HB2494 - Virtual Credit Cards - Health Insurer Payment Processes
- After January 1, 2020, a contract issued, amended or renewed by a health insurer cannot contain a contractual provision restricting the method of payment to a credit card payment.
- If a health insurer initiates or changes payments to a health care provider using electronic funds transfers, including virtual credit card payments, the health insurer shall do the following:
- Notify you if there is a fee associated with the payment.
- Advise you of the available methods of payment and provide clear instructions on how to select an alternative form of payment.
- Remit or associate each payment (no matter what form of payment) with an explanation of benefits (EOB).
HB2494 - Network Leasing provisions
- If a health insurer acquires the provider network of another health insurer, the health insurer who has the contract with you will have an affirmative obligation to notify you that the network has been sold or leased to another health insurer.
- The new law provides you with several clear options under these circumstances. You may:
- Continue the provider relationship with the health insurer that acquired the network, with the assumption that it is under the same terms of the original contract. Check your contract to make sure that there are no negative implications of choosing this option.
- Terminate the provider relationship with the acquiring health insurer. In this case, the termination provisions of your original contract may come into play (in other words, termination must be in writing and needs to be done within a certain number of days).
- Alternatively, you should be provided with the option of entering into a new contract with the acquiring health insurer. This provision gives you a chance to renegotiate the terms of the contract, especially reimbursement rates.
The new law does not apply to terms that are disclosed and agreed to by you, in your original contract, which may give the health insurer the right to sell or lease you as a network provider. Dentists should be alert to these contract provisions and make every attempt to amend their existing contract once the new law takes effect.
SB1105 – Direct Primary Care Agreements
Although we have heard that many Arizona dentists offer in-house membership plans to patients, technically Arizona law limited such plans to just your osteopathic and medical colleagues. Without the "safe harbor" that is now offered by SB1105, dentists offering these plans could be subject to Department of Insurance laws governing pre-paid dental plans. The legislation specifically excludes a direct primary care plan from the definition of "insurance."
Here are couple of important features of the new law:
Requires that an agreement: a) be in writing; b) be signed by the primary care provider or an agent of the provider and the individual patient or their legal representative; c) permits either party to terminate the agreement upon submitting a 30-day written notice to the other party; d) includes terms for relocation and military duty; e) specifies the periodic fee and any additional fees for ongoing care; f) describes the scope of primary care services covered by the periodic fee; g) specifies the duration of the agreement and any automatic renewal periods; and h) provides a prominent disclaimer expressing that the agreement is not an insurance policy.
The Bill prescribes disclaimer language that must be included in the contract. Most importantly, consumers need to understand that they are not purchasing an insurance policy.
That disclaimer should read:
Notice: The organization facilitating the direct primary care agreement is not an insurance company and the direct primary care company guidelines and agreement are not an insurance policy. Participation in the direct primary care agreement or a subscription to any of its documents should not be considered to be a health insurance policy. Regardless of whether you receive treatment for health care issues through the direct primary care agreement, you are always personally responsible for paying any additional health care expenses you may incur. If you have health insurance, it may include, at no additional charge, some of the preventive services that are also available under this direct primary care agreement. The primary care provider may not bill your health insurance for primary care services provided under this direct primary care agreement.
In addition, the new law:
- Prohibits a direct primary care provider from declining to accept a new direct primary care patient or to discontinue care to an existing patient solely because of the patient`s health status.
- Prohibits a direct primary care provider from charging different fees for comparable services based on a patient`s health status or gender.
- Permits a direct primary care provider to decline to accept a patient if the practice has reached its maximum capacity or if the provider is unable to provide the appropriate level and type of primary care services required for the patient`s medical condition.
- Allows a direct primary care provider to discontinue care for a direct primary care patient if: a) the patient fails to pay the periodic fee; b) the patient performed an act of fraud; c) the patient repeatedly fails to adhere to a recommended treatment plan; d) the patient is abusive and presents an emotional or physical danger to staff or other patients of the practice; e) the direct primary care provider discontinues operation as a direct primary care provider; f) the direct primary care provider changes the services or scope of practice provided to patients; or g) the direct primary care provider gives a 30-day written notice to the patient terminating the direct primary care agreement.
- Prohibits an agreement from requiring an advance payment of more than 12 months of the periodic fee.
- Requires an agreement to prohibit a direct primary care provider from submitting a claim for reimbursement to a patient`s healthcare insurer for primary care services that are provided to the patient and that are covered under the agreement.
- Permits an agreement to allow the period fee and any additional fees for ongoing care under the agreement to be paid by a healthcare insurer or other third party.
- Requires, if an agreement is discontinued, that payments that were prepaid for the months following the termination of an agreement be returned to the patient.
- Specifies that an agreement for dental services is limited to services offered within a single practice and may not include services offered in other practice entities.
- States that an agreement for medical services does not constitute the transaction of insurance business or a health care services organization.
AzDA will be posting a Direct Primary Care Resource page for members on www.azda.org, including a sample model contract.