What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Surprise Billing in Illinois

Illinois state law (Illinois Public Act 096-1523) provides that you under certain circumstances you are protected from “balance” or “surprise” bills.  This protection applies when you receive care at an in-network facility or ambulatory surgery center from out-of-network providers who provide radiology, anesthesiology, pathology, neonatology, or emergency physician services at that in-network facility.  When you receive care in this situation, charges to you cannot be greater out-of-pocket expenses you would have been covered for from your insurance plan for in-network physician or provider services. The out-of-network provider should not send you a bill.

Exceptions to Illinois Surprise Billing Protections

In some situation, you may still be required to pay an out-of-network bill in certain situations. This protection under Illinois’ surprise billing law only applies to insurance plans regulated by the state of Illinois. If your insurance plan is not regulated by the state, you may still be billed for these out-of-network charges. In addition, these protections only apply to certain out-of-network providers who are based in an in-network facility.  When you go to a facility where you receive these services and the facility itself is out-of-network, you can also receive an out-of-network bill. Similarly, these protections do not apply if you purposely choose a provider not within your insurance network.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

Surprise Billing in Illinois

Illinois state law (Illinois Public Act 096-1523) provides that you under certain circumstances you are protected from “balance” or “surprise” bills.  This protection applies when you receive care at an in-network facility or ambulatory surgery center from out-of-network providers who provide radiology, anesthesiology, pathology, neonatology, or emergency physician services at that in-network facility.  When you receive care in this situation, charges to you cannot be greater out-of-pocket expenses you would have been covered for from your insurance plan for in-network physician or provider services. The out-of-network provider should not send you a bill.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for service es in advance (prior authorization).
  • Cover emergency services by out-of-network
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket

If you believe you’ve been wrongly billed, you may contact:

File a state complaint: If you would like to file a state complaint, please do so with the Illinois Department of Insurance by visiting the link below:

https://www2.illinois.gov/sites/Insurance/Consumers/Pages/File-a-complaint.aspx?utm_medium=301re&utm_source=mybill-nm-org&utm_campaign=mybill&utm_medium=301re&utm_source=mybill-nm-org

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

Visit https://illinoispirg.org/feature/usp/ending-surprise-medical-bills for more information about your rights under Illinois law.