New CHIR Report Examines Federal-State Partnership in No Surprises Act Implementation

By Jack Hoadley, Madeline O’Brien, and Kevin Lucia

The No Surprises Act (NSA), effective as of January 2022, aims to protect consumers facing surprise medical bills after receiving care from out-of-network providers under circumstances beyond their control.

In a new report for the Commonwealth Fund, CHIR’s Jack Hoadley, Madeline O’Brien, and Kevin Lucia examine how states are working with the federal government to implement this landmark law. Authors analyzed legislation and regulatory documents related to the NSA, including enforcement letters issued to each state by the Centers for Medicare and Medicaid Services, and conducted interviews with insurance regulators in 12 states.

Key findings from the report include:

  • Most states are sharing the responsibility of enforcing the NSA with the federal government on a provision-by-provision basis.
  • Disputes over determining insurer payments to out-of-network providers will be resolved by the federal independent dispute resolution system in a majority of states.
  • Some state systems for determining provider payments are more favorable to providers than the federal default, raising concerns about potential reimbursement rate inflation (and ultimately higher premiums).
  • While the NSA expands consumer protections against surprise medical bills in many states, some state laws go further, such as protecting consumers in state-regulated health plans against surprise out-of-network ground ambulance bills.
  • Federal and state officials highlighted the importance of educating consumers, providers, and insurers about the NSA’s protections.

You can read the full report here. For any questions, contact Jack Hoadley at

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