Health & Benefits

What is "surprise billing"?  

Some health care providers are in your health plan's network. These providers are called "in-network" or "participating providers." Usually, in-network providers agree to accept a certain amount for services. The in-network provider can only bill you for the difference between: 

• the agreed amount, and 
• the amount your plan pays.

Some health care providers are not in your health plan's network. These providers are called "out-of-network" or "non-participating providers." Out-of-network providers do not agree to accept a certain amount for services. The amount your health care plan will pay is often limited. The provider can bill you for the full amount of the difference between:

• the amount the provider charges, and 
• the amount your plan pays.

This is sometimes called "balance billing" or "surprise billing."

The No Surprises Act became law in 2022 to help prevent certain types of surprise billing. Before the federal No Surprises Act, you could have received a surprise bill if you received medical services from an out-of-network provider. This is true even if: 

• you didn't know, or would have no reason to know, that the services were from an out-of-network provider, or 
• you couldn't avoid receiving services from an out-of-network provider, such as in an emergency.  

Many states, including Illinois, have also enacted laws that protect against surprise billing.  

Does surprise billing apply to Medicare and Medicaid patients?

No. If you are covered by Medicare or Medicaid, you are already protected against “surprise billing.”  

What does the federal No Surprises Act cover?

Under the No Surprises Act, you have a few protections if your medical coverage is through your employer, the health insurance marketplace, or certain individual medical plans. The federal law bans:

• Surprise bills for most emergency services. It covers the situation where you get services from an out-of-network provider without approval beforehand. The law also protects against surprise billing by out-of-network air ambulance services. 
• Out-of-network balance billing for most emergency and some non-emergency services. For example, it bans out-of-network coinsurance or copayments. You can’t be charged more than in-network cost-sharing for these services.
• Out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) provided by out-of-network providers as part of a patient’s visit to an in-network facility.

Additionally, the federal law requires that health care providers and facilities give you an easy-to-understand notice that explains:

• Your billing protections,
• Who to contact if you have concerns that a provider or facility has violated the protections, and 
• That patient consent When someone gives permission for someone else to do something is required to waive To give up a legal right or pardon a fee billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

Plans not required to provide services

Even though most employer and individual group health plans provide services that are protected by the No Surprises Act, a plan is generally not required to provide those services.  The No Surprises Act applies if a plan provides the applicable services.

Illinois No Surprises Act

Illinois also has a No Surprises Act. Under Illinois law, you cannot be charged greater out-of-pocket expenses than you would have been charged for covered, in-network physician or provider services. Also, the out-of-network provider should not send you a bill. 

The Illinois No Surprises Act does not override the federal No Surprises Act. Instead, it works to complement the federal law and provide broad protections for individuals. 

What if I am uninsured?

If you are uninsured, in most cases, these rules make sure you can get a good faith An honest effort to do something estimate of how much your care will cost before you receive it. Learn more about the federal and state law rules. 

What should I do if to report a No Surprises Act violation?

If you believe you’ve been wrongly billed, you may contact:
Federal No Surprises Helpdesk at: 1-800-985-3059
Illinois Department of Insurance Office of Consumer Health Insurance
320 West Washington Street
Springfield, IL 62767
Toll-free: 877-527-9431
TDD: 866-323-5321
Fax: 217-558-2083