Which providers and facilities are exempt from the No Surprises Act and why?

1. What the law covers and why exemptions exist

Congress wrote the NSA to protect consumers from “surprise” bills for emergency care and specified non‑emergency care where patients lack meaningful choice; but lawmakers also carved out exceptions where other laws, payer arrangements, or practical considerations applied—for example, state law variation, ERISA‑governed self‑funded plans, and some ambulance services—creating a statutory and regulatory patchwork of coverage and exemptions ^{[1] [2] [3]}. The plain policy reason: Congress balanced consumer protection against preemption, existing regulatory regimes and the technical limits of federal authority in areas like state‑regulated plans and certain transportation services ^[2].

2. ERISA and self‑funded employer plans: a federal preemption wrinkle

Many state surprise‑billing laws historically did not apply to self‑funded employer plans because ERISA governs those plans; the NSA is federal, but implementation interacts with both federal and state regimes. The NAIC and related analyses emphasize that self‑insured employer plans remain a distinct regulatory category that complicates the scope of protections and exemptions in practice ^[2]. Available sources do not provide a line‑by‑line legal map here; regulators and courts continue to interpret how ERISA interacts with NSA implementation ^{[2] [5]}.

3. Ambulance services: a commonly noted exemption

Multiple summaries flag ground ambulance services as often outside the NSA’s protections or treated differently: healthinsurance.org explicitly notes that the NSA does not apply to many ground ambulance services and that state laws have been the primary mechanism for addressing ambulance balance billing, with only limited state expansions of protection ^[3]. NAIC reporting likewise highlights gaps and state‑by‑state variation in protections for ambulances, undercutting any simple “all providers covered” narrative ^[2].

4. Providers and facilities sometimes treated differently

Federal CMS materials describe categories of providers and facilities that the rules target (emergency departments, in‑network hospitals, out‑of‑network clinicians in certain settings), but also show the rulemaking and FAQs addressing limits and exceptions—meaning not every facility or provider type is identically covered and CMS guidance is evolving ^{[6] [1]}. Industry groups and legal observers note that portions of the IDR process and payment‑methodology rules (QPA) remain in litigation or enforcement discretion, which affects how and whether some out‑of‑network payments are resolved under the NSA ^{[4] [5]}.

5. Implementation frictions: IDR, QPA and enforcement discretion

The Departments’ evolving FAQs and industry analyses report that courts (notably Texas Medical Association cases) and administrative adjustments have created periods of enforcement discretion—e.g., extensions on QPA methodology enforcement—leaving practical exemptions or temporary tolerances for certain payors or service scenarios until final rules or appeals resolve the disputes ^[4]. This means that, beyond statutory exemptions, regulatory uncertainty can produce de facto exceptions in how protections reach specific providers or claims ^{[4] [5]}.

6. What the reporting does not definitively say

Available sources do not list a comprehensive, authoritative checklist of every provider or facility exempted under the NSA; rather, CMS pages, NAIC summaries and legal commentaries describe broad categories (ambulance services, interplay with ERISA/self‑funded plans, state law carve‑outs) and emphasize ongoing rulemaking and litigation that affect scope ^{[1] [2] [4]}. For a precise determination about a particular provider or claim, CMS rule pages and current FAQs are the primary references and are being updated as litigation and rulemaking proceed ^{[6] [1]}.

7. Bottom line for consumers and providers

Consumers should assume the NSA protects them from surprise emergency bills in many—but not all—scenarios; providers and payors should expect continued legal and regulatory change, particularly around ambulance services, ERISA‑governed plans and the IDR/QPA processes that determine payments ^{[1] [2] [4]}. Watch CMS’s rules and FAQs for updates—those documents and ongoing court decisions will determine whether specific providers or facilities are exempt, or merely operating under temporary enforcement discretion ^{[6] [4]}.