DENTAL CARE ACCESS: AN OVERVIEW

Transcription

1 WISCONSIN LEGISLATIVE COUNCIL Special Committee Staff Brief 00-1 DENTAL CARE ACCESS: AN OVERVIEW One East Main Street, Suite 401 P.O. Box 2536 Madison, WI (608) Fax: (608)

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3 TABLE OF CONTENTS Introduction...1 Part I Medical Assistance and BadgerCare Coverage of Dental Services...1 A. Brief Description of MA and BadgerCare Programs...1 B. Covered Dental Services Under MA and BadgerCare...4 C. Reimbursement Methodology; Copayments...5 D. Number of Persons Covered Under MA and BadgerCare; Those Receiving Dental Services...6 Part II Other Programs Related to Dental Care Access...9 A. Migrant and Community Health Centers...9 B. Volunteer Health Care Provider Program...10 C. Area Health Education Centers...11 D. Loan Assistance Programs; Dental Health Professional Shortage Areas...11 E. Healthy Smiles for Wisconsin...13 Part III Educational Programs in Dental Occupations...15 A. Marquette School of Dentistry...15 B. Dental Hygienist Education Marquette University Technical College System...15 C. Dental Assistant Education Private Colleges Technical College System...16 Part IV Dental Care Licensure and Practice Laws...17 A. Introduction...17 B. License Required; Exceptions...17 C. Licensure Requirements...17 D. Scope of Practice and Restrictions for Dental Hygienists...18 E. Anesthesia Dentists Dental Hygienists...21 F. Delegation by Dentists i -

4 Appendix A Wisconsin Medicaid Measures of Dental Service: July June Appendix B Migrant and Community Health Centers Appendix C Dental Health Professional Shortage Areas in Wisconsin Appendix D Location of Dental Hygienist and Dental Assistant Progams Under the Wisconsin Technical College System Appendix E Enrollment in Dental Hygienist and Dental Assistant Programs Under the Wisconsin Technical College System Appendix F Statutory Definitions of Dentistry and Dental Hygiene [s (8) and (3), Stats.] ii -

5 Joint Legislative Council Madison, Wisconsin Special Committee on August 30, 2000 Dental Care Access STAFF BRIEF 00-1 DENTAL CARE ACCESS: AN OVERVIEW INTRODUCTION This Staff Brief was prepared by Richard Sweet and Laura Rose, Senior Staff Attorneys, Legislative Council Staff, for the Joint Legislative Council s Special Committee on Dental Care Access. The committee is directed to examine ways to increase access to dental care by underserved populations in Wisconsin, particularly those persons enrolled in Medical Assistance (MA) and BadgerCare. PART I MEDICAL ASSISTANCE AND BADGERCARE COVERAGE OF DENTAL SERVICES This Part briefly describes the Wisconsin MA and BadgerCare programs; the dental services covered under these programs and required copayments for these services; reimbursements to dental care providers under the program; and data regarding the number of persons receiving dental services under these programs. A. BRIEF DESCRIPTION OF MA AND BADGERCARE PROGRAMS The Wisconsin MA program is a joint federal and state program providing medical benefits to certain categories of persons with low incomes or disabilities. Coverage is provided to certain categorically needy groups of families, pregnant women and children. These groups are: Aid to Families with Dependent Children (AFDC): persons who would have met AFDC eligibility criteria as of July 16, 1996; Other AFDC-related groups. Healthy Start groups [pregnant women, infants and children up to age six with family incomes up to 185% of the federal poverty level (FPL)]. Staff Brief 00-1 Page 1

6 Healthy Start children between the ages of 6 and 19 with family incomes up to 100% of the FPL. Coverage under MA is required to be provided under federal law to the first three groups; coverage of the Healthy Start children in the last group is optional under federal law. tests. Individuals in these groups must meet maximum monthly income tests, as well as asset The following asset and income limits under MA for AFDC and AFDC-related groups are as follows: Family Size Asset Limit Maximum Monthly Income 1 $1,000 $ , , , , , ,000 1, ,000 1,099 Source: Legislative Fiscal Bureau. Informational Paper #44, Medical Assistance Program, p. 11. Not counted in the asset limit are such assets as the home, an automobile, certain burial funds and personal effects. Under federal law, states have the option of providing coverage to medically needy families, pregnant women and children. These groups meet the same eligibility criteria as the categorically needy groups but have higher monthly income and asset limits. Medically needy persons qualify for MA by spending down their income and assets on medical expenses to the point where they become financially eligible for MA. The income level to which they must spend down to become eligible for MA is somewhat higher than the categorically needy income level. MA coverage is also provided to certain categorically needy persons who are aged, blind or disabled. These persons are: Page 2 Joint Legislative Council

