77R12679 E
By Maxey, Thompson, Flores, Gallego, Gray H.B. No. 3507
Substitute the following for H.B. No. 3507:
By Maxey C.S.H.B. No. 3507
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the regulation of dentistry and the provision of dental
1-3 services.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 ARTICLE 1. DENTAL SERVICES UNDER THE MEDICAL
1-6 ASSISTANCE PROGRAM
1-7 SECTION 1.01. Subchapter B, Chapter 32, Human Resources Code,
1-8 is amended by adding Section 32.053 to read as follows:
1-9 Sec. 32.053. DENTAL SERVICES. (a) For purposes of this
1-10 section, the "dental necessity" for a dental service or product is
1-11 based on whether a prudent dentist, acting in accordance with
1-12 generally accepted practices of the professional dental community
1-13 and within the parameters of the American Dental Association and
1-14 within the quality assurance criteria of the American Academy of
1-15 Pediatric Dentistry, as applicable, would provide the service or
1-16 product to a patient to diagnose, prevent, or treat orofacial pain,
1-17 infection, disease, dysfunction, or disfiguration.
1-18 (b) A dental service or product may not be provided under
1-19 the medical assistance program unless there is a dental necessity
1-20 for the service or product.
1-21 (c) In providing dental services under the medical
1-22 assistance program, the department shall:
1-23 (1) ensure that a stainless steel crown is not used as
1-24 a preventive measure;
2-1 (2) require a dentist participating in the medical
2-2 assistance program to document, through x-rays or other methods
2-3 established by department rule, the dental necessity for a
2-4 stainless steel crown before the crown is applied;
2-5 (3) require a dentist participating in the medical
2-6 assistance program to comply with a minimum standard of
2-7 documentation and recordkeeping for each of the dentist's patients,
2-8 regardless of whether the patient's costs are paid privately or
2-9 through the medical assistance program;
2-10 (4) replace the 15-point system used for determining
2-11 the dental necessity for hospitalization and general anesthesia
2-12 with a more objective and comprehensive system developed by the
2-13 department; and
2-14 (5) take all necessary action to eliminate fraud in
2-15 the provision of dental services under the medical assistance
2-16 program, including:
2-17 (A) adopting a zero-tolerance policy toward
2-18 fraud;
2-19 (B) aggressively investigating and prosecuting
2-20 any dentist who abuses the system for reimbursement under the
2-21 medical assistance program; and
2-22 (C) randomly auditing all dentists participating
2-23 in the medical assistance program and conducting targeted audits of
2-24 dentists whose billing activities under the medical assistance
2-25 program are excessive or otherwise inconsistent with the billing
2-26 activities of other similarly situated dentists.
2-27 (d) In setting reimbursement rates for dental services under
3-1 the medical assistance program, the department shall:
3-2 (1) set the reimbursement rate for a stainless steel
3-3 crown at an amount equal to the reimbursement rate for an amalgam
3-4 or resin filling;
3-5 (2) reduce the amount of the hospitalization fee in
3-6 effect on December 1, 2000, and redistribute amounts made available
3-7 through reduction of that fee to other dental services for which
3-8 adequate accountability measures exist; and
3-9 (3) eliminate the behavior management fee, except for
3-10 patients diagnosed with a mental or physical disability, and the
3-11 nutritional consultation fee and redistribute amounts made
3-12 available through elimination of those fees to other commonly
3-13 billed dental services for which adequate accountability measures
3-14 exist.
3-15 (e) The department shall develop the minimum standard
3-16 described by Subsection (c)(3) in cooperation with the State Board
3-17 of Dental Examiners.
3-18 SECTION 1.02. If before implementing any provision of this
3-19 article a state agency determines that a waiver or authorization
3-20 from a federal agency is necessary for implementation of that
3-21 provision, the agency affected by the provision shall request the
3-22 waiver or authorization and may delay implementing that provision
3-23 until the waiver or authorization is granted.
3-24 ARTICLE 2. REGULATION OF TELEDENTISTRY
3-25 SECTION 2.01. For purposes of this article, a licensed
3-26 dentist may delegate orally, in writing, or through advanced audio
3-27 and video telecommunications services a service, task, or procedure
4-1 to a dental hygienist who is under the supervision and
4-2 responsibility of the dentist, if:
4-3 (1) the dental hygienist is licensed to perform the
4-4 service, task, or procedure;
4-5 (2) the supervising dentist examines the patient
4-6 either in person or through advanced audio and video
4-7 telecommunications services:
4-8 (A) at the time the service, task, or procedure
4-9 is performed by the dental hygienist; or
4-10 (B) during the 12 calendar months preceding the
4-11 date of performance of the service, task, or procedure by the
4-12 dental hygienist; and
4-13 (3) the dental hygienist does not:
4-14 (A) diagnose a dental disease or ailment;
4-15 (B) prescribe a treatment or a regimen;
4-16 (C) prescribe, order, or dispense medication; or
4-17 (D) perform any procedure that is irreversible
4-18 or involves the intentional cutting of soft or hard tissue by any
4-19 means.
