Direct Primary Care Arrangements 50-State Survey

Direct-to-consumer healthcare arrangements can sometimes implicate state insurance laws, especially when those arrangements involve the provision of unlimited healthcare services for a fixed fee. Yet both providers and patients are increasingly interested in entering into these direct contracts, and state insurance regulators are paying attention.

In approximately half of US states, new laws explicitly exempt direct primary care (DPC) arrangements from insurance regulation. These laws often apply to a narrow scope of arrangements and require providers to build patient protections into their contracts – such as clear cancellation and refund terms.

While these new laws provide certainty for some providers, questions remain:

How could these arrangements be regulated in states that have not passed DPC laws?
How might regulators think about arrangements that are close to, but fall outside of, those described in the state laws (such as arrangements covering certain types of specialty care)?

DPC Laws Map

Does State Have A DPC Law?

Yes

No, But Guidance or Proposed Legislation

McDermott is closely tracking these laws and advising clients on what they mean for different business models. This is a high-level guide to the current state laws on DPC arrangements.

KEY CONSIDERATIONS

Many of the laws follow a model act, but there is significant variation from state to state
Some state DPC laws only apply to physicians; others include clinicians such as physician assistants, nurse practitioners and dentists
Whether a physician group or intermediary entity can take advantage of the regulatory protection of a DPC law varies by state
Some state laws are explicitly limited to primary care, while others are broad enough to include mental health and specialist services
Some states require providers to impose caps or limitations on the number of services offered under a direct patient arrangement
Many states explicitly mandate that a provider’s monthly membership fee must exceed the per-visit charge for a single service
Some states allow employers or health plans to pay the monthly fee, while others prohibit such third-party payor arrangements
Most states regulate the content of the DPC agreement, and many require that specific disclaimers be included; because these disclaimers vary by state, an agreement with patients residing in multiple states may require a laundry list of regulatory language
Most state laws include consumer protection requirements, such as prohibiting practices from charging an annual fee up front, limiting how often providers can make changes to the periodic fees, and mandating that practices adopt liberal cancellation and prorated refund policies

NEED MORE INFORMATION?

Reach out about accessing our detailed 50-state survey on DPC laws, including key information about:

The types of providers eligible to enter into DPC arrangements
Rules regarding the number of services included or the amount of the membership fee
Mandatory content and disclaimers for patient contracts
Cancellation and refund requirements

DIRECT PRIMARY CARE ARRANGEMENTS

50-STATE SURVEY

DPC Laws Map

Does State Have A DPC Law?

KEY CONTACTS

Kate McDonald

Emily R. Curran