N.Y. Public Health Law § 4406-i: Utilization review determinations for medically fragile children

§ 4406-i. Utilization review determinations for medically fragile

children. 1. Notwithstanding any inconsistent provision of the health

maintenance organization's clinical standards, the health maintenance

organization, and any utilization review agent under contract with such

health maintenance organization, 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.

2. Health maintenance organizations 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:

(a) 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. In the case of Medicaid managed care, health

maintenance organizations shall continue to cover services until that

child achieves age-appropriate functional capacity.

(b) 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.

(c) Accommodate unusual stabilization and prolonged discharge plans

for medically fragile children, as appropriate. Health maintenance

organizations, 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.

(d) It is the health maintenance organization's network management

responsibility 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. In the case of

Medicaid managed care, payments shall not be denied to a discharging

hospital or other facility due to lack of an available post-discharge

provider as long as they have worked with the utilization review agent

to identify an appropriate provider.

(e) This section does not limit any other rights the 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 subdivision one-b of

section forty-nine hundred four of this chapter.

(f) Health maintenance organizations 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 health maintenance

organization for out-of-network providers when participating providers

cannot meet the child's needs.

3. In the case of Medicaid managed care, when rendering or arranging

for care or payment, both the provider and the health maintenance

organization shall inquire of, and shall consider the desires of the

family of a medically fragile child including, but not limited to, the

availability and capacity of the family, the need for the family to

simultaneously care for the family's other children, and the need for

parents to continue employment.

4. In the case of Medicaid managed care, the health maintenance

organization shall pay for all days of inpatient hospital care at a

participating specialty care center for medically fragile children when

the health maintenance organization and the specialty care facility

mutually agree the patient is ready for discharge from the specialty

care center to the patient's home but requires specialized home services

that are not available or in place, or the patient is awaiting discharge

to a residential health care facility when no residential health care

facility bed is available given the specialized needs of the medically

fragile child. In the case of Medicaid managed care, the health

maintenance organization shall pay, for all days of residential health

care facility care at a participating specialty care center for

medically fragile children when the health maintenance organization and

the specialty care facility mutually agree the patient is ready for

discharge from the specialty care center to the patient's home but

requires specialized home services that are not available or in place.

In the case of Medicaid managed care, such requirements shall apply

until the health plan can identify and secure admission to an alternate

provider rendering the necessary level of services. The specialty care

center shall facilitate placement efforts to effectuate the discharge.

5. In the event a health maintenance organization 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 such participation agreement and to all claims submitted to, or

payments made by, any other health maintenance organizations, insurers

or payors making payment to the specialty care center pursuant to the

provisions of that participation agreement.