4-20 SECTION 2.02. (a) In this section:
4-21 (1) "Dental professional" means:
4-22 (A) a dentist licensed under Subtitle D, Title
4-23 3, Occupations Code; or
4-24 (B) a dental hygienist licensed under Chapter
4-25 262, Occupations Code, practicing under the supervision of a
4-26 dentist.
4-27 (2) "Student" means a person who is under 19 years of
5-1 age, is enrolled in a public school, and receives dental services
5-2 under Chapter 32, Human Resources Code.
5-3 (3) "Teledentistry dental services" means a dental
5-4 service that utilizes, in whole or in part, advanced
5-5 telecommunications technology including:
5-6 (A) compressed digital interactive video, audio,
5-7 or data transmission;
5-8 (B) clinical data transmission via computer
5-9 imaging for teleradiology or telepathology; and
5-10 (C) other technology that facilitates access in
5-11 rural and underserved counties to dental services or dental
5-12 specialty expertise.
5-13 (b) The commissioner of human services shall appoint a
5-14 program administrator to administer a pilot program that uses
5-15 teledentistry and other methods of delivering dental services to
5-16 provide dental services to students in one public school district
5-17 in the state.
5-18 (c) The program administrator shall establish an advisory
5-19 committee to assist the program administrator in developing and
5-20 implementing the pilot program.
5-21 (d) In developing the pilot program, the program
5-22 administrator shall design the program in a manner that:
5-23 (1) increases access to dental services and enhances
5-24 the delivery of dental services to students;
5-25 (2) ensures the provision of oral health education
5-26 services;
5-27 (3) provides for effective and appropriate supervision
6-1 by a dentist of other dental professionals providing care under the
6-2 program; and
6-3 (4) enables the state to determine whether extension
6-4 of the use of teledentistry would improve the delivery of dental
6-5 services.
6-6 (e) The program administrator shall adopt procedures as
6-7 necessary to:
6-8 (1) ensure that appropriate care, including quality of
6-9 care, is provided to students who receive teledentistry dental
6-10 services;
6-11 (2) ensure adequate supervision of dental
6-12 professionals who are not dentists and who provide teledentistry
6-13 dental services;
6-14 (3) establish the maximum number of dental
6-15 professionals who are not dentists that a dentist may supervise;
6-16 and
6-17 (4) require a face-to-face consultation with a dentist
6-18 within a certain number of days following a teledentistry dental
6-19 service.
6-20 (f) Only a teledentistry dental service initiated or
6-21 provided by a licensed dentist in this state may be reimbursed
6-22 under the Medicaid program. Medicaid reimbursement for a
6-23 teledentistry dental service shall be at the same rate as the
6-24 Medicaid program reimburses for a comparable in-person dental
6-25 service. A request for reimbursement may not be denied solely
6-26 because an in-person consultation between a dentist or other dental
6-27 professional and a patient did not occur. Reimbursement for a
7-1 dental hygienist for service shall be made through the supervising
7-2 dentist.
7-3 (g) A dental hygienist must act under the remote supervision
7-4 of a local dentist. Both the dentist and the hygienist must be
7-5 located within the boundaries of the school district served by the
7-6 pilot program.
7-7 (h) Images and assessment information shall be sent by the
7-8 dental hygienist to a supervising dentist either live or by means
7-9 of store and forward technology. After a dentist has reviewed the
7-10 required information, the dentist may authorize the provision of
7-11 preventive services by the dental hygienist located at the school.
7-12 (i) A dental hygienist participating in the pilot program
7-13 may initiate screening and assessment services and, under the
7-14 supervision of a dentist, may perform any procedure the hygienist
7-15 is authorized to perform under law.
7-16 (j) A teledentistry dental service may not be provided if an
7-17 in-person consultation with a dentist is reasonably available to a
7-18 student. Dentists and other dental professionals participating in
7-19 the pilot program shall make a good faith effort to identify and
7-20 coordinate with existing providers to preserve and protect existing
7-21 dental care systems and dental relationships.
