RELATING TO PRIMARY CARE.

HB1965

HOUSE OF REPRESENTATIVES

H.B. NO.

1965

THIRTY-THIRD LEGISLATURE, 2026

STATE OF HAWAII

A BILL FOR AN ACT

relating
to PRIMARY CARE.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

PART I

����
SECTION 1.
�

The legislature finds that a strong primary care system is the
foundation of affordable, high-quality healthcare.
�
Better access to, and utilization of, primary
care improves chronic disease management, increases life expectancies, reduces
avoidable healthcare visits, and lowers healthcare costs.
�
However, the legislature recognizes that,
Hawaii currently faces an acute primary care access crisis.
�
According to the university of Hawaii's most
recent workforce assessment, the State has a shortage of approximately seven
hundred sixty-eight full-time equivalent providers, with the single largest
shortage being in primary care.
�

According to the assessment, approximately one hundred fifty-two
additional primary care providers are needed statewide.

����
The legislature also recognizes that, while
the costs of operating a business in Hawaii, including rent, staffing,
overhead, and insurance, have increased significantly, primary care
reimbursements have remained stagnant.
�

As a result, providers are leaving insurance networks, retiring early,
or closing their practices due to unsustainable financial pressures.

����
The legislature believes that abusive
insurance practices, such as blanket utilization reviews, downcoding, and
restrictive prior authorization, undermine the sustainability of primary care
practices and restrict patients' access to timely and necessary care.

����
Accordingly, the purpose of this Act is to
strengthen and protect primary care in Hawaii by:

����
(1)
�
Requiring
each health carrier to allocate, initially, at least six per cent of the
carrier's total medical expenditures directly to primary care providers, with
the percentage increasing incrementally to twelve per cent;

����
(2)
�
Ensuring
that funds reach treating providers without being diverted through
administrative mechanisms;

����
(3)
�
Prohibiting
downcoding and abusive utilization review practices;

����
(4)
�
Requiring
prompt reimbursement payments; and

����
(5)
�
Expanding
enforcement, transparency, data reporting, and rural access protections to
stabilize the State's primary care workforce.

PART II

����
SECTION 2.
�

Chapter 431, Hawaii Revised Statutes, is amended by adding a new article
to be appropriately designated and to read as follows:

"
ARTICLE

PRIMARY
CARE PROTECTION ACT

PART
i.
�
GENERAL PROVISIONS

����
�
431:
�
-A
�
Definitions.

�
As

used
in this article:

����
"Commissioner" means the
commissioner of insurance.

����
"Community access primary care
site" means a clinic that offers same-day or episodic primary care
services, maintains referral capability, and ensures documented follow-up care.

����
"Covered person" means a person
enrolled in a health benefit plan offered or administered by a health carrier.

����
"Health benefit plan" means a
policy, contract, certificate, or agreement entered into, offered by, or issued
by a health carrier to provide, deliver, arrange for, pay for, or reimburse any
of the costs of health care services pursuant to chapter 87A, 431, 432, or 432D;
provided that "health benefit plan" does not include limited-benefit,
dental-only, or vision‑only plans.

����
"Health carrier" has the same
meaning as defined in section 431:26-101.

����
"Primary care" means
comprehensive health care services furnished by a primary care provider
practicing in family medicine, internal medicine, pediatrics, geriatrics,
obstetrics, or gynecology.

����
"Primary care access visit" means
a guidelines-based primary care visit furnished in an urgent care, same-day, or
walk-in setting to a covered person who has not designated a primary care
provider.

����
"Primary care provider" or
"provider" means a physician, advanced practice registered nurse, or
physician's assistant who:

����
(1)
�
Is
designated by a covered person as the person's usual source of primary care;

����
(2)
�
Provides
a plurality of a covered person's care visits in a twenty-four-month lookback
period; or

����
(3)
�
Furnishes
a primary care access visit to a covered person at a community access primary
care site.

