Level I, II, or III? The MA Licensing Tier Guide

Massachusetts may be moving toward one of the most structured medical spa licensing models in the country. Under H 5087, the state would sort medical spas into three licensing tiers based on procedure risk, with different oversight expectations depending on what the spa actually offers. The bill is still pending in the Joint Committee on Public Health as of March 2026, so this is not yet the law. But it is the clearest proposed framework Massachusetts has put forward, which makes it highly relevant for any spa trying to plan ahead.

The practical question is simple: what level would your spa fall into, and what kind of director would that level require? That is where the tier system becomes useful.

Start With the Most Important Status Note

Before getting into the tiers, one point matters most: H 5087 has not been enacted yet. It is a pending bill, not an active licensing law. At the same time, the Massachusetts brief makes clear that there is already enforceable scope-of-practice guidance in place from the Massachusetts Board of Registration of Cosmetology and Barbering. That guidance says working in or near a medical environment does not expand an aesthetician’s scope, and cosmetic licensure does not authorize medical or invasive procedures, even if a physician is on-site.

So while the tiered licensing system is still proposed, Massachusetts operators should already be reviewing staff roles and procedure assignments now.

What H 5087 Would Do

H 5087 proposes a three-tier licensing framework for medical spas based on the risk level and nature of the procedures offered. It would create Level I, Level II, and Level III categories, each with progressively stricter requirements. The bill also includes an exemption for wholly practitioner-owned spas where at least one owner practices on site for a majority of the time at each location. If passed, current operating spas would have 120 days from the effective date to register, then one additional year to submit the full license application. New spas would need licensure before opening.

That means the tier question is not just academic. It affects licensing, director requirements, and physical presence expectations.

Level I: Cosmetology and Electrology Services

Level I is the lowest-risk category under the proposed system. It covers procedures that stay within the scope of a licensed electrologist, cosmetologist, or aesthetician. The examples listed in the Massachusetts summary include facials, waxing, basic skin treatments, and electrolysis. Level I procedures would continue to require licensing from the existing cosmetology or electrology boards, and medical oversight would not be required for Level I procedures alone.

This tier matters because some businesses may assume they are operating as a med spa when, under the proposed Massachusetts framework, their services may still fit entirely into a non-medical category.

Level II: Minimally Invasive Medical Aesthetic Procedures

Level II is where the structure starts changing. This level covers minimally invasive procedures with minor to moderate patient risk that still constitute the practice of medicine or nursing. The examples in the brief include medical-grade chemical peels, laser/IPL treatments, microneedling, and non-injectable neuromodulators. Under H 5087, Level II spas would need a medical spa license from the Massachusetts Department of Public Health. They would also need to designate a clinical director, who can be a physician or nurse, and that person must be physically present at least 10% of the time the spa is open. A site director is also required, although the roles can be combined.

This is a major shift for operators offering procedures that feel routine in aesthetics but still fall into the medical or nursing side of practice.

Level III: Higher-risk Invasive Procedures

Level III is the highest-risk tier in the proposed model. It covers more invasive procedures carrying greater risk than Level II, again involving the practice of medicine or nursing. The Massachusetts summary lists injectable neuromodulators like Botox, dermal fillers, IV therapy, PRP, GLP-1 or compounded injectables, and thread lifts as examples. Level III spas would need a Level III medical spa license, and they would be required to designate a physician as medical director. That medical director must be physically present for at least 10% of the hours the spa is open. The summary also notes that all practitioners must have sufficient training for the procedures they perform and must be supervised as required by their license.

This is where the proposed Massachusetts model becomes especially important for growth-focused med spas. If your business includes injectables, IV services, PRP, or compounded products, the oversight expectation becomes much more specific.

The Easiest Way to Think About the Tiers

A simple way to read the proposed framework is this:

• Level I covers traditional cosmetology and electrology services with no medical oversight requirement for those services alone.
• Level II covers lower-risk medical aesthetic services and requires a clinical director plus a site director.
• Level III covers higher-risk invasive procedures and requires a physician medical director.

That is exactly why the proposed tier system matters operationally. It is not only about licensing. It is about matching the right kind of clinical oversight to the services being offered.

General Requirements That Apply Across the Proposed System

H 5087 also includes several requirements that would apply broadly across tiers. A medical spa is defined as any business providing medical aesthetic procedures. Patient records would need to be maintained for at least seven years. All practitioners would need sufficient training in the procedures they provide and supervision consistent with their license type. The exemption for wholly practitioner-owned spas would apply only if at least one owner practices on site for a majority of the time at each location.

These are important details because even businesses focused mostly on the director requirement still need to think about records, supervision, and training infrastructure.

What Massachusetts Spas Should Be Doing Now

The Massachusetts brief is very practical about next steps. It says operators should immediately make sure aestheticians and cosmetologists are not performing medical or invasive procedures, regardless of whether a physician is on-site, and should review and document staff scope-of-practice limitations. On the pending H 5087 side, spas should assess which level their services would fall under, identify qualified clinical director and medical director candidates, make sure they can meet the 10% physical presence requirement, build a seven-year record retention system, and monitor the bill’s progress.

That makes this more than a watch-and-wait issue. Even though the bill is still pending, the operational planning can start now.

Why the Director Requirement is the Real Pivot Point

The most important feature of the proposed Massachusetts model is that Level II and Level III do not carry the same oversight requirement.

At Level II, the spa needs a clinical director, and that role can be filled by a physician or nurse. At Level III, the spa needs a physician medical director. Both levels also carry a 10% physical presence requirement, but the title and professional qualifications change depending on the risk tier.

That means the right question is not just “Do we need a director?” The better question is: What tier are we really operating in, and what kind of director does that tier require?

The Wellness MD Group Angle

That is where this proposed Massachusetts framework becomes practical for growth-minded operators. A spa offering Level II services does not need the same oversight model as one offering Level III procedures. The proposed law is built around risk, and the director requirement changes with that risk level. Massachusetts operators should be matching their services to the right tier now so they are not caught flat-footed if H 5087 moves forward. For spas that fall into Level II or Level III, director selection will be one of the most important readiness decisions they make.

The Bottom Line

Massachusetts H 5087 would create a tiered licensing framework that sorts med spas by procedural risk. Level I stays in the traditional cosmetology and electrology lane. Level II would require a clinical director. Level III would require a physician medical director. Both higher tiers also come with a 10% physical presence expectation. The bill is still pending, but the current scope-of-practice guidance is already enforceable, which means Massachusetts spas should already be reviewing staff roles, service menus, and director needs now.