7 Supplemental Security Income (SSI)-eligible persons, including persons over age 65; and persons totally and permanently disabled and totally and permanently blind. Certain low-income Medicare beneficiaries. As with medically needy families, pregnant women and children, states have the option of providing coverage under federal law to medically needy, aged, blind and disabled persons. The same spend down principles apply, but with higher income and asset levels than apply to medically needy families, pregnant women and children. The federal government provides approximately 60% of the funding for the MA program. The State of Wisconsin provides approximately 40% in matching funds. Federal law governs the basic structure of the program, pursuant to 42 U.S.C. s et. seq. States are required to provide certain mandatory services under MA, but have discretion regarding coverage of optional services and are also responsible for the direct administration of the program. Under federal law, all states are required to provide comprehensive dental services to children enrolled in MA. Adult dental coverage is optional under MA. However, about 2/3 of the states cover some adult dental services, but many of these states impose considerable limitations on those services. The general category of adult dental service and the number of states providing that service are: Emergency services: 42 states. Preventive services (prophylaxis, sealants): 27 states. Diagnostic services (clinical oral evaluations): 32 states. Routine restorative services (amalgam, resin restoratives): 29 states. More complex restorative procedures (crowns, bridges and dentures): 30 states. Wisconsin MA covers services for adults in each of the above categories. BadgerCare is the state s version of the federal children s health insurance program. Under BadgerCare, services provided are identical to those provided under the MA program. However, the eligibility criteria are different. Generally, BadgerCare covers persons who are above the eligibility requirements for MA but have incomes at or below 185% of the FPL. Families with children are eligible for coverage. Once families are enrolled, they may remain in BadgerCare until the family income exceeds 200% of the FPL. There is no asset test under BadgerCare as there is under MA. To be eligible for BadgerCare, a person must: Be a U.S. citizen or a qualified alien. Be a resident of Wisconsin (physically present with the intent to reside). Cooperate in providing his or her Social Security number. Staff Brief 00-1 Page 3

8 For a nonpregnant adult with a child, cooperate as necessary in locating an absent parent, in establishing paternity, and in establishing a medical support order. Cooperate in the Health Insurance Premium Payment (HIPP) program. This is a program where, in certain situations, the state will enroll a BadgerCare family in an insurance program offered by the family s employer. Not be covered by a major medical health insurance policy (individual or family coverage), currently or within the last three calendar months. Not have access to an employer s group health plan that covers the family and where the employer pays 80% or more of the premium. Not have access to a state employee s family health plan. Pay a monthly premium of no more than 3% of countable family income if their income is greater than 150% of the FPL. B. COVERED DENTAL SERVICES UNDER MA AND BADGERCARE Section HFS , Wis. Adm. Code, outlines dental services covered under MA (and BadgerCare). Within each general category of dental services, more specific types of services are enumerated both in the Administrative Code and in the Wisconsin MA dental provider handbook; however, these are not listed here. The following general categories of services are covered under MA and BadgerCare. Services are covered for both children and adults unless otherwise indicated: Diagnostic procedures: Clinical oral examinations; radiographs and tests; and laboratory examinations. Preventive services: Dental prophylaxis services (cleanings) and topical fluoride treatments are provided for both children and adults. Sealants and passive space maintenance appliances are provided for children. Restorative services: Amalgam restorations (including polishing, resin restorations); and other restorative services, including inlays and crowns and upgraded cast crowns. Endodontic services: Pulpotomy; root canal therapy; and periapical services. Periodontic services: Surgical services (including usual post-operative services), including gingivectomy; scaling and root planing; full mouth debridement; and periodontal maintenance procedures. Removable prosthodontic services: Complete dentures (including routine post-delivery care); partial dentures (including routine post-delivery care); repairs to both complete and partial dentures, denture reline procedures; and maxillofacial prosthetics. Page 4 Joint Legislative Council

9 Fixed prosthondontic services: Miscellaneous fixed prosthodontic services, such as recementing a fixed partial denture; retainers; stress breakers; and fixed partial denture repair. Oral and maxillofacial surgery services: Extractions (including local anesthesia and routine post-operative care); surgical extractions (including local anesthesia and routine postoperative care); other surgical procedures (such as tooth reimplantation and biopsy); removal of tumors, cysts and neoplasms; treatment of fractures, reduction of dislocation and management of other temporomandibular joint dysfunction; repair of traumatic wounds, complicated suturing; and other repair procedures. Orthodontic services: (these services are covered only for children up through age 20): only in a case of severe malocclusion. Adjunctive general services: (these services are provided for both children and adults): palliative treatment of dental pain; anesthesia; hospital calls and application of desensitizing medicament. There are some limitations on services provided. First of all, there are frequency limitations on some services. For example, dental cleanings are limited to two cleanings per year for children and one per year for adults. Sealants are provided once every three years. Denture relining is provided only once every three years. In addition to frequency limitations, there are prior authorization requirements for many of the services covered under MA and BadgerCare. Prior authorization is a written authorization issued by DHFS to a provider prior to the provision of a service. Prior authorization is required for many dental services, such as all periodontal services; partial and full dentures and denture relining; certain crowns; certain endodontic services, such as molar root canals; and fluoride treatments for adults (but not children). As a result of 1999 Wisconsin Act 9 (the Biennial Budget Act), prior authorization is no longer required for a second dental cleaning per year for children between the ages of 13 and 20. Prior to the passage of Act 9, this prior authorization for a second cleaning was required for this age group. Prior authorization for two cleanings per year is not required for children under the age of 13. C. REIMBURSEMENT METHODOLOGY; COPAYMENTS Under Wisconsin MA and BadgerCare, the rate of reimbursement for services is based on the MA dental maximum fee schedule. A provider is reimbursed the lesser of either the billed amount or the maximum allowable fee established under the MA program. The current MA reimbursement rates for dental services are 65% of the usual and customary charges in effect for calendar year 1998 for services to children, and 69% of the usual and customary charges in effect for calendar year 1998 for services to adults. A rate increase to reach these levels was enacted through 1999 Wisconsin Act 9. Dental services are reimbursed on a fee-for-service basis in all counties except for Milwaukee, Kenosha, Racine and Waukesha. In those four counties, dental care for MA and BadgerCare recipients is provided through health maintenance organizations (HMOs) and dental care is included in the HMO rate. In those four counties, the payment for dental services is negotiated between the HMO and the dentist. Staff Brief 00-1 Page 5

