NY State Senate Bill S8844

Archive: Last Bill Status - In Senate Committee Rules Committee

Introduced
In Committee
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- Passed Senate
- Passed Assembly
Delivered to Governor
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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jul 29, 2020	referred to rules

S8844 (ACTIVE) - Details

See Assembly Version of this Bill:: A3076
Current Committee:: Senate Rules
Law Section:: Public Health Law
Laws Affected:: Amd §4900, Pub Health L; amd §4900, Ins L
Versions Introduced in Other Legislative Sessions:: 2009-2010: A723
2011-2012: A662
2013-2014: A2693
2015-2016: A445
2017-2018: A2539
2021-2022: S599, S8113, A879

S8844 (ACTIVE) - Summary

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.

S8844 (ACTIVE) - Sponsor Memo

 
BILL NUMBER: S8844

SPONSOR: BENJAMIN
 
TITLE OF BILL:

An act to amend the public health law and the insurance law, in relation
to the definition of clinical peer reviewer

 
PURPOSE OR GENERAL IDEA OF BILL:

To ensure that a health plan may only deny payment for an otherwise
covered benefit upon the review of a physician or other health care
professional licensed in NYS and, when appropriate, board certified in
the same or similar specialty as the treatment under review.

 
SUMMARY OF SPECIFIC PROVISIONS:

Section 1 of the bill would amend section 4900 of the Public Health Law
to re-define the qualifications of a "clinical peer reviewer" who a,
health plan or insurer may use to deny payment for an otherwise covered
benefit on the basis that the treatment is not medically necessary.

Under current law, only when a claim dispute arises to the level of an
external appeal, does any qualification for such a "clinical peer
reviewer" apply.

This legislation would:

* require that when the clinical peer reviewer is a physician, he or she
would be board-certified or board eligible in the same or similar
specialty as the physician who typically recommends the treatment or
manages the condition under review;

* require all clinical peer reviewers, whether physicians or other
health care professionals, be licensed or certified in New York State;

* apply the same qualifications for clinical peer reviewers to the
initial internal health plan utilization review process.

Section 2 of the bill would amend section 4900 of the Insurance Law to
make the identical changes described above.

Section 3. of the bill is the effective date.


 
JUSTIFICATION:  Under current law, the only qualification required for
a utilization review agent, a person who, on behalf of a health care
plan or insurer, may deny payment for an otherwise covered benefit on
the basis that it is not medically necessary, is that such reviewer be a
physician or health care professional licensed somewhere and trained in
utilization review practice. There is no requirement that the reviewing
agent be trained in the same specialty as the health care professional
who would typically recommend the treatment that is under review.

Therefore, a patient's treatment recommendation may be reviewed by a
provider working for the health plan who is not qualified to review the
treatment that has been recommended. This can result in medically neces-
sary care being inappropriately denied or unnecessarily delayed.  The
similar specialty qualification had been required by the 1996 Managed
Care Bill of Rights. However, in 1998, in enacting the External Appeals
Law, the requirement was not continued for utilization review. This
legislation would restore this requirement, and in addition, ensure that
all reviewers at both levels of appeal be licensed or certified in New
York State, and when appropriate, such reviewing physicians be either
board certified or board eligible in that specialty.

 
PRIOR LEGISLATIVE HISTORY:

2002: A.11479 - passed Assembly

2004: A.3441 - passed Assembly

2005-2006: A.2206-B - passed Assembly

2007-2008: S.3450 Third reading in Senate / A.4609 - passed Assembly

2009-2010: A.723 - passed Assembly

2011-2012: A.662 passed Assembly

2013-2014: A.2693 - advanced to third reading calendar

2015-2016: S.4783-A Insurance Committee / A.445-A - advanced to third
reading calendar

2017-2018: A.2539 - advanced to third reading calendar

2019-2020: Passed assembly

 
FISCAL IMPLICATIONS:

None

 
EFFECTIVE DATE:
Ninety days after enactment.

S8844 (ACTIVE) - Bill Text download pdf


                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  8844

                            I N  S E N A T E

                              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:

  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:
  (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,

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets

                      [ ] is old law to be omitted.
                                                           LBD03373-04-0

S. 8844                             2

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;
  [(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

S. 8844                             3

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
  (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

S. 8844                             4

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-
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.

S. 8844                             5

  [(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.

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The New York State Senate

senate Bill S8844

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Archive: Last Bill Status - In Senate Committee Rules Committee

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S8844 (ACTIVE) - Details

S8844 (ACTIVE) - Summary

S8844 (ACTIVE) - Sponsor Memo

S8844 (ACTIVE) - Bill Text download pdf

Comments

senate Bill S8844

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Sponsored By

Brian A. Benjamin

Archive: Last Bill Status - In Senate Committee Rules Committee

Your Voice

Actions

S8844 (ACTIVE) - Details

S8844 (ACTIVE) - Summary

S8844 (ACTIVE) - Sponsor Memo

S8844 (ACTIVE) - Bill Text download pdf

Comments