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Regular Session, 2014
SENATE BILL NO. 516
BY SENATORS BUFFINGTON, DORSEY-COLOMB, GUILLORY AND MILLS AND
REPRESENTATIVE STUART BISHOP
HEALTH CARE. Provides for direct primary care. (8/1/14)
AN ACT1
To enact Part VII of Chapter 15 of Title 37 of the Louisiana Revised Statutes of 1950, to be2
comprised of R.S. 37:1360.81 through 1360.91, relative to direct primary care; to3
provide for definitions; to provide for prohibitions on discrimination; to provide for4
direct fees; to provide for prohibited and authorized practices; to provide for5
acceptance and discontinuation of patients; to provide exemptions from state6
insurance laws; to provide for business conduct; to provide for annual reports; to7
provide for violations and penalties; to provide for rules and regulations; and to8
provide for related matters.9
Be it enacted by the Legislature of Louisiana:10
Section 1. Part VII of Chapter 15 of Title 37 of the Louisiana Revised Statutes of11
1950, comprised of R.S. 37:1360.81 through 1360.91, is hereby enacted to read as follows:12
PART VII. DIRECT PRIMARY CARE PRACTICE13
§1360.81. Definitions14
For the purposes of this Part, the terms stated in this Section have the15
meanings assigned to them, respectively, unless the context otherwise requires:16
(1) "Board" means the Louisiana State Board of Medical Examiners.17 SB NO. 516
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(2) "Direct agreement" means a written agreement entered into between1
a direct practice and an individual direct patient, the parent or legal guardian2
of the direct patient, or a family of direct patients whereby the direct practice3
charges a direct fee as consideration for being available to provide and4
providing primary care services to the individual direct patient. A direct5
agreement shall describe the specific health care services the direct practice will6
provide and be terminable at will upon written notice by the direct patient.7
(3) "Direct fee" means a fee charged by a direct practice as consideration8
for being available to provide and providing primary care services as specified9
in a direct agreement.10
(4) "Direct patient" means a person who is party to a direct agreement11
and is entitled to receive primary care services under the direct agreement from12
the direct practice.13
(5) "Direct patient-provider primary care practice" and "direct14
practice" means a physician, group, or entity that meets the following criteria:15
(a) Is any of the following:16
(i) A physician who provides primary care services through a direct17
agreement.18
(ii) A group of physicians who provide primary care services through a19
direct agreement.20
(iii) An entity that sponsors, employs, or is otherwise affiliated with a21
group of physicians who provide primary care services only through a direct22
agreement, which entity is wholly owned by the group of physicians or is a23
nonprofit corporation exempt from taxation under Section 501(c)(3) of the24
Internal Revenue Code and is not otherwise regulated under Title 22 of the25
Louisiana Revised Statutes of 1950. Such entity shall not be prohibited from26
sponsoring, employing, or being otherwise affiliated with other types of health27
care providers not engaged in a direct practice.28
(iv) "Direct patient-provider primary care practice" or "direct practice"29 SB NO. 516
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shall not include an organization or an entity that contracts with a primary care1
practice for the provision of research, technological, operational, and2
administrative support, but such an entity or an organization does not provide3
a direct medical care service.4
(b) Enters into direct agreements with direct patients or parents or legal5
guardians of direct patients.6
(c) Does not accept payment for health care services provided to direct7
patients from any entity subject to regulation under Title 22 of the Louisiana8
Revised Statues of 1950.9
(d) Does not provide, in consideration for a direct fee, services,10
procedures, or supplies such as prescription drugs except as provided in R.S.11
37:1360.84(B), hospitalization costs, major surgery, dialysis, high level12
radiology, including but not limited to X-ray computed tomography, positron13
emission tomography, magnetic resonance imaging, or invasive radiology,14
rehabilitation services, procedures requiring general anesthesia, or similar15
advanced procedures, services, or supplies.16
(6) "Health insurance issuer" means an entity subject to the insurance17
laws and regulations of this state or subject to the jurisdiction of the insurance18
commissioner that contracts or offers to contract or enters into an agreement19
to provide, deliver, arrange for, pay for, or reimburse any of the costs of health20
care services, including a sickness and accident insurance company, a health21
maintenance organization, a preferred provider organization, or any similar22
entity, or any other entity providing a plan of health insurance or health23
benefits.24
(7) "Physician" means a natural person who is the holder of an25
allopathic (MD) degree or an osteopathic (DO) degree from a medical college26
in good standing with the board who holds a license, permit, certification, or27
registration issued by the board to engage in the practice of medicine in the28
state of Louisiana.29 SB NO. 516
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(8) "Primary care" means routine health care services, including1
screening, assessment, diagnosis, and treatment for the purpose of promotion2
of health, and detection and management of disease or injury.3
§1360.82. Prohibition on discrimination4
