HB 111-DENTAL HYGIENIST ADVANCED PRAC PERMIT  1:37:56 PM CHAIR COSTELLO reconvened the meeting and announced the consideration of CS FOR HOUSE BILL NO. 111(FIN) "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." She noted that this was the first hearing and the intention was to hear the introduction and take invited and public testimony. 1:38:23 PM REPRESENTATIVE IVY SPOHNHOLZ, Alaska State Legislature, Juneau, Alaska, sponsor of HB 111, introduced the legislation paraphrasing the following: HB 111 creates an Advanced Practice Permit, which will allow experienced, licensed dental hygienists to provide preventative oral health care to underserved populations at senior centers, health care facilities, day cares, and schools, and for Alaskans who are eligible for public assistance, are homebound, or who live in underserved rural communities. Oral health care plays a crucial role in the overall health and well-being of Alaskans. Poor oral health care contributes to poor overall health. This problem is worst amongst our state's most vulnerable populations. Many low income individuals and families in Alaska don't regularly seek oral healthcare due to cost, apprehension of dental work, access, and trouble finding a provider. Bad oral health is linked to cardiovascular disease, Alzheimer's, osteoporosis, as well as poor nutrition and other serious health issues. So, increasing access to preventative dental health care through dental hygienists will save and improve Alaskan's health and well-being. Currently, dental hygienists can practice in a dentist's practice or practice semi-independently if they have a collaborative agreement with a dentist, similar to what Physicians Assistants do. An Advanced Practice Permit will allow dental hygienists to care for underserved populations at senior centers, health care facilities, day cares, and schools, and for Alaskans who are eligible for public assistance, are homebound, or who live in an underserved community if they have the following: 1. minimum of 4,000 hours of clinical experience, and 2. are approved by the Alaska Board of Dental Examiners. The bill lays out the specific services allowed under the permit and the specific populations that a licensed dental hygienist can provide services to without the supervision or physical presence of a licensed dentist. This list has been developed in consultation with the Alaska Dental Society, Board of Dental Examiners, and Alaska Dental Hygienists Association (Section 2 (a) services and Section 2 (b) populations). The Advanced Practice Permit-holder will have to maintain malpractice insurance, provide a written notice of their service limitations, and make a referral to a licensed dentist nearby if further dental treatment is needed (Section 2 (d)). This will allow dental hygienists to practice to the full scope of their training, credentials, and professional experience. Alaska won't be the first state to make these changes. Dental hygienists are able to practice under advance practice permits or similar permits in six other states (Colorado, Washington, Montana, Maine, Connecticut, and California) and 40 other states are considered "direct access" states, meaning that dental hygienists can initiate treatment based on their assessment of a patient's needs without the authorization or presence of a dentist Lastly, I'll note that we have already made important changes to this bill at the recommendation of the Board of Dental Examiners and the Alaska Dental Society, including • requiring permit-holders to maintain patient records for at least 7 years, • making sure that the Board of Dental Examiners has separately certified a dental hygienist to administer local anesthesia, and • empowering DHSS to make regulations related to the bill. CHAIR COSTELLO requested the sectional analysis for HB 111. 1:42:49 PM CHELSEA WARD-WALLER, Staff, Representative Ivy Spohnholz, Alaska State Legislature, Juneau, Alaska, presented the sectional analysis for HB 111 on behalf of the sponsor. Section 1  Ability of practice of dental hygienists. (e) Amends AS 08.32.110. to allow a licensed dental hygienist who holds an advanced practice permit issued by the board to perform duties allowed by the permit. Section 2  Advanced practice permits. Adds a new section under AS 08.32.125 creating the advanced practice permit and providing requirements as follows: (a) The Board of Dental Examiners may issue an advanced practice permit to a licensed dental hygienist with a minimum 4,000 documented hours of clinical experience. This subsection lists what duties fall under advanced practice permits: general oral health & cleaning, providing treatment plans, screenings, taking radiographs, and/or delegating to dental assistants. (b) A licensed dental hygienist holding an advanced practice permit may provide services to a patient who is not able to receive dental treatment because of age, infirmity, or disability. The patient may be a resident of a senior center, residential health facility, or held in a local correctional facility. The patient may also be enrolled in certain schools, receiving benefits under the Special Supplemental Food Program (WIC), homebound, or a resident of a community that has a shortage of dental health professionals. (c) A licensed dental hygienist holding an advanced practice permit