House File 2434 - Introduced HOUSE FILE 2434 BY COMMITTEE ON HEALTH AND HUMAN SERVICES (SUCCESSOR TO HSB 506) A BILL FOR An Act relating to insurance coverage for health care services 1 provided pursuant to a referral by an out-of-network primary 2 care provider. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 4 TLSB 5285HV (1) 91 nls/ko

H.F. 2434 Section 1. NEW SECTION . 514C.37 Primary care providers —— 1 insurance requirements. 2 1. As used in this section, unless the context otherwise 3 requires: 4 a. “Covered benefit” means a health care service to which a 5 covered person is entitled under the terms of a health benefit 6 plan. 7 b. “Covered person” means a policyholder, subscriber, 8 enrollee, or other individual participating in a health benefit 9 plan. 10 c. “Direct primary care agreement” means an agreement 11 between a primary care provider and a covered person, or the 12 covered person’s representative, in which the primary care 13 provider agrees to provide health care services for a specified 14 period of time to the covered person for a service charge. 15 d. “Health benefit plan” means a policy, contract, 16 certificate, or agreement offered or issued by a health carrier 17 to provide, deliver, arrange for, pay for, or reimburse any of 18 the costs of health care services. 19 e. “Health care professional” means the same as defined in 20 section 514J.102. 21 f. “Health care services” means the same as defined in 22 section 514J.102. 23 g. “Health carrier” means the same as defined in section 24 514J.102. 25 h. “Primary care provider” means a health care professional 26 trained to serve as the first contact and to provide continuous 27 and comprehensive care to a covered person, and includes but 28 is not limited to any of the following licensed or certified 29 health care professionals who provide primary care: 30 (1) A physician who is a family or general practitioner, a 31 pediatrician, an internist, an obstetrician, or a gynecologist. 32 (2) An advanced registered nurse practitioner. 33 (3) A physician assistant. 34 2. a. Notwithstanding the uniformity of treatment 35 -1- LSB 5285HV (1) 91 nls/ko 1/ 3

H.F. 2434 requirements of section 514C.6, a health carrier shall not deny 1 coverage for a covered benefit provided to a covered person 2 solely on the basis that the covered person’s referral to 3 receive the covered benefit was made by a primary care provider 4 who does not participate in the health carrier’s provider 5 network. 6 b. A health carrier shall not impose a deductible, 7 coinsurance, or copayment for a covered benefit for which a 8 covered person was referred by the covered person’s primary 9 care provider in excess of the deductible, coinsurance, or 10 copayment applicable for the covered benefit had the covered 11 person been referred by a health care professional that 12 participates in the health carrier’s provider network. 13 c. A health carrier may require a primary care provider to 14 provide evidence that the primary care provider has executed a 15 direct primary care agreement with the covered person, which 16 evidence may include a written attestation or a copy of the 17 executed direct primary care agreement. 18 3. This section applies to a covered benefit for which a 19 covered person’s primary care provider referred the covered 20 person on or after July 1, 2026. 21 4. The commissioner of insurance may adopt rules pursuant to 22 chapter 17A to administer this section. 23 EXPLANATION 24 The inclusion of this explanation does not constitute agreement with 25 the explanation’s substance by the members of the general assembly. 26 This bill relates to insurance coverage for health care 27 services provided pursuant to a referral by an out-of-network 28 primary care provider. 29 Under the bill, a health carrier (carrier) shall not deny 30 coverage for a covered benefit provided to a covered person 31 solely on the basis that the referral to receive the covered 32 benefit was made by the covered person’s primary care provider 33 (PCP) who does not participate in the carrier’s network. 34 A carrier shall not impose a deductible, coinsurance, or 35 -2- LSB 5285HV (1) 91 nls/ko 2/ 3

H.F. 2434 copayment for a covered benefit for which a covered person was 1 referred by the covered person’s PCP greater than what would 2 be applicable to the same benefit had the covered person been 3 referred by an in-network health care professional. A carrier 4 may require a PCP to provide evidence that the PCP executed a 5 direct primary care agreement with the covered person, which 6 evidence may include a written attestation or a copy of the 7 executed agreement. “Covered benefit”, “direct primary care 8 agreement”, and “primary care provider” are defined in the 9 bill. 10 The bill applies to covered benefits for which a covered 11 person’s primary care provider referred the covered person on 12 or after July 1, 2026. 13 The commissioner of insurance may adopt rules to administer 14 the bill. 15 -3- LSB 5285HV (1) 91 nls/ko 3/ 3