HB 111-DENTAL HYGIENIST ADVANCED PRAC PERMIT  3:43:16 PM CO-CHAIR FIELDS announced that the next order of business would be HOUSE BILL NO. 111, "An Act relating to the practice of dental hygiene; relating to advanced practice permits for dental hygienists; relating to dental assistants; prohibiting unfair discrimination under group health insurance against a dental hygienist who holds an advanced practice permit; relating to medical assistance for dental hygiene services; and providing for an effective date." 3:43:40 PM REPRESENTATIVE SPOHNHOLZ explained that HB 111 would create an advanced practice permit allowing experienced, licensed dental hygienists to provide preventative oral health care to underserved populations, as well as to those who are eligible for public assistance, are homebound, or who live in an underserved community. She said that the permit would be available to dental hygienists who have a minimum of 4,000 hours of applied clinical experience and are approved by the Alaska Board of Dental Examiners. 3:44:30 PM REPRESENTATIVE MCCARTY recalled that the last time HB 111 was presented, he had asked for clarification on the 4,000 hours. REPRESENTATIVE SPOHNHOLZ expressed that there was a miscommunication. She said that a dental hygienist goes through an educational program, becomes a licensed dental hygienist, and then can practice in the community under the supervision of a dentist. HB 111 would create an advanced practice permit that would require 4,000 hours of clinical experience. She introduced Ms. Virgin to provide more clarity on the matter. 3:46:15 PM KATRINA VIRGIN, President, Alaska Dental Hygienists' Association, said that Representative McCarty's assertion that the requirement of 8,000 hours is incorrect; the requirement would be 4,000 of clinical experience under the supervision of a dentist. 3:47:09 PM REPRESENTATIVE MCCARTY expressed understanding of the requirement of 4,000 hours of clinical experience and five or more years in the field, but said that he doesn't see educational requirements in the proposed legislation. He then said that after the previous committee meeting, he studied the other states with an advanced practice permit equivalent, in an effort to understand their criteria. He shared his perception that the other states have higher criteria than Alaska would have under the proposed legislation, and mentioned being concerned about reciprocity. He asked Ms. Virgin to address the concern. MS. VIRGIN characterized the requirements under HB 111 as "double" what the other states mandate. For example, she said, Washington's advanced practice permit requires two years' experience, which is approximately the same as what is proposed under HB 111. Maine's advanced practice permit, established in 2008, requires 2,000 hours of clinical experience. Massachusetts' permit, established in 2009, asks for 3 years' experience. Connecticut's permit, established in 1999, requires 2 years' experience. Colorado's permit, established in 1987, has no additional requirements after graduation. REPRESENTATIVE MCCARTY asked whether all of the aforementioned states require a bachelor's degree to be a dental hygienist. MS. VIRGIN replied that they do not. REPRESENTATIVE MCCARTY expressed understanding that some other states require a dental hygienist to have a bachelor's degree, take special courses, and pass an exam on law and ethics. He said that he doesn't see such language in the proposed legislation. MS. VIRGIN said that she's not sure what he's referring to as far as continuing education required by other states. She said that Alaska requires continuing education credits in order for dental hygienists to renew their licenses, which is every two years. REPRESENTATIVE MCCARTY agreed that dental hygienists have continuing education requirements, but he said that he doesn't know how many credits are required. He expressed understanding that obtaining the advanced practice permit under HB 111 would mean having the ability to practice independently and stated that the permit would come with higher standards for the practitioner. He expressed concern about how to ensure public safety. He stated that other states require a certain amount of experience and "almost double" the continuing education requirements, and that an individual would hold a dental hygienist license as well as an advanced license. He then restated his perception that the standard for advanced practice dental hygienists in Alaska would be lower than the standards in other states, and expressed concern that such a dental hygienist from Alaska would not be recognized in another state. 