Bill Text: NY A03076 | 2019-2020 | General Assembly | Amended
Bill Title: Relates to the definition of a clinical peer reviewer by clarifying that such term shall be applicable for the entire utilization review and external appeal article and means either a physician or a health care professional with certain qualifications.
Spectrum: Partisan Bill (Democrat 10-0)
Status: (Engrossed - Dead) 2020-07-20 - REFERRED TO RULES [A03076 Detail]
Download: New_York-2019-A03076-Amended.html
STATE OF NEW YORK ________________________________________________________________________ 3076--A Cal. No. 338 2019-2020 Regular Sessions IN ASSEMBLY January 28, 2019 ___________ Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, L. ROSENTHAL, COLTON, JAFFEE, ABINANTI, D'URSO, LIFTON -- read once and referred to the Committee on Health -- advanced to a third reading, passed by Assembly and delivered to the Senate, recalled from the Senate, vote reconsidered, bill amended, ordered reprinted, retaining its place on the order of third reading 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-restricted10license to practice medicine; or11(ii) a health care professional other than a licensed physician who:12(A) where applicable, possesses a current and valid non-restricted13license, certificate or registration or, where no provision for a14license, certificate or registration exists, is credentialed by the15national accrediting body appropriate to the profession; and16(B) is in the same profession and same or similar specialty as the17health care provider who typically manages the medical condition or18disease or provides the health care service or treatment under review;19or20(iii) for purposes of a determination involving substance use disorder21treatment:EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD03373-03-9A. 3076--A 2 1(A) a physician who possesses a current and valid non-restricted2license to practice medicine and who specializes in behavioral health3and has experience in the delivery of substance use disorder courses of4treatment; or5(B) a health care professional other than a licensed physician who6specializes in behavioral health and has experience in the delivery of7substance use disorder courses of treatment and, where applicable,8possesses a current and valid non-restricted license, certificate or9registration or, where no provision for a license, certificate or regis-10tration exists, is credentialed by the national accrediting body appro-11priate to the profession; or12(iv) for purposes of a determination involving treatment for a mental13health condition:14(A) a physician who possesses a current and valid non-restricted15license to practice medicine and who specializes in behavioral health16and has experience in the delivery of mental health courses of treat-17ment; or18(B) a health care professional other than a licensed physician who19specializes in behavioral health and has experience in the delivery of a20mental health courses of treatment and, where applicable, possesses a21current and valid non-restricted license, certificate, or registration22or, where no provision for a license, certificate or registration23exists, is credentialed by the national accrediting body appropriate to24the profession; and25(b) for purposes of title two of this article:26(i)] a physician who: 27 [(A)] (i) possesses a current and valid non-restricted license to 28 practice medicine under article one hundred thirty-one of the education 29 law; 30 [(B)] (ii) where applicable, is board certified or board eligible in 31 the same or similar specialty as the health care provider who typically 32 manages the medical condition or disease or provides the health care 33 service or treatment under review or appeal; 34 [(C)] (iii) has been practicing in such area of specialty for a period 35 of at least five years; [and] 36 (iv) for purposes of a determination involving substance use disorder 37 treatment, possesses a current and valid non-restricted license to prac- 38 tice medicine and specializes in behavioral health and has experience in 39 the delivery of substance use disorder courses of treatment; 40 (v) for purposes of a determination involving treatment for a mental 41 health condition, possesses a current and valid non-restricted license 42 to practice medicine and who specializes in behavioral health and has 43 experience in the delivery of mental health courses of treatment; and 44 [(D)] (vi) is knowledgeable about the health care service or treatment 45 under review or appeal; or 46 [(ii)] (b) a health care professional other than a licensed physician 47 who possesses a current and valid non-restricted license or certif- 48 ication under title eight of the education law: 49 [(A)] (i) where applicable, possesses a current and valid non-res- 50 tricted license, certificate or registration; 51 [(B)] (ii) where applicable, is credentialed by the national accredit- 52 ing body appropriate to the profession in the same profession and same 53 or similar specialty as the health care provider who typically manages 54 the medical condition or disease or provides the health care service or 55 treatment under review or appeal;A. 3076--A 3 1 [(C)] (iii) has been practicing in such area of specialty for a period 2 of at least five years; 3 [(D)] (iv) is knowledgeable about the health care service or treatment 4 under review or appeal; [and] 5 (v) for purposes of a determination involving substance use disorder, 6 specializes in behavioral health and has experience in the delivery of 7 substance use disorder courses of treatment and, where applicable, 8 possesses a current and valid non-restricted license, certificate or 9 registration or, where no provision for a license, certificate or regis- 10 tration exists, is credentialed by the national accrediting body appro- 11 priate to the profession; 12 (vi) for purposes of a determination involving treatment for a mental 13 health condition, specializes in behavioral health and has experience in 14 the delivery of mental health courses of treatment and, where applica- 15 ble, possesses a current and valid non-restricted license, certificate, 16 or registration or, where no provision for a license, certificate or 17 registration exists, is credentialed by the national accrediting body 18 appropriate to the profession; and 19 [(E)] (vii) where applicable to such health care professional's scope 20 of practice, is clinically supported by a physician who possesses a 21 current and valid non-restricted license to practice medicine. 