§ 3217-J — Utilization review determinations for medically fragile children

§ 3217-j. Utilization review determinations for medically fragile\nchildren. (a) Notwithstanding any inconsistent provision of the\ninsurer's clinical standards, the insurer, and any utilization review\nagent under contract with such insurer, shall administer and apply the\nclinical standards (and make determinations of medical necessity)\nregarding medically fragile children in accordance with the requirements\nof this section and any regulations with special considerations and\nprocesses for utilization review related to medically fragile children.\n (b) Insurers shall undertake the following with respect to medically\nfragile children, and as applicable, shall ensure that their contracted\nutilization review agents undertake the following with respect to\nmedically fragile children:\n (1) Consider as medically necessary all covered services that assist\nmedically fragile children in reaching their maximum functional\ncapacity, taking into account the appropriate functional capacities of\nchildren of the same age.\n (2) Shall not base determinations solely upon review standards\napplicable to (or designed for) adults to medically fragile children.\nDeterminations shall take into consideration the specific needs of the\nchild and the circumstances pertaining to their growth and development.\n (3) Accommodate unusual stabilization and prolonged discharge plans\nfor medically fragile children, as appropriate. Insurers, and as\napplicable their contracted utilization review agents, shall consider\nwhen developing and approving discharge plans issues including sudden\nreversals of condition or progress, which may make discharge decisions\nuncertain or more prolonged than for other children or adults.\n (4) It is the insurer's network management responsibility under a\nmanaged care health insurance contract as defined in subsection (c) of\nsection four thousand eight hundred one of this chapter to identify an\navailable provider of needed covered services, as determined through a\nperson centered care plan, to effect safe discharge from a hospital or\nother facility.\n (5) This section does not limit any other rights a medically fragile\nchild may have, including the right to appeal the denial of out of\nnetwork coverage at in-network cost sharing levels where an appropriate\nin-network provider is not available pursuant to subsection a-two of\nsection four thousand nine hundred four of this chapter.\n (6) Insurers shall contract with providers with demonstrated expertise\nin caring for the medically fragile children. Network providers shall\nrefer to appropriate network community and facility providers for\ncovered services to meet the needs of the child or seek authorization\nfrom the insurer for out-of-network providers when participating\nproviders cannot meet the child's needs.\n (c) In the event an insurer enters into a participation agreement with\na specialty care center for medically fragile children in this state,\nthe requirements of this section shall apply to that participation\nagreement and to all claims submitted to, or payments made by, any other\ninsurers, health maintenance organizations or payors making payment to\nthe specialty care center pursuant to the provisions of that\nparticipation agreement.\n