Bill Text: NY S01319 | 2023-2024 | General Assembly | Introduced

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Bill Title: Creates clinical standards and special consideration and processes for utilization review related to care for medically fragile children; makes changes to the effectiveness thereof.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Passed) 2023-06-30 - SIGNED CHAP.170 [S01319 Detail]

Download: New_York-2023-S01319-Introduced.html

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                STATE OF NEW YORK
        ________________________________________________________________________

                                          1319

                               2023-2024 Regular Sessions

                    IN SENATE

                                    January 11, 2023
                                       ___________

        Introduced  by  Sen.  RIVERA -- read twice and ordered printed, and when
          printed to be committed to the Committee on Rules

        AN ACT to amend the public health law and the insurance law, in relation
          to clinical standards for utilization review  of  care  for  medically
          fragile  children; to amend a chapter of the laws of 2022 amending the
          public health law and the insurance law relating to enhancing coverage
          and care for medically fragile children, as  proposed  in  legislative
          bills  numbers  S.2121-C and A.289-C, in relation to the effectiveness
          thereof; and to repeal certain provisions of the public health law and
          the insurance law relating to medically fragile children

          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:

     1    Section  1. Subparagraphs (iv) and (v) of paragraph (a) of subdivision
     2  2 of section 4900 of the public health law, subparagraph (iv) as amended
     3  and subparagraph (v) as added by a chapter of the laws of 2022  amending
     4  the public health law and the insurance law relating to enhancing cover-
     5  age  and care for medically fragile children, as proposed in legislative
     6  bills numbers S.2121-C and A.289-C, are amended to read as follows:
     7    (iv) for purposes of a determination involving treatment for a  mental
     8  health condition:
     9    (A)  a  physician  who  possesses  a  current and valid non-restricted
    10  license to practice medicine and who specializes  in  behavioral  health
    11  and  has  experience  in the delivery of mental health courses of treat-
    12  ment; or
    13    (B) a health care professional other than  a  licensed  physician  who
    14  specializes in behavioral health and has experience in the delivery of a
    15  mental  health  courses  of treatment and, where applicable, possesses a
    16  current and valid non-restricted license, certificate,  or  registration
    17  or,  where  no  provision  for  a  license,  certificate or registration
    18  exists, is credentialed by the national accrediting body appropriate  to
    19  the profession; [or

         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD04301-01-3
        S. 1319                             2

     1    (v) for purposes of a determination involving treatment of a medically
     2  fragile child:
     3    (A)  a  physician  who  possesses  a  current and valid non-restricted
     4  license to practice medicine and who is board certified or board  eligi-
     5  ble  in pediatric rehabilitation, pediatric critical care, or neonatolo-
     6  gy; or
     7    (B) a physician who  possesses  a  current  and  valid  non-restricted
     8  license  to  practice  medicine  and  is  board certified in a pediatric
     9  subspecialty directly relevant to the patient's medical condition;] and
    10    § 2. Paragraph (b) of subdivision 2 of  section  4900  of  the  public
    11  health  law,  as  amended  by a chapter of the laws of 2022 amending the
    12  public health law and the insurance law relating to  enhancing  coverage
    13  and  care  for  medically  fragile  children, as proposed in legislative
    14  bills numbers S.2121-C and A.289-C, is amended to read as follows:
    15    (b) for purposes of title two of this article:
    16    (i) a physician who:
    17    (A) possesses a current and valid non-restricted license  to  practice
    18  medicine;
    19    (B) where applicable, is board certified or board eligible in the same
    20  or  similar  specialty as the health care provider who typically manages
    21  the medical condition or disease or provides the health care service  or
    22  treatment under appeal;
    23    (C)  has  been practicing in such area of specialty for a period of at
    24  least five years; and
    25    (D) is knowledgeable about the health care service or treatment  under
    26  appeal; or
    27    (ii) a health care professional other than a licensed physician who:
    28    (A)  where  applicable,  possesses  a current and valid non-restricted
    29  license, certificate or registration;
    30    (B) where applicable, is credentialed by the national accrediting body
    31  appropriate to the profession in the same profession and same or similar
    32  specialty as the health care provider who typically manages the  medical
    33  condition  or  disease  or provides the health care service or treatment
    34  under appeal;
    35    (C) has been practicing in such area of specialty for a period  of  at
    36  least five years;
    37    (D)  is knowledgeable about the health care service or treatment under
    38  appeal; and
    39    (E) where applicable to such health care professional's scope of prac-
    40  tice, is clinically supported by a physician who possesses a current and
    41  valid non-restricted license to practice medicine[; or
    42    (iii) for  purposes  of  a  determination  involving  treatment  of  a
    43  medically fragile child:
    44    (A)  a  physician  who  possesses  a  current and valid non-restricted
    45  license to practice medicine and who is board certified or board  eligi-
    46  ble  in pediatric rehabilitation, pediatric critical care, or neonatolo-
    47  gy, or
    48    (B) a physician who  possesses  a  current  and  valid  non-restricted
    49  license  to  practice  medicine  and  is  board certified in a pediatric
    50  subspecialty directly relevant to the patient's medical condition].
    51    § 3. Subdivision 2-a of section 4900 of  the  public  health  law,  as
    52  amended  by a chapter of the laws of 2022 amending the public health law
    53  and  the  insurance  law  relating  to  enhancing  coverage and care for
    54  medically fragile children, as proposed  in  legislative  bills  numbers
    55  S.2121-C and A.289-C, is amended to read as follows:
        S. 1319                             3

