Direct Primary Care Arrangements Raise Questions for State Insurance Regulators

Over the past year, new health coverage products that are not subject to the consumer protections of the Affordable Care Act have hit the individual market. One type of limited health-insurance-like offering that was already available but is now gaining attention is a direct primary care arrangement, or DPCA. Most often, a DPCA is a contract between a primary care provider and a patient, under which the provider agrees to deliver primary care services in exchange for a monthly fee, which typically runs between $50 and $150.

Under the traditional DPCA the provider does not accept insurance reimbursement, and patients’ fees cover outpatient, nonspecialty services such as preventive services, basic lab services, and chronic disease management. The DPCA typically does not include coverage of prescription drugs, specialty care services, hospitalization, or most other benefits provided by a medical insurance policy. The rising popularity of DPCAs, particularly among the uninsured, raises questions about how the model could affect consumers’ finances and the stability individual market.

In our latest To the Point post for Commonwealth Fund, the faculty with the Georgetown University Center on Health Insurance Reforms took a closer look at state law to understand how states regulate these entities to find that states are split on whether they regulate DPCAs as insurance. The post also highlights some of the concerns that state insurance regulators might want to consider going forward.

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