H.F. 2275 Section 1. NEW SECTION . 135N.1 Direct primary care 1 agreements. 2 1. Definitions. For the purpose of this section: 3 a. “Direct patient” means an individual, or an individual 4 and the individual’s immediate family, that is party to a 5 direct primary care agreement. 6 b. “Direct patient’s representative” means a parent, 7 guardian, or an individual holding a durable power of attorney 8 for health care for a direct patient. 9 c. “Direct primary care agreement” means an agreement 10 between a direct provider and a direct patient, or the direct 11 patient’s representative, in which the direct provider agrees 12 to provide primary care health services for a specified period 13 of time to the direct patient for a direct service charge. 14 d. “Direct provider” means a health care professional 15 licensed, accredited, registered, or certified to perform 16 specified primary care health services consistent with the law 17 of this state. “Direct provider” includes an individual health 18 care professional or other legal health care entity alone or 19 with other health care professionals professionally associated 20 with the individual health care professional or other legal 21 health care entity. 22 e. “Direct service charge” means a charge for primary care 23 health services provided by a direct provider to a direct 24 patient covered by a direct primary care agreement. “Direct 25 service charge” may include a periodic retainer, a membership 26 fee, a subscription fee, or a charge in any other form paid by 27 a direct patient to a direct provider under a direct primary 28 care agreement. 29 f. “Durable power of attorney for health care” means the same 30 as defined in section 144B.1. 31 g. “Primary care health services” means general health care 32 services of the type provided at the time a patient seeks 33 preventive care or first seeks health care services for a 34 specific health concern. Primary care health services include 35 -1- LSB 5639YH (2) 87 ko/rj 1/ 8

H.F. 2275 all of the following: 1 (1) Care which promotes and maintains mental and physical 2 health and wellness. 3 (2) Care which prevents disease. 4 (3) Screening, diagnosing, and treatment of acute or 5 chronic conditions caused by disease, injury, or illness. 6 (4) Patient counseling and education. 7 (5) Provision of a broad spectrum of preventive and curative 8 health care over a period of time. 9 (6) Coordination of care. 10 2. Requirements for a valid direct primary care agreement. 11 a. In order to be a valid agreement, a direct primary care 12 agreement must meet all of the following requirements: 13 (1) Be in writing. 14 (2) Be signed by the direct provider, or an agent of the 15 direct provider, and the direct patient or the direct patient’s 16 representative. 17 (3) Describe the scope of the primary care health services 18 covered by the direct primary care agreement. 19 (4) State each of the direct provider’s locations where 20 a direct patient may obtain primary care health services and 21 specify any out-of-office primary care health services that are 22 covered under the direct primary care agreement. 23 (5) Specify the direct service charge and the frequency 24 at which the direct service charge must be paid by the direct 25 patient. A direct patient shall not be required to pay more 26 than twelve months of a direct service charge in advance. 27 (6) Specify any additional costs for primary care health 28 services not covered by the direct service charge for which the 29 direct patient will be responsible. 30 (7) Specify the duration of the direct primary care 31 agreement, whether renewal is automatic, and if required the 32 procedure for renewal of the direct primary care agreement. 33 (8) Specify the terms and conditions under which the 34 direct primary care agreement may be terminated by the 35 -2- LSB 5639YH (2) 87 ko/rj 2/ 8

