January 1, 2022 (aligned with the federal No Surprises Act)

Idaho (Idaho) does not have a standalone, preexisting surprise billing statute like several other states. Instead, Idaho incorporated NSA-aligned protections through regulatory guidance and enforcement under the Idaho Department of Insurance, ensuring that Idaho consumers are protected from surprise balance bills while relying entirely on federal NSA payment and arbitration processes.

Idaho does not have a state-specific benchmark or independent dispute resolution system.

Idaho’s protections are based on the federal NSA framework, requiring insurers to:

• Prohibit balance billing for emergency services delivered by OON providers or facilities.
• Prohibit balance billing for non-emergency OON services rendered at an in-network facility.
• Limit patient liability to in-network cost-sharing amounts for all NSA-protected scenarios.
• Issue an initial payment reflecting the plan’s NSA-recognized amount — typically the Qualified Payment Amount (QPA).

Idaho does not impose its own UCR, APCD benchmark, or state-defined pricing methodology.

Idaho does not maintain a state-level arbitration or IDR system.

As a result:

• Idaho has no Specified State Law (SSL) recognized by CMS.
• All applicable disputes are handled under the federal NSA IDR system.
• Emergency, in-facility non-emergency, and air ambulance OON payment disputes must all be resolved through federal arbitration.

There is no Idaho-specific alternative pathway for payment disagreements.

Idaho follows the federal negotiation requirements, including:

• The carrier must issue an initial payment or denial.
• A 30-day mandatory negotiation window begins.
• If unresolved, either party may proceed to Federal IDR.

Idaho does not add extra timing or procedural steps beyond what is required under federal law.

Because Idaho relies exclusively on federal IDR, arbitrators must apply the federal statutory criteria, including:

• QPA (primary factor)
• Provider education, training, experience, and patient acuity
• Contracting history within the past four years
• Provider and plan market share
• Case complexity or severity
• Good-faith efforts toward contracting

Idaho law does not add or modify the federal arbitration factors.

Idaho surprise billing protections rely on:

• Idaho Department of Insurance guidance and enforcement
• Integration of federal NSA protections into state oversight
• Federal NSA requirements under 45 CFR 149.510 & 149.520

Idaho’s regulatory framework focuses on patient protections, leaving payment determination and arbitration entirely to federal rules.

CMS has determined that Idaho does not maintain a Specified State Law (SSL) governing out-of-network payment standards.

• Fully insured commercial plans
• Individual health insurance policies
• Small and large group plans
• Self-funded ERISA plans (unless adopting another state’s SSL, which is extremely rare)

• The QPA is the controlling benchmark for OON payment determinations.
• All payment disputes proceed through the federal IDR portal.
• Idaho insurers must follow NSA payment timelines, QPA disclosures, and negotiation rules.
• Idaho’s regulatory environment reinforces NSA consumer protections but does not alter reimbursement processes.