����
"Primary care spending" means
payments for primary care services furnished by a primary care provider that
are paid directly to the treating provider and are not reduced or diverted by
administrative scoring, medical loss ratio adjustments, or intermediary
entities.
�
"Primary care
spending" includes payments for primary care access visits provided at community
access primary care sites.

����
"Total medical expenditures"
means payments to reimburse physical and mental health care services, excluding
expenditures for prescription drugs, vision care, and dental care.

����
�
431:
�
-B
�

Applicability.
�
Except as
provided in part V, this article shall apply to all health carriers offering
health benefit plans in the individual, small group, and large group fully
insured markets and to the Hawaii employer-union health benefits trust fund.

PART II.
�
provider protections

����
�431:
�
-C
�

Primary care investment requirement; direct allocation.
�
(a)
�
Beginning January 1, 2027, primary care
spending shall comprise at least six per cent of each health carrier's total
medical expenditures; provided that the required percentage shall increase to:

����
(1)
�
Nine
per cent by January 1, 2028; and

����
(2)
�
Twelve
per cent by January 1, 2029.

����
(b)
�
The payments required by this section shall:

����
(1)
�
Be
paid directly to primary care providers, not allocated through intermediaries;

����
(2)
�
Not
be reduced by quality metrics, scoring, or shared savings programs;

����
(3)
�
Not
be diverted through wellness programs, unless the wellness program is directly
supervised by a primary care provider;

����
(4)
�
Not
be counted as an administrative expense for medical loss ratio purposes; and

����
(5)
�
If
paid under the per member per month, capitation, or global budgets metrics, be
no less than the fee‑for‑service equivalent.

����
(c)
�

No health carrier shall raise premiums to meet the requirements of this
section.

����
�431:
�
-D
�

Downcoding and inappropriate claim modification; prohibited.
�
(a)
�
No health carrier shall alter, reduce,
reclassify, or downcode any claim submitted by a primary care provider unless
the health carrier:

����
(1)
�
Demonstrates
that the modification is supported by clear, contemporaneous clinical evidence
that is documented in the medical record;

����
(2)
�
Provides
written notice to the primary care provider within five days of the
modification; and

����
(3)
�
Cites
in the notice to the primary care provider the specific clinical guidelines or
standards justifying the modification.

����
(b)
�

The health carrier shall have the burden of proof in justifying any modification
of the claim.

����
(c)
�

A claim may not be downcoded based on:

����
(1)
�
The
documentation format or style, if the clinical elements are present;

����
(2)
�
The
omission of templated language;

����
(3)
�
The
use of telehealth if telehealth is clinically appropriate; or

����
(4)
�
Any
automated scoring systems or algorithmic criteria without clinician oversight.

����
(d)
�

Each downcoded claim shall be subject to expedited external review and a
final determination shall be issued within fifteen calendar days.

����
(e)
�

Health carriers shall maintain an auditable record of each downcoded
claim, including the:

����
(1)
�
Original
and final codes;

����
(2)
�
Provider
and patient identifiers;

����
(3)
�
Financial
impact of the modification;

����
(4)
�
Rationale
for the modification; and

����
(5)
�
Final
outcome, if the modification was appealed or overturned.

����
(f)
�
Each
health carrier shall provide to the commissioner quarterly reports on
downcoding volumes, overturn rates, and financial impacts.

����
(g)
�
Violation
of this section shall constitute unfair or deceptive acts and shall be subject
to penalties under section 431:
�
-K.

����
�431:
�
-E
�

Prompt payments; required.
�
(a)
�
All health carriers shall pay:

����
(1)
�
Electronically-submitted
claims within fifteen business days of the claim's approval; and

����
(2)
�
Claims
submitted on paper within thirty business days of the claim's approval.

����
(b)
�
Late payments shall accrue interest at a rate
of:

����
(1)
�
Ten
per cent annually; and

����
(2)
�
$25
per day after thirty business days.

����
(c)
�

Each health carrier shall submit a quarterly report to the commissioner
detailing the carrier's payment times.

