SB 4

This bill exempts valid direct primary care agreements from the application of insurance law. A “direct primary care agreement,” as defined in the bill, is a contract between a health care provider that provides primary care services under the provider’s scope of practice and an individual patient or the patient’s legal representative or employer in which the health care provider agrees to provide primary care services to the patient for an agreed-upon subscription fee and period of time.

A valid direct primary care agreement is in writing and satisfies all of the following:

1. It is signed by the health care provider or an agent of the health care provider and the individual patient, the patient’s legal representative, or a representative of the patient’s employer.

2. It allows either party to terminate the agreement upon written notice.

3. It describes and quantifies the specific primary care services that are provided under the agreement.

4. It specifies the subscription fee for the agreement and specifies terms for termination of the agreement.

5. It specifies the duration of the agreement.

6. It prohibits the provider and patient from billing an insurer or any other third party on a fee-for-service basis for the primary care services included in the subscription fee under the agreement.

7. It prominently states, in writing, several provisions, including that the agreement is not health insurance and the agreement alone may not satisfy individual or employer insurance coverage requirements under federal law; that the patient is responsible for paying, or directing the patient’s employer to pay, the provider for all services that are not included in the subscription fee under the agreement; that the patient is encouraged to consult with a health insurance advisor, the patient’s health insurance carrier, or the patient’s employer-sponsored health plan, as applicable, before entering into the agreement; and that direct primary care fees might not be credited toward deductibles or out-of-pocket maximum amounts under any health insurance the patient has.

Under the bill, a health care provider may not decline to enter into or terminate a direct primary care agreement with a patient solely because of the patient’s health status. The bill allows a health care provider to decline to accept a patient for a direct primary care agreement only if the health care provider’s practice has reached its maximum patient capacity or if the patient’s medical condition is such that the health care provider is unable to provide the appropriate level and type of primary care services the patient requires. A health care provider may terminate a direct primary care agreement with a patient only if the patient or the patient’s employer fails to pay the subscription fee, the patient fails repeatedly to adhere to the treatment plan, the patient has performed an act of fraud related to the direct primary care agreement, the patient is abusive in a manner described in the bill, the health care provider discontinues operation as a direct primary care provider, or the health care provider believes that the relationship is no longer therapeutic for the patient due to a dysfunctional relationship between the provider and the patient.