BILL ANALYSIS Ó
AB 502
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Date of Hearing: April 28, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 502
Chau - As Amended April 22, 2015
SUBJECT: Dental hygiene.
SUMMARY: Allows alternative dental hygiene practices to
continue to operate and provide care within a certified shortage
area, as specified, regardless of whether or not that area
maintains a designation as a dental health professional shortage
area (DHPSA) in the future. Allows registered dental hygienists
in alternative practice (RDHAPs) to submit claims for dental
hygiene services and requires health plans and insurers to
provide reimbursement, as specified. Specifically, this bill:
1)Prohibits an alternative dental hygiene practice from being
forced to close owing to a loss of its surrounding location's
designation as a DHPSA under the following circumstances:
a) The RDHAPs continue to serve patients that have no or
limited access to dental care, including Medi-Cal program
patients; and,
b) At least 40% of the total alternative dental hygiene
practice serves those underserved populations.
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2)Allows licensed dentists and dental assistants to be part of
professional corporations of RDHAPs.
3)Requires health plans and policies that cover dental services,
including specialized health plans and policies, to do the
following:
a) Allow RDHAPs to submit any claim for dental hygiene
services;
b) Reimburse an RDHAP for dental hygiene services that can
be performed by a registered dental hygienist (RDH) if the
plan or policy provides reimbursement for dental hygiene
services; and,
c) Use the same payment rates for RDHAPs as are provided to
RDHs.
EXISTING LAW:
1) Allows the licensure and regulation of registered dental
hygienists, registered dental hygienists in extended
functions, and registered dental hygienists in alternative
practice by the Dental Hygiene Committee of California
(DHCC).
2) Allows an RDHAP to perform various duties in specified
settings, including DHPSAs, as certified by the Office of
Statewide Health Planning and Development.
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3) Establishes the Knox-Keene Health Care Service Plan Act
of 1975 under the administration and enforcement of the
Department of Managed Health Care, and requires a health
care service plan to reimburse claims, as specified.
4) Provides for the regulation of health insurers by the
California Department of Insurance.
5) Establishes specified standards for health care service
plan contracts covering dental services, health insurance
policies covering dental services, specialized health care
service plan contracts covering dental services, and
specialized health insurance policies covering dental
services.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. The author states RDHAPs provide
necessary professional preventive dental care to patients who
typically have limited or no access to these services. The
author states existing law limits access to RDHAPs by
preventing those who practice in DHPSAs from continuing
practice in those areas once they lose certification. In
addition, the author contends RDHAPs are not currently
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provided with proper financial incentives to provide services,
as health plans and insurers are denying reimbursement for
RDHAP services, despite the services being equivalent to those
billable services provided by an RDH. Finally, the author
asserts there are no current business protections for RDHAPs
in statute, though existing law authorizes them to
incorporate. The author states this bill will remove barriers
in existing law for RDHAPs to practice and increase public
access to quality dental hygiene services.
2)BACKGROUND.
a) California Health Benefits Review Program (CHBRP)
Analysis. At the request of the Legislature, CHBRP, within
the University of California, provides independent analyses
of medical, financial, and public health impacts of
proposed legislation regarding health insurance benefit
mandates and repeals. The following background is based on
the CHBRP review for this bill.
i) RDHAPs. RDHAPs are a subset of RDHs who are
authorized to practice in specified underserved areas,
including residences of homebound individuals, schools,
residential facilities, and DHPSAs. Although RDHAPs and
RDHs share the same scope of practice, RDHs may not
practice dental hygiene in the absence of an on-site
dentist whereas RDHAPs, through additional schooling and
a licensing process, may provide dental hygiene services
without the supervision of a dentist. Once licensed,
RDHAPs are able to administer dental hygiene services in
designated alternative practice settings without the
supervision of a dentist, provided that they identify a
dentist for referrals, consultations, or emergencies.