10 MA recipients who are receiving fee-for-service dental services (as well as other medical services) are responsible for paying part of the costs of most services. Copayments under MA range from $.50 to $3 depending on the service. The copayments are based on the cost of the services received. The following copayments currently apply to Wisconsin MA: Services costing up to $10: $.50 copayment. Services costing from $ $25: $1 copayment. Services costing from $ $50: $2 copayment. Services costing over $50: $3 copayment. Copayments do not apply to services provided to children under 18 years of age. In addition, people in an MA HMO receiving a service provided by the HMO or people in a special Medicaid managed care program receiving a service provided by the managed care program are not responsible for copayments. However, if an MA HMO does not provide dental services, the individual may receive dental services from any MA-certified dentist. In those cases, the recipient may be required to pay a copayment. The same copayment requirements apply to individuals enrolled in BadgerCare. D. NUMBER OF PERSONS COVERED UNDER MA AND BADGERCARE; THOSE RECEIVING DENTAL SERVICES As of July 2000, a total of 483,350 persons in the State of Wisconsin were receiving services under MA and BadgerCare. Of that total, approximately 70,000 persons were BadgerCare enrollees. As of June 2000, there were 3,357 licensed dentists in the State of Wisconsin with a Wisconsin address. Of this number, 1,935 were certified under the MA program. This represents 57.6% licensed dentists in Wisconsin who are MA-certified. In fiscal year 2000 (July 1999-June 2000), 1,421 MA-certified dentists submitted claims under the MA program. This represents 42.3% of licensed dentists in Wisconsin submitting MA claims. Of the 483,350 individuals who are MA-eligible in Wisconsin, 109,647 of these MAeligible persons received dental services in fiscal year This number includes individuals enrolled in BadgerCare. This number represents 22% of MA-eligibles who receive dental services during this fiscal year. Statewide, there are 386 MA recipients per certified dentist submitting claims for fiscal year Page 6 Joint Legislative Council

11 Appendix A to this Staff Brief sets forth a chart prepared by the Department of Health and Family Services (DHFS) which provides county-by-county data on the items discussed in this section. Staff Brief 00-1 Page 7

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13 PART II OTHER PROGRAMS RELATED TO DENTAL CARE ACCESS A. MIGRANT AND COMMUNITY HEALTH CENTERS Migrant and community health centers are corporations that are established for the purpose of bringing primary comprehensive health care to medically underserved areas. A publication of the Wisconsin Primary Health Care Association, the association that represents the centers, describes the purposes of the centers as follows: Health Centers have a long history of providing health care that is accessible to medically underserved populations. In traditional health care delivery models, a variety of obstacles may deter individuals from obtaining the care they need. These barriers may be financial, geographic, perceptual, linguistic or cultural. By directly addressing these impediments, Health Centers provide the safety net that assures health care access to people who would otherwise not receive care. [Wisconsin Primary Health Care Association Directory of Members and Services (1999).] Migrant and community health centers receive funding from a variety of sources, including MA, federal and state funding earmarked for such centers, private insurance and patient revenue based on ability to pay. In 1999 Wisconsin Act 9 (the Biennial Budget Act), $2.5 million in fiscal year and $3 million in fiscal year was appropriated for a grant program for community health centers. Under Act 9, each community health center s percentage of the total amount appropriated by the state is the same as its percentage of the total federal funds received by all of the centers. There are 13 migrant and community health centers in Wisconsin at the following locations: Beloit Area Community Health Center Scenic Bluffs Community Health Center N.E.W. Community Clinic Kenosha Community Health Center Northern Health Centers Family Health Center of Marshfield Health Care for the Homeless of Milwaukee Johnston Community Health Center Beloit Cashton Green Bay Kenosha Lakewood Marshfield Milwaukee Milwaukee Staff Brief 00-1 Page 9