     1    2-a.  "Clinical  standards"  means  those guidelines and standards set
     2  forth in the utilization review plan by  the  utilization  review  agent
     3  whose adverse determination is under appeal or, in the case of medically
     4  fragile  children, those guidelines and standards as required by section
     5  [forty-nine  hundred three-a] forty-four hundred six-i of this [article]
     6  chapter.
     7    § 4. Paragraph (c) of subdivision 10 of section  4900  of  the  public
     8  health  law,  as  amended  by a chapter of the laws of 2022 amending the
     9  public health law and the insurance law relating to  enhancing  coverage
    10  and  care  for  medically  fragile  children, as proposed in legislative
    11  bills numbers S.2121-C and A.289-C, is amended to read as follows:
    12    (c) a description of practice  guidelines  and  standards  used  by  a
    13  utilization  review  agent  in  carrying  out a determination of medical
    14  necessity, which in the case of medically fragile children shall  incor-
    15  porate  the  standards  required by section [forty-nine hundred three-a]
    16  forty-four hundred six-i of this [article] chapter;
    17    § 5. Subdivision 11 of section 4900 of the public health law as  added
    18  by  a chapter of the laws of 2022 amending the public health law and the
    19  insurance law relating to enhancing  coverage  and  care  for  medically
    20  fragile  children, as proposed in legislative bills numbers S.2121-C and
    21  A.289-C is REPEALED.
    22    § 6. Section 4401 of the public health law is amended by adding a  new
    23  subdivision 9 to read as follows:
    24    9.  "Medically fragile child" means an individual who is under twenty-
    25  one years of age and has a chronic debilitating condition or conditions,
    26  who may or may not be hospitalized or institutionalized, and  meets  one
    27  or  more  of the following criteria (a) is technologically dependent for
    28  life or health sustaining functions, (b) requires a  complex  medication
    29  regimen  or medical interventions to maintain or to improve their health
    30  status, or (c) is in need  of  ongoing  assessment  or  intervention  to
    31  prevent  serious deterioration of their health status or medical compli-
    32  cations that place their life, health or development  at  risk.  Chronic
    33  debilitating  conditions  include  bronchopulmonary  dysplasia, cerebral
    34  palsy, congenital heart disease, microcephaly,  pulmonary  hypertension,
    35  and  muscular  dystrophy.  The term "medically fragile child" shall also
    36  include traumatic brain injury, the nature of which  typically  requires
    37  care  in  a  specialty  care center for medically fragile children, even
    38  though the child does not have a chronic debilitating condition or  also
    39  meet  one  of the three conditions of this subdivision.  Notwithstanding
    40  the definitions set forth in this subdivision,  any  patient  which  has
    41  received  prior  approval  from  a  health  maintenance organization for
    42  admission to a specialty care facility for  medically  fragile  children
    43  shall  be  considered a medically fragile child at least until discharge
    44  from that facility occurs.
    45    § 7. Subdivision 1 of section 4902 of the public health law is amended
    46  by adding a new paragraph (l) to read as follows:
    47    (l) The commissioner,  in  consultation  with  the  superintendent  of
    48  financial  services, may, as necessary, promulgate by regulation special
    49  considerations and processes for utilization review related to medically
    50  fragile children. Such regulations may include, at a minimum,  consider-
    51  ations and processes related to:
    52    (i)  medically  necessary  covered services to medically fragile chil-
    53  dren;
    54    (ii) determinations specific to the needs of medically  fragile  chil-
    55  dren;
    56    (iii) stabilization and discharge plans; and
        S. 1319                             4

