The New York State Senate

 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   9098
 
                           I N  A S S E M B L Y
 
                             January 17, 2020
                                ___________
 
 Introduced  by  M.  of  A.  GOTTFRIED  --  read once and referred to the
   Committee on Insurance
 
 AN ACT to amend the public health law and the insurance law, in relation
   to enhancing coverage and care for medically fragile children
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:

   Section  1.  Subparagraph  (iv)  of  paragraph (a) of subdivision 2 of
 section 4900 of the public health law, as added by section 42 of subpart
 A of part BB of chapter 57 of the laws of 2019, is  amended  and  a  new
 subparagraph (v) is added to read as follows:
   (iv)  for purposes of a determination involving treatment for a mental
 health condition:
   (A) a physician who  possesses  a  current  and  valid  non-restricted
 license  to  practice  medicine and who specializes in behavioral health
 and has experience in the delivery of mental health  courses  of  treat-
 ment; or
   (B)  a  health  care  professional other than a licensed physician who
 specializes in behavioral health and has experience in the delivery of a
 mental health courses of treatment and, where  applicable,  possesses  a
 current  and  valid non-restricted license, certificate, or registration
 or, where no  provision  for  a  license,  certificate  or  registration
 exists,  is credentialed by the national accrediting body appropriate to
 the profession; [and] OR
   (V) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT OF A MEDICALLY
 FRAGILE CHILD:
   (A) A PHYSICIAN WHO  POSSESSES  A  CURRENT  AND  VALID  NON-RESTRICTED
 LICENSE  TO PRACTICE MEDICINE AND WHO IS BOARD CERTIFIED OR BOARD ELIGI-
 BLE IN PEDIATRIC REHABILITATION, PEDIATRIC CRITICAL CARE, OR  NEONATOLO-
 GY; OR
   (B)  A  PHYSICIAN  WHO  POSSESSES  A  CURRENT AND VALID NON-RESTRICTED
 LICENSE TO PRACTICE MEDICINE AND  IS  BOARD  CERTIFIED  IN  A  PEDIATRIC
 SUBSPECIALTY DIRECTLY RELEVANT TO THE PATIENT'S MEDICAL CONDITION; AND

  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD14313-03-0

 A. 9098                             2
 
   §  2.  Paragraph  (b)  of  subdivision 2 of section 4900 of the public
 health law, as amended by chapter 586 of the laws of 1998, is amended to
 read as follows:
   (b) for purposes of title two of this article:
   (i) a physician who:
   (A)  possesses  a current and valid non-restricted license to practice
 medicine;
   (B) where applicable, is board certified or board eligible in the same
 or similar specialty as the health care provider who  typically  manages
 the  medical condition or disease or provides the health care service or
 treatment under appeal;
   (C) has been practicing in such area of specialty for a period  of  at
 least five years; and
   (D)  is knowledgeable about the health care service or treatment under
 appeal; or
   (ii) a health care professional other than a licensed physician who:
   (A) where applicable, possesses a  current  and  valid  non-restricted
 license, certificate or registration;
   (B) where applicable, is credentialed by the national accrediting body
 appropriate to the profession in the same profession and same or similar
 specialty  as the health care provider who typically manages the medical
 condition or disease or provides the health care  service  or  treatment
 under appeal;
   (C)  has  been practicing in such area of specialty for a period of at
 least five years;
   (D) is knowledgeable about the health care service or treatment  under
 appeal; and
   (E) where applicable to such health care professional's scope of prac-
 tice, is clinically supported by a physician who possesses a current and
 valid non-restricted license to practice medicine; OR
   (III)  FOR  PURPOSES  OF  A  DETERMINATION  INVOLVING  TREATMENT  OF A
 MEDICALLY FRAGILE CHILD:
   (A) A PHYSICIAN WHO  POSSESSES  A  CURRENT  AND  VALID  NON-RESTRICTED
 LICENSE  TO PRACTICE MEDICINE AND WHO IS BOARD CERTIFIED OR BOARD ELIGI-
 BLE IN PEDIATRIC REHABILITATION, PEDIATRIC CRITICAL CARE, OR  NEONATOLO-
 GY, OR
   (B)  A  PHYSICIAN  WHO  POSSESSES  A  CURRENT AND VALID NON-RESTRICTED
 LICENSE TO PRACTICE MEDICINE AND  IS  BOARD  CERTIFIED  IN  A  PEDIATRIC
 SUBSPECIALTY DIRECTLY RELEVANT TO THE PATIENT'S MEDICAL CONDITION.
   §  3.  Subdivision  2-a  of  section 4900 of the public health law, as
 added by chapter 586 of the laws of 1998, is amended to read as follows:
   2-a. "Clinical standards" means those  guidelines  and  standards  set
 forth  in  the  utilization  review plan by the utilization review agent
 whose adverse determination is under appeal OR, IN THE CASE OF MEDICALLY
 FRAGILE CHILDREN, THOSE GUIDELINES AND STANDARDS AS REQUIRED BY  SECTION
 FORTY-NINE HUNDRED THREE-A OF THIS ARTICLE.
   §  4.  Paragraph  (c)  of subdivision 10 of section 4900 of the public
 health law, as added by chapter 705 of the laws of 1996, is  amended  to
 read as follows:
   (c)  a  description  of  practice  guidelines  and standards used by a
 utilization review agent in carrying  out  a  determination  of  medical
 necessity,  WHICH IN THE CASE OF MEDICALLY FRAGILE CHILDREN SHALL INCOR-
 PORATE THE STANDARDS REQUIRED BY SECTION FORTY-NINE HUNDRED  THREE-A  OF
 THIS ARTICLE;
   §  5. Section 4900 of the public health law is amended by adding a new
 subdivision 11 to read as follows:

