In-Office Dental Plans (Complete)

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

Studies have shown that patients with a benefit plan are much more likely to seek dental care and

accept treatment plans. When a practice is looking to grow without participating in a commercial dental

plan, one option the office might consider is an in-office dental plan. These plans are also known as

dental membership savings plans, or direct primary care agreement plans.

While there are many variants, in general, the patient pays the doctor or dental office a fixed amount of

money on a monthly or annual basis. Preventive services may be covered at no charge. Procedures

other than preventive are then offered at a discounted fee. The plan design is up to the office, as is the

cost to the patient for participating in the plan.

When considering whether to implement such a plan, the office should consider whether revenue lost

by discounting fees for existing cash patients will be offset by revenue gained through new patient

acquisition or completion of treatment delayed for financial reasons. There are several commercial

vendors who assist dental offices in establishing in-office plans for an administrative fee or portion of

the production.

The American Dental Association (ADA) Council on Dental Benefit Programs has developed this toolkit

to help dental practices begin to evaluate an in-office option. The Council appreciates the input and will

continue to update this resource as needed. Please send input to dentalb[email protected].

Step I: Legal Considerations

The ability of a dental office to set up an in-office plan depends on a variety of factors that include local

and state laws, as well as existing contractual relationships between the dentist and third-party payers,

especially those with a “most favored nation” clause. These factors are discussed further in the

questions that follow.

Consulting with your own attorney to determine how these factors affect your business decision is an

important initial step. If necessary, your local bar association may be able to help you find an attorney

knowledgeable in these areas.

Some questions to consider before setting up an in-office dental plan include:

Q. Does your state consider these types of plans to be insurance and, if so, would you have to

license or register with the state accordingly?

A. Your state may have its own rules that affect the establishment of an in-office dental plan. Laws vary

from state to state. Appendix A is the list of states that have enacted direct primary care agreement

legislation, which allows you to implement an in-office dental plan without having to register as an

insurance company. Be sure to comply with any requirements.

Q. How will any managed care contracts you have signed affect an in-office dental plan

implemented by your office? For example, will the managed care plan invoke a “most favored

nation” clause and require you to pass on those fees to its insured members?

A. Your obligations under these contracts might present impediments to your establishing the plan, or

to establishing it in the manner you wish. For example, when your contract with a third party payer

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

contains a “most favored nation” clause it guarantees that the payer will receive the lowest rate that

you charge for any procedure. This means that if your in-office plan fee for a procedure is less than

the fee you have committed to with the payer, the payer is permitted to reimburse you at the lower

fee. You will be accepting the lower fee for all patients covered by your in-office plan, plus all

patients covered by the third-party payer’s plan. Also, the payer could conceivably attempt to go

back to the establishment of your plan to seek partial reimbursement of the previously paid fees, or

merely attempt to set that amount off against future payments to you.

Q. What does the patient have to do to take advantage of this kind of plan?

A. You will need to have a signed agreement from your patient that fully describes the terms and

conditions of the in-office plan.

You should specifically describe the services that are covered by the plan (and state clearly those

services that are not covered), what services will be provided at each visit, how frequently the

patient may receive the covered services, any additional fees the patient might have to pay for

certain services, any restrictions (e.g. limitations on refunds, the consequences of missed

appointments, referrals to specialists, eligibility for enrolling in the plan, etc.).

It is critical that you fully, accurately, and unambiguously describe the terms of the plan, both in the

terms of your agreement with the patient, as well as in advertisements or offers that you make to the

general public (including to your patients).

A clear and unambiguous written statement in the contract of what services are and are not covered

will minimize the chance of any dispute down the road.

Step II: Implementation

After you have conferred with your own attorney and have made the decision to proceed, where do you

begin?

 Calculate the annual fixed dollar amount to be paid by the patient.

 Determine which preventive services will be covered at no additional charge. You will need to

be very specific in defining those procedures and the frequency with which they will be covered.

 Decide the percentage discount you will give to the other covered procedures and remember

that you determine those fees.

Besides the financial aspects of the plan, you need to set some policies about your plan.

 What do you plan to do if a patient cannot receive all the benefits? For example, what if a

patient moves after having only one exam covered by the plan. Can the patient receive a refund

for unused services? All the terms and conditions of the plan must be clearly stated in the

agreement.

 Is specialist care included in the plan? If so, you will need to get an agreement from specialists

to whom you refer to provide a discount. Keep in mind that these specialists can leave the plan

at their discretion. You may also elect to not include this as a feature of your plan.

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

As noted above, there are several commercial vendors who assist dental offices in establishing in-office

plans for an administrative fee or portion of the production.

