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LEGISLATURE
OF
THE
STATE
OF
IDAHO
Sixty-eighth
Legislature
Second
Regular
Session
-
2026
IN
THE
SENATE
SENATE
BILL
NO.
1319
BY
STATE
AFFAIRS
COMMITTEE
AN
ACT
1
RELATING
TO
INSURANCE;
AMENDING
TITLE
41,
IDAHO
CODE,
BY
THE
ADDITION
OF
A
2
NEW
CHAPTER
67,
TITLE
41,
IDAHO
CODE,
TO
PROVIDE
A
SHORT
TITLE,
TO
PRO
-
3
VIDE
LEGISLATIVE
INTENT,
TO
DEFINE
TERMS,
TO
ESTABLISH
PROVISIONS
RE
-
4
GARDING
BILLING
BY
OUT
-
OF
-
NETWORK
PROVIDERS
FOR
EMERGENCY
SERVICES,
TO
5
ESTABLISH
PROVISIONS
REGARDING
SELF
-
FUNDED
PLAN
PARTICIPATION,
AND
TO
6
ESTABLISH
PROVISIONS
REGARDING
ENFORCEMENT;
AND
DECLARING
AN
EMERGENCY
7
AND
PROVIDING
AN
EFFECTIVE
DATE.
8
Be
It
Enacted
by
the
Legislature
of
the
State
of
Idaho:
9
SECTION
1.
That
Title
41,
Idaho
Code,
be,
and
the
same
is
hereby
amended
10
by
the
addition
thereto
of
a
NEW
CHAPTER
,
to
be
known
and
designated
as
Chap
-
1
1
ter
67,
Title
41,
Idaho
Code,
and
to
read
as
follows:
12
CHAPTER
67
13
EMERGENCY
CARE
AFFORDABILITY
ACT
14
41
-
6701.
SHORT
TITLE.
This
chapter
shall
be
known
and
may
be
cited
as
15
the
"Emergency
Care
Affordability
Act."
16
41
-
6702.
LEGISLATIVE
INTENT.
It
is
the
intent
of
the
legislature
in
17
enacting
this
chapter
to
protect
patients
who
are
members
of
a
health
bene
-
18
fit
plan
from
high
-
cost
emergency
medical
bills
for
care
rendered
in
an
out
-
19
of
-
network
freestanding
emergency
room
or
by
out
-
of
-
network
providers.
20
41
-
6703.
DEFINITIONS.
As
used
in
this
chapter:
21
(1)
"Allowed
amount"
means
the
amount
determined
by
a
health
benefit
22
plan
as
payment
in
full
for
a
covered
emergency
health
care
service
or
item
23
when
furnished
by
an
in
-
network
provider
or
in
-
network
facility
of
the
same
24
or
similar
specialty
or
type
in
the
same
geographic
area,
including
any
ap
-
25
plicable
cost
-
sharing
responsibility
of
the
covered
person,
but
excluding
26
billed
charges
or
amounts
determined
by
an
out
-
of
-
network
provider
or
facil
-
27
ity.
28
(2)
"Emergency
medical
condition"
means
a
medical,
mental
health,
or
29
substance
use
disorder
condition
manifesting
itself
by
acute
symptoms
of
30
sufficient
severity,
including
but
not
limited
to
severe
pain
or
emotional
31
distress,
such
that
a
prudent
layperson
who
possesses
an
average
knowledge
32
of
health
and
medicine
could
reasonably
expect
the
absence
of
immediate
med
-
33
ical,
mental
health,
or
substance
use
disorder
treatment
attention
to
result
34
in:
35
(a)
A
condition
placing
the
health
of
the
individual,
or
with
respect
to
36
a
pregnant
woman,
the
health
of
the
woman
or
her
unborn
child,
in
serious
37
jeopardy;
38
(b)
Serious
impairment
to
bodily
functions;
or
39
2
(c)
Serious
dysfunction
of
any
bodily
organ
or
part.
1
(3)
"Emergency
services"
means
a
medical
screening
examination,
as
2
required
pursuant
to
42
U.S.C.
