No Surprises Act Compliance: DOL's 2026 Enforcement Target

The Department of Labor has elevated No Surprises Act compliance to its top enforcement priority for 2026—the first time surprise billing has been designated as a standalone federal enforcement project. This shift signals that EBSA believes many group health plans remain non-compliant four years after implementation, creating immediate compliance risks for Long Island employers who sponsor health insurance benefits.

What the No Surprises Act Requires from Employers

The No Surprises Act, effective since January 1, 2022, protects employees from unexpected medical bills by requiring group health plans to apply in-network cost-sharing for emergency services and certain non-emergency services from out-of-network providers at in-network facilities. Nassau and Suffolk County employers must ensure their health plans comply with NSA requirements regardless of whether they offer fully insured or self-insured coverage.

Key employer obligations include:

• Prohibiting balance billing for emergency services at any facility
• Applying in-network cost-sharing amounts for NSA-protected services
• Counting out-of-network payments toward in-network deductibles and out-of-pocket maximums
• Updating Summary Plan Descriptions to reflect NSA protections
• Ensuring claims processing systems automatically identify and apply NSA protections
• Participating in the federal Independent Dispute Resolution (IDR) process when provider payment disputes arise

The Department of Labor's NSA guidance emphasizes that even fully insured plans create shared compliance responsibility between employers and insurance carriers, meaning plan sponsors cannot simply delegate NSA obligations to their carriers.

Professional plan administration support helps ensure that claims processing systems properly identify NSA-protected services and apply appropriate cost-sharing while maintaining comprehensive documentation of compliance efforts.

EBSA's Six Enforcement Focus Areas

The Department of Labor's 2026 enforcement priorities target specific areas where health plans commonly fail to meet NSA requirements. Long Island employers must understand these focus areas to evaluate their own compliance status and identify potential exposure risks.

Emergency Services Treatment: EBSA will investigate whether health plans properly treat all emergency services under NSA protections, regardless of provider network status. This includes ensuring that emergency room visits, ambulance services, and emergency procedures receive in-network cost-sharing treatment even when provided by out-of-network facilities or providers.

Cost-Sharing Compliance: Plans must apply in-network deductibles, copayments, and coinsurance to services covered under NSA protections. Nassau County employers must verify their carriers or third-party administrators have systems that automatically recognize NSA-protected claims and apply appropriate cost-sharing without manual intervention.

Notice and Disclosure Requirements: Health plans must provide participants with clear information about their NSA rights and protections. This includes updating plan materials, enrollment communications, and claim explanations to reflect NSA protections.

The detailed analysis of DOL health plan enforcement priorities notes that notice violations create separate penalty exposure beyond claims processing failures, making comprehensive participant communication essential for compliance protection.

Claims Processing: The Technical Challenge

The most complex aspect of NSA compliance involves ensuring claims processing systems correctly identify protected services and apply appropriate cost-sharing automatically. Suffolk County employers must verify their carriers and third-party administrators have updated their systems to handle NSA requirements without relying on manual review processes that create delays and errors.

Critical system requirements include:

• Automatic identification of emergency services regardless of facility network status
• Recognition of non-emergency services at in-network facilities involving out-of-network providers
• Application of in-network cost-sharing for all NSA-protected services
• Proper crediting of payments toward in-network deductibles and out-of-pocket maximums
• Generation of accurate explanation of benefits statements reflecting NSA protections

Many Long Island employers discover compliance gaps only when employees receive unexpected bills for services that should have been protected under NSA requirements. These participant complaints can trigger EBSA investigations that examine the entire health plan's compliance status, potentially exposing broader violations beyond the initial complaint.

Professional compliance support helps employers verify their carriers and TPAs have proper NSA processing capabilities while establishing monitoring systems to identify and correct violations before they trigger enforcement action.

Payment Timeliness and IDR Process

The No Surprises Act requires health plans to make timely payments to providers during open negotiations and participate in the federal Independent Dispute Resolution process when payment disputes arise. Nassau and Suffolk County employers must ensure their plans meet these payment obligations to avoid provider complaints that can trigger EBSA investigations.

The payment timeline requirements include:

• Initial payment or denial within 30 days of claim submission
• Good faith payment during 30-day open negotiation period
• Participation in federal IDR process when negotiations fail
• Compliance with IDR payment determinations
• Proper documentation of all payment and negotiation activities

Employers with self-insured plans bear full responsibility for NSA payment compliance, while those with fully insured coverage must verify their carriers meet these obligations. The analysis of DOL enforcement priority changes indicates that payment violations often result in both EBSA penalties and provider lawsuits seeking additional damages.

Prior Authorization Restrictions

The Department of Labor will specifically review whether health plans improperly apply prior authorization requirements to emergency services covered under NSA protections. Long Island employers must ensure their plans cannot deny or delay payment for emergency services based on prior authorization failures.

NSA prior authorization restrictions include:

• Prohibition on prior authorization for emergency services
• Elimination of prior authorization as grounds for claim denial
• Removal of prior authorization requirements from emergency service procedures
• Clear participant communication about emergency service coverage

Many health plans maintain prior authorization procedures that conflict with NSA requirements, creating compliance violations that expose employers to enforcement action. Suffolk County businesses must review their plan documents and carrier procedures to ensure prior authorization requirements don't violate NSA protections.

Compliance Documentation and Investigation Response

EBSA investigations will focus on systemic compliance failures rather than isolated errors, requiring employers to demonstrate comprehensive NSA compliance through detailed documentation and monitoring procedures. Long Island employers must maintain records that show ongoing attention to NSA requirements and prompt correction of any identified violations.

Essential documentation includes:

• Updated Summary Plan Descriptions reflecting NSA protections
• Participant communication materials explaining NSA rights
• Claims processing procedures and system capabilities
• Provider payment records and IDR participation
• Monitoring procedures and compliance verification activities

The complexity of NSA requirements often exceeds the capabilities of internal HR departments, making professional benefits administration support essential for maintaining comprehensive compliance while preparing for potential EBSA investigations.

Taking Action: Preparing for Enhanced Enforcement

Nassau and Suffolk County employers cannot afford to treat NSA compliance as a carrier responsibility—the Department of Labor's enforcement priorities make clear that plan sponsors retain ultimate accountability for ensuring their health plans meet federal surprise billing requirements.

Critical preparation steps include:

• Reviewing current plan documents and participant materials for NSA compliance
• Verifying carrier and TPA systems properly process NSA-protected claims
• Establishing monitoring procedures to identify compliance gaps
• Creating comprehensive documentation systems for EBSA investigation response
• Working with qualified benefits administration professionals who understand NSA requirements

The Department of Labor's designation of NSA compliance as its top 2026 enforcement priority signals that investigation activity will increase significantly, with particular focus on plans that have not fully implemented required protections four years after the law took effect.

Employers with questions about No Surprises Act compliance can reach us at info@bentonoakfield.com.

This content is for informational purposes only and does not constitute legal, tax, or benefits advice. Requirements vary based on employer size, location, and plan structure. Information is current as of 2026-02-16. Employers should consult qualified advisors for guidance on their specific circumstances.