Bill Text: NY S08844 | 2019-2020 | General Assembly | Introduced


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 1-0)

Status: (Introduced - Dead) 2020-07-29 - REFERRED TO RULES [S08844 Detail]

Download: New_York-2019-S08844-Introduced.html



                STATE OF NEW YORK
        ________________________________________________________________________

                                          8844

                    IN SENATE

                                      July 29, 2020
                                       ___________

        Introduced  by Sen. BENJAMIN -- read twice and ordered printed, and when
          printed to be committed to the Committee on Rules

        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
    24  and has experience in the delivery of substance use disorder courses  of
    25  treatment; or
    26    (B)  a  health  care  professional other than a licensed physician who
    27  specializes in behavioral health and has experience in the  delivery  of
    28  substance  use  disorder  courses  of  treatment  and, where applicable,

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD03373-04-0

        S. 8844                             2

     1  possesses a current and valid  non-restricted  license,  certificate  or
     2  registration or, where no provision for a license, certificate or regis-
     3  tration  exists, is credentialed by the national accrediting body appro-
     4  priate to the profession; or
     5    (iv)  for purposes of a determination involving treatment for a mental
     6  health condition:
     7    (A) a physician who  possesses  a  current  and  valid  non-restricted
     8  license  to  practice  medicine and who specializes in behavioral health
     9  and has experience in the delivery of mental health  courses  of  treat-
    10  ment; or
    11    (B)  a  health  care  professional other than a licensed physician who
    12  specializes in behavioral health and has experience in the delivery of a
    13  mental health courses of treatment and, where  applicable,  possesses  a
    14  current  and  valid non-restricted license, certificate, or registration
    15  or, where no  provision  for  a  license,  certificate  or  registration
    16  exists,  is credentialed by the national accrediting body appropriate to
    17  the profession; and
    18    (b) for purposes of title two of this article:
    19    (i)] a physician who:
    20    [(A)] (i) possesses a current  and  valid  non-restricted  license  to
    21  practice  medicine under article one hundred thirty-one of the education
    22  law;
    23    [(B)] (ii) where applicable, is board certified or board  eligible  in
    24  the  same or similar specialty as the health care provider who typically
    25  manages the medical condition or disease or  provides  the  health  care
    26  service or treatment under review or appeal;
    27    [(C)] (iii) has been practicing in such area of specialty for a period
    28  of at least five years; [and]
    29    (iv)  for purposes of a determination involving substance use disorder
    30  treatment, possesses a current and valid non-restricted license to prac-
    31  tice medicine and specializes in behavioral health and has experience in
    32  the delivery of substance use disorder courses of treatment;
    33    (v) for purposes of a determination involving treatment for  a  mental
    34  health  condition,  possesses a current and valid non-restricted license
    35  to practice medicine and who specializes in behavioral  health  and  has
    36  experience in the delivery of mental health courses of treatment; and
    37    [(D)] (vi) is knowledgeable about the health care service or treatment
    38  under review or appeal; or
    39    [(ii)]  (b) a health care professional other than a licensed physician
    40  who possesses a current and  valid  non-restricted  license  or  certif-
    41  ication under title eight of the education law:
    42    [(A)]  (i)  where  applicable,  possesses a current and valid non-res-
    43  tricted license, certificate or registration;
    44    [(B)] (ii) where applicable, is credentialed by the national accredit-
    45  ing body appropriate to the profession in the same profession  and  same
    46  or  similar  specialty as the health care provider who typically manages
    47  the medical condition or disease or provides the health care service  or
    48  treatment under review or appeal;
    49    [(C)] (iii) has been practicing in such area of specialty for a period
    50  of at least five years;
    51    [(D)] (iv) is knowledgeable about the health care service or treatment
    52  under review or appeal; [and]
    53    (v)  for purposes of a determination involving substance use disorder,
    54  specializes in behavioral health and has experience in the  delivery  of
    55  substance  use  disorder  courses  of  treatment  and, where applicable,
    56  possesses a current and valid  non-restricted  license,  certificate  or

