Wisconsin 2023-2024 Regular Session

Wisconsin Senate Bill SB905 Compare Versions

Only one version of the bill is available at this time.

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3	3	2023 - 2024 LEGISLATURE
4	4	2023 SENATE BILL 905
5	5	January 11, 2024 - Introduced by Senators CABRAL-GUEVARA and FELZKOWSKI,
6	6	cosponsored by Representatives DUCHOW, DITTRICH, KITCHENS, MURPHY,
7	7	MURSAU, O'CONNOR and ROZAR. Referred to Committee on Health.
8	8	*AUTHORS SUBJECT TO CHANGE*
9	9	AN ACT to create 146.78 and 600.01 (1) (b) 13. of the statutes; relating to:
10	10	agreements for direct primary care.
11	11	Analysis by the Legislative Reference Bureau
12	12	This bill exempts valid direct primary care agreements from the application of
13	13	insurance law. A direct primary care agreement, as defined in the bill, is a contract
14	14	between a health care provider that provides primary care services under the
15	15	provider's scope of practice and an individual patient, or the patient's legal
16	16	representative, or an employer in which the health care provider agrees to provide
17	17	primary care services to the patient or employee for an agreed-upon subscription fee
18	18	and period of time.
19	19	A valid direct primary care agreement is in writing and satisfies all of the
20	20	following:
21	21	1. It is signed by the health care provider or an agent of the health care provider
22	22	and the individual patient, the patient's legal representative, or a representative of
23	23	the patient's employer.
24	24	2. It allows either party to terminate the agreement upon written notice.
25	25	3. It describes and quantifies the specific primary care services that are
26	26	provided under the agreement.
27	27	4. It specifies the subscription fee for the agreement and specifies terms for
28	28	termination of the agreement.
29	29	5. It specifies the duration of the agreement.
30	30	6. It prohibits the provider and patient from billing an insurer or any other
31	31	third party on a fee-for-service basis for the primary care services included in the
32	32	subscription fee under the agreement.
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36	36	SENATE BILL 905
37	37	7. It prominently states, in writing, several provisions including that the
38	38	agreement is not health insurance and the agreement alone may not satisfy
39	39	individual or employer insurance coverage requirements under federal law; that the
40	40	individual patient is responsible for paying, or directing the individual's employer
41	41	to pay, the provider for all services that are not included in the subscription fee under
42	42	the agreement; that the patient is encouraged to consult with a health insurance
43	43	advisor, the patient's health insurance carrier, or the patient's employer-sponsored
44	44	health plan, as applicable, before entering into the agreement; and that direct
45	45	primary care fees might not be credited toward deductibles or out-of-pocket
46	46	maximum amounts under any health insurance the patient has.
47	47	Under the bill, a health care provider may not decline to enter into or terminate
48	48	a direct primary care agreement with a patient solely because of the patient's health
49	49	status. The bill allows a health care provider to decline to accept a patient for a direct
50	50	primary care agreement only if the health care provider's practice has reached its
51	51	maximum patient capacity or if the patient's medical condition is such that the
52	52	health care provider is unable to provide the appropriate level and type of primary
53	53	care services the patient requires. The bill also provides that a health care provider
54	54	may not decline to enter into a direct primary care agreement with a patient,
55	55	terminate a direct primary care agreement with a patient, or otherwise discriminate
56	56	against a patient in the provision of health care services under a direct primary care
57	57	agreement on the basis of race, color, national origin, religious belief or affiliation,
58	58	sex, disability, age, sexual orientation, or gender identity. A health care provider may
59	59	terminate a direct primary care agreement with a patient only if the patient or the
60	60	patient's employer fails to pay the subscription fee, the patient fails repeatedly to
61	61	adhere to the treatment plan, the patient has performed an act of fraud related to
62	62	the direct primary care agreement, the patient is abusive in a manner described in
63	63	the bill, the health care provider discontinues operation as a direct primary care
64	64	provider, or the health care provider believes that the relationship is no longer
65	65	therapeutic for the patient due to a dysfunctional relationship between the provider
66	66	and the patient.
67	67	The people of the state of Wisconsin, represented in senate and assembly, do
68	68	enact as follows:
69	69	SECTION 1. 146.78 of the statutes is created to read:
70	70	146.78 Direct primary care agreement. (1) DEFINITIONS. In this section:
71	71	(a) “Direct primary care agreement" means a contract between a health care
72	72	provider and an individual patient or the patient's legal representative or an
73	73	employer in which the health care provider agrees to provide primary care services
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81	81	SECTION 1
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83	83	to the individual patient or employee for an agreed-upon subscription fee and period
84	84	of time.
85	85	(b) “Health care provider" means a health care provider under s. 146.81 (1) (a)
86	86	to (p) that provides primary care services under the provider's scope of practice.
87	87	(c) “Primary care services” means outpatient, general health care services of
88	88	the type provided by a main source for regular health care services for patients at the
89	89	time a patient seeks preventive care or first seeks health care services for a specific
90	90	health concern and includes all of the following:
91	91	1. Care that promotes and maintains mental and physical health and wellness.
92	92	2. Care that prevents disease.
93	93	3. Screening, diagnosis, and treatment of acute or chronic conditions caused by
94	94	disease, injury, or illness.
95	95	4. Patient counseling and education.
96	96	5. Provision of a broad spectrum of preventive and curative health care over a
97	97	period of time.
98	98	6. Coordination of care.
99	99	(2) VALID AGREEMENT. A health care provider and an individual patient or the
