Missouri

Multiple DPC practices are located within this state's borders.  Representative Frederick introduced House Bill No. 769 - an act relating to direct health services and defining "medical retainer agreements" now active law and found in Mo. Rev. Stat. § 376.1800-1.   The language has provisions that appropriately prohibit concierge "double dipping" practices, but it fails to clearly define direct primary care. The bill was signed by the governor, on July 2, 2015, making it the 14th state to pass DPC legislation.  Be sure to review the insurance language of Title 20 of the Missouri Code of State Regulations prior to drafting your contract.  In office dispensing should not be a problem in Missouri, as described on page 3 of this document (20 CSR 2150-5.020 Nonpharmacy Dispensing) from the State Board of Registration of the Healing Arts.  A white paper entitled "Where Obamacare Leaves Questions, Direct Primary Care May Offer Answers," By Patrick Ishmael of Missouri's Show-Me Institute (Missouri) was published in October 2015.  DPC practices have been growing in the state, as highlighted by this Springfield News-Leader article by Thomas Gounley.  

Medicaid patients are permitted to sign private contracts with providers for covered services.  DPC physicians will want to "enroll" in Medicaid so that their orders for medications, laboratory studies, and other items will be honored.  

13 CSR 70-4.030 Participant Liability for Medical Services Not Reimbursable to the Provider by the MO HealthNet Agency
 
"(1) When an enrolled MO HealthNet provider provides an item or service to a MO HealthNet participant eligible for the item or service on the date provided, there shall be a presumption that the provider accepts the participant’s MO HealthNet benefits and seeks reimbursement from the MO HealthNet agency in accordance with all of the applicable MO HealthNet rules. This presumption shall be overcome only by written evidence of an agreement between the provider and the participant indicating that MO HealthNet is not the intended payer for the specific item or service but rather that the participant accepts the status and liabilities of a private pay patient."  

Also note that Missouri is conducting an unusual experiment by starting a new "Assistant Physician" category with the passage of Senate Bill No. 716 and Senate Bill No. 754 with language available 20 CSR 2150-2.200 (page 21)  "Assistant Physicians" will be required to sign collaborative agreements with fully licenced physicians.  The "assistant physician" need only graduate medical school, no passage of USMLE Step 3 or COMLEX Level 3 is required, and provisions of the law indicate it might be possible for the "assistant physician" to eventually obtain something akin to residency credit and full licensure for what could most favorably be described as an apprenticeship experience.