2017 - 2018 LEGISLATURE
ASSEMBLY SUBSTITUTE AMENDMENT 1,
TO ASSEMBLY BILL 798
January 26, 2018 - Offered by Representative Sanfelippo.
AB798-ASA1,1,3 1An Act to create 49.45 (24d), 146.78 and 600.01 (1) (b) 13. of the statutes;
2relating to: direct primary care pilot study for Medical Assistance recipients
3and direct primary care agreements.
Analysis by the Legislative Reference Bureau
This substitute amendment allows a health care provider and an individual
patient or employer to enter into a direct primary care agreement and requires the
Department of Health Services to create a work group to study direct primary care
for Medical Assistance recipients and propose a pilot program. A direct primary care
agreement is a contract in which the health care provider agrees to provide routine
health services such as screening, assessment, diagnosis, and treatment for the
purpose of promotion of health or the detection and management of disease or injury.
A valid direct primary care agreement outside of the Medical Assistance program
must, among other things, state that the agreement is not health insurance and that
the agreement alone may not satisfy individual or employer insurance coverage
requirements under federal law. The substitute amendment prohibits
discrimination in the selection of patients to enter into a direct primary care
agreement. The substitute amendment exempts direct primary care agreements
from the application of insurance law.
The substitute amendment requires DHS to convene a work group including
managed care organizations, hospitals, health systems, and health care providers,

including physicians who practice under direct primary care agreements, to study
integrating direct primary care agreements into the Medical Assistance program in
a manner that minimizes disruption of the Medical Assistance managed care
structure. DHS is required to, in consultation with the work group and any other
applicable regulatory agencies, propose a direct primary care pilot program in the
Medical Assistance program and, by December 31, 2018, submit that proposal and
any recommendations of it or the work group to a standing committee in each house
of the legislature with jurisdiction over health, as determined by the presiding officer
of each house. The substitute amendment requires each committee to conduct a
hearing on the report. Each committee must then introduce legislation on a direct
primary care pilot program in the Medical Assistance program based on its findings
as a result of the hearing.
The substitute amendment also requires DHS, in consultation with the work
group, to study and submit a report to the same legislative committees regarding the
implementation of an alternative payment model for potentially preventable
hospital readmissions of Medical Assistance recipients.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB798-ASA1,1 1Section 1 . 49.45 (24d) of the statutes is created to read:
AB798-ASA1,2,42 49.45 (24d) Direct primary care program study; alternative payment model.
3(a) In this subsection, “direct primary care agreement” has the meaning given in s.
4146.78 (1) (a).
AB798-ASA1,3,75 (b) As soon as practicable after the effective date of this paragraph .... [LRB
6inserts date], the department shall convene a work group including managed care
7organizations, hospitals, health systems, and health care providers, including
8physicians who practice under direct primary care agreements, to study integrating
9direct primary care agreements into the Medical Assistance program under this
10subchapter in a manner that minimizes disruption of the Medical Assistance
11managed care structure. The department, in consultation with the work group and
12any other applicable regulatory agencies, such as the federal department of health
13and human services, shall propose a direct primary care pilot program in the Medical

1Assistance program and, by December 31, 2018, shall submit that proposal and any
2recommendations of the work group or the department to a standing committee in
3each house of the legislature with jurisdiction over health, as determined by the
4presiding officer of each house. If the proposed pilot program includes providing
5services to children who are Medical Assistance recipients under direct primary care
6agreements, the direct primary care agreements under the pilot program shall
7provide the children access to a physician.
AB798-ASA1,3,118 (c) Within 60 days of receiving the proposed pilot program under par. (b), each
9committee shall conduct a hearing on the proposal. Each committee shall introduce
10legislation in the 2019 legislative session on a direct primary care pilot program in
11the Medical Assistance program based on its findings as a result of the hearing.
AB798-ASA1,3,1612 (d) By June 30, 2019, the department, in consultation with the work group
13created under par. (b), shall study and submit a report to each legislative committee
14identified under par. (b) regarding the implementation of an alternative payment
15model for potentially preventable hospital readmissions of Medical Assistance
16recipients.
AB798-ASA1,2 17Section 2. 146.78 of the statutes is created to read:
AB798-ASA1,3,18 18146.78 Direct primary care agreement. (1) Definitions. In this section:
AB798-ASA1,3,2219 (a) “Direct primary care agreement" means a contract between a health care
20provider and an individual patient or his or her legal representative or employer in
21which the health care provider agrees to provide routine health care services to the
22individual patient or employees for an agreed-upon fee and period of time.
AB798-ASA1,3,2323 (b) “Health care provider" has the meaning given in s. 146.81 (1) (a) to (p).
AB798-ASA1,4,3
1(c) “Routine health care service" means screening, assessment, diagnosis, and
2treatment for the purpose of promotion of health or the detection and management
3of disease or injury.
AB798-ASA1,4,6 4(2) Valid agreement. A health care provider and an individual patient or an
5employer may enter into a direct primary care agreement. A valid direct primary
6care agreement meets all of the following criteria:
AB798-ASA1,4,77 (a) The agreement is in writing.
AB798-ASA1,4,108 (b) The agreement is signed by the health care provider or an agent of the
9health care provider and the individual patient, the patient's legal representative,
10or a representative of the employer.
AB798-ASA1,4,1211 (c) The agreement allows either party to the agreement to terminate the
12agreement upon written notice to the other party.
AB798-ASA1,4,1413 (d) The agreement describes and quantifies the specific routine health care
14services that are provided under the agreement.
AB798-ASA1,4,1615 (e) The agreement specifies the fee for the agreement and specifies terms for
16termination of the agreement, including any possible refund of fees to the patient.
AB798-ASA1,4,1717 (f) The agreement specifies the duration of the agreement.
AB798-ASA1,4,2018 (g) The agreement prominently states, in writing, that the agreement is not
19health insurance and that the agreement alone may not satisfy individual or
20employer insurance coverage requirements under federal law.
AB798-ASA1,4,2321 (h) The health care provider and the patient are prohibited from billing an
22insurer or any other 3rd party on a fee-for-service basis for the routine health care
23services provided under the agreement.
AB798-ASA1,4,2524 (i) The agreement prominently states, in writing, that the individual patient
25must pay the provider for all services that are not specified under the agreement.
AB798-ASA1,5,7
1(j) The agreement prominently states, in writing, that the patient is
2encouraged to consult with his or her health insurance carrier, if the patient has
3health insurance, before entering into the agreement, that some services provided
4under the agreement may be covered under any health insurance the patient has,
5and that direct primary care fees might not be credited toward deductibles or
6out-of-pocket maximum amounts under the patient's health insurance, if the
7patient has health insurance.
AB798-ASA1,5,13 8(3) Patient selection. In selecting patients with whom to enter into a direct
9primary care agreement, a health care provider may not discriminate on the basis
10of age, citizenship status, color, disability, gender or gender identity, genetic
11information, health status, existence of a preexisting medical condition, national
12origin, race, religion, sex, sexual orientation, or any other protected class. A health
13care provider may base fees under a direct primary care agreement on age.
AB798-ASA1,5,19 14(4) Insurance network participation. A health care provider who has a
15practice in which he or she enters into direct primary care agreements may
16participate in a network of a health insurance carrier only to the extent that the
17provider is willing and able to comply with the terms of the participation agreement
18with the carrier and meet any other terms and conditions of network participation
19as determined by the health insurance carrier.
AB798-ASA1,3 20Section 3. 600.01 (1) (b) 13. of the statutes is created to read:
AB798-ASA1,5,2121 600.01 (1) (b) 13. Valid direct primary care agreements under s. 146.78 (2).
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