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SENATE DOCKET, NO. 747 FILED ON: 1/18/2023
SENATE . . . . . . . . . . . . . . No. 1379
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
Adam Gomez
_________________
To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:
The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
An Act to improve oral health for all Massachusetts residents.
_______________
PETITION OF:
NAME:DISTRICT/ADDRESS :Adam GomezHampdenJason M. LewisFifth Middlesex1/18/2023Sal N. DiDomenicoMiddlesex and Suffolk2/23/2023James B. EldridgeMiddlesex and Worcester3/6/2023 1 of 16
SENATE DOCKET, NO. 747 FILED ON: 1/18/2023
SENATE . . . . . . . . . . . . . . No. 1379
By Mr. Gomez, a petition (accompanied by bill, Senate, No. 1379) of Adam Gomez, Jason M.
Lewis, Sal N. DiDomenico and James B. Eldridge for legislation to improve oral health for all
Massachusetts residents. Public Health.
[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE SENATE, NO. 743 OF 2021-2022.]
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Third General Court
(2023-2024)
_______________
An Act to improve oral health for all Massachusetts residents.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Chapter 71 of the General Laws, as appearing in the 2020 Official Edition,
2is hereby amended by inserting after Section 34H the following new section:-
3 Section 34I. A public school shall notify the parent or legal guardian of a pupil described
4in the second paragraph of section 57 of chapter 71 concerning the importance of oral health
5screenings. The department of public health in, consultation with the board of registration in
6dentistry, shall develop a standard form of notice containing at minimum the following: 1)
7information on the importance of primary teeth; 2) information on the importance of oral health
8to overall health as it relates to learning; 3) contact information for local public health
9departments; 4) information about programs and services to access affordable dental care. 2 of 16
10 SECTION 2. Section 7 of chapter 94C of the General Laws, as so appearing, is hereby
11amended by striking out, in lines 80 and 81, the words "practical nurse or a licensed dental
12hygienist", and inserting in place thereof the following words:- practical nurse, or a licensed
13dental therapist under the supervision of a practitioner as defined in section 1 for the purposes of
14administering analgesics, anti-inflammatories and antibiotics only, or a licensed dental hygienist.
15 SECTION 3. Paragraph (a) of section 9 of said chapter 94C, as so appearing, is hereby
16amended by adding the following paragraph:-
17 A practitioner, as defined in section 1, may cause controlled substances to be
18administered under his direction by a licensed dental therapist, for the purposes of administering
19non-narcotic analgesics, anti-inflammatories and antibiotics only.
20 SECTION 4. Paragraph (c) of said section 9 of said chapter 94C, as so appearing, is
21hereby amended by adding the following paragraph:-
22 A licensed dental therapist who has obtained a controlled substance from a practitioner,
23as defined in section 1, for dispensing to an ultimate user pursuant to paragraph (a) shall return to
24such practitioner any unused portion of the substance which is no longer required by the patient.
25 SECTION 5. Subsection (a) of section 4O of chapter 111 of the General Laws, as so
26appearing, is hereby amended by inserting after the word "disparities", in line 9, the following:-
27 The dental director shall be responsible for recruiting, monitoring progress of, and
28supporting dental health providers. The dental director shall aim to increase the delivery of
29preventative dental services to underserved and vulnerable populations, including but not limited 3 of 16
30to, those residing in dental health provider shortage communities and pediatric and geriatric
31patients.
32 SECTION 6. Said section 4O of said chapter 111 is hereby further amended by inserting
33after the word "to", in line 32, the following word:- “annual”.
34 SECTION 7. Section 43A of chapter 112, as so appearing, is hereby amended by
35inserting after the definition of "Appropriate supervision" the following 2 definitions:-
36 "Board", the board of registration in dentistry or a committee or subcommittee thereof
37established in the department of public health pursuant to sections 9 and 19 of chapter 13,
38chapter 30A and sections 43 to 53, inclusive.