����
�431:
�
-F
�

Retaliation; prohibited.
�
(a)
�
No health carrier shall engage in retaliatory
conduct against a primary care provider who:

����
(1)
�
Files
a complaint;

����
(2)
�
Appeals
a claim;

����
(3)
�
Challenges
downcoding;

����
(4)
�
Advocates
for patient care; or

����
(5)
�
Requests
an audit.

����
(b)
�

For purposes of this section, retaliatory conduct shall include:

����
(1)
�
Reducing
reimbursements;

����
(2)
�
Terminating
the provider;

����
(3)
�
Causing
credentialing delays;

����
(4)
�
Engaging
in selective auditing; or

����
(5)
�
Narrowing
the provider's network.

����
�431:
�
-G
�

Fair contracting standards.
�
(a)
�
No contract between a health carrier and a
primary care provider shall include:

����
(1)
�
A
confidentiality or non-disclosure agreement;

����
(2)
�
Provisions
requiring arbitration for any dispute arising under this article;

����
(3)
�
Any
waiver of the provider's rights; or

����
(4)
�
Any
provisions allowing the health carrier to unilaterally modify the contract.

����
(b)
�

Providers shall receive at least thirty days' notice before any rate
change or contract change.

PART III.
�
transparency and
enforcement

����
�431:
�
-H
�

Annual reporting requirements; health carriers.
�
(a)
�
Each health carrier shall submit to the
commissioner no later than March 31 of each year a primary care transparency
report.

����
(b)
�
The report shall be filed in a form
determined by the commissioner and shall include, for the preceding calendar
year, the health carrier's:

����
(1)
�
Total
medical expenditures;

����
(2)
�
Total
primary care expenditures;

����
(3)
�
Percentage
of total medical expenditures allocated to primary care;

����
(4)
�
Total
amounts paid for primary care access visits and care received at community
access primary care sites;

����
(5)
�
Number
and percentage of claims downcoded;

����
(6)
�
Downcoding
reversal rates;

����
(7)
�
Prior
authorization requests, denials, approvals, and appeals;

����
(8)
�
Average
turnaround times for prior authorization requests;

����
(9)
�
Average
payment times for claims submitted electronically and on paper;

���
(10)
�
Number
of late-paid claims, by month;

���
(11)
�
Provider
contracts terminated, and the reason for each termination;

���
(12)
�
Provider
network participation rates, by island; and

���
(13)
�
Primary
care provider entry and exit counts.

����
(c)
�

Data provided in the report shall be stratified by:

����
(1)
�
Island;

����
(2)
�
County;

����
(3)
�
Provider
type; and

����
(4)
�
Rural
or urban designation.

����
�431:
�

-I
�
Standardized public reporting
format.
�
(a)
�
The commissioner shall establish a
standardized public reporting format, including digital templates, for the
health carriers' annual
primary care transparency reports.

����
(b)
�
The commissioner shall maintain and update at
least annually a publicly accessible website summarizing each health carrier's:

����
(1)
�
Primary
care spending;

����
(2)
�
Downcoding
activities;

����
(3)
�
Prior
authorization performance;

����
(4)
�
Prompt
payment performance;

����
(5)
�
Community
access primary care site and primary care access visit utilization; and

����
(6)
�
Rural
network adequacy measurements.

����
�431:
�

-J
�
Audit authority.
�
(a)
�

The commissioner shall provide oversight of health carriers and may
conduct:

����
(1)
�
Random
audits;

����
(2)
�
Targeted
audits based on complaints or anomalies;

����
(3)
�
Investigations
of downcoding practices;

����
(4)
�
Reviews
of prior authorization systems;

����
(5)
�
Evaluations
of payment timelines; and

����
(6)
�
Inspections
of health carrier offices or delegated entities.