14 Milwaukee Health Services, Inc. Sixteenth Street Community Health Center North Woods Community Health Center Bridge Community Health Clinic Family Health Medical and Dental Center/Centro de Salud Familiar Milwaukee Milwaukee Minong Wausau Wautoma A map showing the locations of the migrant and community health centers and their satellite health centers and service areas is included in Appendix B. All of the above centers provide dental care either through onsite or contracted dental programs. Seven of the above 13 centers have onsite programs--scenic Bluffs Community Health Center, Kenosha Community Health Center, Northern Health Centers, Milwaukee Health Services, Sixteenth Street Community Health Center, Bridge Community Health Center and Family Health Medical and Dental Center. B. VOLUNTEER HEALTH CARE PROVIDER PROGRAM The Wisconsin Department of Administration (DOA) administers a Volunteer Health Care Provider Program. Volunteer health care providers who provide services under the program are, for purposes of the program, considered state agents of DHFS for purposes of the statutes that do the following: (1) authorize the Attorney General to appear for and defend any state employee for acts committed in the lawful course of their duties; (2) require written notice to the Attorney General within 120 days of an event causing an injury, damage or death giving rise to a civil action against state employees; and (3) require the state to pay damages and costs in actions against state employees acting within the scope of their employment. In order to participate in the Volunteer Health Care Provider Program, a volunteer health care provider must submit a joint application with a nonprofit agency to DOA and DOA must approve the application. For purposes of the statute, volunteer health care provider is defined as a physician, dentist, registered nurse, practical nurse, nurse-midwife, optometrist, physician assistant or dietician who receives no income from the practice of that health care profession or who receives no income from the practice of that profession when providing services at the nonprofit agency. DOA approval of an application of a volunteer health care provider is valid for one year and may be renewed by submittal of a joint renewal application with a nonprofit agency. A volunteer health care provider must provide services without charge at the nonprofit agency. The nonprofit agency may provide the following health care services: (1) diagnostic tests; (2) health education; (3) information about available health care resources; (4) office visits; (5) patient advocacy; (6) prescriptions; (7) referral to health care specialists; and (8) dental services, including simple tooth extractions and any necessary suturing related to the extractions, performed by a dentist. The nonprofit agency may not provide emergency medical services, hospitalization or surgery. In addition, the nonprofit agency must provide health care services Page 10 Joint Legislative Council

15 primarily to low-income persons who are uninsured and who are not recipients of MA or Medicare. According to information provided by DOA, there are currently 40 nonprofit clinics participating in the Volunteer Health Care Provider Program and 338 volunteer health care providers. Of the 338 volunteers, 21 are dentists. C. AREA HEALTH EDUCATION CENTERS The Area Health Education Center (AHEC) System began in Wisconsin in 1991 to bring together Wisconsin s academic health programs and its underserved communities. An AHEC System publication describes the system as follows: The Wisconsin Area Health Education Center (AHEC) System is a statewide project dedicated to improving access to quality health care in the state s rural and urban underserved communities. It focuses on developing health professions training programs that encourage future and present health care providers to practice in the areas where they are needed most. The state is divided into four AHEC regions--eastern, Milwaukee, Northern and Southwest--and each of the four regional centers are independent nonprofit corporations with their own governing boards. The system is governed by a 20-person board of directors that includes three persons from each of the regional AHECs and eight other health professionals, academic program and at-large members. The AHEC System is supported by a general purpose revenue (GPR) appropriation of $1,150,000 per fiscal year, as well as federal funds and grants from other sources. The AHEC System has identified oral health as a priority for the biennium. The system has several statewide initiatives relating to oral health, including: (1) working with the Marquette School of Dentistry to develop preceptors to supervise dental students; (2) developing a relationship between the Marquette School of Dentistry and the Department of Public Instruction and developing an Internet Web site with a curriculum to assist teachers regarding oral health; (3) sponsoring a symposium on MA for dental students; (4) working with DHFS on a provider and patient initiative on oral health; and (5) providing course materials to dental students who are working in remote sites through use of technology. In addition, each of the four regional AHECs has initiatives related to oral health. D. LOAN ASSISTANCE PROGRAMS; DENTAL HEALTH PROFESSIONAL SHORTAGE AREAS The State of Wisconsin offers two loan assistance programs to specified health care providers who practice in health professional shortage areas (HPSAs) or other specified shortage areas. Those two programs are the Physician Loan Assistance Program and the Health Care Provider Loan Assistance Program. [ss and , Stats.] Both programs are administered by the Department of Commerce. Neither program includes dentists or dental hygienists, but they are described here since the Department of Commerce is considering a proposal to include them in the programs. Staff Brief 00-1 Page 11

16 Under the Physician Loan Assistance Program, the department may repay up to $50,000 in educational loans obtained by a physician from a public or private lending institution for education in an accredited school of medicine or for postgraduate medical training. In order to participate in the Physician Loan Assistance Program, the Department of Commerce must enter into a written agreement with a physician under which the physician agrees to practice at least 32 clinic hours per week for three years in one or more eligible practice areas in Wisconsin. The physician must agree to care for patients who are insured or for whom health benefits are payable under Medicare, MA or any other governmental program. The agreement must also specify that the responsibility of the department to make the payments is subject to the availability of funds appropriated. Under the Physician Loan Assistance Program, principal and interest due on loans may be repaid by the department at the following rates: (1) up to 40% of the principal of the loan or $20,000, whichever is less, during the first year of participation in the program; (2) up to an additional 40% of the principal of the loan or $20,000, whichever is less, during the second year of participation in the program; and (3) up to an additional 20% of the principal of the loan or $10,000, whichever is less, during the third year of participation in the program. The Department of Commerce is required to establish priorities among eligible applicants if the costs of repaying the loans of all eligible applicants, when added to the cost of loan repayments scheduled under existing agreements, exceeds the amounts appropriated. Several criteria are listed in the statutes for the department to use in establishing priorities. In addition to the Physician Loan Assistance Program, the Department of Commerce also administers a Health Care Provider Loan Assistance Program. The program is very similar to the Physician Loan Assistance Program, but applies to physician assistants, nurse-midwives and nurse practitioners. The educational loan repayment under the Health Care Provider Loan Assistance Program is a maximum of $25,000 per participant, with maximums of $10,000 in the first year, $10,000 in the second year and $5,000 in the third year. For purposes of the above programs, the participant qualifying for loan repayment must practice in a shortage area. Although, as indicated earlier, the two programs do not include dentists or dental hygienists, there are federally designated dental HPSAs in Wisconsin. HPSA designation is sought by persons in a locality in Wisconsin who may submit an application to DHFS. DHFS reviews the application and submits the application to the federal government for HPSA designation. The federal agency that conducts HPSA approvals is the Bureau of Primary Health Care, which is a subunit of the federal Department of Health and Human Services. The 13 dental HPSAs in Wisconsin are listed in Appendix C. In addition, DHFS is awaiting approval of one dental HPSA redesignation in Milwaukee and the approval from the federal government of 12 new dental HPSAs for the counties of Rusk, Washburn, Langlade, Chippewa, Dunn, Barron, Polk, Price, Pepin, Oneida, Vilas and Marinette. According to information provided by DHFS, they have received requests to review dental HPSA designation for 12 additional counties--st. Croix, Pierce, Burnett, Douglas, Bayfield, Sawyer, Taylor, Clark, Trempealeau, Buffalo, Eau Claire and part of Jackson County. Page 12 Joint Legislative Council