1395dd,
that
is
within
the
capability
of
the
3
emergency
department
of
a
hospital,
or
an
emergency
facility
or
provider
4
subject
to
equivalent
federal
or
state
emergency
medical
screening
and
sta
-
5
bilization
obligations,
including
ancillary
services
routinely
available
6
to
the
emergency
department
or
emergency
facility
or
provider
to
evalu
-
7
ate
that
emergency
medical
condition,
and
further
medical
examination
and
8
treatment
that
are
within
the
capabilities
of
the
staff
and
facilities
9
available
at
the
hospital
or
emergency
facility,
as
are
required
pursuant
to
10
42
U.S.C.
1395dd
to
stabilize
the
patient.
1
1
(4)(a)
"Freestanding
emergency
room"
means
any
facility
that:
12
(i)
Is
not
designated
as
a
critical
access
hospital
under
federal
13
law;
14
(ii)
Is
physically
separate
and
distinct
from
the
main
campus
of
a
15
general
acute
care
hospital;
16
(iii)
Principally
provides
unscheduled
emergency
medical
ser
-
17
vices
to
the
general
public
on
a
twenty
-
four
(24)
hour
basis,
18
including
emergency
physician
services,
diagnostic
imaging,
19
laboratory
services,
and
short
-
term
observation
regardless
of
20
whether
inpatient
beds
are
maintained;
21
(iv)
Operates
or
holds
itself
out
as
a
freestanding
emergency
de
-
22
partment,
micro
-
hospital,
specialty
hospital,
or
hospital
outpa
-
23
tient
department;
24
(v)
Submits
claims
for
emergency
or
other
medical
services
to
25
state
-
regulated
health
benefit
plans;
and
26
(vi)
Operates
generally
under
an
out
-
of
-
network
reimbursement
27
strategy
and
participates
directly
or
indirectly
in
the
federal
28
independent
dispute
resolution
process,
whether
in
its
own
name
or
29
through
any
affiliated
entity,
pursuant
to
42
U.S.C.
300gg
-
111.
30
(b)
The
term
"freestanding
emergency
room"
does
not
include:
31
(i)
A
general
acute
care
hospital
operated
as
part
of
a
multi
-
cam
-
32
pus
Idaho
hospital
system
licensed
pursuant
to
chapter
13,
title
33
39,
Idaho
Code;
34
(ii)
Critical
access
hospitals;
and
35
(iii)
A
physician
-
owned,
nonemergency
surgery
center
that
does
36
not
advertise
or
hold
itself
out
as
an
emergency
department
and
37
does
not
provide
twenty
-
four
(24)
hour
emergency
medical
ser
-
38
vices.
39
(c)
For
purposes
of
this
section,
ownership
structure,
federal
program
40
participation,
management
arrangements,
or
physician
staffing
models
41
shall
not
affect
whether
a
facility
is
deemed
a
freestanding
emergency
42
room
if
the
criteria
in
paragraph
(a)
of
this
subsection
are
otherwise
43
satisfied.
44
(5)
"In
-
network
provider"
or
"in
-
network
facility"
means
a
provider
or
45
facility
that
is
contracted
with
a
health
benefit
plan
or
its
contractor
or
46
subcontractor
to
provide
health
care
services
or
emergency
health
care
ser
-
47
vices
to
covered
persons
for
reimbursement
by
the
health
benefit
plan
at
a
48
contracted
rate
as
payment
in
full
for
the
health
care
services,
including
49
applicable
cost
-
sharing
obligations.
50
3
(6)
"Out
-
of
-
network
provider"
or
"out
-
of
-
network
facility"
means
a
1
provider
or
facility
that
is
not
contracted
with
a
health
benefit
plan
or
2
its
contractor
or
subcontractor
to
provide
health
care
services
to
covered
3
persons.
The
term
includes
any
affiliate,
subsidiary,
management
company,
4
staffing
entity,
billing
entity,
or
other
related
entity
that
submits
or
at
-
5
tempts
to
submit
a
claim
for
payment
on
behalf
of,
or
in
connection
with
ser
-
6
vices
furnished
by,
an
out
-
of
-
network
provider
or
out
-
of
-
network
facility.
7
(7)
"Stabilize,"
with
respect
to
an
emergency
medical
condition,
has
8
the
same
meaning
as
provided
in
42
U.S.C.
1395dd(e)(3).
