N.Y. Insurance Law § 3217-j: Utilization review determinations for medically fragile children

§ 3217-j. Utilization review determinations for medically fragile

children. (a) Notwithstanding any inconsistent provision of the

insurer's clinical standards, the insurer, and any utilization review

agent under contract with such insurer, shall administer and apply the

clinical standards (and make determinations of medical necessity)

regarding medically fragile children in accordance with the requirements

of this section and any regulations with special considerations and

processes for utilization review related to medically fragile children.

(b) Insurers shall undertake the following with respect to medically

fragile children, and as applicable, shall ensure that their contracted

utilization review agents undertake the following with respect to

medically fragile children:

(1) Consider as medically necessary all covered services that assist

medically fragile children in reaching their maximum functional

capacity, taking into account the appropriate functional capacities of

children of the same age.

(2) Shall not base determinations solely upon review standards

applicable to (or designed for) adults to medically fragile children.

Determinations shall take into consideration the specific needs of the

child and the circumstances pertaining to their growth and development.

(3) Accommodate unusual stabilization and prolonged discharge plans

for medically fragile children, as appropriate. Insurers, and as

applicable their contracted utilization review agents, shall consider

when developing and approving discharge plans issues including sudden

reversals of condition or progress, which may make discharge decisions

uncertain or more prolonged than for other children or adults.

(4) It is the insurer's network management responsibility under a

managed care health insurance contract as defined in subsection (c) of

section four thousand eight hundred one of this chapter to identify an

available provider of needed covered services, as determined through a

person centered care plan, to effect safe discharge from a hospital or

other facility.

(5) This section does not limit any other rights a medically fragile

child may have, including the right to appeal the denial of out of

network coverage at in-network cost sharing levels where an appropriate

in-network provider is not available pursuant to subsection a-two of

section four thousand nine hundred four of this chapter.

(6) Insurers shall contract with providers with demonstrated expertise

in caring for the medically fragile children. Network providers shall

refer to appropriate network community and facility providers for

covered services to meet the needs of the child or seek authorization

from the insurer for out-of-network providers when participating

providers cannot meet the child's needs.

(c) In the event an insurer enters into a participation agreement with

a specialty care center for medically fragile children in this state,

the requirements of this section shall apply to that participation

agreement and to all claims submitted to, or payments made by, any other

insurers, health maintenance organizations or payors making payment to

the specialty care center pursuant to the provisions of that

participation agreement.