STATE OF NEW YORK
________________________________________________________________________
879
2021-2022 Regular Sessions
IN ASSEMBLY
(Prefiled)
January 6, 2021
___________
Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, L. ROSENTHAL,
COLTON, ABINANTI -- read once and referred to the Committee on Health
AN ACT to amend the public health law and the insurance law, in relation
to the definition of clinical peer reviewer
The People of the State of New York, represented in Senate and Assem-
bly, do enact as follows:
1 Section 1. Subdivision 2 of section 4900 of the public health law, as
2 amended by chapter 586 of the laws of 1998, item (B) of subparagraph
3 (ii) of paragraph (a) as amended by chapter 41 of the laws of 2014 and
4 subparagraph (iii) as amended and subparagraph (iv) of paragraph (a) as
5 added by section 42 of subpart A of part BB of chapter 57 of the laws of
6 2019, is amended to read as follows:
7 2. "Clinical peer reviewer" means:
8 (a) [for purposes of title one of this article:
9 (i) a physician who possesses a current and valid non-restricted
10 license to practice medicine; or
11 (ii) a health care professional other than a licensed physician who:
12 (A) where applicable, possesses a current and valid non-restricted
13 license, certificate or registration or, where no provision for a
14 license, certificate or registration exists, is credentialed by the
15 national accrediting body appropriate to the profession; and
16 (B) is in the same profession and same or similar specialty as the
17 health care provider who typically manages the medical condition or
18 disease or provides the health care service or treatment under review;
19 or
20 (iii) for purposes of a determination involving substance use disorder
21 treatment:
22 (A) a physician who possesses a current and valid non-restricted
23 license to practice medicine and who specializes in behavioral health
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD00261-01-1
A. 879 2
1 and has experience in the delivery of substance use disorder courses of
2 treatment; or
3 (B) a health care professional other than a licensed physician who
4 specializes in behavioral health and has experience in the delivery of
5 substance use disorder courses of treatment and, where applicable,
6 possesses a current and valid non-restricted license, certificate or
7 registration or, where no provision for a license, certificate or regis-
8 tration exists, is credentialed by the national accrediting body appro-
9 priate to the profession; or
10 (iv) for purposes of a determination involving treatment for a mental
11 health condition:
12 (A) a physician who possesses a current and valid non-restricted
13 license to practice medicine and who specializes in behavioral health
14 and has experience in the delivery of mental health courses of treat-
15 ment; or
16 (B) a health care professional other than a licensed physician who
17 specializes in behavioral health and has experience in the delivery of a
18 mental health courses of treatment and, where applicable, possesses a
19 current and valid non-restricted license, certificate, or registration
20 or, where no provision for a license, certificate or registration
21 exists, is credentialed by the national accrediting body appropriate to
22 the profession; and
23 (b) for purposes of title two of this article:
24 (i)] a physician who:
25 [(A)] (i) possesses a current and valid non-restricted license to
26 practice medicine under article one hundred thirty-one of the education
27 law;
28 [(B)] (ii) where applicable, is board certified or board eligible in
29 the same or similar specialty as the health care provider who typically
30 manages the medical condition or disease or provides the health care
31 service or treatment under review or appeal;
32 [(C)] (iii) has been practicing in such area of specialty for a period
33 of at least five years; [and]
34 (iv) for purposes of a determination involving substance use disorder
35 treatment, possesses a current and valid non-restricted license to prac-
36 tice medicine and specializes in behavioral health and has experience in
37 the delivery of substance use disorder courses of treatment;
38 (v) for purposes of a determination involving treatment for a mental
39 health condition, possesses a current and valid non-restricted license
40 to practice medicine and who specializes in behavioral health and has
41 experience in the delivery of mental health courses of treatment; and
42 [(D)] (vi) is knowledgeable about the health care service or treatment
43 under review or appeal; or
44 [(ii)] (b) a health care professional other than a licensed physician
45 who possesses a current and valid non-restricted license or certif-
46 ication under title eight of the education law:
47 [(A)] (i) where applicable, possesses a current and valid non-res-
48 tricted license, certificate or registration;
49 [(B)] (ii) where applicable, is credentialed by the national accredit-
50 ing body appropriate to the profession in the same profession and same
51 or similar specialty as the health care provider who typically manages
52 the medical condition or disease or provides the health care service or
53 treatment under review or appeal;
54 [(C)] (iii) has been practicing in such area of specialty for a period
55 of at least five years;
A. 879 3
1 [(D)] (iv) is knowledgeable about the health care service or treatment
2 under review or appeal; [and]
3 (v) for purposes of a determination involving substance use disorder,
4 specializes in behavioral health and has experience in the delivery of
5 substance use disorder courses of treatment and, where applicable,
6 possesses a current and valid non-restricted license, certificate or
7 registration or, where no provision for a license, certificate or regis-
8 tration exists, is credentialed by the national accrediting body appro-
9 priate to the profession;
10 (vi) for purposes of a determination involving treatment for a mental
11 health condition, specializes in behavioral health and has experience in
12 the delivery of mental health courses of treatment and, where applica-
13 ble, possesses a current and valid non-restricted license, certificate,
14 or registration or, where no provision for a license, certificate or
15 registration exists, is credentialed by the national accrediting body
16 appropriate to the profession; and
17 [(E)] (vii) where applicable to such health care professional's scope
18 of practice, is clinically supported by a physician who possesses a
19 current and valid non-restricted license to practice medicine.
