HF 2434 (LSB 5285HV (1) 91)

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 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 benefit” means a health care service to which a covered person is entitled under the terms of a health benefit plan.
   b.  “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
   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 a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
   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 a covered benefit provided to a covered person solely on the basis that the covered person’s referral to receive the covered benefit 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 a covered benefit 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 benefit 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 a covered benefit 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.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to insurance coverage for health care services provided pursuant to a referral by an out-of-network primary care provider.
   Under the bill, a health carrier (carrier) shall not deny coverage for a covered benefit provided to a covered person solely on the basis that the referral to receive the covered benefit was made by the covered person’s primary care provider (PCP) who does not participate in the carrier’s network. A carrier shall not impose a deductible, coinsurance, or copayment for a covered benefit for which a covered person was referred by the covered person’s PCP greater than what would be applicable to the same benefit had the covered person been referred by an in-network health care professional. A carrier may require a PCP to provide evidence that the PCP executed a direct primary care agreement with the covered person, which evidence may include a written attestation or a copy of the executed agreement. “Covered benefit”, “direct primary care agreement”, and “primary care provider” are defined in the bill.
   The bill applies to covered benefits for which a covered person’s primary care provider referred the covered person on or after July 1, 2026.
   The commissioner of insurance may adopt rules to administer the bill.