 A. 9098                             3
 
   11. "MEDICALLY FRAGILE CHILD" MEANS AN INDIVIDUAL WHO IS  UNDER  TWEN-
 TY-ONE  YEARS  OF AGE AND HAS A CHRONIC DEBILITATING CONDITION OR CONDI-
 TIONS, WHO MAY OR MAY NOT  BE  HOSPITALIZED  OR  INSTITUTIONALIZED,  AND
 MEETS  ONE  OR  MORE  OF  THE  FOLLOWING CRITERIA (A) IS TECHNOLOGICALLY
 DEPENDENT  FOR  LIFE  OR  HEALTH  SUSTAINING  FUNCTIONS,  (B) REQUIRES A
 COMPLEX MEDICATION REGIMEN OR MEDICAL INTERVENTIONS TO  MAINTAIN  OR  TO
 IMPROVE  THEIR HEALTH STATUS, OR (C) IS IN NEED OF ONGOING ASSESSMENT OR
 INTERVENTION TO PREVENT SERIOUS DETERIORATION OF THEIR HEALTH STATUS  OR
 MEDICAL  COMPLICATIONS  THAT  PLACE THEIR LIFE, HEALTH OR DEVELOPMENT AT
 RISK. CHRONIC DEBILITATING CONDITIONS INCLUDE, BUT ARE NOT  LIMITED  TO,
 BRONCHOPULMONARY  DYSPLASIA,  CEREBRAL  PALSY, CONGENITAL HEART DISEASE,
 MICROCEPHALY, PULMONARY HYPERTENSION, AND MUSCULAR DYSTROPHY.  THE  TERM
 "MEDICALLY  FRAGILE CHILD" SHALL ALSO INCLUDE SEVERE CONDITIONS, INCLUD-
 ING BUT NOT LIMITED TO TRAUMATIC BRAIN INJURY, WHICH  TYPICALLY  REQUIRE
 CARE  IN  A  SPECIALTY  CARE CENTER FOR MEDICALLY FRAGILE CHILDREN, EVEN
 THOUGH THE CHILD DOES NOT HAVE A CHRONIC DEBILITATING CONDITION OR  ALSO
 MEET ONE OF THE THREE CONDITIONS OF THIS SUBDIVISION. IN ORDER TO FACIL-
 ITATE  THE  PROMPT  AND  CONVENIENT IDENTIFICATION OF PARTICULAR PATIENT
 CARE SITUATIONS MEETING THE DEFINITIONS OF THIS SUBDIVISION, THE COMMIS-
 SIONER MAY ISSUE WRITTEN GUIDANCE LISTING (BY DIAGNOSIS CODES,  UTILIZA-
 TION  THRESHOLDS,  OR  OTHER  AVAILABLE  CODING OR COMMONLY USED MEDICAL
 CLASSIFICATIONS) THE TYPES OF PATIENT CARE NEEDS  WHICH  ARE  DEEMED  TO
 MEET  THIS DEFINITION. NOTWITHSTANDING THE DEFINITIONS SET FORTH IN THIS
 SUBDIVISION, ANY PATIENT WHICH HAS RECEIVED PRIOR APPROVAL FROM A UTILI-
 ZATION REVIEW AGENT FOR ADMISSION  TO  A  SPECIALTY  CARE  FACILITY  FOR
 MEDICALLY FRAGILE CHILDREN SHALL BE CONSIDERED A MEDICALLY FRAGILE CHILD
 AT LEAST UNTIL DISCHARGE FROM THAT FACILITY OCCURS.
