Out-of-network coverage + balance billing

For Illinois individual + family, and Illinois/Missouri Medicare plan members

Traveling and find you need health care? Members are covered for urgent and emergency care worldwide. Regardless of where you travel, you don't need to take health care coverage worries with you on vacation. We have you covered.

You do not need a referral or prior authorization for urgent or emergency services — no matter where you travel:

• We cover urgent and emergency services while you are outside of our service area (subject to member policy copays, coinsurance, deductibles, and maximum allowable fees).
• Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. 
• Depending on the health care professional, the service could cost you more or not be paid for at all by your plan. Charging you this extra amount is called balance billing.

Care received by an out-of-network provider is covered under these circumstances:

 Emergency services

Emergency Services received from an out-of-network provider if the member cannot reach an in-network provider.

All follow-up care should be done by a plan provider. If you are out of the area and unable to see a plan provider, call your primary care provider for a referral to an out-of-network provider. These services require our approval.

 Urgent care services

• If you receive out-of-network urgent care services, you are covered by your plan for charges up to the maximum allowable fee. If there is a difference between the maximum allowable fee and what the out-of-network provider bills, you may have to pay the difference. 
• Call Member Services if you have questions about the maximum allowable fee.

If you require urgent or emergency care outside the service area and are unable to get to a plan provider, go to the nearest urgent care or emergency center for treatment. It is important to notify us as soon as possible by calling Member Services.

No surprise billing

Your rights and protections against surprise medical bills

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

What is "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 health care 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 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 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'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 not to be balanced billed for these post-stabilization services.

For additional information, see the applicable state-specific balance billing 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 may 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.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

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.

For additional information, see the applicable state-specific balance billing protections.

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 requiring you to get approval for services in advance (prior authorization).
  • 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've been wrongly billed, you may contact us at 1-866-514-4194.

Visit https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059 for more information about your rights under federal law.