No Surprises Act for Employer Health Plans
What the federal surprise billing law means for an employer group health plan: the protections, the notices, the payment dispute process, and which pieces are still not being enforced. Related: Transparency in Coverage machine-readable files and the price comparison tool.
What the Law Protects Your Employees From
These protections are built into the plan by federal law. They apply whether the plan is fully insured or self-funded.
Emergency Services
Where a plan covers emergency care, participants are protected from surprise bills for emergency care from a nonparticipating provider, including where the plan has no designated network. Employers should check that plan documents and participant communications describe this protection accurately, and ask the carrier or administrator how these claims are handled.
Out-Of-Network Emergency Care
If a plan covers emergency care at an in-network hospital or freestanding emergency department, it must also cover the same emergency services at an out-of-network one. Participants generally pay in-network cost sharing in these situations, so make sure your benefit explanations do not suggest otherwise.
Non-Emergency Care at In-Network Facilities
Participants are protected in many cases from unexpected out-of-network charges from providers such as anesthesiologists or radiologists at an in-network facility. Some exceptions exist and the details are technical, so refer employee questions about a specific bill to the plan administrator or carrier.
Air Ambulance
Where the plan generally covers air ambulance services, participants are protected from surprise out-of-network air ambulance bills. Ground ambulance is treated differently under the federal rules, so employees should not assume the same protection applies there. Confirm current treatment with counsel.
Cost Sharing
For protected services, participant cost sharing must generally be based on in-network rates. That generally means copays, coinsurance and deductibles are calculated as if the provider were in network, and the amounts count toward in-network deductibles and out-of-pocket limits. Confirm how your plan applies this.
Notices
Participants are entitled to notices explaining their protections under the law. Your carrier or administrator usually supplies them. Confirm who is responsible. Look at your plan documents and carrier agreements to see who posts and sends them, and keep a record of the delivery method.
Independent Dispute Resolution for Plans
When a provider and a plan disagree on payment for a protected service, a federal process settles it.
The Federal Process
The federal independent dispute resolution process settles certain payment disputes between providers, facilities and health plans or issuers. Most employers will not run it directly, because carriers and administrators typically handle these disputes, but it helps to know it exists when claims are discussed.
Final Rules
The Departments published final Federal IDR Operations rules in the Federal Register on June 4, 2026, with an effective date of August 3, 2026. They update dispute resolution standards for plans and issuers and change how some disputes are processed. Confirm current requirements with counsel or your plan’s service providers.
Administrative Fee
For disputes initiated on or after June 11, 2026, CMS lists the administrative fee at $15 per party per dispute.
Who Signs Up
Plans that process disputes themselves must register on the IDR Gateway. If a plan uses a third-party administrator, the administrator must register instead. Ask your administrator whether it handles the registration, so the responsibility is not left unassigned. Counsel or your administrator can confirm current requirements.
Payment Disclosures
A plan or issuer must disclose required information with each initial payment, or send a notice of denial. Failing to do so can let a provider request an extension to start the process. Ask your carrier or administrator how these disclosures are generated and tracked, since the process sits with them rather than with the employer.
Self-Insured Plan Attestations
Self-insured plans must state whether they have opted in to any relevant specified state laws. Church and non-federal governmental plans must say whether they are fully insured or self-insured. Which category your plan falls into depends on how it is funded and who sponsors it, so confirm the answer with your administrator or counsel before the attestation is submitted.
In Effect and Delayed
This status comes from a CMS implementation document last revised in August 2023. Check CMS for newer guidance before you rely on it.
Identification Cards
In effect. CMS says plans may use any reasonable method to comply. Many plans already show deductible and out-of-pocket information on member cards or through an online portal, so check what your carrier provides and whether anything needs to be added. Counsel can confirm what applies to your plan.
Provider Directories
In effect, but regulations have not been issued. Plans are not penalized if they follow a good faith interpretation. Directory accuracy is largely in the hands of carriers and networks, so ask yours how often listings are updated and how employees can report errors.
Continuity of Care
In effect, but regulations have not been issued. Plans must keep providing benefits using a reasonable interpretation of the law. If a provider leaves a network mid-treatment, employees may have questions, so know who at your carrier handles those cases and how employees reach them.
Advanced Explanation of Benefits
Not yet in effect. CMS lists a delayed effective date, with enforcement waiting on rulemaking. Until the requirements settle, the practical step is to ask your carrier or administrator how it is preparing, so you are not surprised when timing is confirmed. Counsel can track updates.
Price Comparison
Related requirements took effect on January 1, 2023 and overlap with the Transparency in Coverage rules. Employees may reach these tools through the carrier portal or app, so make sure your open enrollment materials point them to where those tools live and who to call for help.
Gag Clause Attestation
Separate from the above. The annual attestation is due December 31 and applies to fully insured and self-funded plans. See our Michigan compliance calendar. Many sponsors have their carrier or administrator submit it, but confirm in writing who is doing so, and keep a copy of the filing.
Questions Employers Ask
Does the No Surprises Act Apply to Small Employers?
Yes. The protections are built into group health plans regardless of employer size, whether fully insured or self-funded.
Who Sends the Required Notices?
Usually the carrier or administrator. Confirm in writing who is responsible and that it is being done.
Do We Pay the Dispute Fee?
Fees are paid by the parties to a dispute. The listed administrative fee is $15 per party for disputes initiated on or after June 11, 2026.
Do Self-Funded Plans Register for the IDR Gateway?
A plan that processes disputes itself must register. If a third-party administrator handles them, the administrator registers.
Is the Advanced Explanation of Benefits Required Yet?
Not as of the CMS status document we reviewed, which lists it as delayed pending rulemaking. Check CMS for updates.
What Is the Difference Between This and the Gag Clause Attestation?
The gag clause attestation is a separate annual filing due December 31. The surprise billing protections operate automatically in the plan.
Where Do I Start?
Ask your carrier or administrator to confirm the notices, directory process and dispute handling in writing.
Is This Legal Advice?
No. This is general information from benefits advisors. Consult your attorney for your plan.
Related Guides
Related reading: Michigan Benefits Compliance Hub · Michigan Compliance Calendar · HSA, FSA and Section 125 Limits · Gag Clause Prohibition and the Annual Attestation · RxDC Prescription Drug Reporting for Employer Plans · Balance Billing Protections · Provider Directory Accuracy
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