   §  6.  The public health law is amended by adding a new section 4903-a
 to read as follows:
   § 4903-A. UTILIZATION  REVIEW  DETERMINATIONS  FOR  MEDICALLY  FRAGILE
 CHILDREN. 1.  NOTWITHSTANDING ANY INCONSISTENT PROVISION OF THE UTILIZA-
 TION  REVIEW  AGENT'S  CLINICAL  STANDARDS, THE UTILIZATION REVIEW AGENT
 SHALL ADMINISTER AND APPLY THE CLINICAL  STANDARDS  (AND  MAKE  DETERMI-
 NATIONS  OF  MEDICAL  NECESSITY) REGARDING MEDICALLY FRAGILE CHILDREN IN
 ACCORDANCE WITH THE REQUIREMENTS OF THIS  SECTION.  IF  THE  UTILIZATION
 REVIEW  AGENT IS A SEPARATE ENTITY FROM THE HEALTH MAINTENANCE ORGANIZA-
 TION CERTIFIED UNDER ARTICLE FORTY-FOUR  OF  THIS  CHAPTER,  THE  HEALTH
 MAINTENANCE ORGANIZATION SHALL MAKE CONTRACTUAL OR OTHER ARRANGEMENTS IN
 ORDER  TO FACILITATE THE UTILIZATION REVIEW AGENT'S COMPLIANCE WITH THIS
 SECTION.
   2. IN THE CASE OF A  MEDICALLY  FRAGILE  CHILD,  THE  TERM  "MEDICALLY
 NECESSARY"  SHALL  MEAN  HEALTH  CARE AND SERVICES THAT ARE NECESSARY TO
 PROMOTE NORMAL GROWTH AND  DEVELOPMENT  AND  PREVENT,  DIAGNOSE,  TREAT,
 AMELIORATE  OR  PALLIATE  THE EFFECTS OF A PHYSICAL, MENTAL, BEHAVIORAL,
 GENETIC, OR CONGENITAL CONDITION, INJURY OR DISABILITY.  WHEN APPLIED TO
 THE CIRCUMSTANCES OF ANY PARTICULAR MEDICALLY FRAGILE  CHILD,  THE  TERM
 "MEDICALLY  NECESSARY"  SHALL  INCLUDE (A) THE CARE OR SERVICES THAT ARE
 ESSENTIAL TO PREVENT, DIAGNOSE, PREVENT THE WORSENING OF,  ALLEVIATE  OR
 AMELIORATE  THE  EFFECTS  OF AN ILLNESS, INJURY, DISABILITY, DISORDER OR
 CONDITION, (B) THE CARE OR SERVICES THAT ARE ESSENTIAL  TO  THE  OVERALL
 PHYSICAL,  COGNITIVE  AND  MENTAL  GROWTH AND DEVELOPMENTAL NEEDS OF THE
 CHILD, AND (C) THE CARE OR  SERVICES  THAT  WILL  ASSIST  THE  CHILD  TO
 ACHIEVE  OR  MAINTAIN  MAXIMUM  FUNCTIONAL  CAPACITY IN PERFORMING DAILY
 ACTIVITIES, TAKING INTO ACCOUNT BOTH  THE  FUNCTIONAL  CAPACITY  OF  THE
 CHILD  AND THOSE FUNCTIONAL CAPACITIES THAT ARE APPROPRIATE FOR INDIVID-
 UALS OF THE SAME AGE AS THE CHILD. THE UTILIZATION  REVIEW  AGENT  SHALL