����
(b)
�

Each health carrier shall provide, within ten business days of the
commissioner's request, the health carrier's:

����
(1)
�
Claims
adjudication records;

����
(2)
�
Downcoding
algorithms or any automated decision tools used by the health carrier;

����
(3)
�
Internal
guidelines;

����
(4)
�
Utilization
review criteria;

����
(5)
�
Credentialing
files;

����
(6)
�
Financial
data, as necessary to verify compliance; or

����
(7)
�
Any
other data requested by the commissioner.

����
�431:
�

-K
�
Enforcement; penalties.
�
(a)
�

For violations of this article, the commissioner may impose fines of up
to:

����
(1)
�
$5,000
per violation for initial noncompliance;

����
(2)
�
$10,000
per violation for repeated or aggravated violations; and

����
(3)
�
Up
to $500,000 per year for systemic violations.

����
(b)
�

For severe or repeated violations, in addition to imposing fines
pursuant to subsection (a), the commissioner may:

����
(1)
�
Require
corrective action plans;

����
(2)
�
Implement
monitoring requirements;

����
(3)
�
Restrict
new plan approvals;

����
(4)
�
Suspend
rate filings; or

����
(5)
�
Refer
the case to the attorney general for further investigation.

����
(c)
�
All
fines collected under this section shall be deposited into the primary care
stabilization special fund established under section �431:
�
-L.

����
�431:
�

-L
�
Primary care stabilization
special fund; established.
�
(a)
�
There is established a primary care
stabilization special fund within the treasury of the State into which shall be
deposited:

����
(1)
�
Fines
collected under section �431:
�
-K;

����
(2)
�
Appropriations
made by the legislature to the fund;

����
(3)
�
Donations
to the fund; and

����
(4)
�
Federal
grants deposited into the fund;

provided
that all interest accrued by the revenues of the fund shall become part of the
fund.

����
(b)
�

Moneys in the primary care stabilization special fund may be used for:

����
(1)
�
Stabilizing
and expanding access to primary care services in rural areas;

����
(2)
�
Expanding
community access primary care sites;

����
(3)
�
Supporting
workforce development initiatives and workforce retention efforts for primary
care providers, including medicaid workforce development initiatives; and

����
(4)
�
Updating
and expanding the State's telehealth infrastructure.

����
�431:
�
-M
�

Public posting of enforcement actions.
�

(a)
�
The commissioner shall
maintain and make publicly available a database of enforcement actions taken
against health carriers, including any:

����
(1)
�
Violations;

����
(2)
�
Penalties;

����
(3)
�
Corrective
actions; and

����
(4)
�
Post-violation
compliance statuses.

����
(b)
�

Records posted pursuant to subsection (a) shall remain publicly
available for five years.

PART
IV.
�
rural access to primary care
services

����
�431:
�

-N
�
Primary care access
visits.
�
(a)
�
Primary care access visits shall be
recognized as covered primary care services regardless of:

����
(1)
�
Attribution
status;

����
(2)
�
Care
setting; or

����
(3)
�
Whether
the services were provided at a community access primary care site.

����
(b)
�

Health carriers shall reimburse primary care access visits at parity
with standard primary care services.

����
(c)
�

No health carrier shall require prior authorization for any primary care
access visit.

����
(d)
�

Primary care access visits shall not be subject to:

����
(1)
�
Reduced
reimbursement rates;

����
(2)
�
Differential
documentation standards; or

����
(3)
�
Enhanced
utilization review requirements.

����
�431:
�

-O
�
Community access primary care
sites.
�
(a)
�
A community access primary care site shall be
recognized as a covered primary care delivery site if the site:

����
(1)
�
Provides
same-day or walk-in primary care services;

����
(2)
�
Maintains
referral pathways;

����
(3)
�
Documents
follow-up care;

����
(4)
�
Provides
guideline-based care; and

����
(5)
�
Ensures
continuity of care.

����
(b)
�

Community access primary care sites shall not be subject to:

����
(1)
�
Reduced
reimbursement rates;

����
(2)
�
Differential
documentation standards; or

����
(3)
�
Enhanced
utilization review requirements.

