Amendment 39

Amendment ID: S3116-39-R3

3rd Redraft Amendment 39

Direct Primary Care Arrangements

Mr. Tarr moves that the proposed new draft be amended by inserting after section _ the following sections:-

"SECTION_. Chapter 176O of the general laws as appearing in the 2024 official edition is hereby amended by inserting at the end of thereof the following new section:-(31). (a) For the purposes of this section, a “direct primary care arrangement” shall mean a contract between a patient and a primary care provider or primary care practice under which:

1. the patient pays a periodic fee for the provision of primary care services;

2. the provider agrees to provide routine and preventive primary care services without billing a carrier; and

3. the arrangement does not constitute health insurance if it meets the requirements of this section.

(b) A direct primary care arrangement shall not be considered insurance under chapters 175, 176A, 176B, 176G, or 176J, provided that:

1.the arrangement does not cover hospital services, specialty services, or other services outside the scope of primary care;

2. the arrangement does not indemnify against the cost of services provided by third parties; and

3. the arrangement clearly discloses that it is not a health insurance product.

1. describes the primary care services covered by the periodic fee;

2. states the periodic fee and any conditions for changing the fee;

3. states that the arrangement is not insurance and that the patient may need to obtain insurance coverage for services not provided under the arrangement;

4. provides a clear process for termination by either party; and

5. prohibits discrimination based on health status or preexisting conditions.

(d) A primary care provider or primary care practice offering a direct primary care arrangement shall file an annual attestation with the division of insurance confirming compliance with this section.

(e) Nothing in this section shall prohibit a patient enrolled in a direct primary care arrangement from purchasing a health plan or high‑deductible health plan, or from using a health savings account to the extent permitted by federal law.

(f) The division of insurance may promulgate regulations necessary to implement this section.

SECTION _. Notwithstanding any general or special law to the contrary, an enrollee covered under chapters 176O, 176J, or any individual or small group health plan regulated by the division of insurance who elects to receive medically necessary covered items or services at a discounted cash price that is below the de identified minimum negotiated charge for such item or service shall receive credit toward the enrollee’s deductible and out of pocket maximum as if the item or service had been provided by a network provider.

(a) Each health plan shall disclose to enrollees the de identified minimum negotiated charge for covered items and services. If a health care entity does not disclose such charge, the enrollee may reference a benchmark selected by the commissioner of insurance, which may include a third-party source.

(b) A health plan shall not discriminate in the form of payment for any network health care item or service covered under an enrollee’s health plan based solely on the fact that the referral was made by a provider who is not a member of the carrier’s provider network, including a primary care provider participating in a direct primary care arrangement.

(c) If an enrollee elects to utilize a pharmacy discount program, drug manufacturer rebate, or other discount or rebate program from a United States based seller, including purchasing from a licensed prescribing provider such as a direct primary care provider, that results in a lower cost than would have been paid under the enrollee’s health insurance policy, the health plan shall apply the amount paid by the enrollee toward the enrollee’s deductible and out of pocket maximum as if the prescription medication had been purchased from a network pharmacy. The insurer may recognize the value of a discount or coupon toward the deductible. Nothing in this subsection shall be construed to restrict a health plan from requiring standard prior authorization or precertification requirements.

(d) Each health plan shall provide a downloadable or interactive online form for the submission of proof of payment and shall inform enrollees annually of their rights under this section.

(e) At enrollment and renewal, each carrier shall provide notice in plan benefit materials and on its website of the availability of the program established under this section and instructions for how enrollees may utilize it.

(f) If an enrollee utilizes a discounted cash price option that is above the de identified minimum negotiated charge, the health plan shall provide credit toward the enrollee’s deductible and out of pocket maximum equal to the discounted cash price or the de identified minimum negotiated charge, whichever is lower.

(g) If a carrier denies a claim submitted under this section, the carrier shall notify the commissioner of insurance and provide supporting evidence for the denial to both the enrollee and the commissioner. An enrollee may appeal such denial to the commissioner within sixty days, and the commissioner shall adjudicate the appeal within thirty days. If the commissioner determines that the carrier improperly denied the claim, the carrier shall pay the enrollee’s costs and attorney’s fees associated with the appeal, accept the claim, and provide cash compensation equal to the amount of the claim to the enrollee.

(h) If a carrier denies more than twenty claims in any quarter under this section, the commissioner shall notify the attorney general, who may investigate whether such denials constitute an unfair trade practice under chapter 93A."