BILL ANALYSIS Ó AB 502 Page 1 ASSEMBLY THIRD READING AB 502 (Chau) As Amended April 30, 2015 Majority vote ------------------------------------------------------------------- |Committee |Votes |Ayes |Noes | | | | | | | | | | | |----------------+------+----------------------+--------------------| |Business & |10-4 |Bonilla, Jones, |Baker, Chang, | |Professions | |Bloom, Campos, Dodd, |Gatto, Wilk | | | |Eggman, Holden, | | | | |Mullin, Ting, Wood | | | | | | | |----------------+------+----------------------+--------------------| |Health |11-7 |Bonta, Bonilla, |Maienschein, | | | |Burke, Chiu, Gomez, |Chávez, Gonzalez, | | | |Nazarian, |Lackey, Patterson, | | | | |Steinorth, Waldron | | | | | | | | |Ridley-Thomas, | | | | |Rodriguez, Santiago, | | | | |Thurmond, Wood | | | | | | | |----------------+------+----------------------+--------------------| |Appropriations |13-3 |Gomez, Bloom, Bonta, |Bigelow, Chang, | | | |Calderon, Daly, |Gallagher | | | |Eggman, Eduardo | | | | |Garcia, Holden, | | | | |Jones, Quirk, Rendon, | | AB 502 Page 2 | | |Wagner, Weber | | | | | | | | | | | | ------------------------------------------------------------------- SUMMARY: Authorizes registered dental hygienists in alternative practice (RDHAPs), who established practices within certified dental shortage areas, to continue their practice when the shortage area designation is removed; requires insurance companies to reimburse RDHAPs for dental hygiene care legally provided and covered by insurance; and clarifies that RDHAPs are authorized to establish corporations. Specifically, this bill: 1)Authorizes an alternative dental hygiene practice established within a certified shortage area to continue to operate if the certification is removed if the RDHAP continues to serve those patients that lack or have limited access to dental care, and at least 40% of the total patient population is comprised of underserved populations. 2)Exempts professional corporations, rendering professional services by persons duly licensed by the Dental Hygiene Committee of California (DHCC), from the requirement to obtain a certificate of registration in order to render those professional services, and specifies that RDHAPs may be shareholders, officers, or directors of an RDHAP corporation, and that licensed dentists and dental assistants may be professional employees of an RDHAP corporation. 3)Requires health care service plan contracts covering dental services, specialized health care service plan contracts covering dental services, health insurance policies covering dental services, and specialized health insurance policies covering dental services issued, amended, or renewed on or after January 1, 2016, to reimburse RDHAPs for performing dental AB 502 Page 3 hygiene services that may lawfully be performed by registered dental hygienists (RDH) and that are reimbursable under the contracts or policies, and would require the plan or insurer to use the same fee schedule for reimbursing both registered dental hygienists and RDHAP. 4)Makes other clarifying and conforming changes. FISCAL EFFECT: According to the Assembly Appropriations Committee, any costs to the California Department of Insurance and the Department of Managed Health Care to assess compliance with this bill's requirements are expected to be minor and absorbable. COMMENTS: Purpose. This bill is sponsored by the California Dental Hygienists' Association. According to the author, "A number of situations reduce access to RDHAPs. First, California law allows [RDHs]to open practice in geographic areas where people have no access to regular preventive oral care due to an absence or shortage of dentists. However, under current law, RDHAPs who practice in dental health shortage areas can no longer practice in those areas once they are no longer designated a dental shortage area. Second, many dental insurance companies recognize dentists in a dental practice as the billable provider of dental hygiene services and even though RDHAPs provide the same billable services that an RDH provide, billed by the dentist, the insurance companies are denying RDHAP's reimbursement for services. This forces patients who cannot easily access care in a traditional dental office to pay out of pocket for the services of a RDHAP or not receive the care due to finances. Additionally, any patient who goes directly to an RDHAP for preventative services must obtain a dentist's or doctor's prescription to continue those services once they pass 18 months of service with the RDHAP. This is problematic in areas where dentists are in short supply AB 502 Page 4 creating a barrier for patients to obtain much needed services. Finally, the [BPC] authorizes RDHAPs to incorporate. Corporation law would protect the RDHAP's business, however, there is not language in the Corporations Code authorizing RDHAPs to establish corporations, leaving them without critical protections. [This bill] would address these issues and ensure that the public has access to quality dental hygiene services." Background. In 1986, the Office of Statewide Health Planning and Development (OSHPD) created the RDHAP. In 1993, the professional designation was made permanent in statute. An RDHAP must have been engaged in the practice of dental hygiene as a registered dental hygienist in any setting, including educational settings and public health settings, for a minimum of 2,000 hours during the immediately preceding 36 months, complete 150 additional hours of education courses, and pass a written exam. An RDHAP has a unique distinction in that they can work for a dentist or as an employee of another RDHAP as an independent contractor, as a sole proprietor of an alternative hygiene practice, or other locations such as residences of the homebound, schools, residential facilities, and in underserved dental shortage areas, as determined by OSHPD. They may also operate a mobile dental clinic or operate an independent office or offices. As a result, RDHAPs may practice in settings outside of the traditional dental office, and allow patients to receive the same type of professional preventive care they would receive in a dental office in schools, skilled and residential care facilities, hospitals, private homes, and in some instances in an RDHAP's own office. A 2009 survey of California RDHAPs found that more than two-thirds of their patients had no other source of oral health care. RDHAPs also