����
(c)
�

Health carriers shall reimburse services offered at community access
primary care sites at parity with reimbursements for standard primary care
services.

����
�431:
�

-P
�
Attribution standards.
�
A covered person who visits a primary
care provider two or more times within a twelve-month period shall be
provisionally attributed to that primary care provider unless the patient
elects otherwise; provided that attribution shall not be used to:

����
(1)
�
Deny
a claim;

����
(2)
�
Reduce
a reimbursement; or

����
(3)
�
Restrict
the covered person's access to a primary care access visit or community access
primary care site.

����
�431:
�

-Q
�
Telehealth; parity.
�
(a)
�

A telehealth primary care visit shall be reimbursed at parity with
in-person primary care services.

����
(b)
�

Health carriers may not apply to telehealth visits:

����
(1)
�
Additional
prior authorization requirements;

����
(2)
�
Lower
reimbursement rates; or

����
(3)
�
More
restrictive modality rules.

����
(c)
�

Telehealth visits shall be credited equally for purposes of:

����
(1)
�
Attribution;
and

����
(2)
�
Primary
care spending requirements.

����
�431:
�

-R
�
Travel and access
barriers.
�
For residents of islands
or regions without adequate access to primary care services, health carriers
shall:

����
(1)
�
Cover
medically necessary inter-island transportation;

����
(2)
�
Not
deny travel for a lack of local access; and

����
(3)
�
Allow
a community access primary care site or primary care provider to certify access
necessity.

����
�431:
�

-S
�
Nondiscriminatory contracting
in rural areas.
�
(a)
�
Health carriers shall not pay rural primary
care providers less than they pay urban primary care providers for equivalent
services.

����
(b)
�
Health
carriers may consider the primary care provider's geographic location for
purposes of geographic adjustment factors and other adjustments that benefit rural
primary care providers.

����
�431:
�

-T
�
Rural access performance.
�
(a)
�

Each health carrier shall maintain adequate primary care access
standards on a per-island and per-region basis.

����
(b)
�

If a health carrier's primary care access standards are not met, the
carrier shall:

����
(1)
�
Submit
to the commissioner an access remediation plan;

����
(2)
�
Increase
rates;

����
(3)
�
Contract
with a community access primary care site;

����
(4)
�
Expand
access to telehealth; or

����
(5)
�
Expand
access to primary care access visits.

����
(c)
�

A health carrier's persistent failure to meet primary care access
standards shall constitute a violation of this article.

PART V.
�

MED-QUEST IMPLEMENTATION

����
�431:
�

-U
�
Alignment of med-QUEST.
�
The med-QUEST division of the department
of human services shall implement this article to the extent permitted by
federal law by:

����
(1)
�
Adopting,
according to the increments provided in section 431:
�
-C(a), the twelve per cent primary care
spending requirement;

����
(2)
�
Enforcing
the direct allocation of payments to primary care providers;

����
(3)
�
Applying
downcoding prohibitions;

����
(4)
�
Enforcing
prompt payment requirements; and

����
(5)
�
Incorporating
these provisions into all contracts with medicaid managed care organizations.

����
�431:
�

-V
�
Federal approvals and waiver
authority.
�
(a)
�
The med-QUEST division of the department of
human services shall seek any federal approvals necessary to implement this
part, including:

����
(1)
�
State
plan amendments;

����
(2)
�
Modifications
to demonstration waivers under section 1115 of the Social Security Act;
and

����
(3)
�
Any
updates required to actuarial certifications.

����
(b)
�

The med-QUEST division may implement interim compliance measures while
awaiting federal approval, as permitted by federal guidelines.

����
�431:
�

-W
�
Medicaid primary care access
stabilization.
�
The med-QUEST
division of the department of human services shall ensure geographically
reasonable access to primary care in the State by:

����
(1)
�
Requiring
managed care organizations to maintain adequate networks of primary care
providers;

����
(2)
�
Supporting
telehealth parity;

����
(3)
�
Ensuring
the statewide availability of primary care access visits and community access
primary care sites; and

����
(4)
�
Reimbursing
medically necessary inter-island travel when appropriate.