3:52:41 PM REPRESENTATIVE SPOHNHOLZ offered to clarify that HB 111, in creating the advanced practice permit requiring 4,000 hours of clinical practice on top of a bachelor's degree, would be the highest standard in the nation for this type of permit. She pointed out that Ms. Virgin explained that other states require between 2,000 and 3,000 hours of clinical experience, while Alaska would require 4,000. She said that Ms. Virgin also stated that not every state requires a bachelor's degree to become a dental hygienist, and said that achieving a bachelor's degree is the first step in the process, followed by 4,000 hours of clinical experience, followed then by the application for the advanced practice permit. She stressed that the standards under HB 111 would be the highest in the nation, and she expressed reluctance at the idea of "backing up" standards in Alaska in order to establish reciprocity with other states. She reiterated her earlier statement that this proposed legislation is the result of a carefully crafted compromise between the Alaska Dental Hygienists' Association and the Alaska Dental Society. 3:54:01 PM REPRESENTATIVE KAUFMAN asked Ms. Virgin to comment on AS 08.36.075, which establishes standards regarding dental radiological equipment, and how it would translate to the statutes amended by HB 111. MS. VIRGIN directed attention to an amendment which would change page 2, line 17, of the proposed legislation and quoted, "expose and develop radiography, and maintain and register dental radiological equipment as provided in AS 08.36.075." She said that it refers to current statutes and regulations already in effect. 3:55:40 PM REPRESENTATIVE SPOHNHOLZ added that there is a draft amendment addressing radiological equipment. CO-CHAIR FIELDS suggesting returning to the question of radiological equipment after the amendments. REPRESENTATIVE KAUFMAN said, "That specific amendment is not present." REPRESENTATIVE SPOHNHOLZ said that if Representative Kaufman was not satisfied with the answer, an amendment could be offered to reference the specific statute. She also said that dental hygienists in the state of Alaska are already required to adhere to AS 08.36.075, and that she's comfortable amending the proposed legislation to be more specific, if necessary. REPRESENTATIVE KAUFMAN said that he would like the amendment in order to avoid confusion. 3:56:54 PM REPRESENTATIVE SNYDER, referring to the earlier comments from Representative McCarty regarding possible license reciprocity, asked whether dental hygienists moving from other states would "not necessarily be required" to have earned their license following achievement of a bachelor's degree. MS. VIRGIN replied, "That is correct." 3:57:39 PM CO-CHAIR FIELDS asked Mr. Logan to confirm that the Alaska Dental Society is comfortable with the proposed legislation. He said that he wants to ensure expansion of services to underserved areas without destabilizing the market for established dentists. 3:58:18 PM DAVID LOGAN, DDS, Executive Director, Alaska Dental Society, stated that the Alaska Dental Society supports HB 111. He expressed that all health care practitioners should be used at their "best and highest levels," and the proposed legislation is an opportunity for dental hygienists to expand their practice opportunities while filling a need in underserved communities. 3:59:04 PM The committee took an at-ease from 3:59 p.m. to 4:00 p.m. 4:00:46 PM CO-CHAIR FIELDS moved to adopt Amendment 1 to HB 111, labeled 32-LS0480\A.1, Fisher, 3/30/21, which read as follows: Page 3, line 31, through page 4, line 1: Delete all material. Reletter the following subsection accordingly. 4:01:03 PM REPRESENTATIVE KAUFMAN objected for the purpose of discussion. 4:01:08 PM CO-CHAIR FIELDS explained that he has concerns that the term "independent contractor" could have implications regarding labor laws. He said that he developed Amendment 1 in coordination with Representative Spohnholz, and he asked for her confirmation that Amendment 1 is a friendly amendment. 4:01:48 PM REPRESENTATIVE SPOHNHOLZ agreed that Amendment 1 is a friendly amendment. 4:02:06 PM REPRESENTATIVE MCCARTY noted that an advanced dental hygienist could be an employer, which means different labor laws would apply. CO-CHAIR FIELDS responded that the passage of House Bill 79 during the Thirtieth Alaska State Legislature codified decades of case law in terms of the relationship between employees, independent contractors, and employers. He said that it's best to follow that statute for consistency. 