Step III: Example

This example is for illustration purposes only. Dentists will need to determine the annual fees,

percentage discounts and covered procedures.

Covered Procedures

Frequency

Cost

D0120 – Periodic Oral Evaluation

D1110 – Prophylaxis

D0274 – Bitewings

2 times per plan year

1 time per plan year

$400 or $300 or $150 annually

All other dental procedures

No limit

20% or 15% or 10% discount off

dentist’s full fee

Step IV: In-Office Dental Plan Calculator

Accurately predicting the financial impact of your in-office dental plan is essential to its success. Our in-

office dental plan calculator is designed to help you determine potential impact on your practice income

with different plan designs.

The calculator will allow you to estimate the total annual revenue from your in-office dental plan and

compare it to the total amount of revenue you are currently generating from patients without dental

benefits. In addition, you will be able to estimate the financial impact of bringing new patients, who are

interested in this type of program, into your office.

Step V. Your In-Office Dental Plan

Before you put your in-office plan in place, it is imperative you have the plan and accompanying

agreement reviewed by a competent attorney.

There are several commercial vendors who assist dental offices in establishing in-office plans for an

administrative fee or portion of the production.

Step VI: Summary

 Determine the annual fixed dollar amount to be paid by the patient.

 Determine the preventive procedures that will be covered at no additional charge.

 Determine the percentage discount for other procedures.

 Be sure to have your own attorney review your plan and accompanying agreement.

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

Additional Resource Materials

Dental Benefit Information

 ADA.org/dentalinsurance

Appendix A: Direct Primary Care Agreements In-Office Health and Dental Plans

 This may not be a complete listing of all states with direct primary care agreement legislation,

but is provided to help dentists in those states comply with any laws pertaining to direct primary

care agreements.

Appendix B: General Contract Considerations

Appendix C: Checklist and Considerations for Your In-Office Dental Plan

Appendix D: Marketing and Promotional Letter

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

Appendix A: Direct Primary Care Agreements

In-Office Health and Dental Plans

Direct Primary Care Agreement (DPCA) laws provide guidance and restrictions for health care

providers that establish private agreements with their patients providing specified scope of services for

an established periodic fee. The laws generally establish the following:

 Contracting requirements

 Restrictions on billing or filing claims with carriers

 Exemptions from state insurance authority regulation or oversight

 Certain patient notification requirements

Direct Primary Care Agreement Legislation

States That Include Dental

Twenty states include dental in the definition of health care provider authorized to engage in DPCA.

(*Two states are dental specific.)

Direct Primary Care Agreements – In-Office Plans

June 13, 2022

Direct Primary Care Agreement (DPCA) laws provide guidance and restrictions for health care providers that

establish private agreements with their patients providing specified scope of services for an established

periodic fee. The laws generally establish: contracting requirements; restrictions on billing/filing claims with

carriers; exemptions from state insurance authority regulation/oversight; and certain patient notification

requirements.

20* States Include Dental in the Definition of Health Care Provider Authorized to

Engage in DPCA; (* 2 are Dental Specific)

