Relating to insurance coverage for health care services provided pursuant to a referral by an out-of-network primary care provider

This bill relates to insurance coverage for health care services provided pursuant to a referral by an out-of-network primary care provider. Under the bill, a health carrier (carrier) shall not deny coverage for a covered benefit provided to a covered person solely on the basis that the referral to receive the covered benefit was made by the covered person’s primary care provider (PCP) who does not participate in the carrier’s network. A carrier shall not impose a deductible, coinsurance, or copayment for a covered benefit for which a covered person was referred by the covered person’s PCP greater than what would be applicable to the same benefit had the covered person been referred by an in-network health care professional. A carrier may require a PCP to provide evidence that the PCP executed a direct primary care agreement with the covered person, which evidence may include a written attestation or a copy of the executed agreement. “Covered benefit”, “direct primary care agreement”, and “primary care provider” are defined in the bill. The bill applies to covered benefits for which a covered person’s primary care provider referred the covered person on or after July 1, 2026. The commissioner of insurance may adopt rules to administer the bill.