House File 2356 - IntroducedA Bill ForAn Act 1relating to agreements between individuals and health
2care professionals for the provision of certain primary care
3health services for a service charge that covers an agreed
4upon period of time.
5BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1   Section 1.  NEW SECTION.  135N.1  Direct primary care
2agreements.
   31.  Definitions.  For the purpose of this section:
   4a.  “Direct patient” means an individual, or an individual
5and the individual’s immediate family, that is party to a
6direct primary care agreement.
   7b.  “Direct patient’s representative” means a parent,
8guardian, or an individual holding a durable power of attorney
9for health care for a direct patient.
   10c.  “Direct primary care agreement” means an agreement
11between a direct provider and a direct patient, or the direct
12patient’s representative, in which the direct provider agrees
13to provide primary care health services for a specified period
14of time to the direct patient for a direct service charge.
   15d.  “Direct provider” means a health care professional
16licensed, accredited, registered, or certified to perform
17specified primary care health services consistent with the law
18of this state. “Direct provider” includes an individual health
19care professional or other legal health care entity alone or
20with other health care professionals professionally associated
21with the individual health care professional or other legal
22health care entity.
   23e.  “Direct service charge” means a charge for primary care
24health services provided by a direct provider to a direct
25patient covered by a direct primary care agreement. “Direct
26service charge”
may include a periodic retainer, a membership
27fee, a subscription fee, or a charge in any other form paid by
28a direct patient to a direct provider under a direct primary
29care agreement.
   30f.  “Durable power of attorney for health care” means the same
31as defined in section 144B.1.
   32g.  “Primary care health services” means general health care
33services of the type provided at the time a patient seeks
34preventive care or first seeks health care services for a
35specific health concern. Primary care health services include
-1-1all of the following:
   2(1)  Care which promotes and maintains mental and physical
3health and wellness.
   4(2)  Care which prevents disease.
   5(3)  Screening, diagnosing, and treatment of acute or
6chronic conditions caused by disease, injury, or illness.
   7(4)  Patient counseling and education.
   8(5)  Provision of a broad spectrum of preventive and curative
9health care over a period of time.
   10(6)  Coordination of care.
   112.  Requirements for a valid direct primary care agreement.
   12a.  In order to be a valid agreement, a direct primary care
13agreement must meet all of the following requirements:
   14(1)  Be in writing.
   15(2)  Be signed by the direct provider, or an agent of the
16direct provider, and the direct patient or the direct patient’s
17representative.
   18(3)  Describe the scope of the primary care health services
19covered by the direct primary care agreement.
   20(4)  State each of the direct provider’s locations where
21a direct patient may obtain primary care health services and
22specify any out-of-office primary care health services that are
23covered under the direct primary care agreement.
   24(5)  Specify the direct service charge and the frequency
25at which the direct service charge must be paid by the direct
26patient. A direct patient shall not be required to pay more
27than twelve months of a direct service charge in advance.
   28(6)  Specify any additional costs for primary care health
29services not covered by the direct service charge for which the
30direct patient will be responsible.
   31(7)  Specify the duration of the direct primary care
32agreement, whether renewal is automatic, and if required the
33procedure for renewal of the direct primary care agreement.
   34(8)  Specify the terms and conditions under which the
35direct primary care agreement may be terminated by the
-2-1direct provider. A termination of the direct primary care
2agreement by the direct provider shall include a minimum of
3a thirty-calendar-day advance, written notice to the direct
4patient or to the direct patient’s representative.
   5(9)  Specify that the direct primary care agreement may
6be terminated at any time by the direct patient upon written
7notice to the direct provider.
   8(10)  State that if the direct primary care agreement is
9terminated by either the direct patient or the direct provider
10all of the following apply:
   11(a)  Within thirty calendar days of the date of the notice of
12termination from either party, the direct provider shall refund
13all unearned direct service charges to the direct patient.
   14(b)  Within thirty calendar days of the date of the notice
15of termination from either party, the direct patient shall pay
16all outstanding earned direct service charges to the direct
17provider.
   18(11)  Include a notice in bold, twelve-point font that states
19substantially as follows:
20NOTICE. This direct primary care agreement is not health
21insurance and is not a plan that provides health coverage
22for purposes of any federal mandates. This direct primary
23care agreement only covers the primary care health services
24described in this agreement. It is recommended that you obtain
25health insurance to cover health care services not covered
26under this direct primary care agreement. You are personally
27responsible for the payment of any additional health care
28expenses you may incur.
   29b.  The direct provider shall provide the direct patient, or
30the direct patient’s representative, with a fully executed copy
31of the direct primary care agreement at the time the direct
32primary care agreement is executed.
   333.  Application for a direct primary care agreement.  If
34a direct provider requires a prospective direct patient to
35complete an application for a direct primary care agreement,
-3-1the direct provider shall provide a written disclaimer on each
2application that informs the prospective direct patient of the
3direct patient’s financial rights and responsibilities and
4that states that the direct provider will not bill a health
5insurance carrier for primary care health services covered
6under the direct primary care agreement. The disclaimer shall
7also include the identical notice required by subsection 2,
8paragraph “a”, subparagraph (11).
   94.  Notice required for changes to the terms or conditions of
10a direct primary care agreement.
   11a.  A direct provider shall provide at least a
12sixty-calendar-day advance, written notice to a direct patient
13of any of the following changes to a direct primary care
14agreement:
   15(1)  Any change in the scope of the primary care health
16services covered under the agreement.
   17(2)  Any change in the direct provider’s locations where the
18direct patient may access primary care health services.
   19(3)  Any change in the out-of-office services that are
20covered under the direct primary care service agreement.
   21(4)  Any change in the direct service charge.
   22(5)  Any change in the additional costs for primary care
23health services not covered by the direct service charge.
   24(6)  Any change in the renewal terms.
   25(7)  Any change in the terms to terminate the agreement.
   26b.  A direct provider shall provide the notice by mailing
27a letter to the address of the direct patient that the direct
28provider has on file. The postmark date on the letter shall be
29the first day of the required sixty-calendar-day notice period.
   305.  Discrimination based on an individual’s health status.  A
31direct provider shall not refuse to accept a new direct patient
32or discontinue care of an existing direct patient based solely
33on the new direct patient’s or the existing direct patient’s
34health status.
   356.  A direct primary care agreement is not insurance.
-4-
   1a.  A direct primary care agreement is not insurance and
2shall not be subject to the authority of the commissioner of
3insurance. Neither a direct care provider, nor an agent of
4a direct care provider, shall be required to be licensed by
5the commissioner to transact the business of insurance in this
6state or to obtain a certificate issued by the commissioner to
7market or offer a direct primary care agreement.
   8b.  A direct provider shall not bill an insurer for a service
9provided under a direct primary care agreement. A direct
10patient may submit a request for reimbursement to an insurer if
11permitted under the direct patient’s policy of insurance. This
12paragraph does not prohibit a direct provider from billing a
13direct patient’s insurance for a service provided to the direct
14patient by the direct provider that is not provided under the
15direct primary care agreement.
   167.  Third-party payment of a direct service charge.  A direct
17provider may accept payment of a direct service charge for
18a direct patient either directly or indirectly from a third
19party. A direct provider may accept all or part of a direct
20service charge paid by an employer on behalf of an employee who
21is a direct patient of the direct provider. A direct provider
22shall not enter directly into an agreement with an employer
23relating to a direct primary care agreement between the direct
24provider and employees of the employer, other than an agreement
25to establish the timing and method of the payment of a direct
26service charge paid by the employer on behalf of the employee.
   278.  Sale or transfer of a direct primary care agreement.  A
28direct primary care agreement shall not be sold or transferred
29by a direct care provider without the prior written consent
30of the direct patient who is a party to the direct primary
31care agreement. A direct patient shall not sell or transfer a
32direct primary care agreement to which the direct patient is a
33party.
34EXPLANATION
35The inclusion of this explanation does not constitute agreement with
-5-1the explanation’s substance by the members of the general assembly.
   2This bill relates to agreements between individuals and
3health care professionals for the provision of certain primary
4care health services for a service charge that covers an agreed
5upon period of time.
   6The bill defines a direct primary care agreement as an
7agreement between a direct provider and a direct patient,
8or the direct patient’s representative, in which the direct
9provider agrees to provide primary care health services to
10the direct patient for a direct service charge for the period
11of time designated in the agreement. A direct patient is an
12individual, or an individual and the individual’s immediate
13family. A direct provider is defined in the bill. A direct
14service charge is a charge for primary care health services, as
15defined in the bill, provided by a direct provider to a direct
16patient and may include a periodic retainer, a membership fee,
17a subscription fee, or other charge paid by a direct patient to
18a direct provider.
   19The bill requires that a direct primary care agreement must
20be in writing, must be signed by the direct provider and the
21direct patient, must describe the scope of the primary care
22health services included under the agreement, must state each
23direct provider location where primary care health services may
24be obtained by a direct patient, must specify any out-of-office
25services that are included under the agreement, must specify
26the direct service charge and how often it must be paid, must
27specify any additional costs that may be assessed to the direct
28patient for primary care health services not covered by the
29direct service charge, and it must specify the duration of the
30direct primary care agreement and how the agreement is renewed.
   31The bill requires that the terms and conditions for
32termination of the direct primary care agreement by the direct
33provider or the direct patient be included in the agreement.
   34The bill requires that a notice be included on the direct
35primary care agreement and application that advises that the
-6-1agreement is not health insurance and is not a plan that
2provides health coverage for purposes of any federal mandates.
3The notice advises that the agreement only covers the primary
4care health services described in the agreement and recommends
5that the direct patient obtain health insurance to cover other
6health care services as the patient is responsible for all
7additional expenses incurred.
   8A direct provider shall give a copy of the executed direct
9primary care agreement to the direct patient.
   10The bill requires a direct provider to give at least
11a 60-calendar-day advance, written notice to an existing
12direct patient of changes, as outlined in the bill, to a
13direct primary care service agreement. A direct provider is
14prohibited from refusing to accept a new direct patient or
15discontinuing care for an existing direct patient based solely
16on the patient’s health status.
   17The bill provides that a direct primary care agreement
18is not insurance and is not subject to the authority of the
19commissioner of insurance. A direct care provider is not
20required to be licensed by the commissioner to transact the
21business of insurance in this state, or to obtain a certificate
22issued by the commissioner to market or offer a direct primary
23care agreement.
   24The bill prohibits a direct provider from billing an insurer
25for services provided under a direct primary care agreement.
26A direct patient may submit a request for reimbursement to
27an insurer if permitted under the direct patient’s policy of
28insurance. A direct provider may bill a direct patient’s
29insurance for services provided by the direct provider that are
30not provided under a direct primary care agreement.
   31A direct provider may accept payment of a direct service
32charge for a direct patient either directly or indirectly from
33a third party. A direct provider may accept all or part of
34a direct service charge paid by an employer on behalf of an
35employee but may not enter directly into an agreement with an
-7-1employer relating to a direct primary care agreement between
2the direct provider and employees of that employer.
   3The bill allows a direct provider to sell or transfer a
4primary care agreement with the prior written consent of the
5direct patient. A direct patient shall not sell or transfer a
6direct primary care agreement.
-8-
ko/rj