CHBRP estimates that RDHAPs annually provide dental
hygiene services to approximately 598,400 patients. In a
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2009 survey, RDHAPs estimated that, on average, about a
tenth of their patients were privately insured, a third
were uninsured, and over half were covered through public
assistance programs, such as Medi-Cal.
ii) Current barriers to practice. According to DHCC,
there are currently 563 licensed RDHAPs (524 of which are
practicing) throughout California, as compared with
approximately 31,000 licensed RDHs. Due to their small
numbers, unique designation, and barriers to
participation in some networks, RDHAPs often experience
difficulty gaining recognition as providers from payers
and receiving compensation for their services. In a 2009
descriptive survey of the RDHAP workforce, 82% of
practicing RDHAPs reported maintaining employment in a
traditional dental office setting for an average of three
days per week in order to support two days of alternative
practice, citing significant administrative barriers to
receiving consistent reimbursement for services delivered
under their RDHAP licensure. Accordingly, in 2009,
RDHAPs identified administrative hassle as a significant
impediment (4.0 on a 5-point scale) to providing direct
patient care and reported spending approximately
one-third of RDHAP practice time on administrative
activities.
iii) Policies in other states. There are currently 37
states, including California, that are direct-access
states for dental hygienists, meaning that a dental
hygienist can initiate treatment based on his or her
assessment of patient's needs without the specific
authorization of a dentist, treat the patient without the
presence of a dentist, and can maintain a
provider-patient relationship. These services are
generally provided in settings such as Head Start
centers, schools, federally qualified health centers
(FQHCs), and long-term care facilities. In 16 states,
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there is statutory or regulatory language allowing the
state Medicaid program to directly reimburse dental
hygienists for services rendered.
b) Federal criteria for DHPSAs. A geographic area will be
designated as having a dental professional shortage if the
following three criteria are met:
i) The area is a rational area for the delivery of
dental services;
ii) One of the following conditions prevails in the
area:
(1) The area has a population to
full-time-equivalent dentist ratio of at least
5,000:1; or,
(2) The area has a population to
full-time-equivalent dentist ratio of less than
5,000:1 but greater than 4,000:1 and has unusually
high needs for dental services or insufficient
capacity of existing dental providers.
iii) Dental professionals in contiguous areas are
overutilized, excessively distant, or inaccessible to the
population of the area under consideration.
Populations with unusually high needs for dental services
are defined as those where more than 20% of the population
has incomes below the poverty level, or areas where the
majority of the population does not have a fluoridated
water supply.
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c) Legislative oversight hearing. On March 17, 2014, the
Senate Committee on Business, Professions, and Economic
Development and the Assembly Committee on Business,
Professions, and Consumer Protections held a joint
oversight hearing to discuss a Sunset Review Report on the
DHCC. The report discussed at the hearing identified
barriers to RDHAP practice, including the closure of a
dental practice when the area no longer meets criteria as a
DHPSA, and the ability for DHAPs to collect payment for
services rendered. The staff recommendation examined at
the joint hearing included amending existing law to reduce
these two specific barriers.
d) Denti-Cal State Audit. On December 11, 2014, the
California State Auditor issued a report titled "California
Department of Health Care Services: Weaknesses in Its
Medi-Cal Dental Program Limit Children's Access to Dental
Care." The report stated that insufficient number of
dental providers willing to participate in Medi-Cal, low
reimbursement rates and a failure to adequately monitor the
program, led to limited access to care and low utilization
rates for Medi-Cal beneficiaries across the state. The
Audit found that 16 counties either have no active
providers or do not have providers willing to accept new
Medi-Cal patients, and 16 other counties have an
insufficient number of providers.
Recent changes in federal and state laws that have expanded
Medi-Cal coverage could increase the number of children and
adults who can receive additional covered dental services
from 2.7 million to as many as 6.4 million, bringing into
question the state's ability to provide timely and adequate
care to beneficiaries.
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e) Impact of this bill. The CHBRP analysis anticipates
multiple impacts on the dental coverage of patients, and
utilization rates for RDHAPs.
There are currently no RDHAPs that participate as
contracted network providers in DHMOs (dental health
maintenance organizations) or DPPOs (dental preferred
provider organizations) in the state. It is not
anticipated that RDHAPs will become participating providers
in either type of dental insurance plan under this bill due
to their scope of practice and network participation
requirements.
