Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing.

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When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. If you receive care outside of your health plan’s network, you may have additional costs or have to pay the entire bill. 

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service, called “balance billing.”

“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’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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.

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 can 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.

 

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

 

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

• You’re only responsible for paying your share of the cost (copayments, coinsurance, and deductible)

• Generally, your health plan must:  cover emergency services without requiring you to get approval for services in advance, cover emergency services by out-of-network providers, base what you owe the provider or facility on what it would pay an in-network provider or facility and show that amount in your explanation of benefits, and count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit

 

If you think you’ve been wrongly billed, visit https://www.cms.gov/nosurprises/consumers or contact CMS at 1-800-985-3059.  Also reference:  State of Illinois Surprise Billing Law, Public Act 096-1523 or contact the Illinois Department of Insurance:  320 West Washington Street, Springfield, IL 62767 or 1-877-527-9431