Senate File 2276 S-5075 Amend Senate File 2276 as follows: 1 2. By striking everything after the enacting clause and 2 inserting: 3 < Section 1. Section 135N.1, Code 2022, is amended by 4 striking the section and inserting in lieu thereof the 5 following: 6 135N.1 Direct health care agreements. 7 1. Definitions. For the purpose of this section: 8 a. “Direct health care agreement” means an agreement between 9 a provider and a patient, or the patient’s representative, in 10 which the provider agrees to provide health care services for a 11 specified period of time to the patient for a service charge. 12 b. “Durable power of attorney for health care” means the same 13 as defined in section 144B.1. 14 c. “Health care services” means services for the diagnosis, 15 prevention, treatment, cure, or relief of a health condition, 16 illness, injury, or disease. “Health care services” includes 17 dental care services. 18 d. “Patient” means an individual, or an individual and the 19 individual’s immediate family, that is a party to a direct 20 health care agreement. 21 e. “Patient’s representative” means a parent, guardian, or 22 an individual holding a durable power of attorney for health 23 care for a patient. 24 f. “Provider” means a health care professional licensed, 25 accredited, registered, or certified to perform health care 26 services consistent with the laws of this state. “Provider” 27 includes an individual health care professional or other 28 legal health care entity alone or with other health care 29 professionals professionally associated with the individual 30 health care professional or other legal health care entity. 31 g. “Service charge” means a charge for health care services 32 provided by a provider to a patient covered by a direct health 33 care agreement. “Service charge” may include a periodic 34 retainer, a membership fee, a subscription fee, or a charge in 35 -1- SF 2276.3601 (1) 89 (amending this SF 2276 to CONFORM to HF 2200) ko/rn 1/ 5 #2.

any other form paid by a patient to a provider under a direct 1 health care agreement. 2 2. Requirements for a valid direct health care agreement. 3 a. In order to be a valid agreement, a direct health care 4 agreement must meet all of the following requirements: 5 (1) Be in writing. 6 (2) Be signed by the provider, or an agent of the provider, 7 and the patient or the patient’s representative. 8 (3) Describe the scope of the health care services covered 9 by the direct health care agreement. 10 (4) State each of the provider’s locations where a patient 11 may obtain health care services and specify any out-of-office 12 health care services that are covered under the direct health 13 care agreement. 14 (5) Specify the service charge and the frequency at which 15 the service charge must be paid by the patient. A patient 16 shall not be required to pay more than twelve months of a 17 service charge in advance. 18 (6) Specify any additional costs for health care services 19 not covered by the service charge for which the patient will 20 be responsible. 21 (7) Specify the duration of the direct health care 22 agreement, whether renewal is automatic, and if required, the 23 procedure for renewal. 24 (8) Specify the terms and conditions under which the direct 25 health care agreement may be terminated by the provider. 26 A termination of the direct health care agreement by the 27 provider shall include a minimum of a thirty-calendar-day 28 advance, written notice to the patient or to the patient’s 29 representative. 30 (9) Specify that the direct health care agreement may be 31 terminated at any time by the patient upon written notice to 32 the provider. 33 (10) State that if the direct health care agreement is 34 terminated by either the patient or the provider all of the 35 -2- SF 2276.3601 (1) 89 (amending this SF 2276 to CONFORM to HF 2200) ko/rn 2/ 5