Additionally, RDHAPs are already allowed to submit claims
as out-of-network providers to DPPO plans, however the rate
of reimbursement and likelihood of having the claim paid
varies by plan, service, and the certification requirements
of each plan. This bill is likely to increase the
likelihood of claims being paid and RDHAPs being recognized
by DPPOs as out-of-network providers only.
Finally, reduced paperwork, changes to professional
corporation requirements and staffing, certification
requirements, and barriers to providing and being
reimbursed for care will not change the out-of-network
nature of RDHAP care or the limitations on where they can
practice. However, it could increase the number and/or
amount of time spent by RDHAPs practicing independently in
DHPSAs and alternative practice settings.
3)SUPPORT. The California Dental Hygienists' Association, the
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sponsor of the bill, and supporters state this bill improves
access to dental hygiene care for vulnerable populations that
cannot easily access traditional dental offices by
strengthening the RDHAP practice in current law. Supporters
state RDHAPs are recognized dental providers that provide the
healthcare system with innovative services essential to
expanding dental services to patients throughout California.
Supporters argue this bill removes current barriers to RDHAP
practice and improves the ability of RDHAPs to take dental
hygiene care to patients.
4)OPPOSITION. The California Dental Association states in
opposition, on a prior version of the bill, the primary reason
for the development of the RDHAP license is to bring dental
hygiene services to dentally underserved populations and into
underserved communities. According to the opposition, it is
not aware of any existing problems with DHPSAs that have lost,
or are in danger of losing, their designations and potentially
reducing access to care, and that it is unclear what effect a
DHPSA reclassification would have on the surrounding
community. The opposition concludes that should guidelines
should be placed into statute for RDHAPs who work in
reclassified DHPSAs to ensure the practice retains the intent
of the law to increase dental services to underserved
populations.
5)PREVIOUS LEGISLATION.
a) AB 1174 (Bocanegra), Chapter 662, Statutes of 2014,
authorizes certain allied dental professionals, including
RDHs and RDHAPs, to perform additional activities using
telehealth.
b) AB 1334 (Salinas), Chapter 850, Statutes of 2006, RDHAPs
to provide services to patients without a prescription from
a dentist or a physician and surgeon for the first 18
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months after the first date of service.
6)POLICY COMMENT. At the time of this analysis, there do not
appear to be records of existing DHPSAs within California
losing their designation. The Committee may wish to consider
the need for immediate action on these specific provisions of
this bill, since the future needs and services provided for
dental care of vulnerable populations may have changed by the
time any DHPSAs lose their designation.
7)TECHNICAL AMENDMENT. This bill allows RDHAPs to continue to
provide services in DHPSAs which have lost their
classification, on the condition that they continue to provide
services to patients who have limited or no access to dental
care, and at least 40% of the practice serves those
underserved populations. The current language is unclear as
to whether the 40% requirement applies to the percentage of
practicing providers who must serve an underserved population,
or the percentage of clientele which must be underserved. The
author has indicated the intent was to require the latter
option in the bill; therefore the Committee may suggest the
clarifying, technical amendment:
In Section 1926 of the Business and Professions Code:
(d) Dental health professional shortage areas, as certified by
the Office of Statewide Health Planning and Development in
accordance with existing office guidelines. An alternative
dental hygiene practice established within a certified
shortage area shall not be required to close due to the
removal of the dental health professional shortage area
designation if the registered dental hygienist in alternative
practice continues to serve those patients that lack or have
limited access to dental care including, but not limited to,
Medi-Cal program patients, and at least 40 percent of the
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total patient population of the alternative dental hygiene
practice serves those is comprised of those underserved
populations.
REGISTERED SUPPORT / OPPOSITION:
Support
California Dental Hygienists' Association (sponsor)
Several individuals (prior version)
Opposition
California Dental Association (prior version)
Analysis Prepared by:An-Chi Tsou / HEALTH / (916) 319-2097
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