State SealARIZONA HOUSE OF REPRESENTATIVES

 

SB 1105: direct primary care agreements

PRIME SPONSOR: Senator Carter, LD 15

BILL STATUS: House Engrossed

                               

 

Overview

☐ Prop 105 (45 votes) ☐ Prop 108 (40 votes) ☐ Emergency (40 votes) ☐ Fiscal NoteRepeals statutes regarding direct primary care provider plans (plan) and creates the statutory framework for direct primary care agreements (agreement).

History

A direct primary care provider plan means a primary care provider (PCP), group, entity or practice that collects on a prepaid basis fees to conduct primary health care for enrollees. A plan does not constitute the transaction of insurance business or a health care services organization if the plan does not assume financial risk or agree to cover services provided by a third party. Insurance is a contract by which one undertakes to indemnify another or to pay a specified amount upon determinable contingencies (A.R.S §§  20-103 and 20-123).

A plan allows the arrangement for primary health care for those who enroll and is required be in writing with a copy given to the enrollee at the time of signing the plan. The plan is required to describe the following: 1) the specific provider access; 2) the primary health care services a PCP provides; 3) the enrollee's total payment obligation; and 4) the terms of cancelation, including terms for relocation and military duty. An enrollee may cancel a plan for any reason with written notice, and a plan is prohibited from charging different fees based on an enrollee's health status or sex, if the services are comparable. The plan must provide a disclaimer that states: 1) the organization facilitating the plan is not an insurance company; 2) the company guidelines and plan operation are not an insurance policy; 3) participation in the plan should not be considered to be a health insurance policy; and 4) you are always responsible for the payment of any additional medical expenses you incur, whether you receive treatment for medical issues through the plan. A PCP is not allowed to submit a claim for payment to any health insurer or any health insurer's contractor or subcontractor for primary health care services for someone under a plan (A.R.S § 44-1799.92).

Provisions

1.       Repeals the requirements for plans. (Sec. 2, 4)

2.       Establishes the statutory framework for agreements. (Sec. 5)

3.       Requires an agreement be provided to a patient or patient's legal representative and must:

a.       Be in writing;

b.       Be signed by the PCP or agent of the PCP and the patient or patient's legal representative;

c.        Allow either party to terminate the agreement on a 30-day written notice to the other party;

d.       Include terms for relocation and military duty;

e.       Describe the scope of primary care services that are covered by the periodic fee;

f.         Specify the periodic fee for the agreement and any additional fees for ongoing care under the agreement;

g.       Specify the duration of the agreement and any automatic renewal periods; and

h.       Provide a written disclaimer and notice that states the agreement is not health insurance. (Sec. 5)

4.       Prohibits a direct PCP from declining to accept a new direct primary care patient, discontinuing care to an existing patient or charging different fees for comparable services based on the patient's health status or gender. (Sec. 5)

5.       Allows a direct PCP to decline to accept a patient if:

a.       The provider has reached maximum capacity; or

b.       The patient's medical condition is such that a provider is unable to provide the appropriate level and type of services required. (Sec. 5)

6.       Authorizes a direct PCP to discontinue care for a patient if:

a.       The patient fails to pay the periodic fee;

b.       The patient has performed an act of fraud;

c.        The patient repeatedly fails to adhere to the recommended treatment plan;

d.       The patient is abusive and presents an emotional or physical danger to staff or other patients of the direct PCP;

e.       The direct PCP discontinues practicing as a direct primary care provider;

f.         The direct PCP changes the services offered or the scope of practice provided to patients; or

g.       The direct PCP gives a 30-day written notice to the patient. (Sec. 5)

7.       Prohibits an agreement from requiring more than 12-months of the periodic fee in advance. (Sec. 5)

8.       Requires all prepaid payments be returned to the patient for the months following the termination of the agreement. (Sec. 5)

9.       States that an agreement prohibit a direct PCP from submitting a claim for reimbursement to the patient's health care insurer for primary care services that are provided to the patient and that are covered under the agreement. (Sec. 5)

10.   Specifies that an agreement may allow the periodic fee and any additional fees for ongoing care under the agreement to be paid by a health care insurer or other third party. (Sec. 5)

11.   Specifies that an agreement for dental services is limited to services offered within a single practice and may not include services offered in other practice entities. (Sec. 5)

12.   Clarifies that an agreement for medical or dental services does not constitute the transaction of insurance business or a health care services organization in this state for regulation under Title 20. (Sec. 5)

13.   Defines terms relating to agreements. (Sec. 5)

14.   Makes technical and conforming changes. (Sec. 1, 3)

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18.   Fifty-fourth Legislature                       SB 1105

19.   First Regular Session                            Version 3: House Engrossed

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21.   ---------- DOCUMENT FOOTER ---------