39 "Collaborative management agreement", a written agreement that complies with section
40B between a dental therapist and a supervising dentist, as defined in section 43A, who holds a
41valid license issued pursuant to section 45, who agrees to provide the appropriate level of
42communication and consultation with a licensed dental therapist to ensure patient health and
43safety.
44 SECTION 8. Said section 43A of said chapter 112, as so appearing, is hereby further
45amended by inserting after the definition of "Dental hygienist" the following definition:-
46 "Dental therapist", a person who has been licensed by the board to practice dental therapy
47under section 51B, and who has the appropriate training and works pursuant to a collaborative
48management agreement as provided in section 51B.
49 SECTION 9. Said section 43A of said chapter 112, as so appearing, is hereby further
50amended by adding the following definition:- 4 of 16
51 "Supervising dentist", a dentist licensed in Massachusetts who is a provider enrolled in
52the division of medical assistance, or who works for an entity that is a provider enrolled in
53division of medical assistance, who maintains an active patient list and routinely provides care,
54and who enters into a collaborative management agreement with a licensed dental therapist.
55 SECTION 10. Said chapter 112, as so appearing, is hereby further amended by inserting
56after section 51A the following section:-
57 Section 51B. (a) Any person of good moral character, who: (i) is a graduate of a master's
58level dental therapist education program that includes both dental therapy and dental hygiene
59education, or an equivalent combination of both dental therapy education and dental hygiene
60education, if all education programs are accredited by the Commission on Dental Accreditation
61and provided by a post-secondary institution accredited by the New England Association of
62Schools and Colleges, Inc.; (ii) passes a comprehensive, competency-based clinical examination
63that is approved by the board and administered by a recognized national or regional dental
64testing service that administers testing for dentists and other dental professionals or equivalent
65examination administered by another entity approved by the board; and (iii) obtains a policy of
66professional liability insurance and shows proof of such insurance as required by rules and
67regulations shall, upon payment of a fee to be determined annually by the commissioner of
68administration under the provision of section 3B of chapter 7, be licensed as a dental therapist
69and be given a certificate to practice in this capacity. A licensed dental therapist shall have
70practiced under the direct supervision of a supervising dentist for a minimum of 2 years or 2,500
71hours, whichever is longer, before practicing under general supervision pursuant to a
72collaborative management agreement. 5 of 16
73 For the purposes of this section, "general supervision" shall mean supervision of
74procedures and services based on a written collaborative management agreement between a
75licensed dentist and a licensed dental therapist but not requiring a prior exam or diagnosis by a
76supervising dentist or the physical presence of a supervising dentist during the performance of
77those procedures and services unless required by the supervising dentist in the collaborative
78management agreement.
79 (b) Any person licensed as a dental therapist under this section may also be registered as
80a dental hygienist and be given a certificate to practice in this capacity.
81 (c) An applicant for licensure as a dental therapist educated in the commonwealth must
82graduate from a master's level dental therapy education program that is accredited by the
83Commission on Dental Accreditation provided by a post-secondary institution accredited by the
84New England Association of Schools and Colleges, Inc. All dental therapy educational programs
85in the commonwealth must include at least one licensed dentist as an instructor. The board shall
86provide guidance for any educational entity or institution that may operate all or some portion of
87a master's level program, or may collaborate with other educational entities, including but not
88limited to universities, colleges, community colleges, and technical colleges, to operate all or
89some portion of a master's level program. The board may also provide guidance to develop
90mechanisms to award advanced standing to students who have completed coursework at other
91educational programs accredited by the Commission on Dental Accreditation. All education
92programs must prepare students to perform all procedures and services within the dental therapy
93scope of practice as set forth in this section. 6 of 16
94 The educational curriculum for a dental therapist educated in the commonwealth shall
95include training on serving patients with special needs including, but not limited to, people with
96developmental disabilities including autism spectrum disorders, mental illness, cognitive
97impairment, complex medical problems, significant physical limitations and the vulnerable
98elderly.