 A. 9098                             4

 BASE  ITS  DETERMINATION  ON  MEDICAL  AND  OTHER  RELEVANT  INFORMATION
 PROVIDED BY THE CHILD'S PRIMARY CARE PROVIDER, OTHER HEALTH CARE PROVID-
 ERS, SCHOOL, LOCAL SOCIAL SERVICES, AND/OR LOCAL PUBLIC HEALTH OFFICIALS
 THAT  HAVE  EVALUATED  THE  CHILD, AND THE UTILIZATION REVIEW AGENT WILL
 ENSURE THE CARE AND SERVICES ARE PROVIDED IN SUFFICIENT AMOUNT, DURATION
 AND SCOPE TO REASONABLY BE EXPECTED TO PRODUCE THE INTENDED RESULTS  AND
 TO  HAVE  THE  EXPECTED  BENEFITS  THAT  OUTWEIGH  THE POTENTIAL HARMFUL
 EFFECTS.
   3. UTILIZATION  REVIEW  AGENTS  SHALL  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  CAPACI-
 TY,  TAKING  INTO ACCOUNT THE APPROPRIATE FUNCTIONAL CAPACITIES OF CHIL-
 DREN OF THE SAME AGE. HEALTH MAINTENANCE ORGANIZATIONS MUST CONTINUE  TO
 COVER  SERVICES  UNTIL  THAT  CHILD  ACHIEVES AGE-APPROPRIATE FUNCTIONAL
 CAPACITY. A MANAGED CARE PROVIDER, AUTHORIZED BY SECTION  THREE  HUNDRED
 SIXTY-FOUR-J  OF THE SOCIAL SERVICES LAW, SHALL ALSO BE REQUIRED TO MAKE
 PAYMENT FOR COVERED SERVICES REQUIRED TO COMPLY WITH FEDERAL EARLY PERI-
 ODIC SCREENING, DIAGNOSIS, AND TREATMENT ("EPSDT") STANDARDS, AS  SPECI-
 FIED BY THE COMMISSIONER OF HEALTH.
   (B)  SHALL NOT BASE DETERMINATIONS SOLELY UPON REVIEW STANDARDS APPLI-
 CABLE TO (OR DESIGNED FOR) ADULTS TO MEDICALLY FRAGILE  CHILDREN.  ADULT
 STANDARDS INCLUDE, BUT ARE NOT LIMITED TO, MEDICARE REHABILITATION STAN-
 DARDS  AND  THE "MEDICARE 3 HOUR RULE." DETERMINATIONS HAVE TO 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.  ISSUES  UTILIZATION
 REVIEW  AGENTS  MUST  CONSIDER  WHEN  DEVELOPING AND APPROVING DISCHARGE
 PLANS INCLUDE, BUT ARE NOT LIMITED TO:  SUDDEN REVERSALS OF CONDITION OR
 PROGRESS, WHICH MAY MAKE DISCHARGE DECISIONS UNCERTAIN OR MORE PROLONGED
 THAN FOR OTHER CHILDREN OR ADULTS;  NECESSARY  TRAINING  OF  PARENTS  OR
 OTHER  ADULTS  TO  CARE  FOR MEDICALLY FRAGILE CHILDREN AT HOME; UNUSUAL
 DISCHARGE DELAYS ENCOUNTERED IF  PARENTS  OR  OTHER  RESPONSIBLE  ADULTS
 DECLINE  OR  ARE  SLOW  TO  ASSUME  FULL  RESPONSIBILITY  FOR CARING FOR
 MEDICALLY FRAGILE CHILDREN; THE NEED TO AWAIT  AN  APPROPRIATE  HOME  OR
 HOME-LIKE  ENVIRONMENT  RATHER  THAN  DISCHARGE  TO A HOUSING SHELTER OR
 OTHER INAPPROPRIATE SETTING FOR MEDICALLY FRAGILE CHILDREN, THE NEED  TO
 AWAIT  CONSTRUCTION ADAPTATIONS TO THE HOME (SUCH AS THE INSTALLATION OF
 GENERATORS OR OTHER EQUIPMENT); AND LACK OF AVAILABLE SUITABLE  SPECIAL-
 IZED CARE (SUCH AS UNAVAILABILITY OF PEDIATRIC NURSING HOME BEDS, PEDIA-
 TRIC  VENTILATOR  UNITS,  PEDIATRIC PRIVATE DUTY NURSING IN THE HOME, OR
 SPECIALIZED PEDIATRIC HOME CARE SERVICES).   UTILIZATION  REVIEW  AGENTS
 MUST  DEVELOP  A PERSON CENTERED DISCHARGE PLAN FOR THE CHILD TAKING THE
 ABOVE SITUATIONS INTO CONSIDERATION.
   (D) IT IS THE UTILIZATION REVIEW AGENT'S NETWORK MANAGEMENT  RESPONSI-
 BILITY  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; 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.    UTILIZATION  REVIEW
 AGENTS  ARE  REQUIRED  TO APPROVE THE USE OF OUT-OF-NETWORK PROVIDERS IF
 THE HEALTH  MAINTENANCE  ORGANIZATION  DOES  NOT  HAVE  A  PARTICIPATING
 PROVIDER TO ADDRESS THE NEEDS OF THE CHILD.

 A. 9098                             5
 
   (E) UTILIZATION REVIEW AGENTS MUST ENSURE THAT MEDICALLY FRAGILE CHIL-
 DREN RECEIVE SERVICES FROM APPROPRIATE PROVIDERS THAT HAVE THE EXPERTISE
 TO  EFFECTIVELY  TREAT  THE  CHILD AND MUST CONTRACT WITH PROVIDERS WITH
 DEMONSTRATED EXPERTISE IN CARING FOR  THE  MEDICALLY  FRAGILE  CHILDREN.
 NETWORK  PROVIDERS  SHALL  REFER  TO  APPROPRIATE  NETWORK COMMUNITY AND
 FACILITY PROVIDERS TO MEET THE NEEDS OF THE CHILD OR SEEK  AUTHORIZATION
 FROM  THE  UTILIZATION  REVIEW  AGENT  FOR OUT-OF-NETWORK PROVIDERS WHEN
 PARTICIPATING PROVIDERS CANNOT MEET THE CHILD'S NEEDS.  THE  UTILIZATION
 REVIEW AGENT MUST AUTHORIZE SERVICES AS FAST AS THE ENROLLEE'S CONDITION
 REQUIRES  AND IN ACCORDANCE WITH ESTABLISHED TIMEFRAMES IN THE CONTRACTS
 OR POLICY FORMS.
   4. A HEALTH MAINTENANCE ORGANIZATION SHALL HAVE A PROCEDURE  BY  WHICH
 AN  ENROLLEE  WHO  IS A MEDICALLY FRAGILE CHILD WHO REQUIRES SPECIALIZED
 MEDICAL CARE OVER A PROLONGED PERIOD OF TIME, MAY RECEIVE A REFERRAL  TO
 A  SPECIALTY  CARE  CENTER FOR MEDICALLY FRAGILE CHILDREN. IF THE HEALTH
 MAINTENANCE ORGANIZATION, OR THE PRIMARY CARE PROVIDER OR THE SPECIALIST
 TREATING THE PATIENT, IN CONSULTATION WITH A  MEDICAL  DIRECTOR  OF  THE
 UTILIZATION REVIEW AGENT, DETERMINES THAT THE ENROLLEE'S CARE WOULD MOST
 APPROPRIATELY BE PROVIDED BY SUCH A SPECIALTY CARE CENTER, THE ORGANIZA-
 TION SHALL REFER THE ENROLLEE TO SUCH CENTER. IN NO EVENT SHALL A HEALTH
 MAINTENANCE  ORGANIZATION  BE REQUIRED TO PERMIT AN ENROLLEE TO ELECT TO
 HAVE A NON-PARTICIPATING SPECIALTY CARE CENTER, UNLESS THE  ORGANIZATION
 DOES  NOT  HAVE  AN  APPROPRIATE  SPECIALTY  CARE  CENTER  TO  TREAT THE
 ENROLLEE'S DISEASE OR CONDITION WITHIN ITS NETWORK. SUCH REFERRAL  SHALL
 BE  PURSUANT  TO A TREATMENT PLAN DEVELOPED BY THE SPECIALTY CARE CENTER
 AND APPROVED BY THE HEALTH  MAINTENANCE  ORGANIZATION,  IN  CONSULTATION
