HF 2434 (LSB 5285HV (5) 91)

RELATING TO INSURANCE COVERAGE FOR HEALTH CARE SERVICES  PROVIDED PURSUANT TO A REFERRAL BY AN OUT-OF-NETWORK PRIMARY  CARE PROVIDER. 

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  NEW SECTION.  514C.37  Primary care providers —— insurance requirements.
   1.  As used in this section, unless the context otherwise requires:
   a.  “Covered benefits” means the same as defined in section 514J.102.
   b.  “Covered person” means the same as defined in section 514J.102.
   c.  “Direct primary care agreement” means an agreement between a primary care provider and a covered person, or the covered person’s representative, in which the primary care provider agrees to provide health care services for a specified period of time to the covered person for a service charge.

   d.  “Health benefit plan” means the same as defined in section 514J.102.
   e.  “Health care professional” means the same as defined in section 514J.102.
   f.  “Health care services” means the same as defined in section 514J.102.
   g.  “Health carrier” means the same as defined in section 514J.102.
   h.  “Primary care provider” means a health care professional trained to serve as the first contact and to provide continuous and comprehensive care to a covered person, and includes but is not limited to any of the following licensed or certified health care professionals who provide primary care:
   (1)  A physician who is a family or general practitioner, a pediatrician, an internist, an obstetrician, or a gynecologist.
   (2)  An advanced registered nurse practitioner.
   (3)  A physician assistant.
   2.  a.  Notwithstanding the uniformity of treatment requirements of section 514C.6, a health carrier shall not deny coverage for covered benefits provided to a covered person solely on the basis that the covered person’s referral to receive the covered benefits was made by a primary care provider who does not participate in the health carrier’s provider network.
   b.  A health carrier shall not impose a deductible, coinsurance, or copayment for covered benefits for which a covered person was referred by the covered person’s primary care provider in excess of the deductible, coinsurance, or copayment applicable for the covered benefits had the covered person been referred by a health care professional that participates in the health carrier’s provider network.
   c.  A health carrier may require a primary care provider to provide evidence that the primary care provider has executed a direct primary care agreement with the covered person, which evidence may include a written attestation or a copy of the executed direct primary care agreement.
   3.  This section applies to covered benefits for which a covered person’s primary care provider referred the covered person on or after July 1, 2026.
   4.  The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.

______________________________
PAT GRASSLEY
Speaker of the House

______________________________
AMY SINCLAIR
President of the Senate

   I hereby certify that this bill originated in the House and is known as House File 2434, Ninety-first General Assembly.

______________________________
MEGHAN NELSON
Chief Clerk of the House

Approved _______________, 2026

______________________________
KIM REYNOLDS
Governor