Illinois § 36

§ 36.

Complaint of incorrect charges. (a) A beneficiary who, taking into account the reimbursement, if any, by the issuer, incurs a cost in excess of the in-network cost-sharing for a covered service from a provider, facility, or hospital that was listed as in-network in the plan's provider directory prior to or at the time of the provision of services may file a complaint with the Department. The Department shall investigate the complaint and determine if the provider was incorrectly included in the plan's provider directory when the beneficiary made the appointment or received the service. (b) Upon the Department's confirmation of the allegations in the complaint that the beneficiary incurred a cost in excess of the in-network cost-sharing for covered services provided by an incorrectly included provider when the appointment was made or service was provided, the issuer shall reimburse the beneficiary for all costs incurred in excess of the in-network cost-sharing. However, if the issuer has paid the claim to the provider directly, the issuer shall notify the beneficiary and the provider of the beneficiary's right to reimbursement from the provider for any payments in excess of the in-network cost-sharing amount pursuant to 42 U.S.C. 300gg-139(b), and the issuer's notice shall specify the in-network cost-sharing amount for the covered services. The amounts paid by the beneficiary within the in-network cost-sharing amount shall apply towards the in-network deductible and out-of-pocket maximum, if any. (Source: P.A. 103-650, eff. 1-1-25.)