struggle to find referrals to dentists for patients in need of more advanced care and charge lower fees than dentists. The DHCC licenses and regulates approximately 509 RDHAPs. AB 502 Page 5 Prescription Requirements. Business and Professions Code Section 1931 allows a RDHAP to provide dental hygiene services to a patient without referral by a dentist for up to 18 months. However, after 18 months a patient needs to have a prescription from a dentist or a physician and surgeon in order to continue dental hygiene services with the RDHAP. The prescription is valid for up to two years. According to the author, this is problematic in areas where dentists are in short supply creating a barrier for patients to obtain much needed basic preventive care services. According to the author, RDHAPs have proven to be safe providers who refer patients to dentists when major dental issues arise outside of their scope of practice to treat. There is no precedent for requiring a practice agreement for licensure, nor for services delivered within a professional's own scope of practice. This is unique in that most restrictions requiring a prescription of one provider to another are for specialty care, not for primary preventive health care services. In practice, this is simply an administrative hurdle, time consuming for providers, and has not been shown to contribute to positive patient outcomes. The author indicates that patients should have their choice of dental hygiene care provider, and the public should not need a prescription to receive basic preventive care. According to the sponsors, an RDHAP is the only oral health care provider a patient has access to, and if a prescription is not obtained, the patient cannot even continue to receive preventative dental hygiene care, even though the need for and benefits of that care still exist. Dental Health Professional Shortage Areas (DHPSAs). According to OSHPD, DHPSAs are based on the evaluation of criteria established through federal regulation to identify geographic areas or population groups with a shortage of dental providers. The federal DHPSA designation identifies areas as having a shortage of dental providers on the basis of availability of dentists and AB 502 Page 6 other dental auxiliaries. To qualify for designation as a DHPSA, an area must be: 1) a rational service area; have a population to general practice dentist ratio of 5,000:1 or 4,000:1 plus population features demonstrating "unusually high need"; and 2) a lack of access to dental care in surrounding areas because of excessive distance, overutilization, or access barriers. According to OSHPD, there are 53 DHPSAs. Approximately 5% of Californians live in a DHPSA. The DHCC noted in their 2014 Sunset Review Report that problems have arisen when the shortage area in which an RDHAP sets up a practice is redesignated as a non-shortage area. Existing law requires the RDHAP to close down the practice when this occurs. The DHCC views this as "counterproductive...as the closure of the practice would leave patients with no access to dental hygiene services." According to the sponsors, when a DHPSA in San Luis Obispo was faced with losing its designation status, RDHAPs in that area fought to keep the designation area so that patients could continue to be served. This bill seeks to prevent patients from losing access to established dental care should an area lose its DHPSA. Reimbursement for Services. Currently, many dental insurance companies recognize dentists in a dental practice as the billable provider of dental hygiene services and even though RDHAPs provide the same billable services that an RDH provide, billed by the dentist, the insurance companies are denying RDHAP's reimbursement for services. In its 2014 Sunset Review Report, the DHCC identified as a barrier to RDHAP practice the inability for RDHAPs to collect payment for services rendered. The DHCC noted that RDHAPs have difficulty collecting payment for services from insurance companies based outside of California. This is because not all states have the RDHAP provider status making them ineligible for reimbursement. As a result, some patients who cannot easily access care in a traditional dental office are forced to pay out of pocket for the services of a RDHAP or not receive care due to financial constraints. AB 502 Page 7 Professional Corporations. A professional corporation is an organization made up of individuals of the same trade or profession. The Moscone-Knox Professional Corporations Act of 1968 authorized the formation of professional corporations to obtain certain benefits of the corporate form of doing business, such as limited legal liability. At that time, only medical, law and dental professional corporations were envisioned; there are now 15 authorized healing arts professional corporations. Current law specifies which healing arts licensees may be shareholders, officers, directors or professional employees of professional corporations controlled by a differing profession if the sum of all shares owned by those licensed persons does not exceed 49% of the total shares of the professional corporation. Business and Professions Code Section 1962 authorizes an association, partnership, corporation, or group of three or more registered RDHAPs to practice under an assumed or fictitious name if the association, partnership, corporation, or group holds a permit issued by the DHCC authorizing the holder to use that name connection with the holder's practice, as specified. According to the sponsors, this section was intended to allow RDHAPs to incorporate to gain the protections afforded by corporation law, most importantly, protection against personal liability. However, conforming changes were not made to the Corporations Code. This bill would specify that RDHAPs may be shareholders, officers, or directors of an RDHAP corporation, and specify that licensed dentists and dental assistants may be professional employees of an RDHAP corporation. Policy Issues: DHPSAs. The sponsors assert that it is necessary to allow RDHAPs who have established practices in DHPSAs to be able to continue that practice, even if that designation is later removed. AB 502 Page 8 However, while there is anecdotal evidence that this is a concern, it does not appear that any DHPSA has in fact been un-designated as a shortage area. Analysis Prepared by: Eunie Linden / B. & P. / (916) 319-3301 FN: 0000413