An Act to Expand Direct Health Care Service Arrangements

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STATE OF MAINE
_____
IN THE YEAR OF OUR LORD
TWO THOUSAND TWENTY-FIVE
_____
H.P. 995 - L.D. 1511
An Act to Expand Direct Health Care Service Arrangements
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 22 MRSA c. 403-A, headnote is amended to read:
CHAPTER 403-A
DIRECT PRIMARY HEALTH CARE SERVICE AGREEMENTS
Sec. 2. 22 MRSA §1771, as enacted by PL 2017, c. 112, §1, is amended to read:
§1771. Direct primary health care service agreements
1. Definitions. As used in this section, unless the context otherwise indicates, the
following terms have the following meanings.
A. "Direct primary health care service agreement" means a contractual agreement
between a direct primary health care provider and an individual patient, or the patient's
legal representative, in which:
(1) The direct primary health care provider agrees to provide primary health care
services to the individual patient for an agreed-to fee over an agreed-to period of
time; and
(2) The direct primary health care provider agrees not to bill 3rd parties on a fee-
for-service or capitated basis for services already covered in the direct primary
health care service agreement.
B. "Direct primary health care provider" means an individual who is a licensed
allopathic physician or osteopathic physician or other advanced health care practitioner
who is authorized to engage in independent medical practice in this State, who is
qualified to provide primary care services and who chooses to practice direct primary
health care by entering into a direct primary health care service agreement with
patients. The term includes, but is not limited to, an individual primary health care
provider or a group of primary health care providers.
APPROVED
JUNE 18, 2025
BY GOVERNOR
CHAPTER
358
PUBLIC LAW
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C. "Primary care" means outpatient, nonspecialty health care services or the
coordination of health care for the purpose of:
(1) Promoting or maintaining mental and physical health and wellness; and
(2) The diagnosis, treatment or management of acute or chronic conditions caused
by disease, injury or illness.
D. "Health care" has the same meaning as in section 1711-C, subsection 1, paragraph
C.
2. Not insurance. A direct primary health care service agreement is not an insurance
policy and is not subject to regulation by the Department of Professional and Financial
Regulation, Bureau of Insurance.
3. Ability to contract. A direct primary health care service agreement is an agreement
between the direct primary health care provider and either an individual or the individual's
representative, regardless of whether the periodic fee or other fees are paid by the
individual, the individual's representative or a 3rd party.
4. Covered services. A direct primary health care service agreement covers only the
services specified in the agreement. Any goods or services that are not covered by the
direct primary health care service agreement may be billed separately.
5. Disclosure. A direct primary health care service agreement must clearly state within
the agreement that direct primary health care services are not considered health insurance
and do not meet requirements of any federal law mandating individuals to purchase health
insurance and that the fees charged in the agreement may not be reimbursed or apply
towards a deductible under a health insurance policy with an insurer.
6. Other care not prohibited. A primary health care provider is considered a direct
primary health care provider only when the provider is engaged in a direct primary health
care service agreement with a patient or group of patients. A primary health care provider
is not prohibited from providing care to other patients under a separate agreement or
contract with an insurer.
7. Other agreements not prohibited. This section does not prohibit a direct primary
health care provider from entering into:
A. An agreement with an insurer offering a policy specifically designed to supplement
a direct primary health care service agreement; or
B. A pilot program for direct primary care or direct health care with a federal or state
agency that provides health coverage.
Sec. 3. 24-A MRSA §4303, sub-§22, as amended by PL 2019, c. 178, §1, is further
amended to read:
22. Denial of referral by out-of-network provider prohibited. Beginning January
1, 2018, a carrier may not deny payment for any health care service covered under an
enrollee's health plan based solely on the basis that the enrollee's referral was made by a
direct primary health care provider who is not a member of the carrier's provider network.
A carrier may not apply a deductible, coinsurance or copayment greater than the applicable
deductible, coinsurance or copayment that would apply to the same health care service if
the service was referred by a participating primary care provider. A carrier may require a
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direct primary health care provider making a referral who is not a member of the carrier's
provider network to provide information demonstrating that the provider is a direct primary
health care provider through a written attestation or copy of a direct primary health care
service agreement with an enrollee and may request additional information necessary to
implement this subsection. As used in this subsection, "direct primary health care provider"
has the same meaning as in Title 22, section 1771, subsection 1, paragraph B.