following apply: 1 (a) Within thirty calendar days of the date of the notice of 2 termination from either party, the provider shall refund all 3 unearned service charges to the patient. 4 (b) Within thirty calendar days of the date of the notice 5 of termination from either party, the patient shall pay all 6 outstanding earned service charges to the provider. 7 (11) Include a notice in bold, twelve-point type that states 8 substantially as follows: 9 NOTICE. This direct health care agreement is not health 10 insurance and is not a plan that provides health coverage for 11 purposes of any federal mandates. This direct health care 12 agreement only covers the health care services described in 13 this agreement. It is recommended that you obtain health 14 insurance to cover health care services not covered under this 15 direct health care agreement. You are personally responsible 16 for the payment of any additional health care expenses you may 17 incur. 18 b. The provider shall provide the patient, or the patient’s 19 representative, with a fully executed copy of the direct health 20 care agreement at the time the direct health care agreement is 21 executed. 22 3. Application for a direct health care agreement. If 23 a provider requires a prospective patient to complete an 24 application for a direct health care agreement, the provider 25 shall provide a written disclaimer on each application that 26 informs the prospective patient of the patient’s financial 27 rights and responsibilities and that states that the provider 28 will not bill a health insurance carrier for health care 29 services covered under the direct health care agreement. The 30 disclaimer shall also include the identical notice required by 31 subsection 2, paragraph “a” , subparagraph (11). 32 4. Notice required for changes to the terms or conditions of 33 a direct health care agreement. 34 a. A provider shall provide at least a sixty-calendar-day 35 -3- SF 2276.3601 (1) 89 (amending this SF 2276 to CONFORM to HF 2200) ko/rn 3/ 5

advance, written notice to a patient of any of the following 1 changes to a direct health care agreement: 2 (1) Any change in the scope of the health care services 3 covered under the agreement. 4 (2) Any change in the provider’s locations where the patient 5 may access health care services. 6 (3) Any change in the out-of-office services that are 7 covered under the direct health care service agreement. 8 (4) Any change in the service charge. 9 (5) Any change in the additional costs for health care 10 services not covered by the service charge. 11 (6) Any change in the renewal terms. 12 (7) Any change in the terms to terminate the agreement. 13 b. A provider shall provide the notice by mailing a letter 14 to the last known address of the patient that the provider has 15 on file. The postmark date on the letter shall be the first day 16 of the required sixty-calendar-day notice period. 17 5. Discrimination based on an individual’s health status 18 or preexisting condition. A provider shall not do any of 19 the following based on a patient’s or prospective patient’s 20 preexisting condition or health status: 21 a. Refuse to accept a new patient. 22 b. Refuse to renew a direct health care agreement. 23 c. Establish an additional service charge for a direct 24 health care agreement. 25 6. A direct health care agreement is not insurance. 26 a. A direct health care agreement shall be deemed to not 27 be insurance and shall not be subject to the authority of the 28 commissioner of insurance. Neither a provider or an agent of a 29 provider shall be required to be licensed by the commissioner 30 to transact the business of insurance in this state, or to 31 obtain a certificate issued by the commissioner to market or 32 offer a direct health care agreement. 33 b. A provider shall not bill an insurer for a health care 34 service provided under a direct health care agreement. A 35 -4- SF 2276.3601 (1) 89 (amending this SF 2276 to CONFORM to HF 2200) ko/rn 4/ 5

patient may submit a request for reimbursement to an insurer 1 if permitted under the patient’s policy of insurance. This 2 paragraph does not prohibit a provider from billing a patient’s 3 insurance for a health care service provided to the patient by 4 the provider that is not covered under the direct health care 5 agreement. 6 7. Third-party payment of a service charge. A provider 7 may accept payment of a service charge for a patient either 8 directly or indirectly from a third party. A provider may 9 accept all or part of a service charge paid by an employer 10 on behalf of an employee who is a patient of the provider. 11 A provider shall not enter directly into an agreement with 12 an employer relating to a health care agreement between the 13 provider and employees of the employer, other than an agreement 14 to establish the timing and method of the payment of a service 15 charge paid by the employer on behalf of the employee. 16 8. Sale or transfer of a direct health care agreement. A 17 direct health care agreement shall not be sold or transferred 18 by a provider without the prior written consent of the patient 19 who is a party to the direct health care agreement. A patient 20 shall not sell or transfer a direct health care agreement to 21 which the patient is a party. 22 Sec. 2. EFFECTIVE DATE. This Act, being deemed of immediate 23 importance, takes effect upon enactment. 24 Sec. 3. APPLICABILITY. This Act applies to direct health 25 care agreements that are fully executed on or after the date 26 of enactment. > 27 ______________________________ CRAIG WILLIAMS -5- SF 2276.3601 (1) 89 (amending this SF 2276 to CONFORM to HF 2200) ko/rn 5/ 5