Washington

Quick Facts

Key Provisions

• A Direct Patient-Provider Primary Care (DPC) agreement is legally defined as a contract for primary care services paid with a monthly fee and is explicitly not considered an insurance product under state law (RCW 48.150.060).
• DPC practices are exempt from the licensing and financial solvency requirements of the state's insurance code (Title 48 RCW), reducing regulatory burdens.
• A broad range of licensed professionals, including any 'health care provider' regulated under Title 18 RCW (such as physicians, PAs, and NPs), are eligible to own and operate a DPC practice.
• Before entering into any patient agreements, a DPC practice must file an annual statement with the Office of the Insurance Commissioner to certify its compliance with state DPC laws.
• All patient agreements must be in writing and must clearly specify the scope of primary care services that are covered by the monthly direct fee.
• The law prohibits DPC practices from declining to accept new patients or discontinuing care for existing patients solely based on the patient's health status, ensuring non-discriminatory access to care (RCW 48.150.050).
• DPC practices are forbidden from entering into participating provider contracts with insurance carriers for any services covered under the direct agreement, and they cannot be listed in an insurer's provider network for those services.
• While a practice may discontinue care if it reaches maximum patient capacity or if a patient's needs exceed the provider's scope of practice, the law does not mandate a specific notice period for termination.
• For services provided under the direct agreement, practices are prohibited from accepting payment from regulated insurance carriers or specific state-funded health plans, reinforcing the direct-pay model.

Medication Dispensing

Washington's DPC statute (Chapter 48.150 RCW) does not include specific rules or exemptions for in-office medication dispensing. Consequently, DPC providers who wish to dispense medications must adhere to the state's general laws that govern this practice. These regulations are primarily outlined in Title 18 RCW and are enforced by the Washington State Department of Health and the Pharmacy Quality Assurance Commission. DPC providers must comply with all standard requirements for labeling, storage, record-keeping, and practitioner registration applicable to any physician dispensing medications. While the DPC membership fee cannot be paid by insurance, providers are still able to write prescriptions for patients to fill at an external pharmacy using their insurance benefits.

Medicaid Provisions

Washington law creates a distinct separation between DPC practices and state-funded health programs. The statute, Chapter 48.150 RCW, explicitly prohibits DPC practices from accepting payments from several key state-managed health plans for services covered by the direct agreement. This prohibition includes state employee health plans (governed by Chapter 41.05 RCW), the state's Basic Health Plan (Chapter 70.47 RCW), and Cascade Care plans (Chapter 70.47A RCW). This means that patients enrolled in these specific public and employee insurance programs cannot use their plan benefits to pay for DPC membership fees. The current legislation does not mention any state-sponsored DPC pilot programs or waivers for Medicaid beneficiaries.