     1    (iv) payment for the care of medically fragile children.
     2    § 8. Section 4903-a of the public health law is REPEALED.
     3    §  9.  The public health law is amended by adding a new section 4406-i
     4  to read as follows:
     5    § 4406-i. Utilization  review  determinations  for  medically  fragile
     6  children.  1.  Notwithstanding  any inconsistent provision of the health
     7  maintenance organization's clinical standards,  the  health  maintenance
     8  organization,  and any utilization review agent under contract with such
     9  health maintenance organization, shall administer and apply the clinical
    10  standards (and  make  determinations  of  medical  necessity)  regarding
    11  medically  fragile  children in accordance with the requirements of this
    12  section and any regulations with special  considerations  and  processes
    13  for utilization review related to medically fragile children.
    14    2. Health maintenance organizations shall undertake the following with
    15  respect  to  medically fragile children, and as applicable, shall ensure
    16  that their contracted utilization review agents undertake the  following
    17  with respect to medically fragile children:
    18    (a)  Consider  as medically necessary all covered services that assist
    19  medically fragile children in reaching their maximum functional  capaci-
    20  ty,  taking  into account the appropriate functional capacities of chil-
    21  dren of the same age. In the case of Medicaid managed care, health main-
    22  tenance organizations shall continue to cover services until that  child
    23  achieves age-appropriate functional capacity.
    24    (b)  Shall not base determinations solely upon review standards appli-
    25  cable to (or designed for) adults to medically fragile children.  Deter-
    26  minations shall take into consideration the specific needs of the  child
    27  and the circumstances pertaining to their growth and development.
    28    (c)  Accommodate  unusual  stabilization and prolonged discharge plans
    29  for medically  fragile  children,  as  appropriate.  Health  maintenance
    30  organizations,  and  as  applicable  their contracted utilization review
    31  agents, shall consider when developing  and  approving  discharge  plans
    32  issues  including  sudden  reversals  of condition or progress which may
    33  make discharge decisions uncertain or  more  prolonged  than  for  other
    34  children or adults.
    35    (d)  It  is  the  health maintenance organization's network management
    36  responsibility to identify  an  available  provider  of  needed  covered
    37  services,  as  determined through a person centered care plan, to effect
    38  safe discharge from a hospital or other facility. In the case  of  Medi-
    39  caid  managed care, payments shall not be denied to a discharging hospi-
    40  tal or other facility due to lack of an available post-discharge provid-
    41  er as long as they have worked with  the  utilization  review  agent  to
    42  identify an appropriate provider.
    43    (e) This section does not limit any other rights the medically fragile
    44  child  may  have,  including  the  right  to appeal the denial of out of
    45  network coverage at in-network cost sharing levels where an  appropriate
    46  in-network  provider  is  not available pursuant to subdivision one-b of
    47  section forty-nine hundred four of this chapter.
    48    (f) Health maintenance organizations  shall  contract  with  providers
    49  with  demonstrated  expertise  in caring for the medically fragile chil-
    50  dren.  Network providers shall refer to  appropriate  network  community
    51  and  facility  providers  for  covered services to meet the needs of the
    52  child or seek authorization from the health maintenance organization for
    53  out-of-network providers when participating providers  cannot  meet  the
    54  child's needs.
    55    3.  In  the case of Medicaid managed care, when rendering or arranging
    56  for care or payment, both the provider and the health maintenance organ-
        S. 1319                             5