H.F. 2275 direct provider. A termination of the direct primary care 1 agreement by the direct provider shall include a minimum of 2 a thirty-calendar-day advance, written notice to the direct 3 patient or to the direct patient’s representative. 4 (9) Specify that the direct primary care agreement may 5 be terminated at any time by the direct patient upon written 6 notice to the direct provider. 7 (10) State that if the direct primary care agreement is 8 terminated by either the direct patient or the direct provider 9 all of the following apply: 10 (a) Within thirty calendar days of the date of the notice of 11 termination from either party, the direct provider shall refund 12 all unearned direct service charges to the direct patient. 13 (b) Within thirty calendar days of the date of the notice 14 of termination from either party, the direct patient shall pay 15 all outstanding earned direct service charges to the direct 16 provider. 17 (11) Include a notice in bold, twelve-point font that states 18 substantially as follows: 19 NOTICE. This direct primary care agreement is not health 20 insurance and is not a plan that provides health coverage 21 for purposes of any federal mandates. This direct primary 22 care agreement only covers the primary care health services 23 described in this agreement. It is recommended that you obtain 24 health insurance to cover health care services not covered 25 under this direct primary care agreement. You are personally 26 responsible for the payment of any additional health care 27 expenses you may incur. 28 b. The direct provider shall provide the direct patient, or 29 the direct patient’s representative, with a fully executed copy 30 of the direct primary care agreement at the time the direct 31 primary care agreement is executed. 32 3. Application for a direct primary care agreement. If 33 a direct provider requires a prospective direct patient to 34 complete an application for a direct primary care agreement, 35 -3- LSB 5639YH (2) 87 ko/rj 3/ 8

H.F. 2275 the direct provider shall provide a written disclaimer on each 1 application that informs the prospective direct patient of the 2 direct patient’s financial rights and responsibilities and 3 that states that the direct provider will not bill a health 4 insurance carrier for primary care health services covered 5 under the direct primary care agreement. The disclaimer shall 6 also include the identical notice required by subsection 2, 7 paragraph “a” , subparagraph (11). 8 4. Notice required for changes to the terms or conditions of 9 a direct primary care agreement. 10 a. A direct provider shall provide at least a 11 sixty-calendar-day advance, written notice to a direct patient 12 of any of the following changes to a direct primary care 13 agreement: 14 (1) Any change in the scope of the primary care health 15 services covered under the agreement. 16 (2) Any change in the direct provider’s locations where the 17 direct patient may access primary care health services. 18 (3) Any change in the out-of-office services that are 19 covered under the direct primary care service agreement. 20 (4) Any change in the direct service charge. 21 (5) Any change in the additional costs for primary care 22 health services not covered by the direct service charge. 23 (6) Any change in the renewal terms. 24 (7) Any change in the terms to terminate the agreement. 25 b. A direct provider shall provide the notice by mailing 26 a letter to the address of the direct patient that the direct 27 provider has on file. The postmark date on the letter shall be 28 the first day of the required sixty-calendar-day notice period. 29 5. Discrimination based on an individual’s health status. A 30 direct provider shall not refuse to accept a new direct patient 31 or discontinue care of an existing direct patient based solely 32 on the new direct patient’s or the existing direct patient’s 33 health status. 34 6. A direct primary care agreement is not insurance. 35 -4- LSB 5639YH (2) 87 ko/rj 4/ 8

H.F. 2275 a. A direct primary care agreement is not insurance and 1 shall not be subject to the authority of the commissioner of 2 insurance. Neither a direct care provider, nor an agent of 3 a direct care provider, shall be required to be licensed by 4 the commissioner to transact the business of insurance in this 5 state or to obtain a certificate issued by the commissioner to 6 market or offer a direct primary care agreement. 7 b. A direct provider shall not bill an insurer for a service 8 provided under a direct primary care agreement. A direct 9 patient may submit a request for reimbursement to an insurer if 10 permitted under the direct patient’s policy of insurance. This 11 paragraph does not prohibit a direct provider from billing a 12 direct patient’s insurance for a service provided to the direct 13 patient by the direct provider that is not provided under the 14 direct primary care agreement. 15 7. Third-party payment of a direct service charge. A direct 16 provider may accept payment of a direct service charge for 17 a direct patient either directly or indirectly from a third 18 party. A direct provider may accept all or part of a direct 19 service charge paid by an employer on behalf of an employee who 20 is a direct patient of the direct provider. A direct provider 21 shall not enter directly into an agreement with an employer 22 relating to a direct primary care agreement between the direct 23 provider and employees of the employer, other than an agreement 24 to establish the timing and method of the payment of a direct 25 service charge paid by the employer on behalf of the employee. 26 8. Sale or transfer of a direct primary care agreement. A 27 direct primary care agreement shall not be sold or transferred 28 by a direct care provider without the prior written consent 29 of the direct patient who is a party to the direct primary 30 care agreement. A direct patient shall not sell or transfer a 31 direct primary care agreement to which the direct patient is a 32 party. 33 EXPLANATION 34 The inclusion of this explanation does not constitute agreement with 35 -5- LSB 5639YH (2) 87 ko/rj 5/ 8

