Affordable Care Act

The Patient Protection and Affordable Care Act, Pub. L. No. 11-148, 124 Stat. 119, § 10104 contains a provision in Section 10104 stating that HHS “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." (Here is a link to the law - run a search for "direct primary care" to find the provision.)

So what are the components of a "qualified health plan?"  Note that all of bolded areas are where DPC has an effect on plan usage.

Essential Health Benefits:

  • Ambulatory patient services
  • Emergency services (reduced)
  • Hospitalization (reduced)
  • Maternity and newborn care
  • Mental health / substance abuse / behavioral health
  • Prescription drugs (reduced)
  • Rehabilitative and habilitative services and devices
  • Laboratory services (reduced)
  • Preventive and wellness services and chronic disease management
  • Pediatric services including oral and vision care


Federal HHS Definitions of a "DPC Medical Home" and "Primary Care Services":

Treatment of Direct Primary Care Medical Home, 76 Fed. Reg. 41900 (July 15, 2011) (amending section 1301(a)(3) of the Affordable Care Act) A "Direct Primary Care Medical Home" plan is defined as “an arrangement where a fee is paid by an individual, or on behalf of an individual, directly to a medical home for primary care services, consistent with the program established in Washington." (Federal Register Citation)

Treatment of Direct Primary Care Medical Home, 77 Fed. Reg. 18423 (Mar. 27, 2012) "Primary Care Services" are defined as “routine health care services, including screening, assessment, diagnosis, and treatment for the purpose of promotion of health, and detection and management of disease or injury."  (Federal Register Citation)

Additional HHS Federal Register Comments:

“We considered allowing an individual to purchase a direct primary care medical home plan and separately acquire wrap-around coverage.  However DPCMHs are providers, not insurance companiesallowing a separate offering would require consumers to make two payments for full medical coverage, adding complexity…” (Federal Register Citation)

“While we recognize the importance of accreditation and quality assurance, we are not establishing that direct PCMHs be accredited in order to participate in QHP networks.  We encourage QHP issuers to consider the accreditation, licensure, or performance of all network providers.”

“We do not interpret that phrase as including providers of non-primary care services, such as specialists.” (Federal Register citation)

“We are not directing exchanges to create incentives for contracting with direct PCMHs.  We encourage exchanges to promote, and QHP issues to explore, innovative models of delivery along the care spectrum.”