99 Not later than January 1, 2020, the board shall approve a comprehensive, competency-
100based clinical dental therapy examination that includes assessment of technical competency in
101performing the procedures and services within the scope of practice as set forth in this section, to
102be administered by a recognized national or regional dental testing service that administers
103testing for dentists and other dental professionals. The examination shall be comparable to the
104examination given to applicants for a dental license but only for the limited scope of dental
105services in the dental therapy scope of practice as set forth in this section.
106 (d) The board shall grant a dental therapy license by examination to an applicant, upon
107payment of a fee as determined annually by the secretary of administration and finance under
108section 3B of chapter 7, provided the applicant is of good moral character and has: (i) met the
109eligibility requirements as defined by the board; (ii) submitted documentation to the board of a
110passing score on a comprehensive, competency-based clinical examination, or combination of
111examinations, that includes both dental therapy and dental hygiene components and is approved
112by the board and administered by a recognized national or regional dental testing service that
113administers testing for dentists and other dental professionals; and (iii) submitted to the board
114documentation of a passing score on the Massachusetts Dental Ethics and Jurisprudence
115Examination or any other successor examination. An applicant failing to pass the examination
116shall be entitled to re-examination pursuant to the rules and guidelines established by the 7 of 16
117Commission on Dental Competency Assessments, for which the applicant shall pay a fee as
118determined annually by the secretary of administration and finance under section 3B of chapter
1197.
120 The board shall require as a condition of granting or renewing a license under this
121section, that the dental therapist apply to participate in the medical assistance program
122administered by the secretary of health and human services in accordance with chapter 118E and
123Title XIX of the Social Security Act and any federal demonstration or waiver relating to such
124medical assistance program for the limited purposes of ordering and referring services covered
125under such program, provided that regulations governing such limited participation are
126promulgated under said chapter 118E. A dental therapist practicing in a dental therapist role who
127chooses to participate in such medical assistance program as a provider of services shall be
128deemed to have fulfilled this requirement.
129 The board shall grant a license by credentials, without further professional examination,
130to a dental therapist licensed in another jurisdiction, upon payment of a fee as determined
131annually by the secretary of administration and finance under section 3B of chapter 7, provided
132the applicant is of good moral character and has: (i) met the eligibility requirements as defined
133by the board; (ii) furnished the board with satisfactory proof of graduation from an education
134program, or combination of education programs, providing both dental therapy and dental
135hygiene education that meets the standards of the Commission on Dental Accreditation,
136provided, however, that an applicant who graduated from a dental therapy education program
137established before the Commission on Dental Accreditation established a dental therapy
138accreditation program is eligible notwithstanding the lack of accreditation of the program at the
139time the education was received; (iii) submitted documentation of a passing score on a dental 8 of 16
140therapy examination administered by another state or testing agency that is substantially
141equivalent to the board-approved dental therapy examination for dental therapists as defined in
142this section; (iv) submitted documentation of a passing score on the Massachusetts Dental Ethics
143and Jurisprudence Examination or any other successor examination; and (v) submitted
144documentation of completion of 2 years or 2,500 hours, whichever is longer, of practice. If such
145practice requirement is not met, a dental therapist shall be required to complete the remaining
146hours or years, whichever is longer, under direct supervision in the Commonwealth prior to
147practicing under general supervision.
148 (e) Pursuant to a collaborative management agreement, a dental therapist licensed by the
149board may perform: (i) all acts of a public health dental hygienist as set forth in regulations of the
150board and (ii) all acts in the Commission on Dental Accreditation's dental therapy standards.
151Dental therapists shall have the authority to perform an oral evaluation and assessment of dental
152disease and formulate an individualized treatment plan as authorized by the supervising dentist in
153the collaborative management agreement. A dental therapist may dispense and administer the
154following medications within the parameters of the collaborative management agreement and
155with the authorization of the supervising dentist: non-narcotic analgesics, anti- inflammatories
156and antibiotics. The authority to dispense and administer shall extend only to the categories of
157drugs identified in this paragraph and may be further limited by the collaborative management
158agreement. A dental therapist is prohibited from dispensing or administering narcotic analgesics.
