NY State Senate Bill 2021-S599

Archive: Last Bill Status - In Senate Committee Health Committee

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

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2021	referred to health

co-Sponsors

2021-S599 (ACTIVE) - Details

See Assembly Version of this Bill:: A879
Current Committee:: Senate Health
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
2019-2020: S8844, A3076

2021-S599 (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.

2021-S599 (ACTIVE) - Sponsor Memo

                                
 
BILL NUMBER: S599

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:

2019-20: S.8844/A3076A
2017-18: A.2539
2015-16: S.4783-A /A.445-A
2013-14: A.2693 2011-12: A.662
2009-10: A.723 2007-08: S.3450 / A.4609
2005-06: A.2206-B
2003-04: A.3441
2001-02:A.11479

 
FISCAL IMPLICATIONS:  None

 
EFFECTIVE DATE:
Ninety days after enactment.

2021-S599 (ACTIVE) - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                    599
 
                        2021-2022 Regular Sessions
 
                             I N  S E N A T E
 
                                (PREFILED)
 
                              January 6, 2021
                                ___________
 
 Introduced  by Sen. BENJAMIN -- read twice and ordered printed, and when
   printed to be committed 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

 S. 599                              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;

 S. 599                              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:

 S. 599                              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

 S. 599                              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.

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Senate Bill S599

Sponsored By

Archive: Last Bill Status - In Senate Committee Health Committee

co-Sponsors

2021-S599 (ACTIVE) - Details

2021-S599 (ACTIVE) - Summary

2021-S599 (ACTIVE) - Sponsor Memo

2021-S599 (ACTIVE) - Bill Text download pdf

Comments

Senate Bill S599

Share this bill

Sponsored By

Brian Benjamin

Archive: Last Bill Status - In Senate Committee Health Committee

co-Sponsors

James Gaughran

2021-S599 (ACTIVE) - Details

2021-S599 (ACTIVE) - Summary

2021-S599 (ACTIVE) - Sponsor Memo

2021-S599 (ACTIVE) - Bill Text download pdf

Comments