H.F. 2275 the explanation’s substance by the members of the general assembly. 1 This bill relates to agreements between individuals and 2 health care professionals for the provision of certain primary 3 care health services for a service charge that covers an agreed 4 upon period of time. 5 The bill defines a direct primary care agreement as an 6 agreement between a direct provider and a direct patient, 7 or the direct patient’s representative, in which the direct 8 provider agrees to provide primary care health services to 9 the direct patient for a direct service charge for the period 10 of time designated in the agreement. A direct patient is an 11 individual, or an individual and the individual’s immediate 12 family. A direct provider is defined in the bill. A direct 13 service charge is a charge for primary care health services, as 14 defined in the bill, provided by a direct provider to a direct 15 patient and may include a periodic retainer, a membership fee, 16 a subscription fee, or other charge paid by a direct patient to 17 a direct provider. 18 The bill requires that a direct primary care agreement must 19 be in writing, must be signed by the direct provider and the 20 direct patient, must describe the scope of the primary care 21 health services included under the agreement, must state each 22 direct provider location where primary care health services may 23 be obtained by a direct patient, must specify any out-of-office 24 services that are included under the agreement, must specify 25 the direct service charge and how often it must be paid, must 26 specify any additional costs that may be assessed to the direct 27 patient for primary care health services not covered by the 28 direct service charge, and it must specify the duration of the 29 direct primary care agreement and how the agreement is renewed. 30 The bill requires that the terms and conditions for 31 termination of the direct primary care agreement by the direct 32 provider or the direct patient be included in the agreement. 33 The bill requires that a notice be included on the direct 34 primary care agreement and application that advises that the 35 -6- LSB 5639YH (2) 87 ko/rj 6/ 8

H.F. 2275 agreement is not health insurance and is not a plan that 1 provides health coverage for purposes of any federal mandates. 2 The notice advises that the agreement only covers the primary 3 care health services described in the agreement and recommends 4 that the direct patient obtain health insurance to cover other 5 health care services as the patient is responsible for all 6 additional expenses incurred. 7 A direct provider shall give a copy of the executed direct 8 primary care agreement to the direct patient. 9 The bill requires a direct provider to give at least 10 a 60-calendar-day advance, written notice to an existing 11 direct patient of changes, as outlined in the bill, to a 12 direct primary care service agreement. A direct provider is 13 prohibited from refusing to accept a new direct patient or 14 discontinuing care for an existing direct patient based solely 15 on the patient’s health status. 16 The bill provides that a direct primary care agreement 17 is not insurance and is not subject to the authority of the 18 commissioner of insurance. A direct care provider is not 19 required to be licensed by the commissioner to transact the 20 business of insurance in this state, or to obtain a certificate 21 issued by the commissioner to market or offer a direct primary 22 care agreement. 23 The bill prohibits a direct provider from billing an insurer 24 for services provided under a direct primary care agreement. 25 A direct patient may submit a request for reimbursement to 26 an insurer if permitted under the direct patient’s policy of 27 insurance. A direct provider may bill a direct patient’s 28 insurance for services provided by the direct provider that are 29 not provided under a direct primary care agreement. 30 A direct provider may accept payment of a direct service 31 charge for a direct patient either directly or indirectly from 32 a third party. A direct provider may accept all or part of 33 a direct service charge paid by an employer on behalf of an 34 employee but may not enter directly into an agreement with an 35 -7- LSB 5639YH (2) 87 ko/rj 7/ 8