How the practice is legally built.

The $129/month DPC membership covers primary care services: unlimited virtual visits, same-day escalation, chronic condition baseline management, prescription renewals, basic care coordination, and Letters of Medical Necessity as an included benefit of membership.

Medicare Part B services billed separately — CCM 99490/99491/99437/99439, RTM 98975/98977/98980/98981/98985, RPM 99453/99454/99457/99458, PCM 99424-99427, TCM 99495/99496, ACP 99497/99498, PIN/CHI G0019/G0023 — are NOT included in the membership fee. They are distinct services requiring:

• Separate patient consent per CMS requirements
• Documented clinical time distinct from primary care visits
• Connected monitoring device where required (RTM/RPM)
• Separate accounting ledger that segregates membership revenue from CMS reimbursement

The membership agreement explicitly excludes these services. A member who does not consent to CCM or RTM still receives full DPC primary care — membership value is not conditioned on Part B enrollment.

Altru.care is enrolled as a Medicare Part B provider under its own entity NPI, with the physician's individual NPI assigned as the rendering provider. This is the structure CMS expects for a practice that bills care-management codes.

DPC practices are not required to opt out of Medicare. CMS policy confirms that a DPC practice can bill Medicare for services that are not part of the membership fee, provided the documentation supports that the service is distinct. The operative guidance is 42 CFR 405.440 (opt-out rules — we do NOT opt out) and CMS MLN MM11043 on CCM documentation.

Open item (Ryan): Finalize the exact attestation language Altru.care uses on the CMS 855I and confirm the DPC disclosure requirements. Flagged YELLOW until executed.

The attending physician holds active licensure in all 50 states plus DC, maintained through the Interstate Medical Licensure Compact and individual state licenses where the Compact does not apply. Every clinical document is signed by a physician licensed in the patient's state of residence at the time of service.

Phase 1 — General supervision (current): All AI-generated clinical outputs (LMNs, care plans, RTM reviews, coding summaries) are produced in draft by Sage (Altru.care's Claude-based clinical AI) and reviewed, edited, and signed by the physician before release. No AI output exits without physician attestation. This model does not depend on state-by-state supervisory licensure for non-physician staff.

Phase 2 — Direct supervision (planned): Adds licensed clinical staff (NPs, PAs, clinical pharmacists) operating under incident-to billing. This phase is blocked pending Ryan's opinion on incident-to billing across state lines under the 2026 CMS general-supervision expansion.

Letters of Medical Necessity (LMNs) establish that an expense is for the diagnosis, cure, mitigation, treatment, or prevention of disease under IRC § 213(d)(1)(A). An LMN signed by a licensed physician is the standard documentation HSA/FSA administrators require to reimburse otherwise-dual-use items (companion care, home modifications, specific fitness equipment, wellness services).

Altru.care does not issue an LMN on request. Every letter is reviewed against the patient's documented clinical condition; if the physician determines the expense is not medically necessary, no letter is issued and no fee is charged. This is the gating mechanism that distinguishes physician-governed LMN issuance from the form-factory models currently under regulatory scrutiny.

Open item (Ryan): Complete the IRS 213(d) opinion on LMN issuance for the specific companion-care and home-modification categories most common in the co-op.care partnership pipeline. Flagged YELLOW until the opinion is on file.

Every clinical artifact Altru.care produces passes through a hard intercept: Sage generates the draft, a physician reviews it, and only a physician-signed version is released. This is documented in the practice's Clinical AI Governance Policy and surfaced on every released artifact via ClinicalSwipe attestation metadata.

This architecture implements the physician-governance principle endorsed in AMA clinical AI guidance and aligns with the patient-safety framing in the Lantos et al. JAMA 2026 editorial on AI in clinical care. No autonomous clinical decisions. No unattested releases.

Altru.care is a HIPAA Covered Entity. SolvingHealth, the technology MSO that licenses CareOS to Altru.care, is a HIPAA Business Associate with an executed BAA. Sub-processors (model vendors, cloud infrastructure, communication tools) are tiered under sub-BAAs with minimum-necessary data-flow restrictions.

Patient data is processed under the minimum-necessary standard. Model inference is routed to BAA-executed endpoints only. The practice does not use patient PHI for model training or for any purpose not directly required for the patient's care.