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

                                 445--A
                                                          Cal. No. 5

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                               (PREFILED)

                             January 7, 2015
                               ___________

Introduced  by  M.  of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, ROSENTHAL,
  SCHIMEL, KAVANAGH, COLTON, JAFFEE, ABINANTI -- read once and  referred
  to the Committee on Health -- advanced to a third reading, amended and
  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 and subparagraph (iii) of paragraph (a)
as added by chapter 41 of the laws  of  2014,  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

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

                      [ ] is old law to be omitted.
                                                           LBD04173-02-5

A. 445--A                           2

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; 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 appeal;
  [(C)] (III) has been practicing in such area of specialty for a period
of at least five years;
  (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; and
  [(D)] (V) 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;
  (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; and
  [(E)] (VI) 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.
  S  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 and subparagraph (C) of paragraph 1 as added by
chapter 41 of the laws of 2014, is amended to read as follows:

A. 445--A                           3

  (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; 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;
  (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; and
  [(iv)] (E) 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;

A. 445--A                           4

  [(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)  is knowledgeable about the health care service or treatment under
REVIEW OR appeal; and
  [(v)] (F) 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.
  S  3.  This  act shall take effect on the ninetieth day after it shall
have become a law.