When you visit an out-of-network doctor or hospital, your medical bills can skyrocket. Here’s why and what you can do about it:
- Higher Costs: Out-of-network services often mean higher deductibles, lower insurance coverage, and balance billing (you pay the difference between the provider’s charge and what insurance covers).
- Example: An $825 doctor’s visit might cost you $140 in-network but $645 out-of-network.
- Key Protections: Federal and Illinois laws (like the No Surprises Act) protect you from surprise bills in emergencies or at in-network facilities when treated by out-of-network providers.
- New Illinois Rules: Starting July 1, 2025, ambulance services will also be capped at in-network rates.
Quick Comparison
| Cost Component | In-Network | Out-of-Network |
|---|---|---|
| Deductible | $1,000 | $3,000 |
| Coinsurance Rate | 20% | 50% |
| Balance Billing Protection | Yes | Limited |
What You Can Do:
- Always confirm your provider is in-network before care.
- Use tools like "Find a Doctor" from your insurer.
- For surprise bills, contact your insurer or Illinois Department of Insurance for help.
Avoiding out-of-network care saves money and stress. Learn more about your rights and how to avoid surprise bills below.
Out-of-network payment process under the No Surprises Act
Out-of-Network Charges and Cost Breakdown
Dealing with out-of-network care can lead to hefty medical bills, often leaving you with much higher out-of-pocket costs compared to in-network services.
Balance Billing and Surprise Medical Bills
One major issue with out-of-network care is balance billing. This happens when an out-of-network provider charges you the difference between their total fee and what your insurance covers. Unlike in-network providers, out-of-network providers don’t have to accept the rates set by your insurer.
Here’s an example: If an out-of-network specialist charges well above your insurer’s allowed rate, you could get a bill for the remaining balance – on top of your deductible and coinsurance. This can lead to unexpected and significant financial strain.
Thankfully, there are protections in place to help. The federal No Surprises Act ensures you won’t face balance billing in emergencies or for certain non-emergency services provided by out-of-network providers at in-network facilities. In Illinois, these protections go even further. As of 2022, state law prohibits balance billing for services provided by non-participating facility-based doctors (like anesthesiologists or radiologists) at in-network hospitals or surgical centers.
Illinois law also ensures that if you’re covered under a state-regulated health plan and receive specific services – like emergency, anesthesiology, or laboratory services – from an out-of-network provider at an in-network facility, you’re only responsible for your usual in-network costs.
These laws provide some relief, but they don’t eliminate the broader challenges of out-of-network expenses.
Higher Deductibles, Coinsurance, and Out-of-Pocket Costs
On top of balance billing, out-of-network care often comes with steeper cost-sharing requirements. For starters, deductibles for out-of-network services are usually much higher. For instance, while your in-network deductible might be $1,000, your out-of-network deductible could jump to $3,000 before your insurer starts covering costs.
Coinsurance rates are another factor. With in-network care, you might pay 20% of the bill, but for out-of-network services, that rate could climb to 50%. This means you’re paying a much larger share of the cost.
Then there’s the issue of out-of-pocket maximums. For 2025, the maximum out-of-pocket limit is $9,200 for individuals and $18,400 for families. However, out-of-network expenses often don’t count toward these limits, leaving you exposed to even higher costs.
| Cost Component | In-Network Example | Out-of-Network Example |
|---|---|---|
| Annual Deductible | $1,000 | $3,000 (example) |
| Coinsurance Rate | 20% | 50% (example) |
| Out-of-Pocket Maximum | $9,200 | May not count toward limit |
| Balance Billing Protection | Standard | Limited |
*These figures are only examples; actual amounts depend on your plan.
In short, even routine care can become significantly more expensive when you go out-of-network, potentially adding thousands to your medical bills for the same services.
Legal Protections and Illinois Rules
Illinois residents are safeguarded against surprise medical bills thanks to a combination of federal and state laws. Together, these measures ensure stronger rights and options when dealing with unexpected out-of-network charges. Here’s how these protections work.
The No Surprises Act
The federal No Surprises Act, introduced in 2022, shields individuals with employer-sponsored, marketplace, or certain individual health plans from surprise bills in many situations. For emergency services, the law ensures you won’t face balance billing – even if the hospital or provider is out-of-network and you didn’t have prior authorization. So, if you’re rushed to an emergency room, you’re protected from extra charges regardless of the facility’s network status.
For non-emergency services, the law prevents out-of-network cost-sharing when you’re treated at an in-network facility but by an out-of-network provider, such as an anesthesiologist or radiologist. Providers are also required to give clear billing notices, including contact details and a statement that your consent is needed to waive these protections.
Uninsured individuals benefit as well, receiving upfront cost estimates before treatment. If the final bill exceeds the estimate by more than $400, they can dispute the charges. If you believe you’ve been improperly billed, you can reach the Federal No Surprises Helpdesk at 1-800-985-3059 for assistance.