159A dental therapist may oversee not more than 2 dental hygienists and 2 dental assistants, but
160shall not oversee public health dental hygienists.
161 After entering into a collaborative management agreement with a supervising dentist,
162dental therapists shall practice under direct supervision for not less than 2,500 clinical hours or 9 of 16
163two years, whichever is longer. After completing 2,500 clinical hours or two years, whichever is
164longer, of practice under direct supervision, dental therapists are authorized to perform all
165procedures and services listed in the Commission on Dental Accreditation's dental therapy
166standards and all procedures and services within the scope of a public health dental hygienist, as
167set forth in regulations by the board, under general supervision if authorized by a supervising
168dentist pursuant to a written collaborative agreement. In addition, the following procedures,
169referred to in this section as advanced procedures, may be performed under direct supervision: (i)
170preparation and placement of direct restoration in primary and permanent teeth; (ii) fabrication
171and placement of single-tooth temporary crowns; (iii) preparation and placement of preformed
172crowns on primary teeth; (iv) indirect and direct pulp capping on permanent teeth; (v) indirect
173pulp capping on primary teeth; and (vi) simple extractions of erupted primary teeth, provided
174however that the advanced procedures may be performed under general supervision if authorized
175by the board pursuant to subsection (f) of this section.
176 Pursuant to a collaborative management agreement, a dental therapist may provide
177procedures and services permitted under general supervision when the supervising dentist is not
178on-site and has not previously examined or diagnosed the patient provided the supervising
179dentist is available for consultation and supervision if needed through telemedicine or by other
180means of communication. If the supervising dentist will not be available, arrangements shall be
181made for another licensed dentist to be available to provide timely consultation and supervision.
182 A dental therapist may not operate independently of, and may not practice or treat any
183patients without, a supervising dentist. A dental therapist is prohibited from practicing without
184entering into a collaborative management agreement with a supervising dentist. 10 of 16
185 (f) By January 1, 2020, the department of public health, in consultation with the board
186and any other entity they deem appropriate, shall begin an evaluation assessing the impact of
187dental therapists practicing under general supervision in Massachusetts and the rest of the United
188States, specifically on: (i) dental therapists' progress in expanding access to safe and effective
189dental services for vulnerable populations including, at a minimum, Medicaid beneficiaries and
190individuals who are underserved as defined in this section; (ii) an appropriate geographic
191distance limitation between the dental therapist and supervising dentist that permits the dental
192therapist to expand access to vulnerable populations including, at a minimum, Medicaid
193beneficiaries and individuals who are underserved as defined in this section; and (iii) the number
194of dental hygienists and dental assistants a dental therapist may oversee.
195 Not before January 1, 2021 and no later than December 1, 2022, the department of public
196health, in consultation with the board and any other entity they deem appropriate, shall make a
197recommendation, based on its assessment of whether dental therapists should be authorized to
198perform one or more of the advanced procedures, as defined in subsection (e) under general
199supervision pursuant to a collaborative management agreement. The department shall also make
200a recommendation on an appropriate geographic distance limitation between the dental therapist
201and supervising dentist that permits the dental therapist to expand access to vulnerable
202populations including, at a minimum, individuals receiving benefits through the division of
203medical assistance and individuals who are underserved as defined in this section. After the
204department completes its assessment and submits its recommendations to the board, the board
205shall make a determination, with consideration to how authorizing general supervision will
206expand access to safe and effective dental services for vulnerable populations including, at a
207minimum, individuals receiving benefits through the division of medical assistance and 11 of 16
208individuals who are underserved as defined in this section, whether to authorize performance of
209one or more of the procedures as identified in subsection (e), under general supervision pursuant
210to a collaborative management agreement.
