Your Rights and Protections Against Surprise Medical Bills
When you get medical care, some of the medical staff or services may not be considered in-network by your insurance company, even if you receive them at an in-network setting. This can lead to issues that pass unexpectedly high costs on to patients. In 2022, the Federal No Surprises Act established protections against such surprise bills. This notice provides you with a basic summary of your rights and protections.
When you get emergency care or treatment by out-of-network providers, at an in-network hospital or ambulatory surgical center, you are protected from surprise or balance-billing.
Important Terms:
“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 healthcare 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 do not 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 not 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.
Certain services at in-network hospitals or ambulatory surgical centers
When you get services from an in-network hospital or ambulatory surgical center, certain providers 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 services by emergency medicine, anesthesia, pathology, radiology, laboratory tests, neonatology, assistant surgeons, hospitalists, or intensivists 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 not balance bill you, unless you give voluntary, written consent giving up your protections.
You are never required to give up your protections from balance billing. You are also never required to get care out-of-network. You have the right to choose a provider or facility in your plan’s network.
Medical services in Illinois are further protected by Illinois Public Act 96-1523 of 2011, which includes rules similar to the Federal No Surprises Act. It shields insured patients against additional out-of-pocket costs from most out-of-network medical staff providing services at an in-network facility. The law explicitly defines this as anyone who provides radiology, anesthesiology, pathology, neonatology or emergency department services in a hospital or ambulatory surgical treatment center. Illinois Public Act 94-0885 also requires insured patients be provided advance notice that healthcare professionals affiliated with the hospital may not be participating within the same insurance plans and networks as the hospital.
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 directly.
Your health plan generally must:
- Cover emergency services, without prior authorization (requiring approval for services in advance).
- Cover emergency services by out-of-network providers.
- 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 benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you have been incorrectly billed, contact the following for help:
HHS Department of Labor and the Office of Personnel Management at 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
Visit https://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=096-1523 for more information
about your rights under Illinois Public Act 96-1523.
For questions pertaining to your bill, directly related to services provided by In Home Medical Group LLC, you may call (866) 663-1199.