Proposed Regulations Would Treat Direct Primary Care and Health Care Sharing Ministries Membership Dues As Qualifying Medical Expenses For Medical Deduction & HSA Reimbursement Purposes

August 8, 2020 is the deadline to comment on Internal Revenue Service (“IRS”) proposed regulations that if adopted as proposed will allow membership payments for participation in direct primary care (“DPC”) and health care sharing ministries (“HCSMs”) to qualify as medical expenses eligible for the itemized deduction under Internal Revenue Code (“Code”) Section 213 and for reimbursement by an employer sponsored health reimbursement arrangement (“HRA”).

Section 213 of the Code allows individuals to take an itemized deduction for expenses for medical care, including insurance for medical care, to the extent the expenses exceed 7.5% of adjusted gross income.

In Executive Order 13877, Improving Price and Quality Transparency in American Healthcare to Put Patients First” (84 FR 30849 (June 27, 2019), President Trump directed the Secretary of the Treasury, to the extent consistent with law, to “propose regulations to treat expenses related to certain types of arrangements, potentially including direct primary care arrangements and healthcare sharing ministries, as eligible medical expenses under Section 213(d)” of the Code.

In response to Executive Order 13877, the proposed regulations proposed that:

  • Payments for DPC arrangements are expenses for medical care under section 213 of the Code. Because these payments are for medical care, a health reimbursement arrangement (HRA) provided by an employer generally may reimburse an employee for DPC arrangement payments.
  • Payments for membership in a HCSM are expenses for medical care under section 213 of the Code. Because these payments are for medical care, an HRA provided by an employer generally may reimburse an employee for HCSM membership payments.

Although DPC and HCSM arrangements have gained increasing popularity as alternatives to traditional health insurance among many taxpayers, current ruling IRS guidance prohibited individual taxpayers from counting DPC or HCSM membership dues as medical expenses for purposes of claiming an itemized medical expense deduction and characterized those amounts as ineligible for nontaxable reimbursement under employer sponsored HRAs.  The proposed regulations would reverse these positions to allow those membership dues paid for a DPC or HCSM membership as defined in the proposed regulations to qualify for the itemized medical expense deduction by individual taxpayers and as exempt from wages when reimbursed as a medical expense by an employer sponsored HRA.  The proposed regulations specify that the rules proposed would become effective for taxable years ending on or after the date of publication of the Treasury decision adopting these rules as final regulations in the Federal Register.  Accordingly, as presently written, amounts paid for DPC or HCSM memberships before the effective date of the final regulations presumably would continue to be treated under existing rules and therefore not be eligible to count as medical expenses for purposes of the itemized medical expense deduction or for reimbursement under a HRA.

The proposed regulations invite comments both on the proposed tax treatment of DPC and HCSM membership dues and the arrangements that the proposed regulations would recognize as qualifying as a DPC or HCSM arrangement for purposes of these rules and address certain other analysis and matters regarding the treatment of membership dues paid to these arrangements.

DPC Definition

Relative to the arrangements that would qualify as a DPC arrangement, the proposed regulations provide that a “direct primary care arrangement” as a contract between an individual and one or more primary care physicians under which the physician or physicians agree to provide medical care (as defined in section 213(d)(1)(A)) for a fixed annual or periodic fee without billing a third party. The proposed regulations define a “primary care physician” as an individual who is a physician (as described in section 1861(r)(1) of the Social Security Act (SSA)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine. This definition is adopted from paragraph (I) of the definition of “primary care practitioner” in section 1833(x)(2)(A)(i) of the SSA. The Treasury Department and the IRS request comments on the definition of primary care physician and on the definition of direct primary care arrangement. In addition, the proposed regulations also invite comments about whether to expand the definition of a direct primary care arrangement to include a contract between an individual and a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5) of the SSA) or other non-physician practitioner who provides primary care services under the contract and on how to define primary care services provided by a non-physician practitioner, including whether the definition of primary care services in section 1833(x)(2)(B) of the SSA is appropriate.

In addition, the Treasury Department and the IRS understand that other types of medical arrangements between health practitioners and individuals exist that do not fall within the definition of direct primary care. For example, an agreement between a dentist and a patient to provide dental care, or an agreement between a physician and a patient to provide specialty care, would not be a direct primary care arrangement but nonetheless may be the provision of medical care under section 213(d). The Treasury Department and the IRS request comments on whether the final regulations should clarify the treatment of other types of arrangements that are similar to direct primary care arrangements but do not meet the definition in the proposed regulations.