211 Should the board, in consultation with the department and any other appropriate entity,
212determine that dental therapists shall have the authority to perform one or more of the procedures
213and services as identified in subsection (e) in their scope of practice under general supervision,
214then the board shall establish regulations no later than six months following the recommendation,
215authorizing dental therapists to perform one or more procedures as identified in subsection (e)
216under general supervision pursuant to a collaborative management agreement after receiving
217advanced practice certification.
218 The board shall grant advanced practice certification for a dental therapist licensed by the
219board to perform all services under general supervision pursuant to a collaborative management
220agreement if the dental therapist provides documentation of completion of at least two years or
2212,500 hours, whichever is longer, of direct supervision pursuant to subsection (a) of this section,
222and satisfying any other criteria established by regulation adopted by the board as authorized in
223this section.
224 Should the board determine that dental therapists shall continue to perform one or more
225of the advanced procedures under direct supervision, the department, in consultation with the
226board, shall re-evaluate annually the impact of dental therapists practicing under general
227supervision in Massachusetts and the rest of the United States, and the board shall annually
228reassess whether to authorize general supervision for the advanced procedures in order to
229improve dental therapists' progress in expanding access to safe and effective dental services for 12 of 16
230vulnerable populations including, at a minimum, individuals receiving benefits through the
231division of medical assistance and individuals who are underserved as defined in this section.
232 (g) The board shall establish appropriate guidelines for a written collaborative
233management agreement. A collaborative management agreement shall be signed and maintained
234by the supervising dentist and the dental therapist and shall be submitted annually to the board.
235 The agreement may be updated as necessary. The agreement shall serve as standing
236orders from the supervising dentist and shall address: (i) practice settings; (ii) any limitation on
237services established by the supervising dentist; (iii) the level of supervision required for various
238services or treatment settings; (iv) patient populations that may be served; (v) practice protocols;
239(vi) record keeping; (vii) managing medical emergencies; (viii) quality assurance; (ix)
240administering and dispensing medications; (x) geographic distance limitations; (xi) oversight of
241dental hygienists and dental assistants; and (xii) referrals for services outside of the dental
242therapy scope of practice. The collaborative management agreement shall include specific
243protocols to govern situations in which the dental therapist encounters a patient who requires
244treatment that exceeds the authorized scope of practice of the dental therapist. The supervising
245dentist is responsible for directly providing, or arranging for another dentist or specialist within
246an accessible geographic distance to provide, any necessary additional services outside of the
247dental therapy scope of practice needed by the patient. A supervising dentist may have a
248collaborative management agreement with not more than 3 dental therapists at the same time.
249Not more than 2 of the dental therapists may practice under general supervision with certification
250to perform one or more of the advanced procedures. A practice or organization with more than
251one practice location listed under the same business name may not employ more than six dental
252therapists, provided, however, that this requirement shall not apply if such an organization or 13 of 16
253practice is a federally qualified health center or look-alike, a community health center, a non-
254profit practice or organization, public health setting as defined by 234 CMR 2.02, or as otherwise
255permitted by the board.
256 (h) No medical malpractice insurer shall refuse primary medical malpractice insurance
257coverage to a licensed dentist on the basis of whether they entered into a collaborative
258management agreement with a dental therapist or public health dental hygienist. A dental
259therapist may not bill separately for services rendered; the services of the dental therapist are the
260services of the supervising dentist and shall be billed as such.