4:03:18 PM REPRESENTATIVE SPOHNHOLZ stated that Amendment 1 would not prohibit an advanced practice dental hygienist from establishing a business. REPRESENTATIVE MCCARTY asked whether the language regarding being an independent contractor is needed. CO-CHAIR FIELDS said it is not needed. REPRESENTATIVE KAUFMAN asked why the language was originally written into the proposed legislation. CO-CHAIR FIELDS replied it was intended to refer to a dental hygienist practicing independently, without the direct supervision of a dentist; however, the intention has been adequately addressed in other sections of the bill. REPRESENTATIVE SPOHNHOLZ said, "That is correct." 4:04:56 PM REPRESENTATIVE KAUFMAN removed his objection to the motion to adopt Amendment 1. There being no further objection, Amendment 1 was adopted. 4:05:03 PM CO-CHAIR FIELDS asked if anyone else objected to Amendment 1. There being no further objection, Amendment 1 was adopted. 4:05:09 PM REPRESENTATIVE KAUFMAN moved to adopt Amendment 2, labeled 32- LS0180\A.7, Fisher, 3/30/21, which read as follows: Page 3, line 1: Delete "receive" Insert "access" 4:05:12 PM CO-CHAIR FIELDS objected for the purpose of discussion. 4:05:17 PM REPRESENTATIVE KAUFMAN explained that Amendment 2 would change the accuracy of the subsection. 4:05:29 PM REPRESENTATIVE SPOHNHOLZ expressed that the word "access" is more precise, therefore, she supports Amendment 2. 4:05:39 PM CO-CHAIR FIELDS removed his objection. There being no further objection, Amendment 2 was adopted. 4:06:02 PM The committee took a brief at-ease. 4:06:52 PM REPRESENTATIVE KAUFMAN moved to adopt Amendment 3, labeled 32- LS0480\A.8, Fisher, 3/30/21, which read as follows: Page 2, lines 5 - 29: Delete all material and insert: "Sec. 08.32.125. Advanced practice permits. (a) The board may issue an advanced practice permit to a licensed dental hygienist with a minimum of 4,000 documented hours of clinical experience. A licensed dental hygienist holding an advanced practice permit may (1) promote oral health and provide disease prevention education and oral systemic health education; (2) remove calcareous deposits, accretions, and stains from the exposed surfaces of the teeth beginning at the epithelial attachment by scaling and polishing techniques; (3) apply topical preventive or prophylactic agents, including silver diamine fluoride, fluoride varnishes, and pit and fissure sealants; (4) remove marginal overhangs; (5) perform preliminary charting and triage to formulate a dental hygiene assessment and dental hygiene treatment plan; (6) expose and develop radiographs; (7) use local periodontal therapeutic agents; (8) perform nonsurgical periodontal therapy; (9) screen for oral cancer; (10) if certified by the board, administer local anesthetic agents; (11) prescribe (A) fluoride that is applied or provided to a patient; and (B) chlorhexidine or a similar antibacterial rinse; and (12) delegate dental operations and services to a dental assistant as provided in AS 08.36.346." 4:06:55 PM CO-CHAIR FIELDS objected for the purpose of discussion. 4:06:56 PM REPRESENTATIVE KAUFMAN said that the language of Amendment 3 is intended to "bring forth the full scope" of practices allowed by a dental hygienist with an advanced practice permit under HB 111. 4:07:18 PM REPRESENTATIVE SPOHNHOLZ moved to adopt Amendment 1 to Amendment 3, labeled 32-LS0480\A.11, Fisher, 3/31/21, which read as follows: Page 1, line 10 of the amendment: Delete "exposed" 4:07:21 PM CO-CHAIR FIELDS objected for purposes of discussion. 4:07:23 PM REPRESENTATIVE SPOHNHOLZ said that, while the overall intent of Amendment 3 is acceptable, she had a concern about the use of "exposed" when it comes to teeth. She said that there are some elements of dental hygiene which require going below the surface of the epithelial attachment, which would not be possible with the adoption of Amendment 3 as written. 4:08:06 PM CO-CHAIR FIELDS removed his objection. There being no further objection, Amendment 1 to Amendment 3 was adopted. 4:08:16 PM CO-CHAIR FIELDS removed his objection to Amendment 3, as amended. There being no further objection, Amendment 3, as amended, was adopted. 4:08:26 PM REPRESENTATIVE MCCARTY moved to adopt Amendment 4, labeled 32- LS0480\A.3, Fisher, 3/30/21, which read as follows: Page 2, line 7, following "experience": Insert "in addition to attained dental hygienist hours" Page 4, line 31, through page 5, line 2: Delete all material and insert: "(10) permitted a dental assistant employed  by or working under the supervision of a dental  hygienist who holds an advanced practice permit issued  by the board under AS 08.32.125 to perform a dental  procedure in violation of AS 08.32.110 or  AS 08.36.346;"    Page 6, line 10: Delete "hygiene" Insert "hygienist" 4:08:30 PM CO-CHAIR FIELDS objected for the purpose of discussion. 