S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   8113
 
                             I N  S E N A T E
 
                             January 25, 2022
                                ___________
 
 Introduced  by  Sen.  CLEARE -- 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
 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.
              

                                                            LBD00261-01-1
 S. 8113                             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. 8113                             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. 8113                             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. 8113                             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 ninetieth day after it shall
 have become a law.