����
�431:
�

-X
�
Payment protections for
medicaid primary care providers.
�
(a)
�
Medicaid managed care organizations shall
reimburse primary care evaluation and management codes at rates at least
equivalent to medicare rates.

����
(b)
�

The med-QUEST division of the department of human services may implement
supplemental payment programs supporting:

����
(1)
�
Rural
primary care providers;

����
(2)
�
Community
access primary care sites;

����
(3)
�
Primary
care access visit expansions; or

����
(4)
�
Providers
treating high-risk or underserved populations.

����
(c)
�

Managed care organizations shall not reduce primary care providers'
reimbursements to offset compliance with the spending requirement in section
431:
�
-U(1).

����
�431:
�

-Y
�
Medicaid workforce
retention.
�
(a)
�
The med‑QUEST division of the
department of human services shall support:

����
(1)
�
Loan
repayment programs for primary care providers;

����
(2)
�
Incentives
for primary care providers to practice in rural and underserved regions;

����
(3)
�
Recruitment
programs for physicians, advanced practice registered nurses, and physician's
assistants; and

����
(4)
�
The
coordination of health care workforce development strategies with the
department of health and university of Hawaii.

����
(b)
�

Moneys from the primary care stabilization special fund established in
section 431:
�
-L may be used to support
medicaid workforce development initiatives.

����
�431:
�

-Z
�
Enforcement for medicaid
managed care organizations.
�
The med-QUEST
division of the department of human services shall coordinate with the
commissioner to provide joint oversight of medicaid managed care organizations and,
to the extent permitted by federal law, may enforce this article by:

����
(1)
�
Requiring
corrective action plans;

����
(2)
�
Freezing
enrollments;

����
(3)
�
Withholding
payments;

����
(4)
�
Implementing
civil penalties; and

����
(5)
�
Declining
contract renewals."

PART III

����
SECTION 3.
�

(a)
�
The insurance commissioner,
department of human services med-QUEST division, and department of health shall
adopt rules pursuant to chapter 91, Hawaii Revised Statutes, as necessary to
implement and enforce this Act.

����
(b)
�

Rulemaking shall include the establishment of:

����
(1)
�
Reporting
templates for health carriers and medicaid managed care organizations;

����
(2)
�
Standards
for rural access to primary care;

����
(3)
�
Audit
procedures and submission formats;

����
(4)
�
Guidelines
for enforcing downcoding restrictions;

����
(5)
�
Reporting
standards for primary care access visits and community access primary care
sites; and

����
(6)
�
Alignment
requirements for medicaid capitation and contract compliance.

����
(c)
�
The
agencies may issue interim rules prior to adopting permanent rules.

����
SECTION 4.
�

The insurance commissioner, department of human services med-QUEST
division, and department of health shall coordinate to:

����
(1)
�
Conduct
joint audits;

����
(2)
�
Exchange
compliance data;

����
(3)
�
Monitor
statewide access to primary care;

����
(4)
�
Evaluate
network adequacy reports;

����
(5)
�
Identify
counties or regions in crisis; and

����
(6)
�
Propose
additional reforms as needed;

provided
that all information sharing shall comply with state and federal
confidentiality laws.

����
SECTION 5.
�

(a)
�
The insurance commissioner,
department of human services med-QUEST division, and department of health shall
jointly develop educational materials informing primary care providers of:

����
(1)
�
The
providers' rights under this Act;

����
(2)
�
Procedures
for challenging downcoding;

����
(3)
�
Procedures
for filing prior authorization appeals;

����
(4)
�
Procedures
for reporting health carrier violations; and

����
(5)
�
Community
access primary care site and primary care access visit billing requirements.