22 [(c)] Nothing [herein] in this subdivision shall be construed to 23 change any statutorily-defined scope of practice. 24 § 2. Subsection (b) of section 4900 of the insurance law, as amended 25 by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of 26 paragraph 1 as amended by chapter 41 of the laws of 2014, subparagraph 27 (C) as amended and subparagraph (D) of paragraph 1 as added by section 28 36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended 29 to read as follows: 30 (b) "Clinical peer reviewer" means: 31 (1) [for purposes of title one of this article:32(A) a physician who possesses a current and valid non-restricted33license to practice medicine; or34(B) a health care professional other than a licensed physician who:35(i) where applicable, possesses a current and valid non-restricted36license, certificate or registration or, where no provision for a37license, certificate or registration exists, is credentialed by the38national accrediting body appropriate to the profession; and39(ii) is in the same profession and same or similar specialty as the40health care provider who typically manages the medical condition or41disease or provides the health care service or treatment under review;42or43(C) for purposes of a determination involving substance use disorder44treatment:45(i) a physician who possesses a current and valid non-restricted46license to practice medicine and who specializes in behavioral health47and has experience in the delivery of substance use disorder courses of48treatment; or49(ii) a health care professional other than a licensed physician who50specializes in behavioral health and has experience in the delivery of51substance use disorder courses of treatment and, where applicable,52possesses a current and valid non-restricted license, certificate or53registration or, where no provision for a license, certificate or regis-54tration exists, is credentialed by the national accrediting body appro-55priate to the profession; orA. 3076--A 4 1(D) for purposes of a determination involving treatment for a mental2health condition:3(i) a physician who possesses a current and valid non-restricted4license to practice medicine and who specializes in behavioral health5and has experience in the delivery of mental health courses of treat-6ment; or7(ii) a health care professional other than a licensed physician who8specializes in behavioral health and has experience in the delivery of9mental health courses of treatment and, where applicable, possesses a10current and valid non-restricted license, certificate, or registration11or, where no provision for a license, certificate or registration12exists, is credentialed by the national accrediting body appropriate to13the profession; and14(2) for purposes of title two of this article:15(A)] a physician who: 16 [(i)] (A) possesses a current and valid non-restricted license to 17 practice medicine under article one hundred thirty-one of the education 18 law; 19 [(ii)] (B) where applicable, is board certified or board eligible in 20 the same or similar specialty as the health care provider who typically 21 manages the medical condition or disease or provides the health care 22 service or treatment under review or appeal; 23 [(iii)] (C) has been practicing in such area of specialty for a period 24 of at least five years; [and] 25 (D) for purposes of a determination involving substance use disorder 26 treatment, possesses a current and valid non-restricted license to prac- 27 tice medicine and who specializes in behavioral health and has experi- 28 ence in the delivery of substance use disorder courses of treatment; 29 (E) for purposes of a determination involving treatment for a mental 30 health condition, possesses a current and valid non-restricted license 31 to practice medicine and who specializes in behavioral health and has 32 experience in the delivery of mental health courses of treatment; and 33 [(iv)] (F) is knowledgeable about the health care service or treatment 34 under review or appeal; or 35 [(B)] (2) a health care professional other than a licensed physician 36 who possesses a current and valid non-restricted license or certif- 37 ication under title eight of the education law: 38 [(i)] (A) where applicable, possesses a current and valid non-res- 39 tricted license, certificate or registration; 40 [(ii)] (B) where applicable, is credentialed by the national accredit- 41 ing body appropriate to the profession in the same profession and same 42 or similar specialty as the health care provider who typically manages 43 the medical condition or disease or provides the health care service or 44 treatment under review or appeal; 45 [(iii)] (C) has been practicing in such area of specialty for a period 46 of at least five years; 47 [(iv)] (D) for purposes of a determination involving substance use 48 disorder treatment, specializes in behavioral health and has experience 49 in the delivery of substance use disorder courses of treatment and, 50 where applicable, possesses a current and valid non-restricted license, 51 certificate or registration or, where no provision for a license, 52 certificate or registration exists, is credentialed by the national 53 accrediting body appropriate to the profession; 54 (E) for purposes of a determination involving treatment for a mental 55 health condition, specializes in behavioral health and has experience in 56 the delivery of mental health courses of treatment and, where applica-A. 3076--A 5 1 ble, possesses a current and valid non-restricted license, certificate, 2 or registration or, where no provision for a license, certificate or 3 registration exists, is credentialed by the national accrediting body 4 appropriate to the profession; 5 (F) is knowledgeable about the health care service or treatment under 6 review or appeal; and 7 [(v)] (G) where applicable to such health care professional's scope of 8 practice, is clinically supported by a physician who possesses a current 9 and valid non-restricted license to practice medicine. 10 [(3)] Nothing [herein] in this subdivision shall be construed to 11 change any statutorily-defined scope of practice. 12 § 3. This act shall take effect on the same date and in the same 13 manner as subpart A of part BB of chapter 57 of the laws of 2019, or on 14 the ninetieth day after it shall have become a law, whichever is later.