Direct Primary Care Plan Resources

Jan 23, 2024

The ADA Center for Professional Success reports that research shows that patients who have a benefit plan are more likely to seek dental care and accept treatment plans. For a growing practice that does not participate in a commercial dental plan, an in-office dental plan (sometimes called a dental membership savings plan or direct primary care agreement) may be a viable option to improve patient engagement and retention.

Although we have heard that many Arizona dentists currently offer in-house membership plans to patients, technically Arizona law has in the past limited such plans to just your osteopathic and medical colleagues.

Without the "safe harbor" that is now offered by the passage of SB1105, dentists offering these plans could be subject to Department of Insurance laws governing pre-paid dental plans. The legislation specifically excludes a direct primary care plan from the definition of "insurance." 

The new law became effective on August 27, 2019 and contains several requirements that members should be familiar with before offering such a program to their patients.

How does a direct primary care plan work?

Under such a plan, the patient pays the doctor or dental office a fixed amount of money on a monthly or annual basis. In return, the patient generally receives preventive services at no charge, with other procedures offered at a discounted fee.

The ADA Council on Dental Benefit Programs and the Arizona Dental Association have developed this resource page to help member dentists evaluate whether an in-office dental plan option is right for them. The toolkit contains a document that addresses common legal considerations and implementation steps, a sample contract that includes the specific language required by Arizona law, an implementation checklist, and a sample letter to introduce the program to patients.

You will also find a link to kit also to an Excel spreadsheet calculator prepared by the ADA Center for Professional Success to help you predict the financial impact of adopting an in-office dental plan.

Important features of the new Arizona law:

Requires that an agreement: a) be in writing; b) be signed by the primary care provider or an agent of the provider and the individual patient or their legal representative; c) permits either party to terminate the agreement upon submitting a 30-day written notice to the other party; d) includes terms for relocation and military duty; e) specifies the periodic fee and any additional fees for ongoing care; f) describes the scope of primary care services covered by the periodic fee; g) specifies the duration of the agreement and any automatic renewal periods; and h) provides a prominent disclaimer expressing that the agreement is not an insurance policy.

The Bill prescribes disclaimer language that must be included in the contract. Most importantly, consumers need to understand that they are not purchasing an insurance policy.

The disclaimer should read as follows:

Notice: The organization facilitating the direct primary care agreement is not an insurance company and the direct primary care company guidelines and agreement are not an insurance policy. Participation in the direct primary care agreement or a subscription to any of its documents should not be considered a health insurance policy. Regardless of whether you receive treatment for health care issues through the direct primary care agreement, you are always personally responsible for paying any additional health care expenses you may incur. If you have health insurance, it may include, at no additional charge, some of the preventive services that are also available under this direct primary care agreement. The primary care provider may not bill your health insurance for primary care services provided under this direct primary care agreement.

In addition, the new law: 

  1. Prohibits a direct primary care provider from declining to accept a new direct primary care patient or to discontinue care to an existing patient solely because of the patient`s health status.
  2. Prohibits a direct primary care provider from charging different fees for comparable services based on a patient`s health status or gender.
  3. Permits a direct primary care provider to decline to accept a patient if the practice has reached its maximum capacity or if the provider is unable to provide the appropriate level and type of primary care services required for the patient`s medical condition.
  4. Allows a direct primary care provider to discontinue care for a direct primary care patient if: a) the patient fails to pay the periodic fee; b) the patient performed an act of fraud; c) the patient repeatedly fails to adhere to a recommended treatment plan; d) the patient is abusive and presents an emotional or physical danger to staff or other patients of the practice; e) the direct primary care provider discontinues operation as a direct primary care provider; f) the direct primary care provider changes the services or scope of practice provided to patients; or g) the direct primary care provider gives a 30-day written notice to the patient terminating the direct primary care agreement.
  5. Prohibits an agreement from requiring an advance payment of more than 12 months of the periodic fee.
  6. Requires an agreement to prohibit a direct primary care provider from submitting a claim for reimbursement to a patient`s healthcare insurer for primary care services that are provided to the patient and that are covered under the agreement.
  7. Permits an agreement to allow the period fee and any additional fees for ongoing care under the agreement to be paid by a healthcare insurer or other third party.
  8. Requires, if an agreement is discontinued, that payments that were prepaid for the months following the termination of an agreement be returned to the patient.
  9. Specifies that an agreement for dental services is limited to services offered within a single practice and may not include services offered in other practice entities.
  10. States that an agreement for medical services does not constitute the transaction of insurance business or a health care services organization.

Here are a number of resources that member dentists can use:

ADA Center for Professional Success Resources

Arizona Dental Association Resources: