§ 4406-I — Utilization review determinations for medically fragile children

§ 4406-i. Utilization review determinations for medically fragile\nchildren. 1. Notwithstanding any inconsistent provision of the health\nmaintenance organization's clinical standards, the health maintenance\norganization, and any utilization review agent under contract with such\nhealth maintenance organization, shall administer and apply the clinical\nstandards (and make determinations of medical necessity) regarding\nmedically fragile children in accordance with the requirements of this\nsection and any regulations with special considerations and processes\nfor utilization review related to medically fragile children.\n 2. Health maintenance organizations shall undertake the following with\nrespect to medically fragile children, and as applicable, shall ensure\nthat their contracted utilization review agents undertake the following\nwith respect to medically fragile children:\n (a) 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. In the case of Medicaid managed care, health\nmaintenance organizations shall continue to cover services until that\nchild achieves age-appropriate functional capacity.\n (b) 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 (c) Accommodate unusual stabilization and prolonged discharge plans\nfor medically fragile children, as appropriate. Health maintenance\norganizations, and as applicable their contracted utilization review\nagents, shall consider when developing and approving discharge plans\nissues including sudden reversals of condition or progress which may\nmake discharge decisions uncertain or more prolonged than for other\nchildren or adults.\n (d) It is the health maintenance organization's network management\nresponsibility to identify an available provider of needed covered\nservices, as determined through a person centered care plan, to effect\nsafe discharge from a hospital or other facility. In the case of\nMedicaid managed care, payments shall not be denied to a discharging\nhospital or other facility due to lack of an available post-discharge\nprovider as long as they have worked with the utilization review agent\nto identify an appropriate provider.\n (e) This section does not limit any other rights the 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 subdivision one-b of\nsection forty-nine hundred four of this chapter.\n (f) Health maintenance organizations shall contract with providers\nwith demonstrated expertise in caring for the medically fragile\nchildren. Network providers shall refer to appropriate network\ncommunity and facility providers for covered services to meet the needs\nof the child or seek authorization from the health maintenance\norganization for out-of-network providers when participating providers\ncannot meet the child's needs.\n 3. In the case of Medicaid managed care, when rendering or arranging\nfor care or payment, both the provider and the health maintenance\norganization shall inquire of, and shall consider the desires of the\nfamily of a medically fragile child including, but not limited to, the\navailability and capacity of the family, the need for the family to\nsimultaneously care for the family's other children, and the need for\nparents to continue employment.\n 4. In the case of Medicaid managed care, the health maintenance\norganization shall pay for all days of inpatient hospital care at a\nparticipating specialty care center for medically fragile children when\nthe health maintenance organization and the specialty care facility\nmutually agree the patient is ready for discharge from the specialty\ncare center to the patient's home but requires specialized home services\nthat are not available or in place, or the patient is awaiting discharge\nto a residential health care facility when no residential health care\nfacility bed is available given the specialized needs of the medically\nfragile child. In the case of Medicaid managed care, the health\nmaintenance organization shall pay, for all days of residential health\ncare facility care at a participating specialty care center for\nmedically fragile children when the health maintenance organization and\nthe specialty care facility mutually agree the patient is ready for\ndischarge from the specialty care center to the patient's home but\nrequires specialized home services that are not available or in place.\nIn the case of Medicaid managed care, such requirements shall apply\nuntil the health plan can identify and secure admission to an alternate\nprovider rendering the necessary level of services. The specialty care\ncenter shall facilitate placement efforts to effectuate the discharge.\n 5. In the event a health maintenance organization enters into a\nparticipation agreement with a specialty care center for medically\nfragile children in this state, the requirements of this section shall\napply to such participation agreement and to all claims submitted to, or\npayments made by, any other health maintenance organizations, insurers\nor payors making payment to the specialty care center pursuant to the\nprovisions of that participation agreement.\n