Rhode Island

Key Provisions

• No Insurance Exemption: Without a specific DPC law, membership agreements exist in a regulatory gray area. The Office of the Health Insurance Commissioner (OHIC) does not explicitly regulate DPC, but agreements could face scrutiny under general insurance statutes if they are structured in a way that resembles a promise of indemnity rather than a fee for direct services.
• Standard Medical Board Governance: DPC physicians are fully regulated by the Rhode Island Board of Medical Licensure and Discipline. Practices must adhere to all standard rules of professional conduct, including obtaining detailed informed consent from patients for membership agreements that clearly outline the scope of services, fee structure, and limitations.
• HSA Incompatibility: Due to the lack of defining state or federal legislation, DPC membership fees are generally not considered qualified medical expenses. This means patients in Rhode Island cannot use Health Savings Account (HSA) funds to pay for their monthly DPC fees and must use post-tax, out-of-pocket money.
• Separation from Insurance Billing: DPC practices operate outside the traditional insurance system and are prohibited from billing a patient's commercial insurance plan or Medicaid for any services already covered by the membership fee. Patients must maintain separate insurance coverage for care not included in the DPC agreement, such as specialist visits and hospitalizations.
• Adherence to General Business Laws: DPC practices must comply with Rhode Island's general business regulations, including any state-specific rules on the corporate practice of medicine and fee-splitting. These foundational laws affect how a DPC practice can be owned, structured, and operated.

Medicaid Provisions

Rhode Island's Medicaid program does not currently have any specific provisions, pilot programs, or waivers designed to integrate the Direct Primary Care model. While the state has made significant investments to support primary care for Medicaid beneficiaries, including substantial rate increases and grants for new Medicaid-accepting practices, these initiatives are aimed at the traditional fee-for-service system. The DPC payment structure, which relies on a direct monthly fee from the patient, is fundamentally incompatible with Medicaid's billing framework. As a result, DPC practices in Rhode Island cannot accept Medicaid for services covered under their membership agreements, and Medicaid patients cannot use their benefits to join a DPC practice.