2023 New York Laws › PBH - Public Health › Article 44 - Health Maintenance Organizations › 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.