preemption and opt‑in rules that affect how protections and exemptions play out in practice [2] [8].
3. Where federal guidance and litigation have changed the operational picture
CMS and the Departments of Labor, Health and Human Services, and Treasury have issued layered FAQs and rulemaking implementing the statute; those materials (and recent litigation such as TMA III) have occasionally altered how agencies enforce protections and calculate payment benchmarks like the Qualified Payment Amount (QPA) — producing temporary enforcement discretion or updates to which providers/facilities must comply with particular procedures [4] [5]. That means whether a particular billing practice results in an enforceable “surprise bill” can depend on the timing of service and which guidance or court rulings apply [5].
4. State law, ERISA plans and the “who’s exempt” practicalities
The federal law establishes minimum protections but interacts with state rules: where a state law provides a specific payment amount or dispute process that applies to a plan, that state regime can preempt federal rules for state‑regulated plans; additionally, certain employer self‑funded plans governed by ERISA may be exempted from state law but are still subject to the federal NSA in many respects — resulting in a patchwork that affects which providers/facilities are effectively exempt in given situations [2] [8]. Analysts and industry groups continue to flag gaps (for example for some ambulance services or certain plan types) as areas where patients may still face balance billing depending on state and plan status [7] [2].
5. Areas of dispute and ongoing uncertainty
Scholars and industry observers report continuing disputes about how to classify providers, what data must be used to set benchmark payments (QPA), and whether particular provider groups are exploiting procedural paths in the IDR process — all of which affect which providers or facilities appear effectively exempt from meaningful payment constraints [9] [5]. CMS reporting and legal challenges show the subject remains contested; agency FAQs and forthcoming rulemaking have been and will be the primary mechanisms to clarify exceptions and narrow exemptions [4] [5].
6. How to determine whether a specific provider or facility is exempt in practice
To decide whether a named provider or facility type is statutorily exempt, one must: (a) identify the service context (emergency, air ambulance, non‑emergency OON at an in‑network facility, ground ambulance, etc.), (b) check whether the patient’s plan is state‑regulated or ERISA/self‑funded (and whether state law applies), and (c) consult current CMS FAQs and the Departments’ guidance for timing‑sensitive enforcement or calculation rules such as QPA methodology; CMS’s No Surprises Act resources and recent FAQs are the authoritative administrative sources to consult [10] [4] [5].
Limitations: available sources do not list a single, simple checklist of “every provider/facility statutorily exempt”; instead the statute, agency guidance, and state‑plan interactions define pockets of exemption (notably most ground ambulance and certain plan‑jurisdiction issues) and the practical reach depends on context and evolving agency guidance [2] [7] [4].