BILL NUMBER: AB 1174 AMENDED BILL TEXT AMENDED IN ASSEMBLY APRIL 9, 2013 AMENDED IN ASSEMBLY MARCH 21, 2013 INTRODUCED BY AssemblyMemberBocanegraMembers Bocanegra and Logue FEBRUARY 22, 2013 An act to amend Sections 1752.4, 1753.5, 1753.6, and 1910 of the Business and Professions Code, and to add Section 14132.726 to the Welfare and Institution Code, relating to oral health. LEGISLATIVE COUNSEL'S DIGEST AB 1174, as amended, Bocanegra. Dental professionals: teledentistry under Medi-Cal. (1) Existing law, the Dental Practice Act, establishes the Dental Board of California. Existing law creates, within the jurisdiction of the board, a Dental Assisting Council that is responsible for the regulation of dental assistants, registered dental assistants, and registered dental assistants in extended functions and a Dental Hygiene Committee of California, that is responsible for the regulation of registered dental hygienists, registered dental hygienists in alternative practice, and registered dental hygienists in extended functions. Existing law governs the scope of practice for those professionals. This bill would authorize a registered dental assistant to determine which radiographs to perform if he or she has completed a specified educational program. The bill would authorize a registered dental assistant in extended functions licensed on or after January 1, 2010 , to place interim therapeutic restorations, as defined, pursuant to the order, control, and full professional responsibility of a licensed dentist, as specified. The bill would authorize a registered dental hygienist tooperate dental radiography equipment for the purpose of oral radiography, and, after submitting to the committee evidence of satisfactory completion of a course of instruction approved by the committee, determine which radiographs to perform and place interim therapeutic restorations upon the order of a licensed dentist. (2) Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including certain dental services, as specified. Existing law provides that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for "teleophthalmology and teledermatology by store and forward," as defined to mean the asynchronous transmission of medical information to be reviewed at a later time by a licensed physician or optometrist, as specified, at a distant site. This bill would enact similar provisions relating to the use of teledentistry, as defined, under the Medi-Cal program. The bill would provide that, to the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient shall not be required under the Medi-Cal program for "teledentistry by store and forward." The bill would define that term to mean an asynchronous transmission of dental information to be reviewed at a later time by a licensed dentist at a distant site, where the dentist at the distant site reviews the dental information without the patient being present in real time, as defined and as specified. The bill would also provide that dentist participation in services provided at an intermittent clinic, as defined, through the use of telehealth, as defined, shall be considered a billable encounter under Medi-Cal. The bill would also require, on or before January 1, 2017, the department to report to the Legislature the number and type of services provided, and the payments made related to the application of teledentistry, as specified. Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no. THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS: SECTION 1. Section 1752.4 of the Business and Professions Code is amended to read: 1752.4. (a) A registered dental assistant may perform all of the following duties: (1) All duties that a dental assistant is allowed to perform. (2) Mouth-mirror inspections of the oral cavity, to include charting of obvious lesions, existing restorations, and missing teeth. (3) Apply and activate bleaching agents using a nonlaser light-curing device. (4) Use of automated caries detection devices and materials to gather information for diagnosis by the dentist. (5) Obtain intraoral images for computer-aided design (CAD), milled restorations. (6) Pulp vitality testing and recording of findings. (7) Place bases, liners, and bonding agents. (8) Chemically prepare teeth for bonding. (9) Place, adjust, and finish direct provisional restorations. (10) Fabricate, adjust, cement, and remove indirect provisional restorations, including stainless steel crowns when used as a provisional restoration. (11) Place post-extraction dressings after inspection of the surgical site by the supervising licensed dentist. (12) Place periodontal dressings. (13) Dry endodontically treated canals using absorbent paper points. (14) Adjust dentures extra-orally. (15) Remove excess cement from surfaces of teeth with a hand instrument. (16) Polish coronal surfaces of the teeth. (17) Place ligature ties and archwires. (18) Remove orthodontic bands. (19) All duties that the board may prescribe by regulation. (b) A registered dental assistant may only perform the following additional duties if he or she has completed a board-approved registered dental assistant educational program in those duties, or if he or she has provided evidence, satisfactory to the board, of having completed a board-approved course in those duties. (1) Remove excess cement with an ultrasonic scaler from supragingival surfaces of teeth undergoing orthodontic treatment. (2) The allowable duties of an orthodontic assistant permitholder as specified in Section 1750.3. A registered dental assistant shall not be required to complete further instruction in the duties of placing ligature ties and archwires, removing orthodontic bands, and removing excess cement from tooth surfaces with a hand instrument. (3) The allowable duties of a dental sedation assistant permitholder as specified in Section 1750.5. (4) The application of pit and fissure sealants. (5) Determine which radiographs to perform. (c) Except as provided in Section 1777, the supervising licensed dentist shall be responsible for determining whether each authorized procedure performed by a registered dental assistant should be performed under general or direct supervision.