17 E. HEALTHY SMILES FOR WISCONSIN Healthy Smiles for Wisconsin is a program operated by Children s Health Alliance of Wisconsin and funded primarily through the federal Centers for Disease Control and Prevention (CDC). In addition, Healthy Smiles for Wisconsin receives $60,000 in GPR appropriated for dental sealant programs. Healthy Smiles has developed a book on how to run sealant programs that has been requested by persons starting sealant programs in other states. According to information provided by Healthy Smiles, the Healthy Smiles initiative has two goals: Develop a statewide plan for working with schools and communities to increase access to oral health education, prevention, and treatment services for school-aged children. Through the Back to School for Healthy Smiles Initiative, develop a plan for incorporating school-based and school-linked education, prevention, and service delivery strategies into dental hygiene education programs in the Wisconsin Technical College System and at Marquette University. Healthy Smiles for Wisconsin will address three primary oral health issues during 2000: (1) youth oral health surveillance and data collection; (2) dental sealants; and (3) oral health education. Staff Brief 00-1 Page 13

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19 PART III EDUCATIONAL PROGRAMS IN DENTAL OCCUPATIONS A. MARQUETTE SCHOOL OF DENTISTRY The state s only dental school is the Marquette School of Dentistry, located in Milwaukee. The school has approximately 300 students pursuing the degree of Doctor of Dental Surgery (DDS) and 25 students pursuing a master s level degree in a dental specialty. In order to get a DDS degree, a student must complete four years of dental school after completing his or her undergraduate program. The Marquette School of Dentistry receives a subsidy from the State of Wisconsin to provide a reduced level of tuition for 100 Wisconsin residents who attend this school. The tuition for nonresidents is $31,000 per year and the tuition for residents of Wisconsin is $19,333. In addition, the dental school receives $2.8 million per year from DHFS for education and clinical care. According to information provided by the Marquette School of Dentistry, the first year of the program is focused on basic sciences, with some students beginning dental courses designed to initiate fine motor skill development and hand/eye coordination. The second year of the program consists of an increasing amount of preclinical activities, fine-tuning the motor skills and learning more complex techniques in a preclinical laboratory setting, with minimal patient contact. The third and fourth years focus on clinical activities. B. DENTAL HYGIENIST EDUCATION 1. Marquette University Marquette University offers a four-year baccalaureate program in dental hygiene. The program is being phased-out over a period of time and will end in May There are 24 to 30 students in each class, except that the incoming class in the Fall of 2000, which will be the program s final incoming class, is 16 students. The program is a four year program, with the final two years focusing on clinical experience. 2. Technical College System Eleven technical college districts in the Technical College System offer associate degree programs to prepare students to become dental hygienists. Appendix D shows the locations of dental hygienist programs, as well as dental assistant programs. In the school year, there were 677 students enrolled in the dental hygienist program--129 full-time and 548 parttime. Appendix E sets forth the enrollment levels of students in dental occupation programs in the Wisconsin Technical College System in the school year. Staff Brief 00-1 Page 15

20 C. DENTAL ASSISTANT EDUCATION 1. Private Colleges According to information provided by the Educational Approval Board, there are five private dental assistant programs licensed by the State of Wisconsin: (a) Dental Assisting Centers Institute (Milwaukee); (b) Institute of Dental Assisting (Middleton); (c) Professional Dental Assistant Training (Hartland); (d) Professional Institute of Dental Assisting, Inc. (Janesville); and (e) University of St. Frances (Joliet, IL). The information provided by the Educational Approval Board identifies the first four programs as 80-hour courses. In addition, the Institute of Dental Assisting in Middleton, although licensed by the Educational Approval Board, is in inactive status. 2. Technical College System Four technical college districts in the Technical College System offer short-term training programs and seven districts offer more extensive one-year training programs to prepare students to become dental assistants. A map showing the locations of those programs is set forth in Appendix D. In addition, the head count enrollment of students in the dental assistant programs in the school year is set forth in Appendix E. As indicated by Appendix E, the shortterm dental assistants program requires completion of about 15 credits, while the one-year program requires completion of about 29 credits. Page 16 Joint Legislative Council

