Benefits Programs


Direct Reimbursement

These excerpts are reprinted with permission from the American Dental Association’s brochure“Direct Reimbursement – A Guide for the Dental Office.”

NYSDA and the American Dental Association (ADA) actively promote dental benefit plans that stress fee-for-service, freedom-of-choice and quality of care. One of the most innovative models of dental benefits is Direct Reimbursement (DR), a simple concept that allows companies to self-fund dental benefits in a very cost-effective way. NYSDA and the ADA enthusiastically support the concept of DR, and we encourage you to join us in this important effort.

NYSDA recognizes that most dentists do not wish to be involved with the formal presentation of the DR concept to employers. This task is best left in the hands of qualified benefits experts, such as consultants, trained brokers and third-party administrators. Most dentists, however, can strive to educate people about DR, and all are encouraged to include DR in their discussions with patients and friends. Only through education will DR claim a significant share of the dental benefits market.

What is Direct Reimbursement?
DR is a self-funded program that reimburses an individual based on a percentage of dollars spent for dental care, not on the type of treatment provided; it also allows patients to seek treatment from the dentists of their choice.

DR is a straight-forward accounting process: Once a company has implemented a DR plan, an employee visits the dentist of his or her choice, receives treatment and arranges for payment, and later presents a paid receipt or proof of treatment to the employer or administrator of the plan for reimbursement.

Reimbursement is based on a plan design by the employer to meet both company and employee needs. One company, for example, might reimburse 100% of the first $200 of dental expenses and 80% of the next $1,000, resulting in a total annual maximum benefit of $1,000 per individual. Another company might reimburse 75% of the first $1,000 of dental expenses, resulting in a total annual maximum benefit of $750 per individual. Plan design varies widely among companies.

How is DR different from other benefit options?
Unlike some forms of dental benefits, DR allows patients to visit any dentist they choose. It frees patients to plan treatment with their dentists alone, with no third-party interference through exclusions or limitations on treatment. There are no predetermination or pre-authorization requirements, no UCR, and typically no deductibles.

Who are the best Direct Reimbursement prospects?
Without question, the best prospects for Direct Reimbursement are companies where you are personally acquainted with the owner, an executive, the benefits manager or human resources director. These are the people who are able to make or influence benefits plan purchasing decisions. Many prospects will appreciate hearing about a cost-effective dental benefit option that previously has not been presented to them.

To request copies of the ADA’s brochure for employers“Direct Reimbursement – The Dental Benefits Plan for Smart Companies” for your office or, “Direct Reimbursement –A Guide for the Dental Office,” intended to educate both yourself and your staff about the DR concept, contact NYSDA Office of Health Affairs.