        S. 8844                             3

     1  registration or, where no provision for a license, certificate or regis-
     2  tration  exists, is credentialed by the national accrediting body appro-
     3  priate to the profession;
     4    (vi)  for purposes of a determination involving treatment for a mental
     5  health condition, specializes in behavioral health and has experience in
     6  the delivery of mental health courses of treatment and,  where  applica-
     7  ble,  possesses a current and valid non-restricted license, certificate,
     8  or registration or, where no provision for  a  license,  certificate  or
     9  registration  exists,  is  credentialed by the national accrediting body
    10  appropriate to the profession; and
    11    [(E)] (vii) where applicable to such health care professional's  scope
    12  of  practice,  is  clinically  supported  by a physician who possesses a
    13  current and valid non-restricted license to practice medicine.
    14    [(c)] Nothing [herein] in  this  subdivision  shall  be  construed  to
    15  change any statutorily-defined scope of practice.
    16    §  2.  Subsection (b) of section 4900 of the insurance law, as amended
    17  by chapter 586 of the laws of 1998, item (ii)  of  subparagraph  (B)  of
    18  paragraph  1  as amended by chapter 41 of the laws of 2014, subparagraph
    19  (C) as amended and subparagraph (D) of paragraph 1 as added  by  section
    20  36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended
    21  to read as follows:
    22    (b) "Clinical peer reviewer" means:
    23    (1) [for purposes of title one of this article:
    24    (A)  a  physician  who  possesses  a  current and valid non-restricted
    25  license to practice medicine; or
    26    (B) a health care professional other than a licensed physician who:
    27    (i) where applicable, possesses a  current  and  valid  non-restricted
    28  license,  certificate  or  registration  or,  where  no  provision for a
    29  license, certificate or registration  exists,  is  credentialed  by  the
    30  national accrediting body appropriate to the profession; and
    31    (ii)  is  in  the same profession and same or similar specialty as the
    32  health care provider who typically  manages  the  medical  condition  or
    33  disease  or  provides the health care service or treatment under review;
    34  or
    35    (C) for purposes of a determination involving substance  use  disorder
    36  treatment:
    37    (i)  a  physician  who  possesses  a  current and valid non-restricted
    38  license to practice medicine and who specializes  in  behavioral  health
    39  and  has experience in the delivery of substance use disorder courses of
    40  treatment; or
    41    (ii) a health care professional other than a  licensed  physician  who
    42  specializes  in  behavioral health and has experience in the delivery of
    43  substance use disorder  courses  of  treatment  and,  where  applicable,
    44  possesses  a  current  and  valid non-restricted license, certificate or
    45  registration or, where no provision for a license, certificate or regis-
    46  tration exists, is credentialed by the national accrediting body  appro-
    47  priate to the profession; or
    48    (D)  for  purposes of a determination involving treatment for a mental
    49  health condition:
    50    (i) a physician who  possesses  a  current  and  valid  non-restricted
    51  license  to  practice  medicine and who specializes in behavioral health
    52  and has experience in the delivery of mental health  courses  of  treat-
    53  ment; or
    54    (ii)  a  health  care professional other than a licensed physician who
    55  specializes in behavioral health and has experience in the  delivery  of
    56  mental  health  courses  of treatment and, where applicable, possesses a

        S. 8844                             4

     1  current and valid non-restricted license, certificate,  or  registration
     2  or,  where  no  provision  for  a  license,  certificate or registration
     3  exists, is credentialed by the national accrediting body appropriate  to
     4  the profession; and
     5    (2) for purposes of title two of this article:
     6    (A)] a physician who:
     7    [(i)]  (A)  possesses  a  current  and valid non-restricted license to
     8  practice medicine under article one hundred thirty-one of the  education
     9  law;
    10    [(ii)]  (B)  where applicable, is board certified or board eligible in
    11  the same or similar specialty as the health care provider who  typically
    12  manages  the  medical  condition  or disease or provides the health care
    13  service or treatment under review or appeal;
    14    [(iii)] (C) has been practicing in such area of specialty for a period
    15  of at least five years; [and]
    16    (D) for purposes of a determination involving substance  use  disorder
    17  treatment, possesses a current and valid non-restricted license to prac-
    18  tice  medicine  and who specializes in behavioral health and has experi-
    19  ence in the delivery of substance use disorder courses of treatment;
    20    (E) for purposes of a determination involving treatment for  a  mental
    21  health  condition,  possesses a current and valid non-restricted license
    22  to practice medicine and who specializes in behavioral  health  and  has
    23  experience in the delivery of mental health courses of treatment; and
    24    [(iv)] (F) is knowledgeable about the health care service or treatment
    25  under review or appeal; or
    26    [(B)]  (2)  a health care professional other than a licensed physician
    27  who possesses a current and  valid  non-restricted  license  or  certif-
    28  ication under title eight of the education law:
    29    [(i)]  (A)  where  applicable,  possesses a current and valid non-res-
    30  tricted license, certificate or registration;
    31    [(ii)] (B) where applicable, is credentialed by the national accredit-
    32  ing body appropriate to the profession in the same profession  and  same
    33  or  similar  specialty as the health care provider who typically manages
    34  the medical condition or disease or provides the health care service  or
    35  treatment under review or appeal;
    36    [(iii)] (C) has been practicing in such area of specialty for a period
    37  of at least five years;
    38    [(iv)]  (D)  for  purposes  of a determination involving substance use
    39  disorder treatment, specializes in behavioral health and has  experience
    40  in  the  delivery  of  substance  use disorder courses of treatment and,
    41  where applicable, possesses a current and valid non-restricted  license,
    42  certificate  or  registration  or,  where  no  provision  for a license,
    43  certificate or registration exists,  is  credentialed  by  the  national
    44  accrediting body appropriate to the profession;
    45    (E)  for  purposes of a determination involving treatment for a mental
    46  health condition, specializes in behavioral health and has experience in
    47  the delivery of mental health courses of treatment and,  where  applica-
    48  ble,  possesses a current and valid non-restricted license, certificate,
    49  or registration or, where no provision for  a  license,  certificate  or
    50  registration  exists,  is  credentialed by the national accrediting body
    51  appropriate to the profession;
    52    (F) is knowledgeable about the health care service or treatment  under
    53  review or appeal; and
    54    [(v)] (G) where applicable to such health care professional's scope of
    55  practice, is clinically supported by a physician who possesses a current
    56  and valid non-restricted license to practice medicine.

        S. 8844                             5

     1    [(3)]  Nothing  [herein]  in  this  subdivision  shall be construed to
     2  change any statutorily-defined scope of practice.
     3    §  3.  This  act  shall  take  effect on the same date and in the same
     4  manner as subpart A of part BB of chapter 57 of the laws of 2019, or  on
     5  the ninetieth day after it shall have become a law, whichever is later.
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