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ARIZONA STATE SENATE
Fifty-Fourth Legislature, First Regular Session
AMENDED
direct primary care agreements
Purpose
Repeals requirements related to direct primary care provider plans and prescribes requirements for direct primary care agreements (agreements).
Background
According to statute, insurance is a contract by which one undertakes to indemnify another or to pay for a specified amount upon determinable contingencies. A direct primary care provider plan (plan) is a primary care provider, group, entity or practice that collects fees on a prepaid basis to provide primary health care for those enrolled in the plan. Current statute specifically exempts plans from the definition of insurance, and additionally states that such plans are not subject to regulation by the Department of Insurance, if the plan does not assume financial risk or agree to indemnify for services provided by a third party (A.R.S. §§ 20-103 and 20-123).
Current
statute requires that every plan is in writing and that a copy of the written
plan is provided to the enrollee when they sign the plan. Additionally, the
plan must describe: 1) specific provider access; 2) primary healthcare services
that the provider will provide; 3) the enrollee’s total payment obligation; and
4) terms of plan cancellation, which must include terms for relocation and
military duty. Plans must also provide a written disclaimer with all materials
distributed by or on behalf of the plan that expresses: 1) the organization
facilitating the plan is not an insurance company; 2) the guidelines and plan
operation are not an insurance policy;
3) participation in the plan or a subscription to any of its documents should
not be considered an insurance policy; and 4) the patient is always personally
responsible for additional medical expenses incurred (A.R.S.
§ 44-1799.92).
There is no anticipated fiscal impact to the state General Fund associated with this legislation.
Provisions
1. Repeals requirements related to plans and establishes requirements for agreements.
2. Requires that an agreement:
a) be in writing;
b) be signed by the primary care provider or an agent of the provider and the individual patient or their legal representative;
c) permits either party to terminate the agreement upon submitting a 30-day written notice to the other party;
d) includes terms for relocation and military duty;
e) specifies the periodic fee and any additional fees for ongoing care;
f) describes the scope of primary care services covered by the periodic fee;
g) specifies the duration of the agreement and any automatic renewal periods; and
h) provides a prominent disclaimer expressing that the agreement is not an insurance policy.
3. Prescribes disclaimer language and specifies that the language must appear in an agreement in a substantially similar form.
4. Prohibits a direct primary care provider from declining to accept a new direct primary care patient or to discontinue care to an existing patient solely because of the patient's health status.
5. Prohibits a direct primary care provider from charging different fees for comparable services based on a patient's health status or gender.
6. Permits a direct primary care provider to decline to accept a patient if the practice has reached its maximum capacity or if the provider is unable to provide the appropriate level and type of primary care services required for the patient's medical condition.
7. Allows a direct primary care provider to discontinue care for a direct primary care patient if:
a) the patient fails to pay the periodic fee;
b) the patient performed an act of fraud;
c) the patient repeatedly fails to adhere to a recommended treatment plan;
d) the patient is abusive and presents an emotional or physical danger to staff or other patients of the practice;
e) the direct primary care provider discontinues operation as a direct primary care provider;
f) the direct primary care provider changes the services or scope of practice provided to patients; or
g) the direct primary care provider gives a 30-day written notice to the patient terminating the direct primary care agreement.
8. Prohibits an agreement from requiring an advance payment of more than 12 months of the periodic fee.
9. Requires an agreement to prohibit a direct primary care provider from submitting a claim for reimbursement to a patient's healthcare insurer for primary care services that are provided to the patient and that are covered under the agreement.
10. Permits an agreement to allow the period fee and any additional fees for ongoing care under the agreement to be paid by a healthcare insurer or other third party.
11. Requires, if an agreement is discontinued, that payments that were prepaid for the months following the termination of an agreement be returned to the patient.
12. 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.
13. States that an agreement for medical services does not constitute the transaction of insurance business or a health care services organization.
14. Defines relevant terms.
15. Makes technical and conforming changes.
16. Becomes effective on the general effective date.
Amendments Adopted by Committee
1. Adds licensed dentists and specified physician assistants to the definition of primary care provider.
2. Adds dental services to the definition of primary care services.
Amendments Adopted by Committee of the Whole
1. Expands the definitions of primary care provider and primary care services as they relate to agreements.
2. Requires that a 30-day written notice be provided before terminating an agreement.
3. Modifies required disclosure language.
4. Expands the permissible conditions under which a direct primary care provider can discontinue care for a patient.
5. Prohibits a direct primary care practice from charging a different fee for similar services based on a patient's health status or gender.
6. Makes technical and conforming changes.
Amendments Adopted by the House of Representatives
1. Replaces the term practice with the term provider.
2. Permits a provider to discontinue care to a patient if a 30-day notice is given to the patient.
3. Requires that an agreement prohibit a provider from submitting a claim for reimbursement to a patient's insurer.
4. Permits an agreement to allow the ongoing care fee to be paid by a healthcare insurer or other third party.
5. 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.
6. Defines relevant terms.
7. Makes technical and conforming changes.
Senate Action House Action
HHS 1/30/19 DPA 8-0-0 HHS 3/21/19 DPA 8-1-0-0
3rd Read 2/13/19 30-0-0 3rd Read 4/10/19 59-1-0
Prepared by Senate Research
April 11, 2019
CRS/kja