20 [(c)] Nothing [herein] in this subdivision shall be construed to
21 change any statutorily-defined scope of practice.
22 § 2. Subsection (b) of section 4900 of the insurance law, as amended
23 by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of
24 paragraph 1 as amended by chapter 41 of the laws of 2014, subparagraph
25 (C) as amended and subparagraph (D) of paragraph 1 as added by section
26 36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended
27 to read as follows:
28 (b) "Clinical peer reviewer" means:
29 (1) [for purposes of title one of this article:
30 (A) a physician who possesses a current and valid non-restricted
31 license to practice medicine; or
32 (B) a health care professional other than a licensed physician who:
33 (i) where applicable, possesses a current and valid non-restricted
34 license, certificate or registration or, where no provision for a
35 license, certificate or registration exists, is credentialed by the
36 national accrediting body appropriate to the profession; and
37 (ii) is in the same profession and same or similar specialty as the
38 health care provider who typically manages the medical condition or
39 disease or provides the health care service or treatment under review;
40 or
41 (C) for purposes of a determination involving substance use disorder
42 treatment:
43 (i) a physician who possesses a current and valid non-restricted
44 license to practice medicine and who specializes in behavioral health
45 and has experience in the delivery of substance use disorder courses of
46 treatment; or
47 (ii) a health care professional other than a licensed physician who
48 specializes in behavioral health and has experience in the delivery of
49 substance use disorder courses of treatment and, where applicable,
50 possesses a current and valid non-restricted license, certificate or
51 registration or, where no provision for a license, certificate or regis-
52 tration exists, is credentialed by the national accrediting body appro-
53 priate to the profession; or
54 (D) for purposes of a determination involving treatment for a mental
55 health condition:
A. 879 4
1 (i) a physician who possesses a current and valid non-restricted
2 license to practice medicine and who specializes in behavioral health
3 and has experience in the delivery of mental health courses of treat-
4 ment; or
5 (ii) a health care professional other than a licensed physician who
6 specializes in behavioral health and has experience in the delivery of
7 mental health courses of treatment and, where applicable, possesses a
8 current and valid non-restricted license, certificate, or registration
9 or, where no provision for a license, certificate or registration
10 exists, is credentialed by the national accrediting body appropriate to
11 the profession; and
12 (2) for purposes of title two of this article:
13 (A)] a physician who:
14 [(i)] (A) possesses a current and valid non-restricted license to
15 practice medicine under article one hundred thirty-one of the education
16 law;
17 [(ii)] (B) where applicable, is board certified or board eligible in
18 the same or similar specialty as the health care provider who typically
19 manages the medical condition or disease or provides the health care
20 service or treatment under review or appeal;
21 [(iii)] (C) has been practicing in such area of specialty for a period
22 of at least five years; [and]
23 (D) for purposes of a determination involving substance use disorder
24 treatment, possesses a current and valid non-restricted license to prac-
25 tice medicine and who specializes in behavioral health and has experi-
26 ence in the delivery of substance use disorder courses of treatment;
27 (E) for purposes of a determination involving treatment for a mental
28 health condition, possesses a current and valid non-restricted license
29 to practice medicine and who specializes in behavioral health and has
30 experience in the delivery of mental health courses of treatment; and
31 [(iv)] (F) is knowledgeable about the health care service or treatment
32 under review or appeal; or
33 [(B)] (2) a health care professional other than a licensed physician
34 who possesses a current and valid non-restricted license or certif-
35 ication under title eight of the education law:
36 [(i)] (A) where applicable, possesses a current and valid non-res-
37 tricted license, certificate or registration;
38 [(ii)] (B) where applicable, is credentialed by the national accredit-
39 ing body appropriate to the profession in the same profession and same
40 or similar specialty as the health care provider who typically manages
41 the medical condition or disease or provides the health care service or
42 treatment under review or appeal;
43 [(iii)] (C) has been practicing in such area of specialty for a period
44 of at least five years;
45 [(iv)] (D) for purposes of a determination involving substance use
46 disorder treatment, specializes in behavioral health and has experience
47 in the delivery of substance use disorder courses of treatment and,
48 where applicable, possesses a current and valid non-restricted license,
49 certificate or registration or, where no provision for a license,
50 certificate or registration exists, is credentialed by the national
51 accrediting body appropriate to the profession;
52 (E) for purposes of a determination involving treatment for a mental
53 health condition, specializes in behavioral health and has experience in
54 the delivery of mental health courses of treatment and, where applica-
55 ble, possesses a current and valid non-restricted license, certificate,
56 or registration or, where no provision for a license, certificate or
A. 879 5
1 registration exists, is credentialed by the national accrediting body
2 appropriate to the profession;
3 (F) is knowledgeable about the health care service or treatment under
4 review or appeal; and
5 [(v)] (G) where applicable to such health care professional's scope of
6 practice, is clinically supported by a physician who possesses a current
7 and valid non-restricted license to practice medicine.
8 [(3)] Nothing [herein] in this subdivision shall be construed to
9 change any statutorily-defined scope of practice.
10 § 3. This act shall take effect on the ninetieth day after it shall
11 have become a law.