See Washington for note on interpretation issue

20 States

Select Provisions

See state law for full review of requirements & restrictions

ALABAMA

SB 94

2017

 Cannot bill a third party any additional fee for services for patients covered

under a dental agreement

 No license required to offer, market, sell or enter into DPCAs

 Periodic fee does not count toward deductible or out-of-pocket max

 Urge consult with health insurer. Insurer may cover services also covered

in DPCA

ARIZONA

SB 1105

2019

 Prohibits DPCPs from submitting a claim to patients’ health care insurer

for DPCA services

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

 Allows health care insurers or other third parties to pay for the periodic fee

and any additional fees for ongoing care under the agreement

ARKANSAS

HB 2240

2017

 Prohibits the healthcare provider from charging or receiving additional

compensation for healthcare services included in the periodic fee

 Allows health care insurers or other third parties to pay for the periodic fee

FLORIDA

HB 7

2019

 Provider may not submit a claim for DPCA services

 Provider allowed to market, sell, or offer to sell a direct medical care

agreement

IDAHO

SB 1062

2015

 Provider or patient prohibited from billing insurer for DPCA services

 Urge consult with health insurer

 Video of Senate Committee hearing

* ILLINOIS

SB 174

2019

 DPCA law is dental-specific

 Dentist and patient prohibited from billing insurer for DPCA services

 Urge consult with health insurer

 Dentist MAY refund unearned direct fees associated with the covered

services in the agreement

 Establishes restrictions on transfer of agreements

INDIANA

SB 303

2017

 Prohibits billing a third party that provides coverage to the patient for the

primary care health services

IOWA

HF 2356

2018

 Dentist may not bill insurance

 A direct patient may submit a request for reimbursement to an insurer if

permitted under the direct patient’s policy of insurance

 Contract must specify any additional costs for primary care health services

not covered by the direct service charge for which the direct patient will be

responsible

 Urge consult with health insurer for DPCA services

 Allows periodic fee/additional fees to be paid by insurer or 3rd party

* LOUISIANA

SB 127

2019

 DPCA law is dental-specific

 Periodic fee does not count toward deductible or out-of-pocket max

 Urge consult with health insurer for DPCA services

 Dentist allowed to market, sell, or offer to sell a direct medical care

agreement

 Patients wouldn’t forfeit their insurance, Medicaid, or Medicare benefits by

purchasing a direct primary care agreement

 Allows a direct dental practice to accept payment of periodic fees for a

direct primary care agreement directly or indirectly from third-parties,

including employers

MICHIGAN

SB 1033

2014

 Provider and patient prohibited from billing insurer for DPCA services

 Provider allowed to market, sell, or offer to sell a direct medical care

agreement

MISSOURI

HB 2168

2022

 Declares In-Office Plan contract is not business of insurance

 Dentist is not required to obtain a certificate of authority or license to

market, sell, or offer to sell In-Office Plan products

 Agreements must meet specified standards

MONTANA

SB 101

2021

 Prohibits provider from submitting claim for services in direct patient care

agreement;

 Allow for the direct fee and any additional fees to be paid by a third party

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

 Exempts direct patient care agreements from state insurance authority

oversight

 Insurers may not prohibit, interfere with, initiate a legal or administrative

proceeding against, or impose a fine or penalty against a health care

provider solely because the provider provides direct patient care solely

because the person pays a direct fee for direct patient care.

NORTH

CAROLINA

HB 471

2020

 Provider may not bill any third parties on a fee for service basis

 Provider and their agent[s] shall not be required to be licensed or certified

to market, sell, or offer to sell direct primary care agreements

OKLAHOMA

SB 560

2015

 Prohibits provider from billing third parties on a fee-for-service basis

 Any per-visit charges under the agreement will be less than the monthly

equivalent of the periodic fee

 DPCA patient does not forfeit coverage under a health benefit plan

 No certification of authority or license required to market, sell or offer to

sell a direct primary care agreement

 A direct primary care membership agreement is not a medical discount

plan

TENNESSEE

SB 2317

2020

 Prohibits billing third party payers

 Charges under the agreement must be less than the monthly equivalent of

the periodic fee

 Periodic fee does not count toward deductible or out-of-pocket max

 Urge consult with health insurer

 DPCA patient does not forfeit coverage under a health benefit plan

 Specifies DPCA is not a discount plan

 Provider not required to obtain certification of authority or license in order

to market, sell, or offer to sell a direct medical care agreement

UTAH

HB 240

2012

 Provider may not submit a claim for DPCA services

 A person or a professional corporation agrees to provide routine health

care services to the individual patient for an agreed upon fee and period of

time

 “Routine health care services” are screening, assessment, diagnosis, and

treatment for the purpose of promotion of health, and detection and

management of disease or injury

VIRGINIA

SB 800

HB 2053

2017

 Provider may not bill insurance

 Urge consult with health insurer/In-surer may cover services also covered

in DPCA

WEST

VIRGINIA

HB 2301

2017

 DPCA patient does not forfeit coverage under a health benefit plan

 Specifies DPCA is not a discount plan

 Provider allowed to market, sell, or offer to sell a direct medical care

agreement

WYOMING

SB 49

2016

 Allows periodic fee/additional fees to be paid by insurer or 3rd party

 Prohibits the provider from charging or receiving additional compensation

for health care services included in the periodic fee

Though dental is included in definitions, State insurance authority interprets dental is not included.

WASHINGTON

SB 5958

2007

 Provider may not bill and insurer or submit a claim for DPCA services

 Urge consult with health insurer/In-surer may cover services also covered

in DPCA

 Allows periodic or other fee to be paid by a 3rd party

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

 Provider allowed to market, sell, or offer to sell a direct medical care

agreement

 NOTE: State insurance authority currently rules dentists are not eligible to

engage in DPCAs

12 States Do Not Include Dental in the Definition of Health Care Provider

Authorized to Engage in DPCA

Colorado

HB 1115

2017

Georgia

SB 18

2019

Kansas

HB 2225

2015

Kentucky

SB 79

2017

Maine

SB 472

2017

Mississippi

SB 2687

2015

Missouri

HB 769

2015

Nebraska

L 817

2016

New

Hampshire

HB 508

2019

Ohio

HB 166

2019

Oregon

SB 86

2011

Texas

HB 1945

2015

Common DPCA Statutory Themes:

Contract provision requirements: scope, periodic fee, termination etc. ** Maximum number of months fees can

be collected ** Periodic fee does not count toward deductible or out-of-pocket maximum ** Urge consult with

health insurer/Insurer may cover services also covered in DPCA ** Dentist may decline patient for cause **

Allows periodic or other fee to be paid by a 3rd party ** Prohibits dentist from charging or receiving additional

compensation for services in the periodic fee ** Allows periodic fee/additional fees to be paid by insurer or 3rd

party ** DPCA patient does not forfeit coverage under a health benefit plan ** Specifies DPCA is not a discount

plan ** Per-visit charges in agreement must be less than monthly periodic fee ** Provider allowed to market, sell,

or offer to sell a direct medical care agreement

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

Appendix B: General Contract Considerations

These are some overarching considerations and are neither meant to be an all-inclusive list nor legal

advice. Legal counsel should be consulted to develop a contract based on the plan design developed

by the practice and can vary between practices. “Member” in the clauses below references the dental

practice patient seeking to enroll in the in-office dental plan. Consider stipulating that:

 The dental practice retains the right to interpret any program stipulations.

 No refunds will be given in the event Member terminates the plan prior to the end of the plan

year.

 The annual membership fee must be paid in full prior to treatment.

 Membership benefits are not transferable, have no cash value and may not be redeemed for

cash.

 This is not an insurance plan and is not subject to regulation by the state department of

insurance.

 Plan membership cannot be combined with current dental insurance plans.

 No insurance claim will be filed for Members under this plan.

 The plan is for individual use only. It is not a group benefits plan.

 Each additional family membership must be paid at the time of the initial membership or at

renewal time.

 Membership fee may be adjusted annually.

 Members are responsible for notifying dental practice of any address or contact changes.

 Missed appointment fees/penalties are ineligible for the membership discount.

 Total payment amount is due at the time services are provided. If full payment is not received at

the time of service, fee discount will be void.

In addition to these general contract considerations, it is important that the contract clearly lay out the

payment requirements to maintain membership in the plan. Some considerations include:

 Membership fee payment schedule.

 Consequences of missed payments.

 Guarantees for treatment fee related to membership plan year.

 What services will be provided as part of the membership plan.

 What services will be provided at a discounted rate and what level of discounts will apply.

 Whether the patient can cancel the plan and the consequence.

 Whether the practice can cancel the plan and the consequence.

 Whether there will be annual maximums on discounts.

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

Appendix C: Checklist and Considerations for Your

In-Office Dental Plan

Use this checklist to help determine all of the key steps necessary to consider before you implement

your own in-office dental plan.

Addressing these items is a good way to begin the development of your plan.

 Consult your own attorney to determine how the implementation of this plan will affect your

business is an important initial step.

 Send a promotional letter to patients without dental benefits.

 Determine the effective date for implementation of your new plan.

 Check with your state to determine if it considers these types of plans to be insurance and make

sure that your plan is compliant with any state law.

 Review all your signed managed care agreements to determine if any clauses may affect your

in-office plan, e.g., most favored nation clauses.

 Determine the annual fees, percentage discounts and covered procedures.

 Have your attorney review your plan and the accompanying patient agreement.

 Start marketing your plan to the public and your uninsured patients. You may want to consider

using social media or local radio and television advertisements as well as direct mail. You may

also want to contact your local Chamber of Commerce for additional promotional opportunities.

In-Office Dental Plans

Dental Membership Savings Plans or Direct Primary Care Agreements

Appendix D: Marketing and Promotional Letter

Date

Dear:

At XX dental, we are always looking for ways to make our dental practice better for our patients. To

make that possible, we are now offering our own in-office dental plan* for patients that do not have a

dental benefits plan from their employer or for patients who do not have an individual dental plan. This

type of dental program has recently been gaining popularity and has been successful for other dental

offices.

Effective {date} my office will offer an in-office dental plan for patients without a dental plan for an

annual fee of $XXX. This fee includes two examinations and cleanings and one set of bitewing x-rays

per year.

All other dental procedures will be given a discount of XX% off of my regular fees. There is no limit on

how much money you can save by using the program.

I strongly urge you to ask my staff about this program and how it may benefit you and I hope that you

will give this serious consideration.

It is our sincere privilege to have you as our patient and please let us know of any questions you have

regarding this new program or how we may serve you better.

We look forward to continue providing you with the dental care you expect and deserve.

Sincerely,

Name

*Consider using your own terminology for the plan name. Examples include direct primary care

agreement or dental membership savings plan.