Illinois Consumer Protections
In addition to federal regulations, Illinois has implemented additional safeguards to further protect residents. The state’s own No Surprises Act complements federal law, ensuring you don’t pay more out-of-pocket for out-of-network services than you would for in-network care.
The Illinois Department of Insurance (IDOI) has been given greater authority through HB4703 to help consumers tackle large out-of-network bills. As IDOI Director Dana Popish Severinghaus stated:
"We look forward to intervening on behalf of more Illinois insurance consumers to fight surprise medical billing."
Starting July 1, 2025, Illinois will introduce SB2405, also known as the Consumer Protection from Surprise Health Care Billing Act, which focuses on ambulance services. This law ensures that non-participating ambulance providers cannot charge you more than in-network rates. It also regulates costs like base charges, advanced life support, and mileage fees while establishing a dispute resolution process. Non-compliance with this act is considered an unlawful practice under the Consumer Fraud and Deceptive Business Practices Act, giving the Attorney General enforcement authority.
Additionally, Illinois has taken steps to eliminate "junk insurance" plans that left consumers vulnerable. In January 2025, the state banned short-term, limited-duration health insurance plans through House Bill 2499. To further support consumers, the Network Adequacy and Transparency Act ensures health plans maintain sufficient provider networks. If you’re having trouble finding in-network care, you can contact your insurer or the IDOI Office of Consumer Health Insurance at 877-527-9431.
Together, these federal and state laws create a robust safety net, addressing scenarios where you have little control over your choice of healthcare providers and reducing the risk of surprise medical bills.
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How to Reduce Out-of-Network Expenses
Avoiding out-of-network charges is often the best way to keep healthcare costs manageable. Taking steps ahead of time can help you dodge unexpected bills and save significant money.
Steps to Avoid Out-of-Network Charges
Staying in-network is the most reliable way to keep your healthcare costs under control. This means choosing doctors, hospitals, and facilities that are part of your insurance plan’s network. Always verify a provider’s network status before scheduling an appointment.
Confirm your provider’s network participation directly with their office. Provider networks can change frequently, and your doctor may no longer be part of your plan without any prior notice. Make sure to specify your exact plan name when asking, not just the insurance company.
If you’re a Blue Cross and Blue Shield of Illinois policyholder, you can use their "Find a Doctor or Hospital" tool available on their website or mobile app. Members who log in get personalized results, including cost comparisons, while guest users can search by entering their plan name, the provider’s name, type of care, and ZIP code. As BCBSIL advises:
"Before choosing a new health plan, you’ll want to check that the doctors you already visit are in that plan’s network. Otherwise, you may end up having to change providers or pay more out of your own pocket."
Understand your policy’s details, including deductibles, coinsurance, and out-of-pocket maximums for in-network and out-of-network care. Knowing this information can help you make smarter decisions about where to seek treatment.
Explore cost-effective care options that keep you in-network. For minor issues, convenience care clinics can be a budget-friendly alternative to traditional doctor visits. For non-emergencies, urgent care centers are often a better choice than emergency rooms.
Telehealth services are another affordable option, especially when your regular provider isn’t available. Many plans cover virtual visits, which can save you money and eliminate the risk of seeing an out-of-network provider.
Get upfront cost estimates for non-emergency procedures. In-network facilities like radiology centers, outpatient surgery centers, and labs often provide the same quality of care as hospitals but at lower prices.
If you’re uninsured or paying out of pocket, you’re entitled to a "Good Faith Estimate" that outlines the expected costs of your care. This can help you avoid surprise expenses.
What to Do When You Get an Out-of-Network Bill
Even with careful planning, out-of-network bills can still happen. Here’s how to handle them:
Review the bill thoroughly. Check for adjustments from your insurer and look for any errors or vague charges. If you don’t already have an itemized bill, request one to see the specific fees. Contact the provider’s billing department to confirm whether a claim was submitted to your insurer and why it might have been denied.
Appeal the charge with your insurance company if you believe it should have been covered. Provide clear reasons and any necessary evidence to support your case. For example, if you received emergency care or were treated by an out-of-network provider at an in-network facility, the No Surprises Act might protect you.
Reach out to the Illinois Department of Insurance (IDOI) if you think you’ve been unfairly billed. Their Office of Consumer Health Insurance can assist with complaints.
Request an external review if your insurer denies coverage for care or treatment. This independent review, conducted by an organization approved by the IDOI, offers an impartial assessment of your insurer’s decision. Remember, you have four months from the final denial to request this review.
For uninsured patients, if a bill exceeds your Good Faith Estimate by $400 or more, you can dispute the charge by first contacting the provider’s billing department.