21 PART IV DENTAL CARE LICENSURE AND PRACTICE LAWS A. INTRODUCTION There are two categories of dental care providers who are licensed by the State of Wisconsin--dentists and dental hygienists. Additional assistance may be provided by dental assistants, who receive some training but are not licensed by the state. According to information provided by the Department of Regulation and Licensing, there are 4,283 persons who are licensed as dentists in Wisconsin (this includes both dentists with Wisconsin addresses and dentists with out-of-state addresses) and 4,074 persons licensed as dental hygienists. Dentists and dental hygienists are licensed by the Dentistry Examining Board, an 11-member examining board in the Department of Regulation and Licensing (six dentists, three dental hygienists and two public members). The statutes governing dentists and dental hygienists are set forth in ch. 447, Stats. The rules are set forth in chs. DE 1 to 12, Wis. Adm. Code. The terms dentistry and dental hygiene are defined statutorily in s (8) and (3), Stats., respectively. Those definitions are included in Appendix F. B. LICENSE REQUIRED; EXCEPTIONS The statutes provide that, with certain exceptions, persons may not practice or offer to practice dentistry, use certain initials or titles with their names that directly or indirectly represent themselves to be engaged in the practice of dentistry, or inform the public directly or indirectly that they can perform or will attempt to perform dental services of any kind, unless licensed to practice dentistry in Wisconsin. The statutes further provide that persons may not practice or offer to practice dental hygiene, represent themselves to the public as a dental hygienist, or use certain names, titles or descriptions that convey the impression that they are a dental hygienist unless licensed to practice dental hygiene in Wisconsin. [See s (1) and (2), Stats.] Exceptions are provided for in the statutes. Under s (3), Stats., no license or certificate is required under ch. 447, Stats., for certain dental students, dental hygiene students, nonclinical instructors in dental science, dental fellows, dental interns and dental residents. In addition, an exception is made for a person licensed to practice dentistry or dental hygiene in another state or country who practices in a program of dental education or research at the invitation of a group of dentists and for persons who practice dentistry or dental hygiene under the jurisdiction of the U.S. Armed Forces, Public Health Service or Veterans Bureau. Further exceptions are also provided for examiners representing a testing service approved by the Dentistry Examining Board, dental laboratories or dental laboratory technicians, and physicians and surgeons who perform specified activities. An additional exception is made for a person who provides remediable procedures, which will be described later in this Part of the Staff Brief. C. LICENSURE REQUIREMENTS The Dentistry Examining Board is required to grant a license to practice dentistry to a person who submits an application for a license, pays the specified fee, submits evidence of Staff Brief 00-1 Page 17

22 graduation from an accredited dental school, submits evidence that he or she has passed the national dental examination and the examination of a dental testing service approved by the board, passes an examination administered by the board on the statutes and rules related to dentistry and completes any other requirements established by the board by rule. The board may grant a license to practice dentistry to a person licensed in good standing to practice dentistry in another state or U.S. territory or in another country if the applicant meets the requirements for licensure established by the board by rule and presents the license and pays the specified fee. In addition, the Dentistry Examining Board is required to grant a license to practice dental hygiene to a person who submits an application for licensure, pays the specified fee, submits evidence of graduation from an accredited dental hygiene school, submits evidence that he or she has passed the national dental hygiene examination and the examination of a dental hygiene testing service approved by the board, passes an examination administered by the board on the statutes and rules related to dental hygiene, and completes any other requirements established by the board by rule. Dentists and dental hygienists licenses are valid for two years and expire on October 1 of odd-numbered years. D. SCOPE OF PRACTICE AND RESTRICTIONS FOR DENTAL HYGIENISTS The statutes provide that a dental hygienist may practice dental hygiene or perform remediable procedures only as an employee or as an independent contractor and only as follows: (1) in a dental office; (2) for a school board or a private school; (3) for a school for the education of dentists or dental hygienists; (4) for specified facilities (e.g., hospitals or correctional facilities); (5) for a local health department; (6) for a charitable institution open to the general public or to members of a religious sect or order; (7) for a nonprofit home health agency; or (8) for a nonprofit dental care program serving primary indigent, economically disadvantaged or migrant worker populations. [s (2) (a), Stats.] A dental hygienist may practice dental hygiene or perform remediable procedures under the circumstances specified in items 1, 4, 6, 7 or 8 in the previous paragraph only as authorized by a dentist who is present in the facility. However, a dental hygienist may do so if a dentist is not in the facility if all of the following conditions are met: 1. The dental hygiene practices or remediable procedures are performed under a written or oral prescription. 2. The dentist who made the prescription has examined the patient at least once during the 12-month period immediately preceding the date on which the prescription was made and the date on which the practices or procedures are performed. 3. The prescription specifies the practices and procedures that the dental hygienist may perform with the informed consent of the patient, or, if applicable, the patient s parent or a legal guardian. 4. If the practices or procedures are performed in a dental office, the patient has been the dentist s patient of record for not less than six months. [s (2) (c), Stats.] Page 18 Joint Legislative Council

