2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 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.