100	100	patient's legal representative or an employer may enter into a direct primary care
101	101	agreement. A valid direct primary care agreement meets all of the following criteria:
102	102	(a) The agreement is in writing.
103	103	(b) The agreement is signed by the health care provider or an agent of the
104	104	health care provider and the individual patient, the patient's legal representative,
105	105	or a representative of the employer.
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131	131	(c) The agreement allows either party to the agreement to terminate the
132	132	agreement upon written notice to the other party subject to the requirements under
133	133	sub. (3) for termination of the agreement by the health care provider.
134	134	(d) The agreement describes and quantifies the specific primary care services
135	135	that are provided under the agreement.
136	136	(e) The agreement specifies the subscription fee for the agreement and specifies
137	137	terms for termination of the agreement, including any possible refund of fees to the
138	138	patient or the patient's employer.
139	139	(f) The agreement specifies the duration of the agreement.
140	140	(g) The health care provider and the patient are prohibited from billing an
141	141	insurer or any other 3rd party on a fee-for-service basis for the primary care services
142	142	included in the subscription fee under the agreement.
143	143	(h) The agreement prominently states, in writing, all of the following:
144	144	1. The agreement is not health insurance and the agreement alone may not
145	145	satisfy individual or employer insurance coverage requirements under federal law.
146	146	2. The individual patient is responsible for paying the provider for all services
147	147	that are not included in the subscription fee under the agreement or directing the
148	148	individual's employer to pay the provider for all services that are not included in the
149	149	subscription fee under the agreement, if applicable.
150	150	3. The patient is encouraged to consult with a health insurance advisor, the
151	151	patient's health insurance carrier, or the patient's employer-sponsored health plan,
152	152	as applicable, before entering into the agreement regarding coverage options for
153	153	health care services that may not be covered through the agreement.
154	154	4. Some services provided under the agreement may be covered under any
155	155	health insurance the patient has.
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183	183	SECTION 1
184	184	SENATE BILL 905
185	185	5. Direct primary care fees might not be credited toward deductibles or
186	186	out-of-pocket maximum amounts under the patient's health insurance, if the
187	187	patient has health insurance.
188	188	(3) PATIENT SELECTION; TERMINATION. (a) A health care provider may not decline
189	189	to enter into a direct primary care agreement or terminate a direct primary care
190	190	agreement with a patient solely because of the patient's health status. A health care
191	191	provider may decline to accept a patient for a direct primary care agreement for only
192	192	any of the following reasons:
193	193	1. The health care provider's practice has reached its maximum patient
194	194	capacity.
195	195	2. The patient's medical condition is such that the health care provider is
196	196	unable to provide the appropriate level and type of primary care services the patient
197	197	requires.
198	198	(b) A health care provider may terminate a direct primary care agreement with
199	199	a patient for only any of the following reasons:
200	200	1. The patient or the patient's employer fails to pay the subscription fee.
201	201	2. The patient repeatedly fails to adhere to the treatment plan recommended
202	202	by the health care provider.
203	203	3. The patient has performed an act of fraud related to the direct primary care
204	204	agreement.
205	205	4. The patient is abusive and presents an emotional or physical danger to the
206	206	staff or other patients of the health care provider.
207	207	5. The health care provider discontinues operation as a provider under direct
208	208	primary care agreements.
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234	234	SECTION 1 SENATE BILL 905
235	235	6. The health care provider believes that the relationship is no longer
236	236	therapeutic for the patient due to a dysfunctional relationship between the health
237	237	care provider and the patient.
238	238	(c) 1. No health care provider may decline to enter into a direct primary care
239	239	agreement with a patient, terminate a direct primary care agreement with a patient,
240	240	or otherwise discriminate against a patient in the provision of health care services
241	241	under a direct primary care agreement on the basis of race, color, national origin,
242	242	religious belief or affiliation, sex, disability, age, sexual orientation, or gender
243	243	identity.
244	244	2. Nothing in this section shall be construed to limit the application of s. 106.52
245	245	to a health care provider's practice.
246	246	(4) INSURANCE NETWORK PARTICIPATION. A health care provider who has a
247	247	practice in which the health care provider enters into direct primary care agreements
248	248	may participate in a network of a health insurance carrier only to the extent that the
249	249	provider is willing and able to comply with the terms of the participation agreement
250	250	with the carrier and meet any other terms and conditions of network participation
251	251	as determined by the health insurance carrier.
252	252	(5) CONSTRUCTION. Nothing in this section shall be construed to limit the
253	253	regulatory authority of the department of safety and professional services or the
254	254	department of agriculture, trade and consumer protection. Nothing in this section
255	255	shall be construed to limit the authority of the office of the commissioner of insurance
256	256	to regulate contracts that do not satisfy the criteria to be a valid direct primary care
257	257	agreement under sub. (2) and that meet the definition of insurance under s. 600.03
258	258	(25).
259	259	SECTION 2. 600.01 (1) (b) 13. of the statutes is created to read:
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287	287	SECTION 2
288	288	SENATE BILL 905
289	289	600.01 (1) (b) 13. Valid direct primary care agreements under s. 146.78 (2).
290	290	(END)
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