Wisconsin 2025-2026 Regular Session

Wisconsin Senate Bill SB4 Compare Versions

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

Old	New	Differences
1	1	2025 - 2026 LEGISLATURE
2	2	LRB-0507/1
3	3	JPC:emw
4	4	2025 SENATE BILL 4
5	5	January 24, 2025 - Introduced by Senators CABRAL-GUEVARA, KAPENGA, NASS and
6	6	TESTIN, cosponsored by Representatives DUCHOW, BROOKS, ARMSTRONG,
7	7	DITTRICH, HURD, MURPHY, O'CONNOR, RODRIGUEZ and WICHGERS. Referred to
8	8	Committee on Health.
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
14	14	contract between a health care provider that provides primary care services under
15	15	the provider’s scope of practice and an individual patient or the patient’s legal
16	16	representative or employer in which the health care provider agrees to provide
17	17	primary care services to the patient for an agreed-upon subscription fee and period
18	18	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
22	22	provider and the individual patient, the patient’s legal representative, or a
23	23	representative of 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. 2025 - 2026 Legislature
30	30	SENATE BILL 4
31	31	- 2 - LRB-0507/1
32	32	JPC:emw
33	33	6. It prohibits the provider and patient from billing an insurer or any other
34	34	third party on a fee-for-service basis for the primary care services included in the
35	35	subscription fee under the agreement.
36	36	7. It prominently states, in writing, several provisions, including that the
37	37	agreement is not health insurance and the agreement alone may not satisfy
38	38	individual or employer insurance coverage requirements under federal law; that the
39	39	patient is responsible for paying, or directing the patient’s employer to pay, the
40	40	provider for all services that are not included in the subscription fee under the
41	41	agreement; that the patient is encouraged to consult with a health insurance
42	42	advisor, the patient’s health insurance carrier, or the patient’s employer-sponsored
43	43	health plan, as applicable, before entering into the agreement; and that direct
44	44	primary care fees might not be credited toward deductibles or out-of-pocket
45	45	maximum amounts under any health insurance the patient has.
46	46	Under the bill, a health care provider may not decline to enter into or
47	47	terminate a direct primary care agreement with a patient solely because of the
48	48	patient’s health status. The bill allows a health care provider to decline to accept a
49	49	patient for a direct primary care agreement only if the health care provider’s
50	50	practice has reached its maximum patient capacity or if the patient’s medical
51	51	condition is such that the health care provider is unable to provide the appropriate
52	52	level and type of primary care services the patient requires. A health care provider
53	53	may terminate a direct primary care agreement with a patient only if the patient or
54	54	the patient’s employer fails to pay the subscription fee, the patient fails repeatedly
55	55	to adhere to the treatment plan, the patient has performed an act of fraud related to
56	56	the direct primary care agreement, the patient is abusive in a manner described in
57	57	the bill, the health care provider discontinues operation as a direct primary care
58	58	provider, or the health care provider believes that the relationship is no longer
59	59	therapeutic for the patient due to a dysfunctional relationship between the provider
60	60	and the patient.
61	61	The people of the state of Wisconsin, represented in senate and assembly, do
62	62	enact as follows:
63	63	SECTION 1. 146.78 of the statutes is created to read:
64	64	146.78 Direct primary care agreement. (1) DEFINITIONS. In this section:
65	65	(a) “Direct primary care agreement” means a contract between a health care
66	66	provider and an individual patient or the patient's legal representative or employer
67	67	in which the health care provider agrees to provide primary care services to the
68	68	individual patient for an agreed-upon subscription fee and period of time. 2025 - 2026 Legislature
69	69	SENATE BILL 4
70	70	- 3 - LRB-0507/1
71	71	JPC:emw
72	72	SECTION 1
73	73	(b) “Health care provider” means a health care provider under s. 146.81 (1) (a)
74	74	to (p) that provides primary care services under the health care provider’s scope of
75	75	practice.
76	76	(c) “Primary care services” means outpatient, general health care services of
77	77	the type provided by a main source for regular health care services for patients at
78	78	the time a patient seeks preventive care or first seeks health care services for a
79	79	specific health concern and includes all of the following:
80	80	1. Care that promotes and maintains mental and physical health and
81	81	wellness.
82	82	2. Care that prevents disease.
83	83	3. Screening, diagnosis, and treatment of acute or chronic conditions caused
84	84	by disease, injury, or illness.
85	85	4. Patient counseling and education.
86	86	5. Provision of a broad spectrum of preventive and curative health care over a
87	87	period of time.
88	88	6. Coordination of care.
89	89	(2) VALID AGREEMENT. A health care provider and an individual patient or
90	90	the patient’s legal representative or employer may enter into a direct primary care
91	91	agreement. A valid direct primary care agreement meets all of the following
92	92	criteria:
93	93	(a) The direct primary care agreement is in writing.
94	94	(b) The direct primary care agreement is signed by the health care provider or 2025 - 2026 Legislature
95	95	SENATE BILL 4
96	96	- 4 - LRB-0507/1
97	97	JPC:emw
98	98	SECTION 1
99	99	an agent of the health care provider and the individual patient, the patient’s legal
100	100	representative, or a representative of the patient’s employer.
101	101	(c) The direct primary care agreement allows either party to the direct