7-22 (k) The program administrator shall establish a control
7-23 group not to exceed 1,000 students to provide a benchmark for
7-24 measuring the performance of the pilot program. Each student in
7-25 the control group shall be examined by a dentist, in person, at the
7-26 end of the program to evaluate the effectiveness of teledentistry
7-27 dental services provided during the program. The examining dentist
8-1 must practice in a dental office located outside the boundaries of
8-2 the school district served by the pilot program.
8-3 (l) The program administrator shall use the results of the
8-4 pilot program to:
8-5 (1) determine the efficacy of teledentistry; and
8-6 (2) determine the effectiveness of teledentistry in
8-7 increasing access to dental services and improving oral health of
8-8 students.
8-9 (m) A dental professional who provides teledentistry dental
8-10 services shall ensure that the informed consent of the student or a
8-11 person authorized to provide consent for the student is obtained
8-12 before teledentistry dental services are provided.
8-13 (n) Students participating in the pilot program must be
8-14 referred to local dentists for restorative care and monitored to
8-15 ensure that restorative services are provided.
8-16 (o) Not later than December 31, 2002, the program
8-17 administrator shall submit a report to the legislature containing
8-18 the following:
8-19 (1) the number of students who received teledentistry
8-20 dental services;
8-21 (2) the types of teledentistry dental services
8-22 provided;
8-23 (3) the cost and level of utilization of teledentistry
8-24 dental services;
8-25 (4) the effect of the pilot program on school
8-26 absenteeism of students in the control group;
8-27 (5) a description of improvements in the oral health
9-1 of students in the pilot program; and
9-2 (6) recommendations for changes in or the expansion of
9-3 the pilot program.
9-4 (p) This article expires and the advisory committee is
9-5 abolished December 31, 2002.
9-6 SECTION 2.03. (a) The commissioner of human services shall
9-7 appoint a program administrator for the teledentistry pilot program
9-8 not later than the 30th day after the effective date of this
9-9 article.
9-10 (b) The program administrator shall appoint an advisory
9-11 committee and shall begin implementing the teledentistry pilot
9-12 program not later than the 30th day after the date the program
9-13 administrator is appointed.
9-14 ARTICLE 3. ALTERNATIVE TRAINING OF DENTAL HYGIENISTS
9-15 SECTION 3.01. Section 256.053, Occupations Code, is amended
9-16 to read as follows:
9-17 Sec. 256.053. ELIGIBILITY FOR LICENSE. To qualify for a
9-18 license, an applicant must be:
9-19 (1) at least 18 years of age;
9-20 (2) a graduate of an accredited high school or hold a
9-21 certificate of high school equivalency; and
9-22 (3) a graduate of a recognized school of dentistry or
9-23 dental hygiene accredited by the Commission on Dental Accreditation
9-24 of the American Dental Association and approved by the board, or
9-25 have provided evidence satisfactory to the board that the applicant
9-26 has completed an alternative dental hygiene training program
9-27 approved by the board that meets the requirements of Section
10-1 256.0531.
10-2 SECTION 3.03. Subchapter B, Chapter 256, Occupations Code, is
10-3 amended by adding Section 256.0531 to read as follows:
10-4 Sec. 256.0531. ALTERNATIVE DENTAL HYGIENE TRAINING PROGRAMS.
10-5 (a) It is the intent of the legislature that programs approved by
10-6 the board under this section provide hygiene training that is
10-7 substantially equivalent to training provided under traditional
10-8 programs.
10-9 (b) An alternative dental hygiene training program must meet
10-10 the following requirements:
10-11 (1) the program must require hygiene students to
10-12 complete four semesters of didactic education from a school of
10-13 dentistry, dental hygiene school, or other educational institution
10-14 approved by the board;
10-15 (2) didactic education shall be provided by
10-16 instruction in the classroom or by distance learning, remote
10-17 coursework, or similar modes of instruction offered by an
10-18 institution accredited by the Commission on Dental Accreditation of
10-19 the American Dental Association;
10-20 (3) didactic education shall include instruction in
10-21 anatomy, pharmacology, x-ray, ethics, jurisprudence, hygiene, and
10-22 any other subject regularly taught in reputable schools of
10-23 dentistry and dental hygiene that the board may require;
10-24 (4) the program must require hygiene students to
10-25 complete not less than 1,000 hours of clinical training under the
10-26 direct supervision of a dentist qualified under Subsection (d) or a
10-27 dental hygienist qualified under Subsection (f) during a 12-month
11-1 period. Students must satisfactorily complete 75 full-mouth
11-2 prophylaxes and demonstrate the ability to accurately record the
11-3 location and extent of dental restorations, chart mobility,
11-4 furcations, gingival recession, keratinized gingiva, and pocket
11-5 depth on six aspects of each tooth; and
11-6 (5) clinical training may occur simultaneously with
11-7 didactic education.