Except as provided in R.S. 37:1360.85, no direct practice shall decline to5
accept any person solely on account of race, religion, national origin, the6
presence of any sensory, mental, or physical disability, education, or economic7
status.8
§1360.83. Direct fee9
A. A direct practice shall charge a direct fee on a periodic basis. The10
amount of the fee and the periodic basis upon which such fee shall be paid shall11
be included in the provisions of the direct agreement. The fee shall represent the12
total amount due for all primary care services specified in the direct agreement13
and may be paid by the direct patient or on his behalf by others.14
B. A direct practice shall maintain appropriate accounts and provide a15
history of payments and services received upon a request of a direct patient.16
C. If a direct patient chooses to pay more than one periodic direct fee in17
advance, the funds shall be held in a trust account and paid to the direct18
practice as earned at the beginning of each period. Any unearned direct fees19
held in trust following receipt of termination of the direct agreement shall be20
promptly refunded to the direct patient.21
D. A direct fee schedule applying to an existing direct patient may not be22
increased over the annual negotiated amount more frequently than annually.23
A direct practice shall provide advance notice to existing patients of any change24
within the fee schedule applying to those existing direct patients. A direct25
practice shall provide notice of any change in the fee not less than sixty days26
from the date of the change.27
§1360.84. Prohibited and authorized practices28
A. A direct practice shall not:29 SB NO. 516
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(1) Enter into a participating provider contract with any health1
insurance issuer or with any health insurance issuer's contractor or2
subcontractor to provide health care services through a direct agreement except3
as set forth in Subsection B of this Section.4
(2) Submit a claim for payment to any health insurance issuer or any5
health insurance issuer's contractor or subcontractor for health care services6
provided to direct patients as covered by their agreement.7
(3) With respect to services provided through a direct agreement, be8
identified by a health insurance issuer or any health insurance issuer's9
contractor or subcontractor as a participant in the health insurance issuer's or10
any health insurance issuer's contractor or subcontractor network for purposes11
of determining network adequacy or being available for selection by an enrollee12
under a health insurance issuer's benefit plan.13
(4) Pay for health care services covered by a direct agreement rendered14
to direct patients by providers other than the providers in the direct practice or15
their employees, except as described in Subsection B of this Section.16
B. A direct practice and provider may:17
(1) Enter into a participating provider contract with a health insurance18
issuer for purposes other than payment of claims for services provided to direct19
patients through a direct agreement. Such physicians shall be subject to all20
other provisions of the participating provider contract applicable to21
participating providers, including but not limited to the right to:22
(a) Make referrals to other participating providers.23
(b) Admit the carrier's members to participating hospitals and other24
health care facilities.25
(c) Prescribe prescription drugs.26
(d) Implement other customary provisions of the contract not dealing27
with reimbursement of services.28
(2) Pay for charges associated with:29 SB NO. 516
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(a) The provision of routine lab and imaging services.1
(b) Dispensing, at no additional cost to the direct patient, of prescription2
drugs prescribed by the direct provider in accordance with state law and3
regulations promulgated by the board.4
(3) Charge an additional fee to direct patients for supplies, medications,5
and specific vaccines provided to direct patients that are specifically excluded6
under the agreement, provided the direct practice notifies the direct patient of7
the additional charge, prior to their administration or delivery.8
§1360.85. Acceptance or discontinuation of patients; third-party payments9
A. A direct practice shall not decline to accept new direct patients or10
discontinue care to existing patients solely because of the patient's health status.11
A direct practice may decline to accept a patient if the practice has reached its12
maximum capacity, or if the patient's medical condition is such that the13
provider is unable to provide the appropriate level and type of health care14
services in the direct practice. As long as a direct practice provides a patient15
notice and the opportunity to obtain care from another physician, a direct16
practice may discontinue care for a direct patient if any one of the following17
conditions is satisfied:18
(1) The patient fails to pay the direct fee under the terms required by the19
direct agreement.20
(2) The patient has performed an act that constitutes fraud.21
(3) The patient repeatedly fails to comply with the recommended22
treatment plan.23
(4) The patient is abusive and presents an emotional or physical danger24
to the staff or other patients of the direct practice.25
(5) The direct practice discontinues operation as a direct practice.26
B. Subject to the restrictions established in this Part, a direct practice27
may accept payment of direct fees directly or indirectly from third parties. A28
direct practice may accept a direct fee paid by an employer on behalf of an29 SB NO. 516