23 A dental hygienist may not diagnose a dental disease or ailment, determine any treatment or any regimen of any treatment outside the scope of dental hygiene, prescribe or order medication, or perform any procedure that involves the intentional cutting of soft or hard tissue of the mouth by any means. [s (2) (d), Stats.] Pursuant to a treatment plan approved by a dentist, a dental hygienist may administer the following upon delegation by a dentist who remains on the premises in which the practices are performed and who is available to the patient throughout the completion of the appointment: (1) oral systemic premedications specified by the Dentistry Examining Board by rule; (2) local anesthesia, if the dental hygienist is certified to do so (as described later in this Staff Brief); (3) subgingival sustained release chemotherapeutic agents specified by the Dentistry Examining Board by rule. [s (2) (e), Stats.] Administrative rules of the Dentistry Examining Board specify certain activities that a dental hygienist may perform while a dentist is present in the facility, practices that a dental hygienist may perform whether or not a dentist is present in the dental facility, and prohibited practices for dental hygienists. Section DE 3.02 (1), Wis. Adm. Code, specifies practices that a dental hygienist may perform while a dentist is present in the facility as follows: DE 3.02 (1) Those practices a dental hygienist may perform while a dentist is present in the dental facility include: (a) Performing complete prophylaxis which may include: 1. Removing calcareous deposits, accretions and stains from the surface of teeth; 2. Performing deep periodontal scaling, including root planing; 3. Polishing natural and restored tooth surfaces. (b) Placing temporary restorations in teeth in emergency situations. (c) Placing in an oral cavity: 1. Rubber dams; and 2. Periodontal surgical dressings. (d) Removing from an oral cavity: 1. Rubber dams; 2. Periodontal surgical dressings; and 3. Sutures. Staff Brief 00-1 Page 19

24 (e) Removing excess cement from teeth, inlays, crowns, bridges and fixed orthodontic appliances. Section DE 3.02 (2), Wis. Adm. Code, specifies practices that a dental hygienist may perform whether or not a dentist is present as follows: DE 3.02 (2) Those practices a dental hygienist may perform whether or not a dentist is present in the dental facility include: (a) Preparing specimens for dietary or salivary analysis; (b) Taking impressions for and fabricating study casts and opposing casts; (c) Making and processing dental radiograph exposures; (d) Conducting a preliminary examination of the oral cavity and surrounding structures which may include preparing case histories and recording clinical findings for the dentist to review; (e) Providing prevention measures, including application of fluorides and other topical agents approved by the American dental association for the prevention of oral disease. Section DE 3.03, Wis. Adm. Code, specifies that a dental hygienist may not do any of the following: (1) Administer or prescribe, either narcotic or analgesics or systemic-affecting nonnarcotic drugs, or anesthetics; (2) Place or adjust dental appliances; (3) Diagnose any condition of the hard or soft tissues of the oral cavity or prescribe treatment to modify normal or pathological conditions of the tissues; and (4) Place and carve restorations, except as specified in s. DE 3.02 (1) (b). E. ANESTHESIA 1. Dentists Administrative rules of the Dentistry Examining Board specify standards for the administration of anesthesia or sedation by dentists. Chapter DE 11, Wis. Adm. Code, specifies requirements that dentists must meet in order to employ or administer: (a) general anesthesia or deep sedation; (b) parenteral sedation; and (c) nitrous oxide inhalation sedation. That chapter of the administrative code also specifies requirements regarding: (a) risk management; (b) examination of the patient prior to administration; (c) familiarity with complications and emergencies; (d) availability of drugs; (e) record keeping; and (f) office facilities and equipment. Section DE 11.12, Wis. Adm. Code, requires that all dentists submit a Page 20 Joint Legislative Council

25 complete report within 30 days to the Dentistry Examining Board of any death or other incident occurring in the outpatient facilities of the dentist that results in temporary or permanent physical or mental injury requiring hospitalization of the patient during, or as a direct result of, dental procedures or anesthesia related to dental procedures. 2. Dental Hygienists The statutes provide that the Dentistry Examining Board must grant a certificate to administer local anesthesia to a dental hygienist who submits evidence satisfactory to the board that he or she satisfies the educational requirements established in rules. The certificate remains in effect while the dental hygienist s license remains in effect unless the certificate is suspended or revoked by the board. Administrative rules regarding certification of dental hygienists to administer local anesthesia are set forth in ch. DE 7, Wis. Adm. Code. Under s. DE 7.03, Wis. Adm. Code, an applicant for a certificate to administer local anesthesia must have a current license to practice as a dental hygienist, provide evidence of current qualification in cardiopulmonary resuscitation (CPR) from either the American Heart Association or the American Red Cross, complete educational requirements specified in the rule, and submit the information required in the rule. The rules specify educational requirements that a dental hygienist must meet in order to receive a certificate to administer local anesthesia. The dental hygienist must take a course in the administration of local anesthesia that is provided by an accredited dental or dental hygiene school. In order to participate in such a course, the dental hygienist must show evidence of current qualification in CPR from either the American Heart Association or the American Red Cross and must provide proof of: (a) possessing a license to practice as a dental hygienist; (b) having graduated from an accredited dental hygiene program; or (c) being enrolled in an accredited dental hygiene program. Under the board s rules, the local anesthesia course for dental hygienists must have specified components and must provide a minimum of 21 hours of instruction. This must include at least 10 hours in specified didactic instruction and at least 11 hours of experience in clinical administration of local anesthesia. [s. DE 7.05, Wis. Adm. Code.] In addition, the rules specify that the dentist is ultimately responsible for all decisions regarding the administration of local anesthesia, particularly in determining the pharmacological and physiological considerations of each individual treatment plan. [s. DE 7.06, Wis. Adm. Code.] F. DELEGATION BY DENTISTS Under the statutes, a dentist may delegate, to a person who is not licensed under ch. 447, Stats., only the performance of remediable procedures, and only if all of the following conditions are met: (1) the unlicensed person performs the remediable procedures in accordance with a treatment plan approved by the dentist; (2) the dentist is on the premises when the unlicensed person performs the remediable procedures; and (3) the unlicensed person s performance of the remediable procedures is subject to inspection by the dentist. [s (1), Stats.] Staff Brief 00-1 Page 21

