S T A T E O F N E W Y O R K
________________________________________________________________________
3076--A
Cal. No. 338
2019-2020 Regular Sessions
I N A S S E M B L Y
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:
Section 1. Subdivision 2 of section 4900 of the public health law, as
amended by chapter 586 of the laws of 1998, item (B) of subparagraph
(ii) of paragraph (a) as amended by chapter 41 of the laws of 2014 and
subparagraph (iii) as amended and subparagraph (iv) of paragraph (a) as
added by section 42 of subpart A of part BB of chapter 57 of the laws of
2019, is amended to read as follows:
2. "Clinical peer reviewer" means:
(a) [for purposes of title one of this article:
(i) a physician who possesses a current and valid non-restricted
license to practice medicine; or
(ii) a health care professional other than a licensed physician who:
(A) where applicable, possesses a current and valid non-restricted
license, certificate or registration or, where no provision for a
license, certificate or registration exists, is credentialed by the
national accrediting body appropriate to the profession; and
(B) is in the same profession and same or similar specialty as the
health care provider who typically manages the medical condition or
disease or provides the health care service or treatment under review;
or
(iii) for purposes of a determination involving substance use disorder
treatment:
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03373-03-9
A. 3076--A 2
(A) a physician who possesses a current and valid non-restricted
license to practice medicine and who specializes in behavioral health
and has experience in the delivery of substance use disorder courses of
treatment; or
(B) a health care professional other than a licensed physician who
specializes in behavioral health and has experience in the delivery of
substance use disorder courses of treatment and, where applicable,
possesses a current and valid non-restricted license, certificate or
registration or, where no provision for a license, certificate or regis-
tration exists, is credentialed by the national accrediting body appro-
priate to the profession; or
(iv) for purposes of a determination involving treatment for a mental
health condition:
(A) a physician who possesses a current and valid non-restricted
license to practice medicine and who specializes in behavioral health
and has experience in the delivery of mental health courses of treat-
ment; or
(B) a health care professional other than a licensed physician who
specializes in behavioral health and has experience in the delivery of a
mental health courses of treatment and, where applicable, possesses a
current and valid non-restricted license, certificate, or registration
or, where no provision for a license, certificate or registration
exists, is credentialed by the national accrediting body appropriate to
the profession; and
(b) for purposes of title two of this article:
(i)] a physician who:
[(A)] (I) possesses a current and valid non-restricted license to
practice medicine UNDER ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION
LAW;
[(B)] (II) where applicable, is board certified or board eligible in
the same or similar specialty as the health care provider who typically
manages the medical condition or disease or provides the health care
service or treatment under REVIEW OR appeal;
[(C)] (III) has been practicing in such area of specialty for a period
of at least five years; [and]
(IV) FOR PURPOSES OF A DETERMINATION INVOLVING SUBSTANCE USE DISORDER
TREATMENT, POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE TO PRAC-
TICE MEDICINE AND SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE IN
THE DELIVERY OF SUBSTANCE USE DISORDER COURSES OF TREATMENT;
(V) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT FOR A MENTAL
HEALTH CONDITION, POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE
TO PRACTICE MEDICINE AND WHO SPECIALIZES IN BEHAVIORAL HEALTH AND HAS
EXPERIENCE IN THE DELIVERY OF MENTAL HEALTH COURSES OF TREATMENT; AND
[(D)] (VI) is knowledgeable about the health care service or treatment
under REVIEW OR appeal; or
[(ii)] (B) a health care professional other than a licensed physician
who POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE OR CERTIF-
ICATION UNDER TITLE EIGHT OF THE EDUCATION LAW:
[(A)] (I) where applicable, possesses a current and valid non-res-
tricted license, certificate or registration;
[(B)] (II) where applicable, is credentialed by the national accredit-
ing body appropriate to the profession in the same profession and same
or similar specialty as the health care provider who typically manages
the medical condition or disease or provides the health care service or
treatment under REVIEW OR appeal;
A. 3076--A 3
[(C)] (III) has been practicing in such area of specialty for a period
of at least five years;
[(D)] (IV) is knowledgeable about the health care service or treatment
under REVIEW OR appeal; [and]
(V) FOR PURPOSES OF A DETERMINATION INVOLVING SUBSTANCE USE DISORDER,
SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE IN THE DELIVERY OF
SUBSTANCE USE DISORDER COURSES OF TREATMENT AND, WHERE APPLICABLE,
POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE, CERTIFICATE OR
REGISTRATION OR, WHERE NO PROVISION FOR A LICENSE, CERTIFICATE OR REGIS-
TRATION EXISTS, IS CREDENTIALED BY THE NATIONAL ACCREDITING BODY APPRO-
PRIATE TO THE PROFESSION;
(VI) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT FOR A MENTAL
HEALTH CONDITION, SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE IN
THE DELIVERY OF MENTAL HEALTH COURSES OF TREATMENT AND, WHERE APPLICA-
BLE, POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE, CERTIFICATE,
OR REGISTRATION OR, WHERE NO PROVISION FOR A LICENSE, CERTIFICATE OR
REGISTRATION EXISTS, IS CREDENTIALED BY THE NATIONAL ACCREDITING BODY
APPROPRIATE TO THE PROFESSION; AND
[(E)] (VII) where applicable to such health care professional's scope
of practice, is clinically supported by a physician who possesses a
current and valid non-restricted license to practice medicine.
[(c)] Nothing [herein] IN THIS SUBDIVISION shall be construed to
change any statutorily-defined scope of practice.