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employee who is a direct patient. However, a direct practice shall not enter into1
a contract with an employer relating to direct practice agreements between the2
direct practice and employees of that employer other than to establish the3
timing and method of the payment of the direct fee by the employer.4
C. Subject to the restrictions established in this Part, a direct practice5
may accept payment of direct fees directly or indirectly from the Louisiana6
Medical Assistance Program or any entity contracting with the state of7
Louisiana to provide managed care in the Louisiana Medical Assistance8
Program, subject to any necessary approval from the Centers for Medicare and9
Medicaid Services.10
§1360.86. Direct practice not an insurer11
A direct practice that complies with the provisions of this Part, is not a12
health insurance insurer and not subject to the provisions of nor the regulations13
under Title 22 of the Louisiana Revised Statutes of 1950.14
§1360.87. Conduct of business; prohibitions15
A person shall not make, publish, or disseminate any false, deceptive, or16
misleading representation or advertising in the conduct of the business of a17
direct practice or relative to the business of a direct practice.18
§1360.88. Misrepresenting the terms of a direct agreement19
A person shall not make, issue, circulate, or cause to be made, issued, or20
circulated, a misrepresentation of the terms of any direct agreement, the21
benefits or advantages promised thereby, or use the name or title of any direct22
agreement misrepresenting the nature thereof.23
§1360.89. Direct agreement requirements; disclaimer24
A.(1) A direct agreement shall include the following disclaimer:25
"This agreement does not provide comprehensive health insurance26
coverage. It provides only the health care services specifically described."27
(2) A direct agreement may not be sold to a group and may not be28
entered with a group of subscribers. A direct agreement shall be an agreement29 SB NO. 516
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between a direct practice and an individual direct patient or a family of direct1
patients.2
(3) Nothing shall prohibit the presentation of marketing materials to3
groups of potential subscribers or their representatives.4
B. A comprehensive disclosure statement shall be distributed to all direct5
patients with their participation forms. The disclosure shall inform a direct6
patient of his financial rights and responsibilities to the direct practice as7
provided for in this Part, encourage a direct patient to obtain and maintain8
insurance for services not provided by the direct practice, and state that the9
direct practice will not bill a health insurance issuer for services covered under10
the direct agreement. The disclosure statement shall include contact11
information for the board.12
§1360.90. Rules13
The board may promulgate all rules and regulations that are necessary14
and proper to effectuate the provisions of this Part.15
§1360.91. Violations16
Violations of this Part shall constitute unprofessional conduct and17
subject violators to any and all sanctions which may be pursued by the board18
pursuant to R.S. 37:1285.19
The original instrument was prepared by Christopher D. Adams. The
following digest, which does not constitute a part of the legislative
instrument, was prepared by Nancy Vicknair.
DIGEST
Buffington (SB 516)
Proposed law provides for direct primary care practice.
Proposed law defines "board", "direct agreement", "direct fee", "direct patient", "direct
patient-provider primary care practice" and "direct practice", "health insurance issuer",
"physician", and "primary care".
Proposed law prohibits certain types of discrimination by a direct practice.
Proposed law provides for a direct fee.
Proposed law provides a direct practice shall charge a direct fee on a periodic basis. The
amount of the fee and the periodic basis upon which such fee shall be paid shall be included SB NO. 516
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in the provisions of the direct agreement. The fee shall represent the total amount due for all
primary care services specified in the direct agreement and may be paid by the direct patient
or on his behalf by others.
Proposed law further provides a direct practice shall maintain appropriate accounts and
provide a history of payments and services received upon a request of a direct patient.
Further provides if a direct patient chooses to pay more than one periodic direct fee in
advance, the funds shall be held in a trust account and paid to the direct practice as earned
at the beginning of each period. Any unearned direct fees held in trust following receipt of
termination of the direct agreement shall be promptly refunded to the direct patient.
Proposed law provides a direct fee schedule applying to an existing direct patient may not
be increased over the annual negotiated amount more frequently than annually. A direct
practice shall provide advance notice to existing patients of any change within the fee
schedule applying to those existing direct patients. A direct practice shall provide notice of
any change in the fee not less than 60 days from the date of the change.
Proposed law provides a direct practice shall not:
(1)Enter into a participating provider contract with any health insurance issuer or with
any health insurance issuer's contractor or subcontractor to provide health care
services through a direct agreement except as set forth in the proposed law.
(2)Submit a claim for payment to any health insurance issuer or any health insurance
issuer's contractor or subcontractor for health care services provided to direct patients
as covered by their agreement.
