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AB956,2,2 2146.78 Direct primary care agreement. (1) Definitions. In this section:
AB956,2,73 (a) “Direct primary care agreement" means a contract between a health care
4provider and an individual patient or his or her legal representative or an employer
5in which the health care provider agrees to provide primary care services to the
6individual patient or employee for an agreed-upon subscription fee and period of
7time.
AB956,2,98 (b) “Health care provider" means a health care provider under s. 146.81 (1) (a)
9to (p) that provides primary care services under the provider's scope of practice.
AB956,2,1310 (c) “Primary care services” means outpatient, general health care services of
11the type provided by a main source for regular health care services for patients at the
12time a patient seeks preventive care or first seeks health care services for a specific
13health concern and includes all of the following:
AB956,2,1414 1. Care that promotes and maintains mental and physical health and wellness.
AB956,3,1
12. Care that prevents disease.
AB956,3,32 3. Screening, diagnosing, and treating acute or chronic conditions caused by
3disease, injury, or illness.
AB956,3,44 4. Patient counseling and education.
AB956,3,65 5. Provision of a broad spectrum of preventive and curative health care over a
6period of time.
AB956,3,77 6. Coordination of care.
AB956,3,10 8(2) Valid agreement. A health care provider and an individual patient or his
9or her legal representative or an employer may enter into a direct primary care
10agreement. A valid direct primary care agreement meets all of the following criteria:
AB956,3,1111 (a) The agreement is in writing.
AB956,3,1412 (b) The agreement is signed by the health care provider or an agent of the
13health care provider and the individual patient, the patient's legal representative,
14or a representative of the employer.
AB956,3,1715 (c) The agreement allows either party to the agreement to terminate the
16agreement upon written notice to the other party subject to the requirements under
17sub. (3) for termination of the agreement by the health care provider.
AB956,3,1918 (d) The agreement describes and quantifies the specific primary care services
19that are provided under the agreement.
AB956,3,2220 (e) The agreement specifies the subscription fee for the agreement and specifies
21terms for termination of the agreement, including any possible refund of fees to the
22patient.
AB956,3,2323 (f) The agreement specifies the duration of the agreement.
AB956,4,3
1(g) The agreement prominently states, in writing, that the agreement is not
2health insurance and that the agreement alone may not satisfy individual or
3employer insurance coverage requirements under federal law.
AB956,4,64 (h) The health care provider and the patient are prohibited from billing an
5insurer or any other 3rd party on a fee-for-service basis for the primary care services
6included in the subscription fee under the agreement.
AB956,4,97 (i) The agreement prominently states, in writing, that the individual patient
8or the employer, if applicable, is responsible for paying the provider for all services
9that are not included in the subscription fee under the agreement.
AB956,4,1610 (j) The agreement prominently states, in writing, that the patient is
11encouraged to consult with his or her health insurance carrier, if the patient has
12health insurance, before entering into the agreement, that some services provided
13under the agreement may be covered under any health insurance the patient has,
14and that direct primary care fees might not be credited toward deductibles or
15out-of-pocket maximum amounts under the patient's health insurance, if the
16patient has health insurance.
AB956,4,21 17(3) Patient selection; termination. (a) A health care provider may not decline
18to enter into a direct primary care agreement or terminate a direct primary care
19agreement with a patient solely because of the patient's health status. A direct
20primary care provider may decline to accept a patient for a direct primary care
21agreement for only any of the following reasons:
AB956,4,2222 1. The health care provider's practice has reached its maximum capacity.
AB956,4,2523 2. The patient's medical condition is such that the health care provider is
24unable to provide the appropriate level and type of primary care services the patient
25requires.
AB956,5,2
1(b) A health care provider may terminate a direct primary care agreement with
2a patient for only any of the following reasons:
AB956,5,43 1. The patient fails to pay the subscription fee or repeatedly fails to adhere to
4the treatment plan recommended by the health care provider.
AB956,5,55 2. The patient has performed an act of fraud.
AB956,5,76 3. The patient is abusive and presents an emotional or physical danger to the
7staff or other patients of the health care provider.
AB956,5,98 4. The health care provider discontinues operation as a provider under direct
9primary care agreements.
AB956,5,1210 5. The health care provider believes that the relationship is no longer
11therapeutic for the patient due to a dysfunctional relationship between the health
12care provider and the patient.
AB956,5,1413 (c) Nothing in this section shall be construed to limit the application of s. 106.52
14to a health care provider's practice.
AB956,5,20 15(4) Insurance network participation. A health care provider who has a
16practice in which he or she enters into direct primary care agreements may
17participate in a network of a health insurance carrier only to the extent that the
18provider is willing and able to comply with the terms of the participation agreement
19with the carrier and meet any other terms and conditions of network participation
20as determined by the health insurance carrier.
AB956,6,2 21(5) Construction. Nothing in this section shall be construed to limit the
22regulatory authority of the department of safety and professional services or the
23department of agriculture, trade and consumer protection. Nothing in this section
24shall be construed to limit the authority of the office of the commissioner of insurance
25to regulate contracts that do not satisfy the criteria to be a valid direct primary care

1agreement under sub. (2) and that meet the definition of insurance under s. 600.03
2(25).
AB956,2 3Section 2. 600.01 (1) (b) 13. of the statutes is created to read:
AB956,6,44 600.01 (1) (b) 13. Valid direct primary care agreements under s. 146.78 (2).
AB956,6,55 (End)
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