Adds to existing law to establish the Emergency Care Affordability Act.

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 ACT1 RELATING TO INSURANCE; AMENDING TITLE 41, IDAHO CODE, BY THE ADDITION OF A2 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, TO5 ESTABLISH PROVISIONS REGARDING SELF-FUNDED PLAN PARTICIPATION, AND TO6 ESTABLISH PROVISIONS REGARDING ENFORCEMENT; AND DECLARING AN EMERGENCY7 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 amended10 by the addition thereto of a NEW CHAPTER, to be known and designated as Chap-11 ter 67, Title 41, Idaho Code, and to read as follows:12 CHAPTER 6713 EMERGENCY CARE AFFORDABILITY ACT14 41-6701. SHORT TITLE. This chapter shall be known and may be cited as15 the "Emergency Care Affordability Act."16 41-6702. LEGISLATIVE INTENT. It is the intent of the legislature in17 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 benefit22 plan as payment in full for a covered emergency health care service or item23 when furnished by an in-network provider or in-network facility of the same24 or similar specialty or type in the same geographic area, including any ap-25 plicable cost-sharing responsibility of the covered person, but excluding26 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, or29 substance use disorder condition manifesting itself by acute symptoms of30 sufficient severity, including but not limited to severe pain or emotional31 distress, such that a prudent layperson who possesses an average knowledge32 of health and medicine could reasonably expect the absence of immediate med-33 ical, mental health, or substance use disorder treatment attention to result34 in:35 (a) A condition placing the health of the individual, or with respect to36 a pregnant woman, the health of the woman or her unborn child, in serious37 jeopardy;38 (b) Serious impairment to bodily functions; or39

2 (c) Serious dysfunction of any bodily organ or part.1 (3) "Emergency services" means a medical screening examination, as2 required pursuant to 42 U.S.C. 1395dd, that is within the capability of the3 emergency department of a hospital, or an emergency facility or provider4 subject to equivalent federal or state emergency medical screening and sta-5 bilization obligations, including ancillary services routinely available6 to the emergency department or emergency facility or provider to evalu-7 ate that emergency medical condition, and further medical examination and8 treatment that are within the capabilities of the staff and facilities9 available at the hospital or emergency facility, as are required pursuant to10 42 U.S.C. 1395dd to stabilize the patient.11 (4)(a) "Freestanding emergency room" means any facility that:12 (i) Is not designated as a critical access hospital under federal13 law;14 (ii) Is physically separate and distinct from the main campus of a15 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 of20 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 to25 state-regulated health benefit plans; and26 (vi) Operates generally under an out-of-network reimbursement27 strategy and participates directly or indirectly in the federal28 independent dispute resolution process, whether in its own name or29 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, title33 39, Idaho Code;34 (ii) Critical access hospitals; and35 (iii) A physician-owned, nonemergency surgery center that does36 not advertise or hold itself out as an emergency department and37 does not provide twenty-four (24) hour emergency medical ser-38 vices.39 (c) For purposes of this section, ownership structure, federal program40 participation, management arrangements, or physician staffing models41 shall not affect whether a facility is deemed a freestanding emergency42 room if the criteria in paragraph (a) of this subsection are otherwise43 satisfied.44 (5) "In-network provider" or "in-network facility" means a provider or45 facility that is contracted with a health benefit plan or its contractor or46 subcontractor to provide health care services or emergency health care ser-47 vices to covered persons for reimbursement by the health benefit plan at a48 contracted rate as payment in full for the health care services, including49 applicable cost-sharing obligations.50

3 (6) "Out-of-network provider" or "out-of-network facility" means a1 provider or facility that is not contracted with a health benefit plan or2 its contractor or subcontractor to provide health care services to covered3 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, has8 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,"11 and "health carrier" shall have the same meanings as provided in section12 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 provides15 emergency services to a covered person shall accept as payment in full the16 health benefit plan's allowed amount for in-network providers of the same17 specialty or type for the same covered emergency service performed at an18 in-network facility in the same geographic area of the state of Idaho, re-19 gardless of the billing entity, modifier usage, unbundling, rebundling, or20 use of affiliated third-party entities. The out-of-network freestanding21 emergency room or physicians and their staff working there shall not bill22 or seek reimbursement for amounts in excess of the allowed amount from the23 covered person who received emergency services.24 (2) In calculating the covered person's cost-sharing responsibility25 for amounts described in subsection (1) of this section, the health benefit26 plan shall apply its in-network benefit design.27 (3) The covered person's health benefit plan shall pay directly to the28 provider the amounts described in subsection (1) of this section, less any29 applicable cost-sharing responsibility of the covered person, without re-30 gard to any assignment of benefits, consent form, financial responsibility31 acknowledgement, or other agreement or instrument executed by the covered32 person.33 (4) Any provision in a consent form or other agreement between a34 provider and a covered person that purports to permit an out-of-network35 provider to bill or seek reimbursement for covered emergency services in36 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 and39 unenforceable.40 (5)(a) If an out-of-network freestanding emergency room furnishing41 emergency services is not enrolled as a participating provider in the42 medicare, medicaid, or TRICARE programs, the provider or facility shall43 provide a clear and conspicuous disclosure to a covered person who is44 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 be46 personally responsible for payment of some or all charges for services47 furnished.48

4 (b) The disclosure required by this subsection shall be made as soon1 as practicable after completion of the medical screening examination2 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 provision5 of emergency services or stabilization of an emergency medical condi-6 tion. The disclosure shall be communicated in plain language that is7 understandable to a reasonable person and may be provided orally or in8 writing. Failure to provide the disclosure required by this subsection9 shall constitute a violation of the provisions of this chapter.10 (6) Failure to provide the disclosure required pursuant to subsection11 (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 contemporaneous14 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, collection18 action, or attempt to obtain payment from a covered person in violation of19 this subsection shall be void and unenforceable as a matter of law, and no20 payment shall be owed by the covered person.21 41-6705. SELF-FUNDED PLAN PARTICIPATION. (1) The provisions of this22 chapter shall apply to a self-funded health plan, including a self-funded23 group health plan governed by the provisions of 29 U.S.C. 1001 et seq., only24 if the plan elects to participate in the provisions of this chapter. To elect25 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 a27 manner prescribed by the director, attesting to the plan's participation in28 and agreement to be bound by the provisions of this chapter. An election made29 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 of32 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 plan34 that elects to participate in the provisions of this chapter shall comply35 with the provisions of this chapter but shall not be considered a carrier36 or health benefit plan subject to the jurisdiction of the director solely by37 virtue of such election.38 41-6706. ENFORCEMENT. (1) Any freestanding emergency room or health39 benefit plan that violates the provisions of this chapter shall be liable40 to pay the reasonable attorney's fees and costs that the covered person or41 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 any44 affiliated, related, or billing entity acting on its behalf to the covered45 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 a1 covered person for reasonable attorney's fees and costs to defend against a2 provider's attempts to collect amounts in excess of the amount for which the3 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 of6 the department of insurance is authorized to inquire of the patient's health7 benefit plan to verify whether the amount paid to the provider is consistent8 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.11

SECTION 2. An emergency existing therefor, which emergency is hereby12 declared to exist, this act shall be in full force and effect on and after13 July 1, 2026.14