4:08:35 PM REPRESENTATIVE MCCARTY said that Amendment 4 addresses his confusion regarding the number of hours of clinical experience required to attain the advanced practice permit. 4:09:15 PM REPRESENTATIVE SPOHNHOLZ stated that what she believes Representative McCarty's desired outcome is would not be achieved by Amendment 4. She said that, with respect to page 4, line 31, through page 5, line 2, Amendment 4 would limit censure to an advanced practice permit dental hygienist, rather than all hygienists. The underlying language of HB 111, she said, allows censure for inappropriate behavior for all dental hygienists, rather than only those holding an advanced practice permit. 4:10:11 PM REPRESENTATIVE MCCARTY requested an at-ease. 4:10:15 PM The committee took an at-ease from 4:10 p.m. to 4:12 p.m. 4:12:36 PM REPRESENTATIVE MCCARTY asked Ms. Virgin whether page 4, line 31, of HB 111, refers to a dental hygienist employing a dental assistant. He then asked whether there are dental hygienists who employ dental assistants. MS. VIRGIN responded that in Alaska it is not currently the case; however, in other states, dental hygienists often employ assistants. 4:14:11 PM REPRESENTATIVE SPOHNHOLZ directed attention to Section 3 of HB 111, beginning on page 4, line 5, noting that it would amend AS 08.32.160, [regarding grounds for discipline, suspension, or , which read: The board may revoke or suspend the license of a dental hygienist, or may reprimand, censure, or discipline a licensee, if, after a hearing, the board finds that the licensee REPRESENTATIVE SPOHNHOLZ then directed attention to proposed paragraph (10), on page 4, line 31 through page 5, line 2, which read as follows:  (10) permitted a dental  assistant employed by a dental hygienist or working  under the supervision of a dental hygienist to perform  a dental procedure in violation of AS 08.32.110 or AS  08.36.346;  REPRESENTATIVE SPOHNHOLZ said that the way Amendment 4 is drafted would prohibit the Board of Dental Examiners from holding accountable dental hygienists who supervise dental assistants and allow them to do work beyond their training. REPRESENTATIVE MCCARTY stated his understanding that the state of Alaska currently doesn't allow dental hygienists to have employees. REPRESENTATIVE SPOHNHOLZ pointed out the language "or working  under the supervision of a dental hygienist", and said that it is common practice for a dental hygienist to supervise a dental assistant, as the assistant has less education and legal authority to perform certain procedures. She said that Amendment 4 would limit censure to only advanced practice dental hygienists, rather than allowing all dental hygienists to be censured. In response to Representative McCarty's follow-up question, Representative Spohnholz explained, "Because all advanced practice dental hygienists will also be dental hygienists, I think the language is broad enough to ensure that an advanced practice dental hygienist who employs a dental assistant, and also a dental hygienist who is not an advanced practice dental hygienist, but who supervises a dental assistant, in both cases they would be able to be censured for inappropriate delegation of responsibilities." REPRESENTATIVE MCCARTY asked, "If we do not put in the term defining it 'advanced,' does that not open up this ... a dental hygienist could now start employing when it hasn't existed before?" 4:17:55 PM SANDON FISHER, Attorney, Legislative Legal Services, Legislative Affairs Agency, explained that under HB 111, a dental hygienist with an advanced practice permit could hire a dental assistant, as evidenced by the language of Section 4, subsection (c). REPRESENTATIVE MCCARTY expressed his belief that the language of Section 4, subsection (c), needs to be reworked. 4:19:52 PM CO-CHAIR FIELDS told Representative McCarty to either withdraw Amendment 4 and rework it, or the committee can vote on it. 4:20:10 PM REPRESENTATIVE KAUFMAN expressed being confused by Amendment 4. 4:20:44 PM REPRESENTATIVE SPOHNHOLZ expressed that the wording of Amendment 4 is unclear and could complicate the proposed legislation moving forward. She suggested withdrawing Amendment 4 and adding a conceptual amendment on page 4, line 31, so that the paragraph would read: (10) permitted a dental assistant employed by an  advanced practice permit dental hygienist or working  under the supervision of a dental hygienist to perform  a dental procedure in violation of AS 08.32.110 or AS  08.36.346; REPRESENTATIVE SPOHNHOLZ said that this would clarify that an advanced practice permit holder would be able to employ dental assistants, and that a dental hygienist in a regular dental practice could supervise dental assistants. 