Balance Billing Illinois: Your Rights and Protections

In Illinois, you have rights and protections against balance billing, which is when a healthcare provider charges you for services that your insurance doesn't cover.

Balance billing is prohibited for emergency services, including emergency room visits and ambulance rides.

If you receive medical services from an out-of-network provider, they can't charge you more than the in-network cost-sharing amount.

You're also protected from balance billing for non-emergency services if your insurance plan requires you to get a referral from your primary care physician.

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Balance billing is a surprise medical bill you may receive when you see a healthcare provider or facility that's not in your health plan's network. This can happen even if you're at an in-network facility, but an out-of-network provider is involved in your care.

You may owe the difference between what your plan pays and the full amount charged for a service, which can be more than what you'd pay for the same service at an in-network provider. This amount may not count toward your annual out-of-pocket limit.

In emergency situations or when you're unexpectedly treated by an out-of-network provider, you may receive a surprise balance bill.

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Balance billing is when an out-of-network healthcare provider bills you for the difference between what your health plan agreed to pay and the full amount charged for a service. This amount is likely to be more than what you would have paid if you had seen an in-network provider.

You may receive an unexpected balance bill if you see a healthcare provider or facility that isn't in your health plan's network, or if you're treated by an out-of-network provider at an in-network facility. This can happen during an emergency or when you're unexpectedly treated by an out-of-network provider.

Out-of-network providers may bill you for the difference between what your plan pays and the full amount charged for a service. This amount may not count toward your annual out-of-pocket limit.

Surprise billing is an unexpected balance bill that can cost thousands of dollars, depending on the procedure or service.

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Balance billing is a situation where you're charged more for a service because the provider isn't part of your health plan's network. This can happen even if you have a good health plan.

You may owe out-of-pocket costs, like a copayment, coinsurance, or deductible, when you see a doctor or other health care provider. These costs are part of having health insurance.

Out-of-network providers can bill you for the difference between what your plan pays 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.

Illinois Law provides additional protections against balance billing. You're protected from balance billing if you receive anesthesiology, emergency, laboratory, pathology, or radiology services provided by an out-of-network provider at an in-network hospital or ambulatory surgical center.

If you have a health plan overseen by the State of Illinois, out-of-network providers can't balance bill you for these services under Illinois law. This means you can't be charged more than your plan's copayments, coinsurance, and/or deductible.

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.

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Here are some key protections you have under Illinois law:

Illinois law also requires your health plan to cover emergency services without prior authorization. This means you can get emergency care without needing to get approval in advance.

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Exceptions to Illinois Surprise Billing Protections exist, so it's essential to understand when you may still be responsible for paying out-of-network bills.

Insurance plans not regulated by the state of Illinois may not be covered by surprise billing protections. This means you could still receive an out-of-network bill for services received from out-of-network providers.

Out-of-network providers based in an in-network facility may not be covered by surprise billing protections if the facility itself is out-of-network.

You're only responsible for paying your share of the cost, such as copayments, coinsurance, and deductible, if you receive services from an out-of-network provider or facility.

Here are the specifics of what you're responsible for paying:

In-network services are a key part of avoiding balance billing in Illinois. You can choose a provider or facility in your plan's network, and that's always the best option.

If you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. But that doesn't mean you'll get a surprise bill - the most those providers can bill you is your plan's in-network cost-sharing amount.

Emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services are examples of services that can't be balance billed, even if the provider is out-of-network.

You're never required to give up your protections from balance billing. You can stick with in-network care and avoid unexpected bills.

Out-of-network providers can't balance bill you for services at in-network facilities, unless you give written consent and give up your protections.

In Illinois, you're protected from surprise medical bills when you receive care at an in-network facility or ambulatory surgery center from out-of-network providers.

These out-of-network providers include radiology, anesthesiology, pathology, neonatology, and emergency physician services.

You cannot be charged more out-of-pocket expenses than you would have been for covered, in-network physician or provider services.

The out-of-network provider should not send you a bill for these services.

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