How Illinois Health Agents Can Help
When avoiding out-of-network charges becomes complicated, expert help can make a difference. Illinois Health Agents assists residents in choosing insurance plans that minimize out-of-network risks and maximize coverage value.
Their brokers are well-versed in the complexities of provider networks and can help you select plans that include your preferred doctors and hospitals. During annual reviews, they’ll evaluate whether your current plan still fits your needs or if changes in provider networks mean it’s time to switch.
If billing disputes arise, Illinois Health Agents can help you navigate your coverage details and guide you through the appeals process. Their familiarity with Illinois insurance regulations ensures they can point you to the right resources and agencies for assistance.
For businesses, Illinois Health Agents helps employers find group health plans with strong networks, reducing the chances of employees facing out-of-network charges. They also educate employees on how to stay in-network and make informed healthcare choices.
Whether you’re looking for individual, family, or group coverage, Illinois Health Agents connects you with plans from top-rated carriers. Their goal is to help you understand your benefits and avoid unexpected costs.
Key Points for Illinois Residents
If you live in Illinois, understanding your rights when it comes to out-of-network medical costs can save you from unexpected financial stress. Here’s what you need to know about your protections and how to handle surprise medical bills.
The No Surprises Act, which took effect in 2022, along with Illinois state laws, shields you from balance billing in emergency situations and at in-network facilities. If you’re covered by Medicare, Medical Assistance, or Veterans Affairs, you’re fully protected. For other types of insurance, Illinois law ensures you’re charged no more than in-network rates when out-of-network care happens unintentionally.
Steps to Take If You Get a Surprise Bill
Receiving an unexpected medical bill can be overwhelming, but you don’t need to pay it right away. First, contact your insurance company to clarify the charges. If the issue isn’t resolved, you can file a complaint with both your insurer and the Illinois Attorney General. Additionally, if you’re uninsured and receive a bill exceeding your Good Faith Estimate by $400 or more, you have the right to dispute it.
Plan Ahead to Avoid Issues
Prevention is key when it comes to avoiding surprise medical bills. Before receiving care, confirm that your providers are part of your insurance network. For scheduled procedures, double-check that everyone involved – like surgeons, anesthesiologists, and lab services – is covered. It’s also a good idea to know the location of your nearest in-network emergency room. If you’re unsure where to start, seeking expert advice can make the process easier.
Illinois Health Agents can provide valuable assistance in navigating provider networks, choosing plans that reduce out-of-network risks, and understanding your coverage. This is especially helpful during annual enrollment periods when insurance networks often change.
Important Numbers to Keep in Mind
On average, surprise bills for emergency room visits can run around $600, but certain procedures may lead to charges in the thousands. If you find yourself in a billing dispute, resources like the Federal No Surprises Helpdesk and the Illinois Department of Insurance are available to assist you. The Illinois Department of Insurance offers additional support for out-of-network billing issues, giving you an extra layer of protection beyond federal measures.
FAQs
How does the No Surprises Act help protect Illinois residents from unexpected out-of-network medical bills?
The No Surprises Act shields Illinois residents from unexpected medical bills by prohibiting balance billing in specific scenarios. For instance, if you need emergency care at an out-of-network facility, you’ll only be responsible for your plan’s in-network cost-sharing amounts, like copayments or coinsurance.
This protection extends to certain non-emergency services at in-network hospitals where out-of-network providers are involved. In these cases, you won’t pay more than the in-network rates. The Act aims to minimize surprise medical expenses and provide Illinois patients with greater financial security.
How can I avoid unexpected out-of-network medical bills in Illinois?
Before receiving care, make sure your healthcare provider or facility is part of your insurance network to avoid unexpected out-of-network charges. This way, your services are billed at the lower, in-network rates covered by your plan. In emergencies, you’re protected by the No Surprises Act, which ensures you’re only responsible for costs at in-network rates, even if you’re treated by an out-of-network provider. For non-emergency situations, request a clear cost estimate upfront and confirm any potential charges if you choose an out-of-network provider. These simple steps can help you stay on top of your healthcare expenses and steer clear of surprise bills.
What should I do if I get an unexpected bill for out-of-network care, even after taking precautions?
If you get an unexpected bill for out-of-network services in Illinois, it’s important to know your rights under the No Surprises Act and state laws. These rules are designed to shield you from balance billing in specific situations, like emergency care or when you’re treated by an out-of-network provider at an in-network facility. In these cases, you should only be responsible for your plan’s in-network costs, such as copayments or coinsurance.
If you suspect there’s an error on the bill, start by contacting your insurance company to dispute the charge. You can also seek assistance from the Illinois Department of Insurance to help sort things out. Make sure to keep detailed records: document every conversation, save copies of your bills, and hold onto any related correspondence to strengthen your case.
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