     1  ization shall inquire of, and shall consider the desires of  the  family
     2  of  a  medically fragile child including, but not limited to, the avail-
     3  ability and capacity of the family, the need for the  family  to  simul-
     4  taneously care for the family's other children, and the need for parents
     5  to continue employment.
     6    4. In the case of Medicaid managed care, the health maintenance organ-
     7  ization  shall  pay for all days of inpatient hospital care at a partic-
     8  ipating specialty care center for medically fragile  children  when  the
     9  health maintenance organization and the specialty care facility mutually
    10  agree  the patient is ready for discharge from the specialty care center
    11  to the patient's home but requires specialized home  services  that  are
    12  not  available  or  in  place, or the patient is awaiting discharge to a
    13  residential health care facility when no residential health care facili-
    14  ty bed is available given the specialized needs of the medically fragile
    15  child. In the case of Medicaid  managed  care,  the  health  maintenance
    16  organization shall pay, for all days of residential health care facility
    17  care  at  a  participating  specialty  care center for medically fragile
    18  children when the health maintenance organization and the specialty care
    19  facility mutually agree the patient is  ready  for  discharge  from  the
    20  specialty  care  center  to  the patient's home but requires specialized
    21  home services that are not available or in place. In the case  of  Medi-
    22  caid  managed  care, such requirements shall apply until the health plan
    23  can identify and secure admission to an alternate provider rendering the
    24  necessary level of services. The specialty care center shall  facilitate
    25  placement efforts to effectuate the discharge.
    26    5.  In  the  event  a  health  maintenance  organization enters into a
    27  participation agreement with a specialty care center for medically frag-
    28  ile children in this state, the requirements of this section shall apply
    29  to such participation agreement and  to  all  claims  submitted  to,  or
    30  payments  made  by, any other health maintenance organizations, insurers
    31  or payors making payment to the specialty care center  pursuant  to  the
    32  provisions of that participation agreement.
    33    § 10. Subdivision 9 of section 4403 of the public health law, as added
    34  by  a chapter of the laws of 2022 amending the public health law and the
    35  insurance law relating to enhancing  coverage  and  care  for  medically
    36  fragile  children, as proposed in legislative bills numbers S.2121-C and
    37  A.289-C, is amended to read as follows:
    38    9. A health maintenance organization shall have procedures for  cover-
    39  age of medically fragile children including[, but not limited to,] those
    40  necessary  to  implement section [forty-nine hundred three-a] forty-four
    41  hundred six-i of this article.
    42    § 11. Subparagraphs (D) and (E) of paragraph 1 of  subsection  (b)  of
    43  section  4900  of  the  insurance  law,  subparagraph (D) as amended and
    44  subparagraph (E) as added by a chapter of the laws of 2022 amending  the
    45  public  health  law and the insurance law relating to enhancing coverage
    46  and care for medically fragile  children,  as  proposed  in  legislative
    47  bills numbers S.2121-C and A.289-C, are amended to read as follows:
    48    (D)  for  purposes of a determination involving treatment for a mental
    49  health condition:
    50    (i) a physician who  possesses  a  current  and  valid  non-restricted
    51  license  to  practice  medicine and who specializes in behavioral health
    52  and has experience in the delivery of mental health  courses  of  treat-
    53  ment; or
    54    (ii)  a  health  care professional other than a licensed physician who
    55  specializes in behavioral health and has experience in the  delivery  of
    56  mental  health  courses  of treatment and, where applicable, possesses a
        S. 1319                             6

     1  current and valid non-restricted license, certificate,  or  registration
     2  or,  where  no  provision  for  a  license,  certificate or registration
     3  exists, is credentialed by the national accrediting body appropriate  to
     4  the profession; [or
     5    (E) for purposes of a determination involving treatment of a medically
     6  fragile child:
     7    (i)  a  physician  who  possesses  a  current and valid non-restricted
     8  license to practice medicine and who is board certified or board  eligi-
     9  ble  in pediatric rehabilitation, pediatric critical care, or neonatolo-
    10  gy; or
    11    (ii) a physician who possesses  a  current  and  valid  non-restricted
    12  license  to  practice  medicine  and  is  board certified in a pediatric
    13  subspecialty directly relevant to the patient's medical condition;] and
    14    § 12. Paragraph 2 of subsection (b) of section 4900 of  the  insurance
    15  law,  as  amended  by  a chapter of the laws of 2022 amending the public
    16  health law and the insurance law relating to enhancing coverage and care
    17  for medically fragile children, as proposed in legislative bills numbers
    18  S.2121-C and A.289-C, is amended to read as follows:
    19    (2) for purposes of title two of this article:
    20    (A) a physician who:
    21    (i) possesses a current and valid non-restricted license  to  practice
    22  medicine;
    23    (ii)  where  applicable,  is  board certified or board eligible in the
    24  same or similar specialty as the  health  care  provider  who  typically
    25  manages  the  medical  condition  or disease or provides the health care
    26  service or treatment under appeal;
    27    (iii) has been practicing in such area of specialty for a period of at
    28  least five years; and
    29    (iv) is knowledgeable about the health care service or treatment under
    30  appeal; or
    31    (B) a health care professional other than a licensed physician who:
    32    (i) where applicable, possesses a  current  and  valid  non-restricted
    33  license, certificate or registration;
    34    (ii)  where  applicable,  is  credentialed by the national accrediting
    35  body appropriate to the profession in the same profession  and  same  or
    36  similar  specialty as the health care provider who typically manages the
    37  medical condition or disease or provides  the  health  care  service  or
    38  treatment under appeal;
    39    (iii) has been practicing in such area of specialty for a period of at
    40  least five years;
    41    (iv) is knowledgeable about the health care service or treatment under
    42  appeal; and
    43    (v) where applicable to such health care professional's scope of prac-
    44  tice, is clinically supported by a physician who possesses a current and
    45  valid non-restricted license to practice medicine[; or
    46    (C) for purposes of a determination involving treatment of a medically
    47  fragile child:
    48    (i)  a  physician  who  possesses  a  current and valid non-restricted
    49  license to practice medicine and who is board certified or board  eligi-
    50  ble  in pediatric rehabilitation, pediatric critical care, or neonatolo-
    51  gy; or
    52    (ii) a physician who possesses  a  current  and  valid  non-restricted
    53  license  to  practice  medicine  and  is  board certified in a pediatric
    54  subspecialty directly relevant to the patient's medical condition].
    55    § 13. Subsection (b-1) of  section  4900  of  the  insurance  law,  as
    56  amended  by a chapter of the laws of 2022 amending the public health law
        S. 1319                             7

     1  and the insurance law  relating  to  enhancing  coverage  and  care  for
     2  medically  fragile  children,  as  proposed in legislative bills numbers
     3  S.2121-C and A.289-C, is amended to read as follows:
     4    (b-1)  "Clinical  standards"  means those guidelines and standards set
     5  forth in the utilization review plan by  the  utilization  review  agent
     6  whose adverse determination is under appeal or, in the case of medically
     7  fragile  children  those guidelines and standards as required by section
     8  [forty-nine hundred three-a] three thousand two hundred seventeen-j  and
     9  four thousand three hundred six-i of this [article] chapter.
    10    §  14. Subsection (j) of section 4900 of the insurance law, as amended
    11  by a chapter of the laws of 2022 amending the public health law and  the
    12  insurance  law  relating  to  enhancing  coverage and care for medically
    13  fragile children, as proposed in legislative bills numbers S.2121-C  and
    14  A.289-C, is amended to read as follows:
    15    (j)  "Utilization review plan" means: (1) a description of the process
    16  for developing the written clinical review criteria; (2)  a  description
    17  of  the  types  of  written  clinical  information  which the plan might
    18  consider in its clinical review, including [but not limited to,]  a  set
    19  of specific written clinical review criteria; (3) a description of prac-
    20  tice  guidelines  and  standards  used  by a utilization review agent in
    21  carrying out a determination of medical necessity, which, in the case of
    22  medically fragile children, shall incorporate the standards required  by
    23  [section forty-nine hundred three-a] sections three thousand two hundred
    24  seventeen-j  and  four  thousand  three  hundred six-i of this [article]
    25  chapter; (4) the procedures for scheduled review and evaluation  of  the
    26  written  clinical  review  criteria; and (5) a description of the quali-
    27  fications and experience of the health care professionals who  developed
    28  the  criteria, who are responsible for periodic evaluation of the crite-
    29  ria and of the health care professionals or others who use  the  written
    30  clinical review criteria in the process of utilization review.
    31    § 15. Subsection (k) of section 4900 of the insurance law, as added by
    32  a  chapter of the laws of 2022 amending the public health and the insur-
    33  ance law relating to enhancing coverage and care for  medically  fragile
    34  children,  as  proposed  in  legislative  bills numbers S. 2121-C and A.
    35  289-C, is REPEALED.
    36    § 16. Subsection (a) of section 107 of the insurance law is amended by
    37  adding a new paragraph 55 to read as follows:
    38    (55) "Medically fragile child" means an individual who is under  twen-
    39  ty-one  years  of age and has a chronic debilitating condition or condi-
    40  tions, who may or may not  be  hospitalized  or  institutionalized,  and
    41  meets  one  or  more  of  the following criteria: (1) is technologically
    42  dependent for life  or  health  sustaining  functions;  (2)  requires  a
    43  complex  medication  regimen  or medical interventions to maintain or to
    44  improve their health status; or (3) is in need of ongoing assessment  or
    45  intervention  to prevent serious deterioration of their health status or
    46  medical complications that place their life, health  or  development  at
    47  risk.  Chronic  debilitating conditions include bronchopulmonary dyspla-
    48  sia, cerebral palsy, congenital heart disease,  microcephaly,  pulmonary
    49  hypertension, and muscular dystrophy. The term "medically fragile child"
    50  shall also include traumatic brain injury, the nature of which typically
    51  require  care in a specialty care center for medically fragile children,
    52  even though the child does not have a chronic debilitating condition  or
    53  also meet one of the three conditions of this subsection.  Notwithstand-
    54  ing  the definitions set forth in this subsection, any patient which has
    55  received prior approval from an insurer for  admission  to  a  specialty
    56  care  facility  for  medically  fragile  children  shall be considered a
        S. 1319                             8

     1  medically fragile child at least  until  discharge  from  that  facility
     2  occurs.
     3    §  17.  Subsection (a) of section 4902 of the insurance law is amended
     4  by adding a new paragraph 14 to read as follows:
     5    (14) The superintendent, in  consultation  with  the  commissioner  of
     6  health,  may,  as  necessary, promulgate by regulation special consider-
     7  ations and processes for utilization review related to medically fragile
     8  children. Such regulations may include, at a minimum, considerations and
     9  processes related to:
    10    (i) medically necessary covered services to  medically  fragile  chil-
    11  dren;
    12    (ii)  determinations  specific to the needs of medically fragile chil-
    13  dren;
    14    (iii) stabilization and discharge plans; and
    15    (iv) payment for the care of medically fragile children.
    16    § 18. Section 4903-a of the insurance law, as added by  a  chapter  of
    17  the laws of 2022 amending the public health and the insurance law relat-
    18  ing  to  enhancing  coverage and care for medically fragile children, as
    19  proposed in legislative  bills  numbers  S.  2121-C  and  A.  289-C,  is
    20  REPEALED.
    21    §  19.  Section  3217-j of the insurance law, as added by a chapter of
    22  the laws of 2022 amending the public health law and  the  insurance  law
    23  relating  to enhancing coverage and care for medically fragile children,
    24  as proposed in  legislative  bills  numbers  S.2121-C  and  A.289-C,  is
    25  REPEALED and a new section 3217-j is added to read as follows:
    26    §  3217-j.  Utilization  review  determinations  for medically fragile
    27  children. (a) Notwithstanding any inconsistent provision of  the  insur-
    28  er's  clinical  standards, the insurer, and any utilization review agent
    29  under contract with such insurer, shall administer and apply  the  clin-
    30  ical  standards (and make determinations of medical necessity) regarding
    31  medically fragile children in accordance with the requirements  of  this
    32  section  and  any  regulations with special considerations and processes
    33  for utilization review related to medically fragile children.
    34    (b) Insurers shall undertake the following with respect  to  medically
    35  fragile  children, and as applicable, shall ensure that their contracted
    36  utilization review  agents  undertake  the  following  with  respect  to
    37  medically fragile children:
    38    (1)  Consider  as medically necessary all covered services that assist
    39  medically fragile children in reaching their maximum functional  capaci-
    40  ty,  taking  into account the appropriate functional capacities of chil-
    41  dren of the same age.
    42    (2) Shall not base determinations solely upon review standards  appli-
    43  cable to (or designed for) adults to medically fragile children.  Deter-
    44  minations  shall take into consideration the specific needs of the child
    45  and the circumstances pertaining to their growth and development.
    46    (3) Accommodate unusual stabilization and  prolonged  discharge  plans
    47  for  medically fragile children, as appropriate. Insurers, and as appli-
    48  cable their contracted utilization review agents,  shall  consider  when
    49  developing   and  approving  discharge  plans  issues  including  sudden
    50  reversals of condition or progress, which may make  discharge  decisions
    51  uncertain or more prolonged than for other children or adults.
    52    (4)  It  is  the  insurer's  network management responsibility under a
    53  managed care health insurance contract as defined in subsection  (c)  of
    54  section  four  thousand eight hundred one of this chapter to identify an
    55  available provider of needed covered services, as determined  through  a
        S. 1319                             9