102	102	primary care agreement to terminate the direct primary care agreement upon
103	103	written notice to the other party subject to the requirements under sub. (3) for
104	104	termination of the direct primary care agreement by the health care provider.
105	105	(d) The direct primary care agreement describes and quantifies the specific
106	106	primary care services that are provided under the direct primary care agreement.
107	107	(e) The direct primary care agreement specifies the subscription fee for the
108	108	direct primary care agreement and specifies terms for termination of the direct
109	109	primary care agreement, including any possible refund of fees to the patient or the
110	110	patient’s employer.
111	111	(f) The direct primary care agreement specifies the duration of the direct
112	112	primary care agreement.
113	113	(g) The health care provider and the patient are prohibited from billing an
114	114	insurer or any other 3rd party on a fee-for-service basis for the primary care
115	115	services included in the subscription fee under the direct primary care agreement.
116	116	(h) The direct primary care agreement prominently states, in writing, all of
117	117	the following:
118	118	1. The direct primary care agreement is not health insurance, and the direct
119	119	primary care agreement alone may not satisfy individual or employer insurance
120	120	coverage requirements under federal law.
121	121	2. The individual patient is responsible for paying the health care provider for 2025 - 2026 Legislature
122	122	SENATE BILL 4
123	123	- 5 - LRB-0507/1
124	124	JPC:emw
125	125	SECTION 1
126	126	all services that are not included in the subscription fee under the direct primary
127	127	care agreement or directing the patient’s employer to pay the health care provider
128	128	for all services that are not included in the subscription fee under the direct
129	129	primary care agreement, if applicable.
130	130	3. The patient is encouraged to consult with a health insurance advisor, the
131	131	patient’s health insurance carrier, or the patient’s employer-sponsored health plan,
132	132	as applicable, before entering into the direct primary care agreement regarding
133	133	coverage options for health care services that may not be covered through the direct
134	134	primary care agreement.
135	135	4. Some services provided under the direct primary care agreement may be
136	136	covered under any health insurance the patient has.
137	137	5. Direct primary care fees might not be credited toward deductibles or out-of-
138	138	pocket maximum amounts under the patient’s health insurance, if the patient has
139	139	health insurance.
140	140	(3) PATIENT SELECTION; TERMINATION. (a) A health care provider may not
141	141	decline to enter into a direct primary care agreement or terminate a direct primary
142	142	care agreement with a patient solely because of the patient’s health status. A
143	143	health care provider may decline to accept a patient for a direct primary care
144	144	agreement for only any of the following reasons:
145	145	1. The health care provider’s practice has reached its maximum patient
146	146	capacity.
147	147	2. The patient’s medical condition is such that the health care provider is 2025 - 2026 Legislature
148	148	SENATE BILL 4
149	149	- 6 - LRB-0507/1
150	150	JPC:emw
151	151	SECTION 1
152	152	unable to provide the appropriate level and type of primary care services the
153	153	patient requires.
154	154	(b) A health care provider may terminate a direct primary care agreement
155	155	with a patient for only any of the following reasons:
156	156	1. The patient or the patient’s employer fails to pay the subscription fee.
157	157	2. The patient repeatedly fails to adhere to the treatment plan recommended
158	158	by the health care provider.
159	159	3. The patient has performed an act of fraud related to the direct primary care
160	160	agreement.
161	161	4. The patient is abusive and presents an emotional or physical danger to the
162	162	staff or other patients of the health care provider.
163	163	5. The health care provider discontinues operation as a health care provider
164	164	under direct primary care agreements.
165	165	6. The health care provider believes that the relationship is no longer
166	166	therapeutic for the patient due to a dysfunctional relationship between the health
167	167	care provider and the patient.
168	168	(c) Nothing in this section shall be construed to limit the application of s.
169	169	106.52 to a health care provider’s practice.
170	170	(4) INSURANCE NETWORK PARTICIPATION. A health care provider who has a
171	171	practice in which the health care provider enters into direct primary care
172	172	agreements may participate in a network of a health insurance carrier only to the
173	173	extent that the health care provider is willing and able to comply with the terms of
174	174	the participation agreement with the health insurance carrier and meet any other 2025 - 2026 Legislature
175	175	SENATE BILL 4
176	176	- 7 - LRB-0507/1
177	177	JPC:emw
178	178	SECTION 1
179	179	terms and conditions of network participation as determined by the health
180	180	insurance carrier.
181	181	(5) CONSTRUCTION. Nothing in this section shall be construed to limit the
182	182	regulatory authority of the department of safety and professional services or the
183	183	department of agriculture, trade and consumer protection. Nothing in this section
184	184	shall be construed to limit the authority of the office of the commissioner of
185	185	insurance to regulate contracts that do not satisfy the criteria to be a valid direct
186	186	primary care agreement under sub. (2) and that meet the definition of insurance
187	187	under s. 600.03 (25).
188	188	SECTION 2. 600.01 (1) (b) 13. of the statutes is created to read:
189	189	600.01 (1) (b) 13. Valid direct primary care agreements under s. 146.78 (2).
190	190	(END)