Direct Primary Care Regulations

Direct Primary Care Regulations: Federal


At Medical Access USA, we have been receiving 100s of questions regarding the legality of our specific direct primary care model. Is direct primary care, in general,  legal under the Affordable Care Act (aka ObamaCare) ? The answer…… yes.  Section 10104 of P.L. 111-148 (Patient Protection and Affordable Care Act) states “The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are other- wise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.”  

As most people know, the success of direct primary care practices is thanks to not having to deal with insurance companies. Under section 1555 of the Affordable Care Act, you can legally drop insurance and you will not be penalized for it. Section 1555 states “No individual, company, business, nonprofit shall be required to participate in any health insurance program created under this Act (or any amendments made by this Act), or in any insurance program expanded by this Act (or any such amendments), and there shall be no penalty or fine imposed upon any such issuer for choosing not to participate in such programs.”

On November 2, 2011, Dr. Bill Cassidy (R-LA) and Jay Inslee (D- WA) introduced H.R. 3315 in the  House of Representatives. H.R. 3315, known as Direct M.D. Care Act of 2011, is requesting for CMS to set up a pilot program that would allow CMS to pay monthly fees to direct primary care physicians. The bill is considered “dead” in Congress and is not expected to go anywhere. Medical Access USA is already working on developing a similar model within CMS with the help of internal CMS staffers as well as Rep. Alan Grayson (D-FL). Rep. Alan Grayson wrote a letter to CMS requesting the pilot program.

The U.S. Department of Health and Human Services and The Centers for Medicare and Medicaid Services have not finalized any rules regarding direct primary care.  As this model becomes more popular, you can expect the federal government to thoroughly regulate it.