NY State Senate Bill 2015-S4783A

Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2016	referred to insurance
Apr 24, 2015	print number 4783a
Apr 24, 2015	amend (t) and recommit to insurance
Apr 15, 2015	referred to insurance

Bill Amendments

Original

A (Active)

2015-S4783 - Details

See Assembly Version of this Bill:: A445
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §4900, Ins L; amd §4900, Pub Health L
Versions Introduced in Other Legislative Sessions:: 2009-2010: A723
2011-2012: A662
2013-2014: S6281, A2693
2017-2018: A2539
2019-2020: A3076
2021-2022: A879

2015-S4783 - Summary

Requires, for purposes of utilization review and external appeals, clinical peer reviewers to be licensed, registered or certified in this state and to be in the same specialty as the health care provider being reviewed.

2015-S4783 - Sponsor Memo

2015-S4783 - Bill Text download pdf

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

                                  4783

                       2015-2016 Regular Sessions

                            I N  S E N A T E

                             April 15, 2015
                               ___________

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

AN ACT to amend the insurance law and the public health law, in relation
  to the definitions of "clinical peer reviewer"  for  the  purposes  of
  utilization review and external appeal

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1.  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:
  (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 PURSUANT TO ARTICLE ONE HUNDRED  THIRTY-ONE
OF THE EDUCATION LAW; 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] ISSUED PURSUANT
TO TITLE EIGHT OF THE EDUCATION LAW; 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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10479-01-5

S. 4783                             2

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) possesses a current and valid non-restricted license  to  practice
medicine  PURSUANT  TO  ARTICLE  ONE HUNDRED THIRTY-ONE OF THE EDUCATION
LAW;
  (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;
  (iii) has been practicing in such area of specialty for a period of at
least five years; and
  (iv) is knowledgeable about the health care service or treatment under
appeal; 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 ISSUED PURSUANT TO TITLE  EIGHT  OF
THE EDUCATION LAW;
  (ii)  [where  applicable,  is credentialed by the national accrediting
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 appeal;
  (iii)]  has  been practicing in such area of specialty for a period of
at least five years;
  [(iv)] (III) is knowledgeable about the health care service or  treat-
ment under appeal; and
  [(v)]  (IV)  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 PURSUANT
TO ARTICLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
  (3) Nothing [herein] IN THIS ARTICLE shall be construed to change  any
statutorily-defined scope of practice.
  S  2.  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 PURSUANT TO ARTICLE ONE HUNDRED THIRTY-ONE
OF THE EDUCATION LAW; 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

S. 4783                             3

national accrediting body appropriate to the profession] ISSUED PURSUANT
TO TITLE EIGHT OF THE EDUCATION LAW; 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,
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) possesses a current and valid non-restricted license  to  practice
medicine  PURSUANT  TO  ARTICLE  ONE HUNDRED THIRTY-ONE OF THE EDUCATION
LAW;
  (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 appeal;
  (C) has been practicing in such area of specialty for a period  of  at
least five years; and
  (D)  is knowledgeable about the health care service or treatment under
appeal; 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 ISSUED PURSUANT TO TITLE EIGHT OF
THE EDUCATION LAW;
  (B) [where applicable, is credentialed  by  the  national  accrediting
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 appeal;
  (C)] has been practicing in such area of specialty for a period of  at
least five years;
  [(D)]  (C) is knowledgeable about the health care service or treatment
under appeal; and
  [(E)] (D) 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 PURSUANT TO  ARTI-
CLE ONE HUNDRED THIRTY-ONE OF THE EDUCATION LAW.
  (c)  Nothing [herein] IN THIS ARTICLE shall be construed to change any
statutorily-defined scope of practice.
  S 3. This act shall take effect on the one hundred twentieth day after
it shall have become a law.

2015-S4783A (ACTIVE) - Details

See Assembly Version of this Bill:: A445
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §4900, Ins L; amd §4900, Pub Health L
Versions Introduced in Other Legislative Sessions:: 2009-2010: A723
2011-2012: A662
2013-2014: S6281, A2693
2017-2018: A2539
2019-2020: A3076
2021-2022: A879

2015-S4783A (ACTIVE) - Summary

2015-S4783A (ACTIVE) - Sponsor Memo

                                BILL NUMBER:S4783A               REVISED 4/29/15

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
treatment under review.

SUMMARY OF SPECIFIC PROVISIONS:  Would amend section 4900 of the
Public Health Law and section 4900 of the Insurance Law to re-define
the qualifications of a "clinical peer reviewer". A "clinical peer
reviewer" is the only type of health care provider 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

JUSTIFICATION:  Under current law, the only qualification required for
a utilization review agent, a person who, on behalf of a health rare
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
necessary 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: A.4609 - passed Assembly 2009-2010: A.723 - passed Assembly
2011-2012: A.662 passed Assembly 2013-2014: A2693 - advanced to 3rd
reading

FISCAL IMPLICATIONS: None

EFFECTIVE DATE:  Ninety days after enactment.

2015-S4783A (ACTIVE) - Bill Text download pdf

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

                                 4783--A

                       2015-2016 Regular Sessions

                            I N  S E N A T E

                             April 15, 2015
                               ___________

Introduced  by  Sen.  DeFRANCISCO -- read twice and ordered printed, and
  when printed to be committed to the Committee on Insurance --  commit-
  tee  discharged, bill amended, ordered reprinted as amended and recom-
  mitted to said committee

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.
                                                           LBD10479-02-5

S. 4783--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:

S. 4783--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;

S. 4783--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.

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Senate Bill S4783A

Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

Bill Amendments

2015-S4783 - Details

2015-S4783 - Summary

2015-S4783 - Sponsor Memo

2015-S4783 - Bill Text download pdf

2015-S4783A (ACTIVE) - Details

2015-S4783A (ACTIVE) - Summary

2015-S4783A (ACTIVE) - Sponsor Memo

2015-S4783A (ACTIVE) - Bill Text download pdf

Comments

Senate Bill S4783A

Share this bill

Sponsored By

John A. DeFrancisco

Archive: Last Bill Status - In Senate Committee Insurance Committee

Bill Amendments

2015-S4783 - Details

2015-S4783 - Summary

2015-S4783 - Sponsor Memo

2015-S4783 - Bill Text download pdf

2015-S4783A (ACTIVE) - Details

2015-S4783A (ACTIVE) - Summary

2015-S4783A (ACTIVE) - Sponsor Memo

2015-S4783A (ACTIVE) - Bill Text download pdf

Comments