9
(8)
"Covered
benefits,"
"covered
person,"
"facility,"
"health
bene
-
10
fit
plan,"
"health
care
provider"
or
"provider,"
"health
care
services,"
1
1
and
"health
carrier"
shall
have
the
same
meanings
as
provided
in
section
12
41
-
5903,
Idaho
Code.
13
41
-
6704.
BILLING
BY
OUT
-
OF
-
NETWORK
PROVIDERS
FOR
EMERGENCY
SER
-
14
VICES.
(1)
An
out
-
of
-
network
freestanding
emergency
room
that
provides
15
emergency
services
to
a
covered
person
shall
accept
as
payment
in
full
the
16
health
benefit
plan's
allowed
amount
for
in
-
network
providers
of
the
same
17
specialty
or
type
for
the
same
covered
emergency
service
performed
at
an
18
in
-
network
facility
in
the
same
geographic
area
of
the
state
of
Idaho,
re
-
19
gardless
of
the
billing
entity,
modifier
usage,
unbundling,
rebundling,
or
20
use
of
affiliated
third
-
party
entities.
The
out
-
of
-
network
freestanding
21
emergency
room
or
physicians
and
their
staff
working
there
shall
not
bill
22
or
seek
reimbursement
for
amounts
in
excess
of
the
allowed
amount
from
the
23
covered
person
who
received
emergency
services.
24
(2)
In
calculating
the
covered
person's
cost
-
sharing
responsibility
25
for
amounts
described
in
subsection
(1)
of
this
section,
the
health
benefit
26
plan
shall
apply
its
in
-
network
benefit
design.
27
(3)
The
covered
person's
health
benefit
plan
shall
pay
directly
to
the
28
provider
the
amounts
described
in
subsection
(1)
of
this
section,
less
any
29
applicable
cost
-
sharing
responsibility
of
the
covered
person,
without
re
-
30
gard
to
any
assignment
of
benefits,
consent
form,
financial
responsibility
31
acknowledgement,
or
other
agreement
or
instrument
executed
by
the
covered
32
person.
33
(4)
Any
provision
in
a
consent
form
or
other
agreement
between
a
34
provider
and
a
covered
person
that
purports
to
permit
an
out
-
of
-
network
35
provider
to
bill
or
seek
reimbursement
for
covered
emergency
services
in
36
amounts
in
excess
of
the
amounts
permitted
pursuant
to
this
chapter,
in
-
37
cluding
any
waiver
of
balance
billing
protections,
assignment
of
benefits,
38
financial
responsibility
acknowledgement,
or
similar
provision,
is
void
and
39
unenforceable.
40
(5)(a)
If
an
out
-
of
-
network
freestanding
emergency
room
furnishing
41
emergency
services
is
not
enrolled
as
a
participating
provider
in
the
42
medicare,
medicaid,
or
TRICARE
programs,
the
provider
or
facility
shall
43
provide
a
clear
and
conspicuous
disclosure
to
a
covered
person
who
is
44
enrolled
in
such
a
program
that
the
provider
or
facility
does
not
par
-
45
ticipate
in
the
applicable
program
and
that
the
covered
person
may
be
46
personally
responsible
for
payment
of
some
or
all
charges
for
services
47
furnished.
48
4
(b)
The
disclosure
required
by
this
subsection
shall
be
made
as
soon
1
as
practicable
after
completion
of
the
medical
screening
examination
2
required
pursuant
to
42
U.S.C.
1395dd,
and
only
when
the
covered
per
-
3
son
is
conscious,
oriented,
and
capable
of
receiving
such
information,
4
and
when
providing
the
disclosure
will
not
interfere
with
the
provision
5
of
emergency
services
or
stabilization
of
an
emergency
medical
condi
-
6
tion.
The
disclosure
shall
be
communicated
in
plain
language
that
is
7
understandable
to
a
reasonable
person
and
may
be
provided
orally
or
in
8
writing.
Failure
to
provide
the
disclosure
required
by
this
subsection
9
shall
constitute
a
violation
of
the
provisions
of
this
chapter.
10
(6)
Failure
to
provide
the
disclosure
required
pursuant
to
subsection
1
1
(5)
of
this
section
shall
give
rise
to
a
rebuttable
presumption
that
the
cov
-
12
ered
person
was
not
informed
of
the
freestanding
emergency
room's
nonpartic
-
13
ipation
in
medicare,
medicaid,
or
TRICARE.
