Nebraska
Nebraska took a step forward on March 30, 2016 when it became the 16th state to sign DPC legislation into law! Nebraska was a ripe political environment for the passage of DPC legislation - State Senator Merv Riepe attended the DPC Summit in the summer of 2015, publicly announced plans to pursue legislation, and he arranged a Nebraska DPC Symposium, and successfully authored and passed LB817 - Adopt the Direct Primary Care Agreement Act. The law can now be found within the Nebraska Revised Statutes Neb. Rev. Stat. §§ 71-9501 through 71-9511 (linked below).
Neb. Rev. Stat. § 71-9501
Neb. Rev. Stat. § 71-9502
Neb. Rev. Stat. § 71-9503
Neb. Rev. Stat. § 71-9504
Neb. Rev. Stat. § 71-9505
Neb. Rev. Stat. § 71-9506
Neb. Rev. Stat. § 71-9507
Neb. Rev. Stat. § 71-9508
Neb. Rev. Stat. § 71-9509
Neb. Rev. Stat. § 71-9510
Neb. Rev. Stat. § 71-9511
In spite of this new law it would still be wise to review the Nebraska Revised Statutes Chapter 44 Insurance section when preparing to draft your contract. Nebraska's definition of insurance is included below. Take note of the HMO rules and "group health plan" definitions as well to ensure you do not get placed in these categories.
Nebraska has also passed legislation (LB 1119) designed to kick start DPC adoption by state employees. It was signed by the governor on 04/18/18. Many of the details are to be determined. Hopefully the program will gather helpful savings data and operate through a voucher mechanism.
In 2019 Kate Gaul, a Research Analyst in the Nebraska Legislative Research Office put together this two page snap shot overview of Direct Primary Care in the state.
"Insurance shall mean a contract whereby one party, called the insurer, for a consideration, undertakes to pay money or its equivalent or to do an act valuable to another party, called the insured, or to his or her beneficiary, upon the happening of the hazard or peril insured against whereby the party insured or his or her beneficiary suffers loss or injury."
In the annotations section of 44-102 the following case law is noted:
"Any insurance company, requiring the payment of fixed premiums in advance, which provide benefits not dependent upon the collection of assessments from other members, and which does not provide for extra assessments if necessary, is not an assessment association. Western Life & Accident Co. v. State Ins. Board, 101 Neb. 152, 162 N.W. 530 (1917)."
We have not reviewed the entire Chapter, but section 44-4209 entitled "Health Insurance Defined" offers the following language:
"Health insurance means any hospital, surgical, or medical expense-incurred policy or health maintenance organization contract. Health insurance does not include (1) accident-only, disability income, hospital confinement indemnity, dental, or credit insurance, (2) coverage issued as a supplement to liability insurance, (3) medicare or insurance provided as a supplement to medicare, (4) insurance arising from workers' compensation provisions, (5) automobile medical payment insurance, (6) any other specific limited coverage, or (7) insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy."
44-32,105. Health maintenance organization, defined.
"Health maintenance organization shall mean any person who undertakes to provide or arrange for the delivery of basic health care services to enrollees on a prepaid basis except for enrollee responsibility for copayments or deductibles."
44-3294. Basic health care services, defined.
"Basic health care services shall include as a minimum the following medically necessary services: Preventive care; emergency care; inpatient and outpatient hospital and physician care; diagnostic laboratory services; diagnostic and therapeutic radiological services; and out-of-area emergency services."
44-4208.02. Group health plan, defined.
"Group health plan means an employee welfare benefit plan as defined by 29 U.S.C. 1002 to the extent that the plan provides any hospital, surgical, or medical expense benefits to employees or their dependents, as defined under the terms of the plan, directly or through insurance, reimbursement, or otherwise."
Dispensing - Physician dispensing is permitted without much hassle if the medications are dispensed to the patient without any charge, but if there is a charge then Nebraska law appears to require physicians to complete a three page pharmacy application and pay $625 to register as a pharmacy. The language (explained below) is unfortunately confusing. It appears that Nurse Practitioners and Physician Assistants may not be allowed to dispense at all, but at a minimum would always need to register (presumably through a different process) even in instances where they were dispensing drugs at no charge to the patient. Most states do not use the “pharmacy” term in such a confusing manner. Typically the act of being a pharmacist means that you are dispensing medications based on prescriptions that you did not write (those that were instead written by other practitioners). In Nebraska they define dispensing practitioners by stating that “Health professionals who dispense and charge for drugs and devices as part of their practice must have a pharmacy license. NOTE: Veterinarians, certified nurse midwives, certified registered nurse anesthetists, nurse practitioners, and physician assistants cannot dispense under this type of license.” This page describes the “Dispensing Practitioner Application Processing And Inspection Information.” Unfortunately this $625 fee is owed on an annual basis each July 1st.
Nebraska Revised Statute 38-2850 states: “As authorized by the Uniform Credentialing Act, the practice of pharmacy may be engaged in by a pharmacist, a pharmacist intern, or a practitioner with a pharmacy license. The practice of pharmacy shall not be construed to include: (1) Practitioners, other than veterinarians, certified nurse midwives, certified registered nurse anesthetists, nurse practitioners, and physician assistants, who dispense drugs or devices as an incident to the practice of their profession, except that if such practitioner engages in dispensing such drugs or devices to his or her patients for which such patients are charged, such practitioner shall obtain a pharmacy license;…