S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                    879
 
                        2021-2022 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                (PREFILED)
 
                              January 6, 2021
                                ___________
 
 Introduced by M. of A. GOTTFRIED, DINOWITZ, GALEF, PAULIN, L. ROSENTHAL,
   COLTON, ABINANTI -- read once and referred to the Committee on Health
 
 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

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

                                                            LBD00261-01-1

 A. 879                              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; 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;

 A. 879                              3
 
   [(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
   (D) for purposes of a determination involving treatment for  a  mental
 health condition:

 A. 879                              4

   (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-
 BLE,  POSSESSES A CURRENT AND VALID NON-RESTRICTED LICENSE, CERTIFICATE,
 OR REGISTRATION OR, WHERE NO PROVISION FOR  A  LICENSE,  CERTIFICATE  OR

 A. 879                              5
 
 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 ninetieth day after it shall
 have become a law.