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2017 SESSION

17102438D
HOUSE BILL NO. 2053
Offered January 11, 2017
Prefiled January 10, 2017
A BILL to amend the Code of Virginia by adding in Chapter 29 of Title 54.1 an article numbered 10, consisting of sections numbered 54.1-2997 through 54.1-2999.2, relating to direct primary care agreements.
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Patrons-- Landes, Anderson, Bell, Richard P., Bell, Robert B., Bloxom, Byron, Campbell, Cline, Cole, Cox, Dudenhefer, Fariss, Farrell, Fowler, Garrett, Head, Helsel, Hodges, Holcomb, Howell, Hugo, Ingram, Jones, Kilgore, Knight, LaRock, Leftwich, Lingamfelter, Marshall, D.W., Massie, Minchew, Morris, O'Bannon, O'Quinn, Orrock, Peace, Pogge, Poindexter, Ransone, Robinson, Rush, Stolle, Villanueva, Ware, Webert, Wilt, Wright and Yost
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Referred to Committee on Commerce and Labor
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Be it enacted by the General Assembly of Virginia:

1. That the Code of Virginia is amended by adding in Chapter 29 of Title 54.1 an article numbered 10, consisting of sections numbered 54.1-2997 through 54.1-2999.2, as follows:

Article 10.
Direct Primary Care Agreements.

54.1-2997. Definitions.

As used in this article, unless the context requires a different meaning:

"Direct primary care agreement" means a written agreement that:

1. Is entered into between a direct primary care practice and a direct primary care patient;

2. Authorizes the direct primary care practice to charge a periodic fee, specified in the agreement, as consideration for providing ongoing primary care to the direct primary care patient;

3. Describes the specific primary care the direct primary care practice will provide for the direct primary care patient;

4. Does not require that more than 12 months of the periodic fee be paid in advance;

5. Provides that (i) any periodic fee is not earned by the direct primary care practice until the applicable month for which the periodic fee has been paid is completed and (ii) upon termination of the agreement all unearned periodic fees are returned to the patient;

6. Provides that any per visit charge shall be less than the monthly equivalent of the periodic fee;

7. Prominently states the disclaimer set forth in subsection A of 54.1-2998; and

8. Specifies (i) the maximum term of the agreement and (ii) that, notwithstanding such maximum term, the agreement is terminable at any time by the direct primary care patient at will upon written notice to the direct primary care practice.

"Direct primary care patient" means an individual who is party to a direct primary care agreement and is entitled to receive primary care from the direct primary care practice pursuant to the terms of the direct primary care agreement. "Direct primary care patient" includes any person authorized by law to enter into a contract on behalf of an individual who is incapable of making an informed decision or, in the case of a minor child, the parent or parents having custody of the child or the child's legal guardian or as otherwise provided by law.

"Direct primary care practice" means (i) a health care provider who furnishes primary care through a direct primary care agreement, (ii) a group of health care providers who furnish primary care through a direct primary care agreement, or (iii) an entity that sponsors, employs, or is otherwise affiliated with a group of health care providers who furnish only primary care through a direct primary care agreement, which entity is wholly owned by the group of health care providers, and which health provider, group of health providers, or entity:

1. Enters into direct primary care agreements with direct primary care patients;

2. Does not accept third-party fee-for-service payments from any health carrier or other person subject to regulation under Title 38.2 for health care services provided to direct primary care patients pursuant to a direct primary care agreement; and

3. Does not provide, in consideration for the periodic fee, any services other than primary care.

Nothing in this definition shall require a health care provider to exclusively participate in direct primary care agreements or prohibit a health care provider from seeking reimbursement for services rendered outside of a direct primary care agreement.

"Health care provider" or "provider" means a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with the laws of the Commonwealth.

"Health carrier" means an entity subject to the insurance laws and regulations of the Commonwealth and subject to the jurisdiction of the State Corporation Commission that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurer licensed to sell accident and sickness insurance, a health maintenance organization, a health services plan, or any other entity providing a plan of health insurance, health benefits, or health care services.

"Network" means the group of participating providers and facilities providing health care services to a particular health carrier's health plan.

"Periodic fee" means a fee charged by a direct primary care practice as consideration for being available to provide and providing primary care as specified in a direct primary care agreement.

"Primary care" means routine health care services, including screening, assessment, diagnosis, and treatment for the purpose of promotion of health and the detection and management of disease or injury.

54.1-2998. Direct primary care agreement requirements; disclosures; disclaimer.

A. Every direct primary care agreement shall include the following disclaimer:

"This agreement does not provide health insurance coverage. It provides only the provision of primary care as specifically described in this agreement."

B. A direct primary care practice shall make the following written information available to prospective direct primary care patients by prominently disclosing in marketing materials and retainer medical agreements that:

1. The direct primary care agreement is not insurance;

2. The direct primary care practice provides only the limited scope of primary care specified in the direct primary care agreement;

3. A patient is required to pay for all services provided by the direct primary care practice that are not specified in the direct primary care agreement; and

4. The agreement standing alone does not satisfy the health benefit requirements as established in the federal Patient Protection and Affordable Care Act (P.L. 111-148), as amended.

C. A direct primary care agreement (i) shall not be entered into with a group of subscribers and (ii) shall be signed by the individual direct patient who is a party to the direct primary care agreement. Nothing in this subsection prohibits the presentation of marketing materials to groups of potential direct primary care patients.

D. A comprehensive disclosure statement shall be distributed to all direct primary care patients with their participation forms. Such disclosure shall (i) inform the direct primary care patients of their financial rights and responsibilities to the direct primary care practice as provided for in this article, (ii) encourage direct primary care patients to obtain and maintain insurance for services not provided by the direct primary care practice, and (iii) state that the direct primary care practice will not bill a health carrier for services covered under the direct primary care agreement.

54.1-2999. Third-party billing in a direct primary care agreement.

A. With respect to services furnished under a direct primary care agreement, no direct primary care practice may submit a claim for payment to a health carrier or a health carrier's contractor or subcontractor, to a self-insured plan, or to the state medical assistance program, with regard to any health care services provided to direct primary care patients covered by their direct primary care agreement.

B. The prohibition in subsection A shall not apply to health care services provided to a direct primary care patient outside of the direct primary care patient's direct primary care agreement.

54.1-2999.1. Direct primary care agreement not insurance.

A. The provisions of Title 38.2 shall not apply to a direct primary care agreement.

B. A direct primary care practice or any provider or other entity that conducts or participates in a direct primary care practice in accordance with the requirements of this article is not:

1. A health carrier and shall not be subject to the jurisdiction of the State Corporation Commission; or

2. Required to obtain a certificate of authority or license under Title 38.2 to market, sell, or offer to sell a direct primary care agreement.

C. Entering into or executing the terms of a direct primary care agreement shall not be considered to be engaging in the business of insurance for purposes of Title 38.2.

D. A direct primary care agreement is not a contract of insurance, subscription contract, or health plan and is not subject to regulation by the State Corporation Commission.

54.1-2999.2. Violations.

A willful or intentional violation of this article by any person shall constitute an act of unprofessional conduct punishable by the Board as set forth in 54.1-2915.