2023 - 2024 LEGISLATURE
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2023 ASSEMBLY BILL 953
January 12, 2024 - Introduced by Representatives DUCHOW, DITTRICH, KITCHENS,
MURPHY, MURSAU, O'CONNOR and ROZAR, cosponsored by Senators
CABRAL-GUEVARA and FELZKOWSKI. Referred to Committee on Health, Aging
and Long-Term Care.
1 AN ACT to create 146.78 and 600.01 (1) (b) 13. of the statutes; relating to:
2 agreements for direct primary care.
Analysis by the Legislative Reference Bureau
This bill exempts valid direct primary care agreements from the application of
insurance law. A direct primary care agreement, as defined in the bill, is a contract
between a health care provider that provides primary care services under the
provider's scope of practice and an individual patient, or the patient's legal
representative, or an employer in which the health care provider agrees to provide
primary care services to the patient or employee for an agreed-upon subscription fee
and period of time.
A valid direct primary care agreement is in writing and satisfies all of the
following:
1. It is signed by the health care provider or an agent of the health care provider
and the individual patient, the patient's legal representative, or a representative of
the patient's employer.
2. It allows either party to terminate the agreement upon written notice.
3. It describes and quantifies the specific primary care services that are
provided under the agreement.
4. It specifies the subscription fee for the agreement and specifies terms for
termination of the agreement.
5. It specifies the duration of the agreement.
6. It prohibits the provider and patient from billing an insurer or any other
third party on a fee-for-service basis for the primary care services included in the
subscription fee under the agreement.
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ASSEMBLY BILL 953
7. It prominently states, in writing, several provisions including that the
agreement is not health insurance and the agreement alone may not satisfy
individual or employer insurance coverage requirements under federal law; that the
individual patient is responsible for paying, or directing the individual's employer
to pay, the provider for all services that are not included in the subscription fee under
the agreement; that the patient is encouraged to consult with a health insurance
advisor, the patient's health insurance carrier, or the patient's employer-sponsored
health plan, as applicable, before entering into the agreement; and that direct
primary care fees might not be credited toward deductibles or out-of-pocket
maximum amounts under any health insurance the patient has.
Under the bill, a health care provider may not decline to enter into or terminate
a direct primary care agreement with a patient solely because of the patient's health
status. The bill allows a health care provider to decline to accept a patient for a direct
primary care agreement only if the health care provider's practice has reached its
maximum patient capacity or if the patient's medical condition is such that the
health care provider is unable to provide the appropriate level and type of primary
care services the patient requires. The bill also provides that a health care provider
may not decline to enter into a direct primary care agreement with a patient,
terminate a direct primary care agreement with a patient, or otherwise discriminate
against a patient in the provision of health care services under a direct primary care
agreement on the basis of race, color, national origin, religious belief or affiliation,
sex, disability, age, sexual orientation, or gender identity. A health care provider may
terminate a direct primary care agreement with a patient only if the patient or the
patient's employer fails to pay the subscription fee, the patient fails repeatedly to
adhere to the treatment plan, the patient has performed an act of fraud related to
the direct primary care agreement, the patient is abusive in a manner described in
the bill, the health care provider discontinues operation as a direct primary care
provider, or the health care provider believes that the relationship is no longer
therapeutic for the patient due to a dysfunctional relationship between the provider
and the patient.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
1 SECTION 1. 146.78 of the statutes is created to read:
2 146.78 Direct primary care agreement. (1) DEFINITIONS. In this section:
3 (a) “Direct primary care agreement" means a contract between a health care
4 provider and an individual patient or the patient's legal representative or an
5 employer in which the health care provider agrees to provide primary care services
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ASSEMBLY BILL 953 SECTION 1
1 to the individual patient or employee for an agreed-upon subscription fee and period
2 of time.
3 (b) “Health care provider" means a health care provider under s. 146.81 (1) (a)
4 to (p) that provides primary care services under the provider's scope of practice.
5 (c) “Primary care services” means outpatient, general health care services of
6 the type provided by a main source for regular health care services for patients at the
7 time a patient seeks preventive care or first seeks health care services for a specific
8 health concern and includes all of the following:
9 1. Care that promotes and maintains mental and physical health and wellness.
10 2. Care that prevents disease.
11 3. Screening, diagnosis, and treatment of acute or chronic conditions caused by
12 disease, injury, or illness.
13 4. Patient counseling and education.
14 5. Provision of a broad spectrum of preventive and curative health care over a
15 period of time.
16 6. Coordination of care.