can provide appropriate services to a patient without the presence, authorization, and supervision of a licensed dentist and without an examination from a licensed dentist. (d) A licensed dental hygienist with an advanced practice permit must maintain professional liability insurance. They must also give the patient, parent, or legal guardian written notice that the treatment provided will be limited to those allowed by the permit, a written recommendation that the patient be examined by a licensed dentist for comprehensive oral care, and assistance in receiving a referral to a licensed dentist for further oral treatment. (e) An advanced practice permit is valid until the license of the dental hygienist expires. A licensed dental hygienist can renew their advanced practice permit at the same time they renew their license. Section 3  Grounds for discipline, suspension, or revocation of  license. Amends AS 08.32.160 to exempt a licensed dental hygienist as permitted under an advanced practice permit from supervision requirements for clinical procedures. Licenses may be revoked if a dental hygienist allows a dental assistant to perform a prohibited procedure, or if the licensee falsified, destroyed, or failed to maintain a patient or facility record for the last seven years. 1:45:39 PM Section 4  Allows a dental hygienist holding an advance practice permit to delegate to a dental assistant the exposure/development of radiographs, the application of preventative agents, and other tasks as specified by the board in regulations. Section 5 Section 5    Prohibits insurance providers from discriminating against dental hygienists holding advanced practice permits. Section 6  This section is amended to include dental hygienist services in the optional services provided by the Department of Health and Social Services. Section 7  Allows the Department of Commerce, Community, and Economic Development, the Department of Health and Social Services, and the Board of Dental Examiners to adopt regulations necessary to implement the changes made in this bill. The regulations may not take effect before the effective date of this bill. Section 8  Section 7 on regulations takes effect immediately. Section 9  Effective date for sections 1-6 is January 1, 2023. 1:46:42 PM CHAIR COSTELLO asked why two departments are involved in licensing, not just the Department of Commerce, Community and Economic Development (DCCED). 1:47:04 PM REPRESENTATIVE SPOHNHOLZ explained that regulations are needed in both Medicaid and in professional licensing to ensure there is clear guidance on implementation for dental hygienists who will provide services to those eligible for public services. CHAIR COSTELLO noted that Section 6 provides the option to offer these services through Medicaid. REPRESENTATIVE SPOHNHOLZ replied the bill does not change the services that are available through Medicaid, but it does allow advanced practice dental hygienists (APDN) who practice independently to offer those services. She clarified that DHSS regulations would need to be changed to reflect this. CHAIR COSTELLO asked her to talk about why the provision in Section 5 that prohibits insurance providers from discriminating against APDNs is in the bill, and whether she anticipated that sort of discrimination. REPRESENTATIVE SPOHNHOLZ explained that in the past insurance companies have used a change in statute as an opportunity to compensate a provider at a different rate. HB 111 seeks to ensure that dental hygienists holding an advanced practice permit who are practicing autonomously continue to be reimbursed at the same rate as though they were practicing under a dental office. The training is the same, but they hold an advanced practice permit and operate an independent practice. She added that there is a shortage of both dentists and dental hygienists in the state. Because most of the problems in dental health care are associated with preventative work, supporting the market for APDHs actually will save money in the long term. 1:49:40 PM SENATOR STEVENS said he assumes the bill will need some changes to reflect the Governor's Executive Order to divide the Department of Health and Social Services (DHSS). REPRESENTATIVE SPOHNHOLZ agreed that changes would be needed because the bill was drafted prior to that Executive Order. 1:50:13 PM SENATOR GRAY-JACKSON said she was pleased to see the provision in Section 5 to prevent discrimination in reimbursement for APDHs practicing independently. She offered her belief that insurance companies will need to be educated. SENATOR STEVENS said he assumes that the eight villages in his district that do not have dentists will not experience a reduction in the quality of care they currently receive. REPRESENTATIVE SPOHNHOLZ replied the expectation is that access to care will improve dramatically with this advanced practice permit for dental hygienists. These experienced professionals have been providing preventative dental care for a very long time and the bill does not change that standard of care. SENATOR STEVENS commented on past battles and said he was pleased that there is continuing progress to help the people in small communities. REPRESENTATIVE SPOHNHOLZ relayed that her office had worked carefully with the Dental Society, the Board of Dental Examiners, and the Alaska Dental Hygienists' Association to craft the bill. The bill was changed to accommodate concerns and she was pleased to see the alignment among all stakeholders. 