����
(b)
�

The educational materials shall be made available through:

����
(1)
�
Online
modules;

����
(2)
�
Webinars;

����
(3)
�
Rural
community training programs; and

����
(4)
�
Provider
associations.

����
SECTION 6.
�

No later than one hundred eighty days after the effective date of this
Act, each health carrier shall submit to the insurance commissioner a
compliance plan:

����
(1)
�
Identifying
the health carrier's designated primary care compliance officer;

����
(2)
�
Confirming
that all contract provisions prohibited by this Act have been removed;

����
(3)
�
Detailing
any changes the health carrier has made to its systems and procedures in
compliance with this Act, including systems and procedures for:

���������
(A)
�
Downcoding
reviews;

���������
(B)
�
Claims
adjudications; and

���������
(C)
�
The
submission of quarterly and annual reports.

����
SECTION 7.
�

The insurance commissioner shall submit a report to the legislature no
later than twenty days prior to the convening of each regular session,
beginning with the regular session of
2027.
�
The
med-QUEST division of the
department of human services shall submit a parallel report annually by the
same date regarding
the application of this Act to
medicaid managed care organizations.
�

Each report shall include for the prior year:

����
(1)
�
Each
health carrier's primary care spending percentages;

����
(2)
�
Each
health carrier's downcoding volumes and overturn rates;

����
(3)
�
Each
health carrier's prior authorization denial and approval metrics;

����
(4)
�
Each
health carrier's compliance rates with prompt payment requirements;

����
(5)
�
Analyses
of rural access to primary care;

����
(6)
�
Community
access primary care site and primary care access visit utilization by island;

����
(7)
�
Enforcement
actions taken; and

����
(8)
�
Any
other findings or recommendations, including any proposed legislation.

����
SECTION
8.
�
The auditor shall conduct an
independent evaluation of the implementation of this Act three years after the
measure's effective date.
�
The evaluation
shall include an assessment of the impact of the Act on:

����
(1)
�
Primary
care provider retention;

����
(2)
�
Clinic
closure rates;

����
(3)
�
Rural
access to primary care;

����
(4)
�
Waiting
times for primary care;

����
(5)
�
Health
carrier compliance with the requirement to spend twelve per cent of total
medical expenditures on primary care; and

����
(6)
�
The
State's overall health care system.

PART IV

����
SECTION 9.
�

This Act does not affect rights and duties that matured, penalties that
were incurred, and proceedings that were begun before its effective date.

����
SECTION 10.
�

In codifying the new sections added by section 2 of this Act, the
revisor of statutes shall substitute appropriate section numbers for the
letters used in designating the new sections in this Act.

����
SECTION 11.
�

This Act shall take effect upon its approval; provided that section 2
shall take effect on July 1, 2026.

INTRODUCED BY:

_____________________________

Report Title:

DHS; Health
Carriers; Primary Care Providers; Primary Care Access Visits; Community Access
Primary Care Sites; Downcoding; MED-QUEST; Prohibitions; Reports; Special Fund

Description:

Requires
all health carriers to allocate, initially, not less than 6% of the carrier's
total medical expenditures to primary care providers, with the percentage
increasingly incrementally to 12%.
�
Requires
health carriers to pay primary care providers directly, rather than through
administrative mechanisms.
�
Places
restrictions on downcoding and claim modifications.
�
Requires health carriers to ensure access to
primary care in rural areas, including access to Primary Care Access Visits and
Community Access Primary Care Sites.
�
Requires
Insurance Commissioner to administer requirements established in bill.
�
Requires the Department of Human Services
Med-QUEST Division to apply the Act, to the extent permitted by federal law and
subject to any federal approvals, to Medicaid managed care organizations.
�
Requires reports.
�
Requires the Auditor to evaluate the impact
of the Act on various metrics 3 years after the measure's effective date.
�
Establishes the primary care stabilization
special fund.

The summary description
of legislation appearing on this page is for informational purposes only and is
not legislation or evidence of legislative intent.