26 Section (12), Stats., defines the term remediable procedures as follows: (12) Remediable procedures means patient procedures that create changes within the oral cavity or surrounding structures that are reversible and do not involve any increased health risks to the patient. The statutes also provide that a dentist may delegate to a dental hygienist the performance of remediable procedures and the administration of oral systemic premedications, local anesthesia and subgingival sustained release chemotherapeutic agents. [s (2), Stats.] Rules of the Dentistry Examining Board specify that a dentist may not delegate any dental procedure of any description to an unlicensed person if the procedure to be delegated: (1) is of a character that may cause damage to the patient s teeth or oral cavity that cannot be remedied without professional intervention; (2) is of a character that may cause adverse or unintended general systemic reaction; or (3) is intended, interpreted or represented to be preliminary assessments, dental hygiene treatment planning, oral screenings, oral prophylaxes, scaling or root planing or dental sealants, or any portion of an oral prophylaxes other than supragingival rubber cup and air polishing after calculus is removed if necessary. [s. DE 12.01, Wis. Adm. Code.] Under the board s rules, a dentist who delegates any dental procedure or function to an unlicensed person must first train or verify the training of the person in the performance of the procedure or function, and must maintain verifiable records on forms approved by the board of successful completion of the training. A dentist or dental hygienist who becomes aware that any dentist is improperly delegating the performance of any dental procedure or function to an unlicensed person, or to a person who is performing the delegated procedure or function in a manner that is less than minimally competent, must report the circumstances to the board. The board s rules also specify that an unlicensed person may remove plaque and materia alba with a mechanical device only if the delegation of the functions complies with ch. DE 12, Wis. Adm. Code. Page 22 Joint Legislative Council

27 APPENDIX A Staff Brief 00-1 Page 23

28 Page 24 Joint Legislative Council

29 Staff Brief 00-1 Page 25

30 Page 26 Joint Legislative Council

31 APPENDIX B Staff Brief 00-1 Page 27

32 Page 28 Joint Legislative Council

33 APPENDIX C Staff Brief 00-1 Page 29

34 Page 30 Joint Legislative Council

35 APPENDIX D Staff Brief 00-1 Page 31

36 Page 32 Joint Legislative Council

37 APPENDIX E Staff Brief 00-1 Page 33

38 Page 34 Joint Legislative Council

39 APPENDIX F STATUTORY DEFINITIONS OF DENTISTRY AND DENTAL HYGIENE [s (8) and (3), Stats.] (8) Dentistry means the examination, diagnosis, treatment, planning or care of conditions within the human oral cavity or its adjacent tissues and structures. Dentistry includes any of the following: (a) Examining into the fact, condition or cause of dental health or dental disease or applying principles or techniques of dental science in the diagnosis, treatment or prevention of or prescription for any of the lesions, dental diseases, disorders or deficiencies of the human oral cavity, teeth, investing tissues, maxilla or mandible, or adjacent associated structures. (b) Extracting human teeth or correcting their malposition. (c) Directly or indirectly, by mail, carrier, person or any other method, furnishing, supplying, constructing, reproducing or repairing prosthetic dentures, bridges, appliances or other structures to be used or worn as substitutes for natural human teeth; or placing such substitutes in the mouth directly or indirectly or adjusting the same; or taking, making or giving advice or assistance or providing facilities for the taking or making of any impression, bite, cast or design preparatory to, or for the purpose of, or with a view to the making, producing, reproducing, constructing, fitting, furnishing, supplying, altering or repairing of any such prosthetic denture, bridge or appliance; or taking impressions for or fitting athletic mouthguards. (d) Administering anesthetics, either general or local, while performing or claiming to perform dental services. (e) Prescribing or administering drugs in the course of or incident to the rendition of dental services, or as part of a representation that dental services have been or will be rendered. (f) Engaging in any of the practices, techniques or procedures included in the curricula of accredited dental schools. (g) Penetrating, piercing or severing the tissues within the human oral cavity or adjacent associated structures. This paragraph does not apply to care or treatment rendered by a physician, as defined in s (5), acting within the scope of the practice of medicine and surgery, as defined in s (9). (h) Developing a treatment plan for a dental patient to treat, operate, prescribe or advise for the patient by any means or instrumentality. Nothing in this paragraph prohibits a dental hygienist from participating in the development of a dental patient's dental hygiene treatment plan (3) Dental hygiene means the performance of educational, preventive or therapeutic dental services. Dental hygiene includes any of the following: (a) Removing supragingival or subgingival calcareous deposits, subgingival cement or extrinsic stains from a natural or restored surface of or a fixed replacement for a human tooth. Staff Brief 00-1 Page 35