In-Office Dental Plans (Complete)

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