11-8 (c) Prior to commencing clinical training, a hygiene student
11-9 must have completed no less than two years of full-time employment
11-10 in a position involving clinical duties with dental patients.
11-11 (d) To be qualified to train a hygiene student under this
11-12 section, a dentist must:
11-13 (1) be licensed in Texas and have practiced in Texas
11-14 for at least five years;
11-15 (2) have completed a certification or calibration
11-16 course approved by the board for purposes of this section; and
11-17 (3) meet recertification requirements at intervals of
11-18 no more than three years.
11-19 (e) A hygiene student who completes the requirements of a
11-20 program under this section must satisfactorily pass the examination
11-21 required for all hygiene license applicants under this chapter.
11-22 (f) A dental hygienist may train hygiene students under this
11-23 section if:
11-24 (1) the dental hygienist is employed by a dentist who
11-25 provides training under this section and the hygienist works under
11-26 the direct supervision of the dentist in the same office as the
11-27 dentist;
12-1 (2) the dental hygienist has practiced full-time
12-2 dental hygiene for the five years immediately preceding the time
12-3 the training is provided; and
12-4 (3) the dental hygienist has completed a certification
12-5 or calibration course approved by the board and meets
12-6 recertification requirements at intervals of no more than five
12-7 years.
12-8 (g) A dentist who supervises a dental hygienist trained
12-9 under this section has the same liability for acts performed by the
12-10 hygienist as if the hygienist were trained in a different manner.
12-11 (h) The board shall implement an alternative dental hygiene
12-12 training program no later than January 1, 2002.
12-13 (i) The board shall appoint an advisory committee to advise
12-14 the board in developing the hygiene training equivalency program.
12-15 The advisory committee consists of the following members appointed
12-16 by the board:
12-17 (1) three dental hygienists nominated by a statewide
12-18 association of dental hygienists;
12-19 (2) three dentists nominated by a statewide
12-20 association of dentists;
12-21 (3) one dental educator nominated by the State Board
12-22 of Dental Examiners; and
12-23 (4) one dental hygienist educator nominated by the
12-24 Hygiene Advisory Committee to the State Board of Dental Examiners.
12-25 (j) In developing the program, the advisory committee board
12-26 shall consider the standards adopted by the Commission on Dental
12-27 Accreditation.
13-1 SECTION 3.04. The program, including the clinical training
13-2 component, must be accredited by the Commission on Dental
13-3 Accreditation by December 31, 2004, or the program expires.
13-4 ARTICLE 4. DELEGATION OF CERTAIN ACTS BY DENTISTS
13-5 SECTION 4.01. Section 258.002, Occupations Code, is amended
13-6 by amending Subsection (b) and adding Subsection (c) to read as
13-7 follows:
13-8 (b) A licensed dentist may delegate, under Subsection (a),
13-9 the application of a pit and fissure sealant to a dental assistant
13-10 if the dentist is a Medicaid provider or the dentist practices in
13-11 an area that the Texas Department of Health has determined is
13-12 underserved. Cleansing of the occlusal and smooth surfaces of the
13-13 teeth by a dental assistant is allowed immediately prior to and for
13-14 the sole purpose of preparing the tooth area for the placement of
13-15 pit and fissure sealants or orthodontic bonding resin, and shall
13-16 not be billed as a prophylaxis.
13-17 (c) The board by rule shall establish guidelines regarding
13-18 the types of dental acts that may be properly or safely delegated
13-19 by a dentist, including a determination of which delegated dental
13-20 acts, if any, require competency testing before a person may
13-21 perform the act.
13-22 SECTION 4.02. Subchapter D, Chapter 262, Occupations Code, is
13-23 amended by adding Section 262.1515 to read as follows:
13-24 Sec. 262.1515. DELEGATION OF DUTIES TO DENTAL HYGIENIST
13-25 PRACTICING IN CERTAIN LONG-TERM CARE FACILITIES AND SCHOOL-BASED
13-26 HEALTH CENTERS. (a) A licensed dentist may delegate a service,
13-27 task, or procedure, pursuant to this section, to a dental
14-1 hygienist, without complying with Section 262.151(a)(2) if:
14-2 (1) the dental hygienist has at least two years'
14-3 experience in the practice of dental hygiene; and
14-4 (2) the service, task, or procedure is performed in
14-5 one of the following locations:
14-6 (A) a nursing facility as defined in Section
14-7 242.301, Health and Safety Code; or
14-8 (B) a school-based health center as defined in
14-9 Section 38.011, Health and Safety Code.