§ 2. Subsection (b) of section 4900 of the insurance law, as amended
by chapter 586 of the laws of 1998, item (ii) of subparagraph (B) of
paragraph 1 as amended by chapter 41 of the laws of 2014, subparagraph
(C) as amended and subparagraph (D) of paragraph 1 as added by section
36 of subpart A of part BB of chapter 57 of the laws of 2019, is amended
to read as follows:
(b) "Clinical peer reviewer" means:
(1) [for purposes of title one of this article:
(A) a physician who possesses a current and valid non-restricted
license to practice medicine; or
(B) a health care professional other than a licensed physician who:
(i) where applicable, possesses a current and valid non-restricted
license, certificate or registration or, where no provision for a
license, certificate or registration exists, is credentialed by the
national accrediting body appropriate to the profession; and
(ii) is in the same profession and same or similar specialty as the
health care provider who typically manages the medical condition or
disease or provides the health care service or treatment under review;
or
(C) for purposes of a determination involving substance use disorder
treatment:
(i) a physician who possesses a current and valid non-restricted
license to practice medicine and who specializes in behavioral health
and has experience in the delivery of substance use disorder courses of
treatment; or
(ii) a health care professional other than a licensed physician who
specializes in behavioral health and has experience in the delivery of
substance use disorder courses of treatment and, where applicable,
possesses a current and valid non-restricted license, certificate or
registration or, where no provision for a license, certificate or regis-
tration exists, is credentialed by the national accrediting body appro-
priate to the profession; or
A. 3076--A 4
(D) for purposes of a determination involving treatment for a mental
health condition:
(i) a physician who possesses a current and valid non-restricted
license to practice medicine and who specializes in behavioral health
and has experience in the delivery of mental health courses of treat-
ment; or
(ii) a health care professional other than a licensed physician who
specializes in behavioral health and has experience in the delivery of
mental health courses of treatment and, where applicable, possesses a
current and valid non-restricted license, certificate, or registration
or, where no provision for a license, certificate or registration
exists, is credentialed by the national accrediting body appropriate to
the profession; and
(2) for purposes of title two of this article:
(A)] a physician who:
[(i)] (A) possesses a current and valid non-restricted license to
practice medicine UNDER ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION
LAW;
[(ii)] (B) where applicable, is board certified or board eligible in
the same or similar specialty as the health care provider who typically
manages the medical condition or disease or provides the health care
service or treatment under REVIEW OR appeal;
[(iii)] (C) has been practicing in such area of specialty for a period
of at least five years; [and]
(D) FOR PURPOSES OF A DETERMINATION INVOLVING SUBSTANCE USE DISORDER
TREATMENT, POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE TO PRAC-
TICE MEDICINE AND WHO SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERI-
ENCE IN THE DELIVERY OF SUBSTANCE USE DISORDER COURSES OF TREATMENT;
(E) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT FOR A MENTAL
HEALTH CONDITION, POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE
TO PRACTICE MEDICINE AND WHO SPECIALIZES IN BEHAVIORAL HEALTH AND HAS
EXPERIENCE IN THE DELIVERY OF MENTAL HEALTH COURSES OF TREATMENT; AND
[(iv)] (F) is knowledgeable about the health care service or treatment
under REVIEW OR appeal; or
[(B)] (2) a health care professional other than a licensed physician
who POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE OR CERTIF-
ICATION UNDER TITLE EIGHT OF THE EDUCATION LAW:
[(i)] (A) where applicable, possesses a current and valid non-res-
tricted license, certificate or registration;
[(ii)] (B) where applicable, is credentialed by the national accredit-
ing body appropriate to the profession in the same profession and same
or similar specialty as the health care provider who typically manages
the medical condition or disease or provides the health care service or
treatment under REVIEW OR appeal;
[(iii)] (C) has been practicing in such area of specialty for a period
of at least five years;
[(iv)] (D) FOR PURPOSES OF A DETERMINATION INVOLVING SUBSTANCE USE
DISORDER TREATMENT, SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE
IN THE DELIVERY OF SUBSTANCE USE DISORDER COURSES OF TREATMENT AND,
WHERE APPLICABLE, POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE,
CERTIFICATE OR REGISTRATION OR, WHERE NO PROVISION FOR A LICENSE,
CERTIFICATE OR REGISTRATION EXISTS, IS CREDENTIALED BY THE NATIONAL
ACCREDITING BODY APPROPRIATE TO THE PROFESSION;
(E) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT FOR A MENTAL
HEALTH CONDITION, SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE IN
THE DELIVERY OF MENTAL HEALTH COURSES OF TREATMENT AND, WHERE APPLICA-
A. 3076--A 5
BLE, POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE, CERTIFICATE,
OR REGISTRATION OR, WHERE NO PROVISION FOR A LICENSE, CERTIFICATE OR
REGISTRATION EXISTS, IS CREDENTIALED BY THE NATIONAL ACCREDITING BODY
APPROPRIATE TO THE PROFESSION;
(F) is knowledgeable about the health care service or treatment under
REVIEW OR appeal; and
[(v)] (G) where applicable to such health care professional's scope of
practice, is clinically supported by a physician who possesses a current
and valid non-restricted license to practice medicine.
[(3)] Nothing [herein] IN THIS SUBDIVISION shall be construed to
change any statutorily-defined scope of practice.
§ 3. This act shall take effect on the same date and in the same
manner as subpart A of part BB of chapter 57 of the laws of 2019, or on
the ninetieth day after it shall have become a law, whichever is later.