In
the
absence
of
contemporaneous
14
documentation
demonstrating
compliance
with
subsection
(5)
of
this
section,
15
the
freestanding
emergency
room
shall
be
prohibited
from
billing,
collect
-
16
ing,
or
seeking
reimbursement
from
the
covered
person
for
any
charges
asso
-
17
ciated
with
the
emergency
services
furnished.
Any
bill,
invoice,
collection
18
action,
or
attempt
to
obtain
payment
from
a
covered
person
in
violation
of
19
this
subsection
shall
be
void
and
unenforceable
as
a
matter
of
law,
and
no
20
payment
shall
be
owed
by
the
covered
person.
21
41
-
6705.
SELF
-
FUNDED
PLAN
PARTICIPATION.
(1)
The
provisions
of
this
22
chapter
shall
apply
to
a
self
-
funded
health
plan,
including
a
self
-
funded
23
group
health
plan
governed
by
the
provisions
of
29
U.S.C.
1001
et
seq.,
only
24
if
the
plan
elects
to
participate
in
the
provisions
of
this
chapter.
To
elect
25
to
participate
in
the
provisions
of
this
chapter,
the
plan
shall
provide
no
-
26
tice,
on
an
annual
basis,
to
the
director
of
the
department
of
insurance,
in
a
27
manner
prescribed
by
the
director,
attesting
to
the
plan's
participation
in
28
and
agreement
to
be
bound
by
the
provisions
of
this
chapter.
An
election
made
29
pursuant
to
this
section
shall
apply
for
the
entire
plan
year
for
which
no
-
30
tice
is
provided.
31
(2)
At
least
once
annually,
the
director
shall
post
on
the
department
of
32
insurance
website
a
list
of
the
self
-
funded
plans
that
have
elected
to
par
-
33
ticipate
in
the
provisions
of
this
chapter.
An
entity
administering
a
plan
34
that
elects
to
participate
in
the
provisions
of
this
chapter
shall
comply
35
with
the
provisions
of
this
chapter
but
shall
not
be
considered
a
carrier
36
or
health
benefit
plan
subject
to
the
jurisdiction
of
the
director
solely
by
37
virtue
of
such
election.
38
41
-
6706.
ENFORCEMENT.
(1)
Any
freestanding
emergency
room
or
health
39
benefit
plan
that
violates
the
provisions
of
this
chapter
shall
be
liable
40
to
pay
the
reasonable
attorney's
fees
and
costs
that
the
covered
person
or
41
health
plan
incurs
to
challenge
the
provider's
or
health
benefit
plan's
ac
-
42
tions.
43
(2)
Any
billing
by
an
out
-
of
-
network
freestanding
emergency
room
or
any
44
affiliated,
related,
or
billing
entity
acting
on
its
behalf
to
the
covered
45
person
in
violation
of
the
provisions
of
this
chapter
shall
be
void
and
unen
-
46
forceable.
47
5
(3)
An
out
-
of
-
network
freestanding
emergency
room
shall
be
liable
to
a
1
covered
person
for
reasonable
attorney's
fees
and
costs
to
defend
against
a
2
provider's
attempts
to
collect
amounts
in
excess
of
the
amount
for
which
the
3
covered
person
is
personally
responsible
pursuant
to
this
chapter.
4
(4)
Upon
receipt
of
written
request
from
an
out
-
of
-
network
freestand
-
5
ing
emergency
room,
covered
person,
or
health
benefit
plan,
the
director
of
6
the
department
of
insurance
is
authorized
to
inquire
of
the
patient's
health
7
benefit
plan
to
verify
whether
the
amount
paid
to
the
provider
is
consistent
8
with
the
provisions
of
this
chapter.
9
(5)
Each
attempt
to
bill
or
collect
amounts
in
violation
of
the
provi
-
10
sions
of
this
chapter
shall
constitute
a
separate
violation.
1
1
SECTION
2.
An
emergency
existing
therefor,
which
emergency
is
hereby
12
declared
to
exist,
this
act
shall
be
in
full
force
and
effect
on
and
after
13
July
1,
2026.
14