17 (2) VALID AGREEMENT. A health care provider and an individual patient or the
18 patient's legal representative or an employer may enter into a direct primary care
19 agreement. A valid direct primary care agreement meets all of the following criteria:
20 (a) The agreement is in writing.
21 (b) The agreement is signed by the health care provider or an agent of the
22 health care provider and the individual patient, the patient's legal representative,
23 or a representative of the employer.
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1 (c) The agreement allows either party to the agreement to terminate the
2 agreement upon written notice to the other party subject to the requirements under
3 sub. (3) for termination of the agreement by the health care provider.
4 (d) The agreement describes and quantifies the specific primary care services
5 that are provided under the agreement.
6 (e) The agreement specifies the subscription fee for the agreement and specifies
7 terms for termination of the agreement, including any possible refund of fees to the
8 patient or the patient's employer.
9 (f) The agreement specifies the duration of the agreement.
10 (g) The health care provider and the patient are prohibited from billing an
11 insurer or any other 3rd party on a fee-for-service basis for the primary care services
12 included in the subscription fee under the agreement.
13 (h) The agreement prominently states, in writing, all of the following:
14 1. The agreement is not health insurance and the agreement alone may not
15 satisfy individual or employer insurance coverage requirements under federal law.
16 2. The individual patient is responsible for paying the provider for all services
17 that are not included in the subscription fee under the agreement or directing the
18 individual's employer to pay the provider for all services that are not included in the
19 subscription fee under the agreement, if applicable.
20 3. The patient is encouraged to consult with a health insurance advisor, the
21 patient's health insurance carrier, or the patient's employer-sponsored health plan,
22 as applicable, before entering into the agreement regarding coverage options for
23 health care services that may not be covered through the agreement.
24 4. Some services provided under the agreement may be covered under any
25 health insurance the patient has.
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1 5. Direct primary care fees might not be credited toward deductibles or
2 out-of-pocket maximum amounts under the patient's health insurance, if the
3 patient has health insurance.
4 (3) PATIENT SELECTION; TERMINATION. (a) A health care provider may not decline
5 to enter into a direct primary care agreement or terminate a direct primary care
6 agreement with a patient solely because of the patient's health status. A health care
7 provider may decline to accept a patient for a direct primary care agreement for only
8 any of the following reasons:
9 1. The health care provider's practice has reached its maximum patient
10 capacity.
11 2. The patient's medical condition is such that the health care provider is
12 unable to provide the appropriate level and type of primary care services the patient
13 requires.
14 (b) A health care provider may terminate a direct primary care agreement with
15 a patient for only any of the following reasons:
16 1. The patient or the patient's employer fails to pay the subscription fee.
17 2. The patient repeatedly fails to adhere to the treatment plan recommended
18 by the health care provider.
19 3. The patient has performed an act of fraud related to the direct primary care
20 agreement.
21 4. The patient is abusive and presents an emotional or physical danger to the
22 staff or other patients of the health care provider.
23 5. The health care provider discontinues operation as a provider under direct
24 primary care agreements.
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1 6. The health care provider believes that the relationship is no longer
2 therapeutic for the patient due to a dysfunctional relationship between the health
3 care provider and the patient.
4 (c) 1. No health care provider may decline to enter into a direct primary care
5 agreement with a patient, terminate a direct primary care agreement with a patient,
6 or otherwise discriminate against a patient in the provision of health care services
7 under a direct primary care agreement on the basis of race, color, national origin,
8 religious belief or affiliation, sex, disability, age, sexual orientation, or gender
9 identity.
10 2. Nothing in this section shall be construed to limit the application of s. 106.52
11 to a health care provider's practice.
12 (4) INSURANCE NETWORK PARTICIPATION. A health care provider who has a
13 practice in which the health care provider enters into direct primary care agreements
14 may participate in a network of a health insurance carrier only to the extent that the
15 provider is willing and able to comply with the terms of the participation agreement
16 with the carrier and meet any other terms and conditions of network participation
17 as determined by the health insurance carrier.
18 (5) CONSTRUCTION. Nothing in this section shall be construed to limit the
19 regulatory authority of the department of safety and professional services or the
20 department of agriculture, trade and consumer protection. Nothing in this section
21 shall be construed to limit the authority of the office of the commissioner of insurance
22 to regulate contracts that do not satisfy the criteria to be a valid direct primary care
23 agreement under sub. (2) and that meet the definition of insurance under s. 600.03
24 (25).
25 SECTION 2. 600.01 (1) (b) 13. of the statutes is created to read:
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ASSEMBLY BILL 953 SECTION 2
1 600.01 (1) (b) 13. Valid direct primary care agreements under s. 146.78 (2).
2 (END)