Direct Health Care Provider Referral Protection Act

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Policy Status

  • Type: Model Policy
  • Status: Draft
  • Date Introduced: July 24, 2026

Task Forces

  • Health and Human Services

    • Tags

  • 2026 Annual Meeting

    • Summary

    Patients who choose direct health care, also known as direct primary care (DPC), pay a monthly membership fee directly to their physician for comprehensive primary care services, bypassing traditional insurance billing for those services.  However, when these patients need specialist care, imaging, labs, or other covered services, insurers may deny payment or impose higher cost-sharing solely because the referral originates from an out-of-network direct health care provider. As a result, insured patients can face full out-of-pocket costs for services their plan would otherwise cover, effectively penalizing them for choosing a more affordable, patient-centered primary care model.  This targeted protection removes a major barrier to DPC adoption, expands patient choice, lowers overall costs, reduces administrative burden, and improves access to high-quality primary care, without requiring carriers to credential or reimburse the direct care provider. 
    Draft

    Direct Health Care Provider Referral Protection Act

    Be it enacted by the Legislature of the State of [STATE]:  

     Section 1. Short title.  

    This Act may be cited as the “Direct Health Care Provider Referral Protection Act.”  

    Section 2. Prohibition on denial of payment and cost-sharing parity.  

    • (a) A carrier may not deny payment for a health care service otherwise covered under an enrollee’s health benefit plan solely because the enrollee’s referral was made by a direct health care provider who is not a member of the carrier’s provider network.  
    • (b) A carrier may not apply a deductible, coinsurance, or copayment greater than would apply if the same health care service had been referred by a participating primary care provider.  

    Section 3. Definitions.  

    As used in this Act:  

    1. “Carrier” means any entity that provides health benefit plans in this state, including an insurer, a health maintenance organization, a hospital or medical service corporation, a health service plan, or any other entity subject to regulation by the [state insurance regulator].  
    2. “Direct health care provider” means a licensed allopathic or osteopathic physician, or other advanced health care practitioner authorized to engage in independent medical practice in this state, who has entered into a direct health care service agreement with an enrollee.  
    3. “Health benefit plan,” “enrollee,” and “participating provider” have the meanings given in [insert reference to existing state insurance code definitions, or the state’s direct health care / direct primary care statute].  

    Section 4. Applicability.  

    This Act applies to all health benefit plans offered, issued, renewed, or amended in this state.  

    Section 5. Effective date.  

    This Act shall take effect for all health benefit plan contracts that are entered into, renewed, or amended one year after the effective date of this Act.