Colorado

Quick Facts

Key Provisions

• A Direct Primary Care agreement is explicitly defined as not being a "health benefit plan" or insurance under Colorado law (C.R.S. § 10-16-1402).
• All DPC arrangements must be documented in a written contract between the provider and the patient or their employer.
• The agreement must clearly and conspicuously state that it is not health insurance and that the patient may need to secure separate coverage for services not included in the agreement, such as hospitalization or specialty care.
• The contract must detail the specific primary care services covered by the periodic fee and the amount of that fee.
• Either the patient or the provider may terminate the agreement at any time by providing 30 days' written notice to the other party.
• If the agreement is terminated, the provider must issue a pro-rata refund to the patient for any periodic fees paid in advance for unused portions of the service period.
• DPC services must be provided by a healthcare professional, such as a physician, who is licensed to practice primary care in Colorado.
• A DPC provider cannot bill any third-party payer, such as an insurance company, for any services that are already covered under the DPC agreement.
• While general anti-discrimination laws apply, the statute permits providers to decline to accept a new patient if their medical condition would create costs that are too high for the practice to manage.

Medication Dispensing

In Colorado, Direct Primary Care practices are permitted to dispense medications directly to their patients, but they must adhere to the state's general physician dispensing laws. These regulations are outlined in the Colorado Revised Statutes (Title 12, Article 42.5) and are overseen by the Colorado Board of Pharmacy. DPC providers do not receive special exemptions; they must comply with all standard requirements, including proper labeling, record-keeping, and storage. This authority allows DPC clinics to offer wholesale or reduced-cost medications as a benefit to their members, but it is important to note that standard limitations, such as those on dispensing controlled substances without appropriate registration, still apply.

Medicaid Provisions

Colorado law places a significant restriction on DPC practices regarding Medicaid beneficiaries. Under C.R.S. § 25.5-4-301, physicians are prohibited from entering into private contracts, including DPC agreements, with Medicaid patients for any services that are covered by the Medicaid program. DPC practices must inform prospective patients of this rule upon enrollment to ensure compliance. This means a patient cannot be enrolled in both Medicaid and a DPC practice for the same set of primary care services. The state has not established any DPC pilot programs or waivers for its Medicaid population, and there are no specific provisions addressing DPC for state employee health plans.