Illinois

Quick Facts

Key Provisions

• A Direct Primary Care (DPC) relationship must be formalized through a written agreement, signed by both the provider and the patient, which details the scope of primary care services, the periodic fee, and all relevant terms.
• The agreement must contain a clear and conspicuous disclosure stating that it is not a health insurance policy and does not meet any individual health insurance coverage requirements.
• As defined in the statute (215 ILCS 5/5120), monthly membership fees were initially capped at $150 per individual. This amount is subject to periodic inflation adjustments as determined by the Illinois Department of Insurance.
• Providers are prohibited from requiring patients to pay for more than 12 months of services in advance, ensuring financial flexibility for patients.
• Patients retain the right to terminate their DPC agreement at any time by providing the practice with a 30-day written notice.
• Upon termination of an agreement, the provider is required to refund a pro-rated portion of any prepaid fees for services that have not yet been rendered.
• The law specifically defines a 'primary care provider' as a physician licensed under the Illinois Medical Practice Act. While Nurse Practitioners and Physician Assistants may operate in DPC settings, the statute's protections are explicitly tied to physician-led practices.
• DPC agreements must be limited to primary care services. They cannot include coverage for hospitalization, specialist services beyond the primary care scope, or major surgical procedures, as this would constitute risk-bearing insurance.
• Practices must prominently display a notice in their office that outlines the terms of their DPC agreements and lists the credentials of the primary care providers.
• The Illinois Department of Insurance is granted oversight to investigate any DPC agreement that violates the provisions outlined in the Direct Primary Care Act.

Medication Dispensing

In Illinois, DPC practices are not granted special medication dispensing privileges and must adhere to the general regulations governing all physicians. Under the rules of the Illinois Department of Financial and Professional Regulation (IDFPR) and the Pharmacy Practice Act (225 ILCS 85/), physicians may dispense limited quantities of pre-packaged medications directly to patients for their immediate needs. This typically includes starter doses or short-term prescriptions. DPC providers cannot operate as a full-service pharmacy, compound medications on a large scale, or dispense controlled substances without obtaining the appropriate pharmacy license. Furthermore, the cost of any dispensed medications must be handled transparently and cannot be presented as a covered benefit under the DPC agreement, which is legally distinct from a prescription drug insurance plan.

Medicaid Provisions

Illinois has not formally integrated Direct Primary Care into its state Medicaid program, which is managed by the Department of Healthcare and Family Services (HFS). The private-pay, periodic fee structure of DPC is fundamentally incompatible with Medicaid's fee-for-service or managed care billing systems, and there are no specific provisions or waivers that allow Medicaid to pay for DPC membership fees directly. The state has not established any DPC-specific pilot programs for Medicaid recipients. Similarly, while some state employee health plans may permit members to use a health savings account (HSA) or flexible spending account (FSA) to pay for DPC fees, there is no formal program that recognizes DPC as a primary coverage option for state employees.