HCSM Definition

The proposed regulations draw their definition of a “health care sharing ministry” from section 5000A(d)(2)(B)(ii) of the Code, which provides that the individual shared responsibility payment (which is zero after December 31, 2018) does not apply to an individual who is a member of a health care sharing ministry. as an organization.  To meet this HCSM definition, the organization must meet each of the following conditions:

  • Described in section 501(c)(3) and is exempt from taxation under section 501(a);
  • Members of which share a common set of ethical or religious beliefs and share medical  expenses among members in accordance with those beliefs and without regard to the State in which a member resides or is employed;
  • Members of which retain membership even after they develop a medical condition;
  • Which (or a predecessor of which) has been in existence at all times since December 31, 1999, and medical expenses of its members have been shared continuously and without interruption since at least December 31, 1999; and
  • Which conducts an annual audit which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request. The Treasury Department and the IRS request comments on the definition of a health care sharing ministry.

Taxpayers and others dealing with HCSM should take particular note that the proposed regulations and its associated Code definition only address the tax consequences of HCSM and DPC arrangements and not their treatment for any other purpose of law.  In this respect, it bears noting that the definition of HCSM in the Code is limited to only those arrangements that meet each of the criteria listed.  In recent years, various state health insurance regulators have expressed concern that some arrangements promoted as HCSM do not meet all of the criteria required by the Code to qualify as HCSM, are sold or marketed as providing equivalent protection and coverage to regulated health insurance products and other reservations about the design and compliance of certain of these arrangements.  Employers contemplating reimbursing these expenses should carefully evaluate the arrangements both for qualification under the Code and the prudence of any such arrangements.  Likewise, individuals contemplating participation also are encouraged to carefully evaluate the arrangements both for their anticipated tax treatment and the reliability of the member’s expectations regarding coverage, eligibility, benefits, implications on eligibility for other insurance coverage, and other relevant concerns.

August 8, 2020 Comment/Request For Public Hearing Deadline

Business or individual taxpayers wishing to express support, opposition or other commentary on the proposed regulation should ensure that their written or electronic comments and requests for a public hearing are submitted in accordance with the procedures set forth in the notice of proposed rulemaking by the August 10, 2020 deadline.

More Information

We hope this update is helpful. For more information about the these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.

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About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney recognized for her leading edge work on health benefit and other related employee benefit, insurance and health care concerns and policy matters.

Board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer, Ms. Stamer is widely known for 30+ years legal and operational management work, coaching, public policy and regulatory affairs leadership and advocacy, training and public speaking and publications. As a significant part of her work, Ms. Stamer has worked extensively domestically and internationally on an demand, special project and ongoing basis with business, government and community organizations and their leaders, spoken and published extensively on human resources, health and other employee benefits and other workforce and services, tax, health care and health benefits, insurance, workers’ compensation and occupational disease, business disaster and distress and many other management topics, As a key focus of this work, Ms. Stamer has worked with public and private employers of all sizes, employee benefit plans, insurance and financial services, health industry and a broad range of public and private domestic and international business, community and government organizations and leaders on pandemic and other health and safety, workforce and performance preparedness, risks and change management, disaster preparedness and response and other operational and tactical concerns throughout her adult life including extensive work both on the tax, health care, insurance and other policy and regulation, design, administration, defense and enforcement of  DPC, HCSM, association health plan, mandate only, short-term limited benefit health insurance and other innovative health benefit, managed care, insurance and care arrangements.  A former lead advisor to the Government of Bolivia on its pension project, Ms. Stamer also has worked internationally and domestically as an advisor to business, community and government leaders on workforce, health care, insurance, benefits and other reform, as well as regularly advises and defends organizations about the design, administration and defense of their organizations workforce, employee benefit and compensation, safety, discipline and other management practices and actions. She has worked, spoken and published extensively on DPC, HCSM and other regulatory and statutory reforms impacting health benefits and health care including speaking on DPC and HCSM tax and other regulatory and enforcement policies on a program on Benefits for Small Employers presented for the American Bar Association Real Property Trusts and Estates Section on March 14, 2020.

Board Certified in Labor and Employment Law By the Texas Board of Legal Specialization, Scribe for the ABA JCEB Annual Agency Meeting with OCR, Vice Chair of the ABA International Section Life Sciences Committee, and the ABA RPTE Employee Benefits & Other Compensation Group and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also serves in leadership of a broad range of professional and civic organizations and shares insights and thought leadership through her extensive publications and public speaking. For more information about Ms. Stamer or her health industry and other experience and involvements, see or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

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One Response to Proposed Regulations Would Treat Direct Primary Care and Health Care Sharing Ministries Membership Dues As Qualifying Medical Expenses For Medical Deduction & HSA Reimbursement Purposes

  1. Don Cooper says:

    Great article, thank you

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