Buffington (SB 516) Act No. 867
New law provides for direct primary care practice.
Defines "board", "direct agreement", "direct fee", "direct patient", "direct patient-provider
primary care practice" and "direct practice", "health insurance issuer", "physician", and
"primary care".
Prohibits certain types of discrimination by a direct practice.
Provides for a direct fee.
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 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.
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.
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.
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 new 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 new 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:
(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.
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.
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.
Provides, subject to the restrictions established in new 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.
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.
Provides a direct practice is not an insurer.
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.
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.
Provides for direct agreement requirements.
Provides the board may promulgate all rules and regulations which are necessary and proper
to effectuate the new law. Provides violations of the new law shall constitute unprofessional conduct and subject
violators to any and all sanctions which may be pursued by the board pursuant to prior law.
Effective August 1, 2014.
(Adds R.S. 37:1360.81-1360.91)