Montana does have a few DPC practices, and fortunately has made repeat efforts at passing well drafted legislation in the 2017 session. Unfortunately 2017's SB 100 was vetoed by the Governor. A prior (poor) effort at DPC legislation was vetoed by the governor on April 27, 2015 and covered in detail in our blog. If you have aspirations of opening a DPC practice in Montana, be sure to begin by reviewing the Montana Code Title 33 Insurance and Insurance Companies, note that Montana prohibits any in-office dispensing.
“A DPC Agreement must meet the following criteria:
1) The provider charges a periodic fee under the agreement;
2) The provider does not bill any third parties on a fee-for-service basis, for services covered by the agreement; and
3) Any visit fee charged by the provider must be less than the monthly equivalent of the periodic fee.”
“After a review of applicable Montana law, including Mont. Code Ann. § 33-1-201, Ogden v. Montana Power Co., 229 Mont. 387 (1987), and Shattuck v Kalispell Regional Med. Ctr., 2011 MT 229, the Commissioner has determined that healthcare providers are not in the business of insurance. In addition, written agreements which meet these specific criteria and clearly outline the primary care services provided under the agreement are not insurance products regulated by the CSI, because there is no risk sharing or indemnification involved.”
“Please note that any variation from this direct primary care definition may involve indemnification of a party, or the transfer or pooling of risk, which may make the agreement fall under the regulation of this agency. In addition, providers entering into agreements for more comprehensive coverage may be regulated by the CSI as “health maintenance organizations” under MCA § 33-31-102.”
“Healthcare provider or others who are considering such direct primary care agreements should contact this agency for a determination of whether a specific agreement does, or does not, constitute “insurance” under Montana law. To avoid consumer confusion, the CSI also recommends that providers include language stating that direct primary care agreements are not insurance, and are not meant to replace health insurance coverage.”
Dispensing - According to Montana Code Annotated (2017) 37-2-104 it is “it is unlawful for a medical practitioner to engage, directly or indirectly, in the dispensing of drugs” except… in an emergency, or “whenever there is no community pharmacy available to the patient,” or “the dispensing of drugs occasionally, but not as a usual course of doing business, by a medical practitioner.” The state does not define what counts as the “usual course of business.” If you decide to risk dispensing medications in Montana it would be wise to make sure your understanding of what geographic barriers count as “no community pharmacy available” and what volume thresholds would trigger the “usual course of business.”
Medicaid - Most physicians will want to review the three options discussed here. DPC practices will likely find that the “Rendering Only Enrollment” is the most effective option. This should ensure that you are credentialed with Medicaid while not obligating you to bill Medicaid for services rendered.