(3)With respect to services provided through a direct agreement, be identified by a
health insurance issuer or any health insurance issuer's contractor or subcontractor
as a participant in the health insurance issuer's or any health insurance issuer's
contractor or subcontractor network for purposes of determining network adequacy
or being available for selection by an enrollee under a health insurance issuer's
benefit plan.
(4)Pay for health care services covered by a direct agreement rendered to direct patients
by providers other than the providers in the direct practice or their employees, except
as described in proposed law.
Proposed law provides a direct practice and provider may:
(1)Enter into a participating provider contract with a health insurance issuer for
purposes other than payment of claims for services provided to direct patients
through a direct agreement. Such physicians shall be subject to all other provisions
of the participating provider contract applicable to participating providers including
but not limited to the right to:
(a)Make referrals to other participating providers.
(b)Admit the carrier's members to participating hospitals and other health care
facilities.
(c)Prescribe prescription drugs.
(d)Implement other customary provisions of the contract not dealing with
reimbursement of services.
(2)Pay for charges associated with: SB NO. 516
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(a)The provision of routine lab and imaging services.
(b)Dispensing, at no additional cost to the direct patient, of prescription drugs
prescribed by the direct provider in accordance with state law and regulations
promulgated by the Louisiana State Board of Medical Examiners (the board).
(3)Charge an additional fee to direct patients for supplies, medications, and specific
vaccines provided to direct patients that are specifically excluded under the
agreement, provided the direct practice notifies the direct patient of the additional
charge, prior to their administration or delivery.
Proposed law provides a direct practice shall not decline to accept new direct patients or
discontinue care to existing patients solely because of the patient's health status. A direct
practice may decline to accept a patient if the practice has reached its maximum capacity,
or if the patient's medical condition is such that the provider is unable to provide the
appropriate level and type of health care services in the direct practice.
Proposed law provides as long as a direct practice provides a patient notice and the
opportunity to obtain care from another physician, a direct practice may discontinue care for
a direct patient if any one of the following conditions is satisfied:
(1)The patient fails to pay the direct fee under the terms required by the direct
agreement.
(2)The patient has performed an act that constitutes fraud.
(3)The patient repeatedly fails to comply with the recommended treatment plan.
(4)The patient is abusive and presents an emotional or physical danger to the staff or
other patients of the direct practice.
(5)The direct practice discontinues operation as a direct practice.
Proposed law provides, subject to the restrictions established in proposed law, a direct
practice may accept payment of direct fees directly or indirectly from third parties. A direct
practice may accept a direct fee paid by an employer on behalf of an employee who is a
direct patient. However, a direct practice shall not enter into a contract with an employer
relating to direct practice agreements between the direct practice and employees of that
employer other than to establish the timing and method of the payment of the direct fee by
the employer.
Proposed law authorizes a direct practice to accept payment of direct fees directly or
indirectly from the La. Medical Assistance Program or any entity contracting with the state
to provide managed care in the program, subject to any necessary approval from the Centers
for Medicare and Medicaid Services.
Proposed law provides a direct practice is not an insurer.
Proposed law provides a person shall not make, publish, or disseminate any false, deceptive,
or misleading representation or advertising in the conduct of the business of a direct practice
or relative to the business of a direct practice.
Proposed law provides a person shall not make, issue, circulate, or cause to be made, issued,
or circulated, a misrepresentation of the terms of any direct agreement, the benefits or
advantages promised thereby, or use the name or title of any direct agreement
misrepresenting the nature thereof.
Proposed law provides for direct agreement requirements. SB NO. 516
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words in boldface type and underscored are additions.
Proposed law provides the board may promulgate all rules and regulations which are
necessary and proper to effectuate the proposed law.
Proposed law provides violations of the proposed law shall constitute unprofessional conduct
and subject violators to any and all sanctions which may be pursued by the board pursuant
to present law.
Effective August 1, 2014.
(Adds R.S. 37:1360.81-1360.91)
Summary of Amendments Adopted by Senate
Senate Floor Amendments to engrossed bill
1. Provides that "direct patient-provider primary care practice" or "direct
practice" will not include an organization or an entity that contracts with a
primary care practice for the provision of research, technological,
operational, and administrative support, but such an entity or an organization
does not provide a direct medical care service.
2. Authorizes a direct practice to accept payment of direct fees from the La.
Medical Assistance Program or any entity contracting with the state to
provide managed care, subject to any necessary approval from the Centers
for Medicare and Medicaid Services.
3. Makes technical changes.