14-10 (b) The patient must be referred to a licensed dentist after
14-11 the completion of a service, task, or procedure performed under
14-12 Subsection (a).
14-13 (c) A dental hygienist may not perform a second set of
14-14 delegated tasks or procedures until the patient has been examined
14-15 by a dentist in compliance with Section 262.151(a)(2).
14-16 (d) A dental hygienist may not perform any service, task, or
14-17 procedure under this section without the express authorization of a
14-18 dentist.
14-19 (e) A service, task, or procedure performed by a dental
14-20 hygienist under this section shall be made part of the patient's
14-21 medical records maintained by the long-term care facility.
14-22 SECTION 4.03. Section 265.003, Occupations Code, is amended
14-23 to read as follows:
14-24 Sec. 265.003. PERMITTED DUTIES. (a) A dental assistant who
14-25 is not professionally licensed may:
14-26 (1) be employed by and work in the office of a
14-27 licensed and practicing dentist; and
15-1 (2) perform one or more delegated dental acts under
15-2 the direct supervision, direction, and responsibility of the
15-3 dentist, including the application of a pit and fissure sealant.
15-4 (b) A dental assistant may apply a pit and fissure sealant
15-5 under Subsection (a) only if the assistant is certified to apply a
15-6 pit and fissure sealant under Section 265.004.
15-7 SECTION 4.04. Chapter 265, Occupations Code, is amended by
15-8 adding Section 265.004 to read as follows:
15-9 Sec. 265.004. PIT AND FISSURE SEALANT CERTIFICATE. (a) The
15-10 board shall issue a pit and fissure sealant certificate to a dental
15-11 assistant who qualifies under this section.
15-12 (b) To qualify for a certificate, an applicant must:
15-13 (1) have at least two years' experience as a dental
15-14 assistant; and
15-15 (2) have successfully completed a minimum of 16 hours
15-16 of clinical and didactic education in pit and fissure sealants
15-17 taken through an accredited dental hygiene program approved by the
15-18 board.
15-19 (c) The educational program under Subsection (b) must
15-20 include courses on:
15-21 (1) infection control;
15-22 (2) cardiopulmonary resuscitation;
15-23 (3) treatment of medical emergencies;
15-24 (4) microbiology;
15-25 (5) chemistry;
15-26 (6) dental anatomy;
15-27 (7) ethics related to pit and fissure sealant
16-1 application;
16-2 (8) jurisprudence related to pit and fissure sealant
16-3 application; and
16-4 (9) the correct application of sealants, including the
16-5 actual clinical application of sealants.
16-6 (d) To maintain a certificate under this section, the dental
16-7 assistant must complete at least six hours of continuing education
16-8 in technical and scientific coursework each year.
16-9 (e) The board shall adopt rules as necessary to implement
16-10 this section, including rules regarding renewal requirements for a
16-11 certificate issued under this section.
16-12 ARTICLE 5. TEMPORARY RECIPROCAL LICENSE IN MEDICALLY
16-13 UNDERSERVED AREAS
16-14 SECTION 5.01. Subchapter C, Chapter 262, Occupations Code, is
16-15 amended by adding Section 262.1015 to read as follows:
16-16 Sec. 262.1015. TEMPORARY RECIPROCAL LICENSE IN MEDICALLY
16-17 UNDERSERVED AREAS. (a) The State Board of Dental Examiners, upon
16-18 payment by the applicant of a fee set by the board, shall grant a
16-19 temporary license to practice dentistry to any reputable dentist or
16-20 a temporary license to practice dental hygiene to any reputable
16-21 dental hygienist who:
16-22 (1) meets all requirements of Section 256.101 except
16-23 those of Subsection (a)(8);
16-24 (2) is employed by a nonprofit corporation that
16-25 accepts Medicaid reimbursement; and
16-26 (3) practices only within a Medically Underserved Area
16-27 as designated by the U.S. Department of Health.
17-1 (b) A license granted under this section expires immediately
17-2 when a licensee fails to meet the requirements of this section.
17-3 ARTICLE 6. REPAYMENT OF DENTAL LOANS
17-4 SECTION 6.01. Section 61.904(a), Education Code, is amended
17-5 to read as follows:
17-6 (a) The board may provide repayment assistance for the
17-7 repayment of any student loan for education at a public or private
17-8 institution of higher education [in this state], including loans
17-9 for undergraduate education, received by a dentist through any
17-10 lender.
17-11 SECTION 6.02. Section 61.903, Education Code, is repealed.
17-12 ARTICLE 7. EFFECTIVE DATE
17-13 SECTION 7.01. This Act takes effect September 1, 2001.