(d) This section shall become operative on January 1, 2010.SEC. 2. Section 1753.5 of the Business and Professions Code is amended to read: 1753.5. (a) A registered dental assistant in extended functions licensed on or after January 1, 2010, is authorized to perform all duties and procedures that a registered dental assistant is authorized to perform as specified in and limited by Section 1752.4, and those duties that the board may prescribe by regulation. (b) A registered dental assistant in extended functions licensed on or after January 1, 2010, is authorized to perform the following additional procedures under direct supervision and pursuant to the order, control, and full professional responsibility of a licensed dentist: (1) Conduct preliminary evaluation of the patient's oral health, including, but not limited to, charting, intraoral and extra-oral evaluation of soft tissue, classifying occlusion, and myofunctional evaluation. (2) Perform oral health assessments in school-based, community health project settings under the direction of a dentist, registered dental hygienist, or registered dental hygienist in alternative practice. (3) Cord retraction of gingiva for impression procedures. (4) Size and fit endodontic master points and accessory points. (5) Cement endodontic master points and accessory points. (6) Take final impressions for permanent indirect restorations. (7) Take final impressions for tooth-borne removable prosthesis. (8) Polish and contour existing amalgam restorations. (9) Place, contour, finish, and adjust all direct restorations. (10) Adjust and cement permanent indirect restorations. (11) Other procedures authorized by regulations adopted by the board. (c) All procedures required to be performed under direct supervision shall be checked and approved by the supervising licensed dentist prior to the patient's dismissal from the office. (d) (1) A registered dental assistant in extended functions licensed on or after January 1, 2010, is authorized to place interim therapeutic restorations, defined as the removal ofcarriescaries using hand instruments and placement of an adhesive restorative material, upon the order of the supervising dentist under general supervision, except as authorized pursuant to paragraph(2)(3) , and pursuant to the order, control, and full professional responsibility of a licensed dentist. (2) A registered dental assistant in extended function may only perform the functions authorized pursuant to paragraph (1) if he or she has completed a board-approved registered dental assistant in extended function education program in performing those functions, or if he or she has provided evidence, satisfactory to the board, of having completed a board-approved course in those functions.(2)(3) The supervising licensed dentist shall be responsible for determining whether the functions authorized pursuant to paragraph (1) may be performed under general or direct supervision. SEC. 3. Section 1753.6 of the Business and Professions Code is amended to read: 1753.6. (a) Each person who holds a license as a registered dental assistant in extended functions on the operative date of this section may only perform those procedures that a registered dental assistant is allowed to perform as specified in and limited by Section 1752.4, and the procedures specified in paragraphs (1) to (6), inclusive, until he or she provides evidence of having completed a board-approved course in the additional procedures specified in paragraphs (1), (2), (5), and (7) to (11), inclusive, of subdivision (b), and paragraph (1) of subdivision (d), of Section 1753.5, and an examination as specified in Section 1753.4: (1) Cord retraction of gingiva for impression procedures. (2) Take final impressions for permanent indirect restorations. (3) Formulate indirect patterns for endodontic post and core castings. (4) Fit trial endodontic filling points. (5) Apply pit and fissure sealants. (6) Remove excess cement from subgingival tooth surfaces with a hand instrument. (b) This section shall become operative on January 1, 2010. SEC. 4. Section 1910 of the Business and Professions Code is amended to read: 1910. A registered dental hygienist is authorized to perform the following procedures under general supervision: (a) Preventive and therapeutic interventions, including oral prophylaxis, scaling, and root planing. (b) Application of topical, therapeutic, and subgingival agents used for the control of caries and periodontal disease. (c) The taking of impressions for bleaching trays and application and activation of agents with nonlaser, light-curing devices. (d) The taking of impressions for bleaching trays and placements of in-office, tooth-whitening devices.(e) Operate dental radiography equipment for the purpose of oral radiography.(f)(e) After submitting to the committee evidence of satisfactory completion of a course of instruction approved by the committee, the following: (1) Determine which radiographs to perform. (2) Place interim therapeutic restorations, defined as the removal ofcarriescaries using hand instruments and placement of an adhesive restorative material, upon the order of a licensed dentist. SEC. 5. Section 14132.726 is added to the Welfare and Institutions Code, to read: 14132.726. (a) To the extent that federal financial participation is available, face-to-face contact between a health care provider and a patient shall not be required under the Medi-Cal program for teledentistry by store and forward. Services appropriately provided through the store and forward process are subject to billing and reimbursement policies developed by the department. (b) A patient receiving teledentistry by store and forward shall be notified of the right to receive interactive communication with the distant dentist, and shall receive an interactive communication with the distant dentist, upon request. If requested, communication with the distant dentist may occur either at the time of the consultation, or within 30 days of the patient's notification of the results of the consultation. (c) Dentist participation in services provided at an intermittent clinic, as defined in Section 1206 of the Health and Safety Code, through the use of telehealth, as defined in Section 2290.5 of the Business and Professions Code, shall be considered a billable encounter under Medi-Cal. (d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this section by means of all-county letters, provider bulletins, and similar instructions. (e) On or before January 1, 2017, the department shall report to the Legislature the number and type of services provided, and the payments made related to the application of store and forward teledentistry as provided, under this section as a Medi-Cal benefit. (f) For purposes of this section, the following definitions apply: (1) "Asynchronous store and forward" means the transmission of a patient's dental information from an originating site to the health care provider at a distant site without the presence of the patient. (2) "Distant site" means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system. (3) "Health care provider" means a person who is licensed under Chapter 4 (commencing with Section 1600) of Division 2 of the Business and Professions Code. (4) "Originating site" means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates. (5) "Synchronous interaction" means a real-time interaction between a patient and a health care provider located at a distant site. (6) "Teledentistry" means the mode of delivering dental health care services and public dental health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's dental health care while the patient is at the originating site and the dental health care provider is at a distant site. Teledentistry includes synchronous interactions and asynchronous store and forward transfers. (7) "Teledentistry by store and forward" means an asynchronous transmission of dental information to be reviewed at a later time by a licensed dentist at a distant site, where the dentist at the distant site reviews the dental information without the patient being present in real time.