4:21:52 PM CO-CHAIR FIELDS asked Representative McCarty if he is amenable to that suggestion. REPRESENTATIVE MCCARTY expressed his agreement. CO-CHAIR FIELDS asked Representative Spohnholz to move her suggestion as a conceptual amendment to Amendment 4. REPRESENTATIVE SPOHNHOLZ said that she would prefer Amendment 4 be withdrawn. 4:22:10 PM REPRESENTATIVE MCCARTY withdrew Amendment 4 and said, "I believe we did not talk about page 6, line 10." CO-CHAIR FIELDS suggested addressing it later. 4:22:39 PM REPRESENTATIVE SPOHNHOLZ moved to adopt Amendment 5, labeled 32- LS0480\A.9, Fisher, 3/30/21, which read as follows: Page 2, line 3, following "AS 08.36.346": Insert "or that a licensed dental hygienist who holds  an advanced practice permit issued by the board under  AS 08.32.125 may delegate to a dental assistant under  AS 08.36.346(c)" REPRESENTATIVE SPOHNHOLZ said that Amendment 5 was recommended by the Alaska Dental Society to add clarity about the ability of dental hygienists to assign tasks to a dental assistant. 4:22:54 PM CO-CHAIR FIELDS objected then withdrew his objection. There being no further objection, Amendment 5 was adopted. 4:23:07 PM REPRESENTATIVE KAUFMAN moved to adopt Amendment 6, labeled 32- LS0480\A.10, Fisher, 3/31/21, which read as follows: Page 2, line 19, following "radiographs": Insert "and maintain and register dental radiological equipment under AS 08.36.075" 4:23:16 PM CO-CHAIR FIELDS objected for the purpose of discussion 4:23:20 PM REPRESENTATIVE KAUFMAN said that the purpose of Amendment 6 is to link the standards of radiological safety and equipment required of dentists to holders of an advanced practice permit. 4:23:48 PM REPRESENTATIVE SPOHNHOLZ stated that she has no objection. 4:23:59 PM CO-CHAIR FELDS withdrew his objection. There being no further objection, Amendment 6 was adopted. 4:24:05 PM REPRESENTATIVE SPOHNHOLZ moved to adopt Conceptual Amendment 7, which would insert "advanced practice permit dental hygienist" after "permitted a dental assistant employed by a" on page 4, line 31, of HB 111. 4:24:16 PM CO-CHAIR FIELDS objected for the purpose of discussion. 4:24:37 PM REPRESENTATIVE MCCARTY stated his agreement and asked that the text read "an" instead of "a". 4:24:43 PM CO-CHAIR FIELDS asked whether there was any objection to Conceptual Amendment 7. [The objection by Co-Chair Fields was treated as removed.] There being none, Conceptual Amendment 7 was adopted. 4:25:01 PM The committee took a brief at-ease. 4:25:21 PM REPRESENTATIVE MCCARTY moved to adopt Conceptual Amendment 8, which would change the language of page 6, line 10, to read "dental hygienist" instead of "dental hygiene". 4:25:32 PM CO-CHAIR FIELDS objected for the purpose of discussion and noted that committee members can see the language on Amendment 4, which was withdrawn. 4:25:43 PM REPRESENTATIVE SPOHNHOLZ objected because the wording would be grammatically incorrect. She said that page 6, line 10, reads "adult dental and dental hygiene services"; therefore, saying "dental hygienist services" would be grammatically incorrect and not what the proposed legislation is trying to achieve. 4:26:05 PM REPRESENTATIVE MCCARTY asked whether there needs to be special recognition in the proposed legislation for insurance purposes. 4:26:36 PM REPRESENTATIVE SPOHNHOLZ explained that Section 6, subsection (b), provides the services which can be billed for, not the providers. CO-CHAIR FIELDS stated that he is comfortable with the existing semantics in subsection (b). 4:27:12 PM REPRESENTATIVE MCCARTY withdrew Conceptual Amendment 8. 4:27:17 PM CO-CHAIR FIELDS stated the intention to move HB 111, as amended, at the end of the meeting. 4:27:34 PM CO-CHAIR FIELDS opened public testimony on HB 111, as amended. After verifying that no one wished to testify, he closed public testimony. [HB 111, as amended, was held and revisited later in the meeting.] HB 111-DENTAL HYGIENIST ADVANCED PRAC PERMIT  5:11:55 PM CO-CHAIR FIELDS announced that the final order of business would be a return to HOUSE BILL NO. 111, "An Act relating to the practice of dental hygiene; relating to advanced practice permits for dental hygienists; relating to dental assistants; prohibiting unfair discrimination under group health insurance against a dental hygienist who holds an advanced practice permit; relating to medical assistance for dental hygiene services; and providing for an effective date." 5:12:02 PM REPRESENTATIVE SCHRAGE moved to report HB 111, as amended, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 111(L&C) was reported out of the House Labor and Commerce Standing Committee.