     1  person  centered  care plan, to effect safe discharge from a hospital or
     2  other facility.
     3    (5)  This  section does not limit any other rights a medically fragile
     4  child may have, including the right to  appeal  the  denial  of  out  of
     5  network  coverage at in-network cost sharing levels where an appropriate
     6  in-network provider is not available pursuant  to  subsection  a-two  of
     7  section four thousand nine hundred four of this chapter.
     8    (6) Insurers shall contract with providers with demonstrated expertise
     9  in  caring  for  the medically fragile children. Network providers shall
    10  refer to  appropriate  network  community  and  facility  providers  for
    11  covered  services  to  meet the needs of the child or seek authorization
    12  from the insurer for out-of-network providers when participating provid-
    13  ers cannot meet the child's needs.
    14    (c) In the event an insurer enters into a participation agreement with
    15  a specialty care center for medically fragile children  in  this  state,
    16  the  requirements  of  this  section  shall  apply to that participation
    17  agreement and to all claims submitted to, or payments made by, any other
    18  insurers, health maintenance organizations or payors making  payment  to
    19  the  specialty  care  center  pursuant to the provisions of that partic-
    20  ipation agreement.
    21    § 20. Section 4306-i of the insurance law, as added by  a  chapter  of
    22  the  laws  of  2022 amending the public health law and the insurance law
    23  relating to enhancing coverage and care for medically fragile  children,
    24  as  proposed  in  legislative  bills  numbers  S.2121-C  and A.289-C, is
    25  amended to read as follows:
    26    § 4306-i. Coverage for medically fragile children. A corporation  that
    27  is  subject  to the provisions of this article shall have procedures for
    28  coverage of medically fragile children [including, but not  limited  to,
    29  those necessary to implement section four thousand nine hundred three-a]
    30  consistent  with  section three thousand two hundred seventeen-j of this
    31  chapter.
    32    § 21. Section 17 of a chapter of the laws of 2022 amending the  public
    33  health law and the insurance law relating to enhancing coverage and care
    34  for medically fragile children, as proposed in legislative bills numbers
    35  S.2121-C and A.289-C, is amended to read as follows:
    36    § 17. This act shall take effect on the first day of [January] Septem-
    37  ber after it becomes a law.
    38    § 22. Sections three, four, six, seven, nine, ten, thirteen, fourteen,
    39  sixteen,  seventeen,  nineteen and twenty of this act shall not apply to
    40  any qualified health plans in the individual and small group  market  on
    41  and  after  the  date, if any, when the federal department of health and
    42  human services determines in writing  that  such  provisions  constitute
    43  state-required benefits in addition to essential health benefits, pursu-
    44  ant to the federal Affordable Care Act and regulations promulgated ther-
    45  eunder.
    46    §  23.  This act shall take effect immediately; provided that sections
    47  one through twenty of this act shall take effect on the same date and in
    48  the same manner as a chapter of the laws of  2022  amending  the  public
    49  health law and the insurance law relating to enhancing coverage and care
    50  for medically fragile children, as proposed in legislative bills numbers
    51  S.2121-C and A.289-C, takes effect.