261 (i) Not less than 50% of the patient panel of a dental therapist, as determined in each
262calendar year, shall consist of patients who receive coverage through the division of medical
263assistanceor are considered underserved provided, however, that this requirement shall not apply
264if the dental therapist is operating in a federally qualified health center or look-alike, community-
265health center, non-profit practice or organization, or other public health setting as defined by 234
266CMR 2.02, or as otherwise permitted by the board. As used in this section, "underserved" means
267individuals who: (i) receive, or are eligible to receive, benefits through the division of medical
268assistance; (ii) receive, or are eligible to receive, social security disability benefits, supplemental
269security income, and/or Massachusetts state supplement program; (iii) live in a dental health
270professional shortage area as designated by the federal department of health and human services;
271(iv) reside in a long-term care facility licensed under section 71 of chapter 111; (v) receive dental
272services at a public health setting as defined by 234 CMR 2.02; (vi) receive benefits, or are
273eligible to receive subsidized insurance through the commonwealth health insurance connector
274authority;; (viii) receive benefits, or are eligible to receive benefits, through the Indian Health
275Service, tribal or urban Indian organizations, or through the contract health service program; (ix) 14 of 16
276receive benefits, or are eligible to receive benefits, through the federal department of veterans
277affairs or other organization serving veterans; (x) are elderly and have trouble accessing dental
278care due to mobility or transportation challenges; (xi) meet the Commission on Dental
279Accreditation's definition of people with special needs; (xii) are uninsured have an annual
280income at or below 305% of the federal poverty level; or (xiii) as otherwise permitted by the
281board.
282 An employer of a dental therapist shall submit quarterly reports to the board that provide
283information concerning the makeup of the dental therapist's patient panel, including the
284percentage of underserved in the patient panel. No later than January 1, 2020, the secretary of
285health and human services may establish by regulation penalties for employers who fail to meet
286the requirements pertaining to the percentage of underserved in the dental therapist's patient
287panel.
288 (j) Not later than January 1, 2020, the board, in consultation with the department shall
289establish regulations to implement the provisions of this section for the practice of dental therapy
290to protect the public health, safety and welfare, including, but not limited to: requirements for
291approval of educational programs; guidelines for collaborative management agreements,
292continuing education requirements, license renewal, standards of conduct, and the investigation
293of complaints, conduct of disciplinary proceedings and grounds for discipline.
294 SECTION 11. Section 259 of chapter 112 of the General Laws, as so appearing, is hereby
295amended by inserting after the word "skills", in line 51, the following:
296 (j) Oral health education; 15 of 16
297 SECTION 12. Section 260 of chapter 112 of the General Laws, as so appear, is hereby
298amended by inserting after the number 7, in line 21, the following:- As a condition for licensure
299or renewal of licensure, the board shall require community health workers to receive education
300or training in oral health.
301 SECTION 13. Section 79L of chapter 233, as so appearing, is hereby amended by
302inserting after the word "dentist," the following words:- dental therapist.
303 SECTION 14. The department of public health, in consultation with the executive office
304of health and human services, shall perform a 5-year evaluation of the impact of dental
305therapists, as established under section 51B of chapter 112 of the General Laws, on patient
306safety, cost-effectiveness and access to dental services. The department may enter into an inter-
307agency agreement with the health policy commission, established under chapter 6D of the
308General Laws, to provide assistance to the department in conducting such evaluation, as it deems
309necessary. The department shall ensure effective measurements of the following outcomes and
310file a report of its findings, which shall include the:
311 (i) Number of dental therapists in the commonwealth each year;
312 (ii) Number of licensed dental therapists in the commonwealth each year;
313 (iii) Number of new and total patients served each year;
314 (iv) Impact on wait times for needed services;
315 (v) Impact on travel time for patients;
316 (vi) Impact on emergency room usage for dental care; and 16 of 16
317 (vii) Costs to the public health care system.
318 The report shall be submitted not later than five years after the date of graduation of the
319first graduating class of dental therapists educated in the commonwealth to the joint committee
320on public heath, the joint committee on health care financing and the senate and house
321committees on ways and means.
322 The center for health information and analysis shall, by the first day of January of each
323year, submit a report including information on:
324 (i) Number of dental therapists in the commonwealth;
325 (ii) Number of licensed dental therapists practicing in the commonwealth;
326 (iii) Number of new and total patients served;
327 (iv) Number of new and total pediatric patients served, including geographic location and
328insurance type;
329 (v) Practice settings; and
330 (vi) Commonly performed procedures and services
331 The first annual report shall be submitted not later than three years after the date of
332graduation of the first graduating class of dental therapists educated in the commonwealth to the
333joint committee on public heath, the joint committee on health care financing and the senate and
334house committees on ways and means.