Montana

Quick Facts

Key Provisions

• Expansive Provider Eligibility: Montana's SB 101 establishes a uniquely broad definition of who can operate a DPC practice. The law extends beyond physicians to include other licensed healthcare providers like nurses and pharmacists, granting 'maximum freedom for all healthcare entrepreneurs to innovate with the DPC model.'
• Exemption from Insurance Regulation: The law explicitly clarifies that a direct patient care agreement does not constitute an insurance product. This critical provision exempts DPC practices from the complex and costly regulations overseen by the state's insurance department, providing legal certainty and reducing administrative overhead.
• Direct Contractual Relationship: DPC practices must operate through a direct agreement between the provider and the patient (or their representative). This agreement outlines the scope of services provided, the recurring membership fee, and the terms of the relationship, bypassing traditional insurance intermediaries.
• Prohibition on Insurance Billing: For services covered under the DPC membership, providers are prohibited from billing any private or public insurance plan. Patients pay their membership fee directly, and these fees cannot be submitted to an insurance company for reimbursement or applied toward a deductible.
• Requirement for Supplementary Coverage: While DPC provides comprehensive primary care, the law acknowledges it is not a substitute for health insurance. DPC agreements do not cover catastrophic events, hospitalizations, specialist visits, or advanced diagnostics, making it essential for members to maintain a separate insurance plan or healthshare membership.
• Freedom in Service Offerings and Fees: The legislation provides significant flexibility for DPC practices to define the scope of services included in their memberships. It does not impose caps on membership fees, allowing the market to determine pricing; the current state average is approximately $87 per month for unlimited primary care access.
• HSA Fund Usage (Federal Mandate): While not a state-specific provision, it's a key factor for Montana residents. Following the passage of the federal One Big Beautiful Bill Act (OBBBA), patients will be permitted to use funds from their Health Savings Accounts (HSAs) to pay for DPC membership fees, effective January 1, 2026.

Medicaid Provisions

Montana is actively exploring the integration of Direct Primary Care with its state Medicaid program. Recent legislative activity, specifically House Bill 953 (HB0953) from the 2027 biennium budget cycle, proposes to 'Revise medicaid laws related to direct primary care.' While this indicates strong interest in creating a pathway for Medicaid recipients to access DPC, it is important to note that this is a developing area. As of now, a formal DPC pilot program or waiver for the state's Medicaid population has not been fully implemented, but the ongoing legislative discussions signal a potential future direction for healthcare access in the state.