1:53:32 PM At ease 1:53:53 PM CHAIR COSTELLO reconvened the meeting and asked Ms. Wing-Heier to talk about Section 5 and how the Division of Insurance would help educate insurance companies to prevent discrimination in reimbursement practices. 1:54:26 PM LORI WING-HEIER, Director, Division of Insurance, Department of Commerce, Community, and Economic Development, Anchorage, Alaska, explained that insurance companies may discriminate, but not unfairly. For example, it is acceptable for an insurance company to file to offer homeowners insurance in Kodiak, but not Barrow. In the case of this bill, insurance companies would be expected to reimburse advanced practice dental hygienists who are active under their own license in a separate clinic. However, it may not be at the same rate as a dentist because dental hygienists currently are not reimbursed at the same rate as dentists. SENATOR GRAY-JACKSON restated her concern that insurance companies may not know about this new law and reject a claim that comes from an APDH because it is not from a dentist. She asked how the division will educate insurance companies so this issue doesn't arise. MS. WING-HEIER responded that once the bill is signed and there is an effective date, the division will notify insurance companies of this change. Consumers are encouraged to contact the division if they have a claim that is not paid the way it should be so the matter can be resolved. CHAIR COSTELLO turned to invited testimony. 1:56:26 PM ROAYANN ROYER, CDA, RDH, MPH, Member, Alaska Dental Hygiene Association, Anchorage, Alaska, testified by invitation in support of HB 111. She gave her credentials and related that she currently practices under a collaborative agreement that allows a hygienist to provide treatment under the general supervision of a dentist, prior to the dentist seeing a patient. MS. ROYER clarified that a dental hygienist holding an advanced practice permit would still provide treatment as a member of a comprehensive oral health care team. She stressed that allowing a hygienist to provide services prior to the diagnosis and treatment planning of a dentist does not compromise the health and safety of a patient or the quality of service they receive. HB 111 offers an opportunity to provide efficient, cost-saving services to the under-served population. Citing her own situation, she said that if she did not have an agreement with a dentist, HB 111 would allow her to continue to provide the current hygienist scope of practice services to the long-term care residents and refer to a dentist as needed. She said she intends to continue her collaborative agreement, but HB 111 provides another option. She noted that the bill also addresses Senator Steven's concern about access to dental care services in villages. Many hygienists who want to work in under-served communities cannot find a dentist with whom to collaborate. Because routine assessment and preventative treatment clearly is less expensive in the long term, dental professionals throughout the state support HB 111. 2:00:40 PM SENATOR STEVENS asked if hygienists who work for Native health organizations are part of the Alaska Dental Hygiene Association. MS. ROYER replied many of them are part of ADHA. She noted that Southcentral Foundation is a member and when she worked for that organization she went to the villages. SENATOR STEVENS asked if non-Natives are able to receive care from Native health care organizations that serve a village. MS. ROYER answered yes. 2:02:01 PM DR. DAVID NIELSON, Chair, Board of Dental Examiners, Anchorage, Alaska, testified by invitation in support of HB 111. Stated that the Board of Dental Examiners supports HB 111 in its current form. The board appreciates that the sponsors of the bill have been receptive to board comments and suggestions for changes. As stipulated in Section 4, he said the dental board will draft regulations stating what additional tasks, if any, a dental hygienist holding an advanced practice permit may delegate to a dental assistant and under what level of supervision. He expressed optimism that the extended effective date would allow time to write those regulations. 2:03:51 PM JOHN ZASADA, Policy Director, Alaska Primary Care Association, Anchorage, Alaska, testified by invitation in support of HB 111. On behalf of APCA, he stated support for the operation and development of Alaska's 29 tribal and non-tribal federally qualified health centers. He relayed that APCA partners with the Alaska Dental Hygiene Association and the Alaska Dental Society. He stated that overall oral health is a vital component of the whole person care that community health centers provide their patients. A frequently cited reason for the shortage of dental services is the lack of providers. Persistent shortages of providers results in providers not working at their highest level of licensure, which creates inefficiencies and decreases provider satisfaction. APCA believes the advanced practice permit will be a valuable addition. 2:06:06 PM CHAIR COSTELLO opened public testimony on HB 111; finding none, she closed public testimony. CHAIR COSTELLO held HB 111 in committee for future consideration.