 WITH  THE  PRIMARY  CARE  PROVIDER, IF ANY, OR A SPECIALIST TREATING THE
 PATIENT, AND THE ENROLLEE OR THE ENROLLEE'S DESIGNEE. IF AN ORGANIZATION
 REFERS AN ENROLLEE TO A SPECIALTY CARE CENTER THAT DOES NOT  PARTICIPATE
 IN  THE  ORGANIZATION'S  NETWORK,  SERVICES  PROVIDED  PURSUANT  TO  THE
 APPROVED TREATMENT PLAN SHALL BE PROVIDED AT NO ADDITIONAL COST  TO  THE
 ENROLLEE  BEYOND  WHAT  THE  ENROLLEE  WOULD  OTHERWISE PAY FOR SERVICES
 RECEIVED WITHIN THE NETWORK.  FOR PURPOSES OF THIS SECTION, A  SPECIALTY
 CARE  CENTER  FOR  MEDICALLY  FRAGILE  CHILDREN  SHALL MEAN A CHILDREN'S
 HOSPITAL AS DEFINED PURSUANT TO SUBPARAGRAPH (IV) OF PARAGRAPH (E-2)  OF
 SUBDIVISION  FOUR  OF SECTION TWENTY-EIGHT HUNDRED SEVEN-C OF THIS CHAP-
 TER, A RESIDENTIAL HEALTH CARE FACILITY AFFILIATED  WITH  SUCH  A  CHIL-
 DREN'S  HOSPITAL,  ANY RESIDENTIAL HEALTH CARE FACILITY WITH A SPECIALTY
 PEDIATRIC BED AVERAGE DAILY CENSUS  DURING  TWO  THOUSAND  SEVENTEEN  OF
 FIFTY  OR MORE PATIENTS, OR A FACILITY WHICH SATISFIES SUCH OTHER CRITE-
 RIA AS THE COMMISSIONER MAY DESIGNATE.
   5. 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  INCLUD-
 ING,  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.
   6.  THE  HEALTH MAINTENANCE ORGANIZATION MUST PAY AT LEAST EIGHTY-FIVE
 PERCENT OF THE FACILITY'S ACUTE CARE RATE, UNLESS A DIFFERENT  RATE  HAS
 BEEN  MUTUALLY  NEGOTIATED, FOR ALL DAYS OF INPATIENT HOSPITAL CARE AT A
 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 RESI-
 DENTIAL HEALTH CARE FACILITY WHEN NO RESIDENTIAL  HEALTH  CARE  FACILITY

 A. 9098                             6

 BED  IS  AVAILABLE  GIVEN THE SPECIALIZED NEEDS OF THE MEDICALLY FRAGILE
 CHILD. THE HEALTH MAINTENANCE ORGANIZATION MUST PAY AT LEAST THE FACILI-
 TY'S MEDICAID SKILLED NURSING FACILITY RATE, UNLESS A DIFFERENT RATE HAS
 BEEN MUTUALLY NEGOTIATED, FOR ALL DAYS OF RESIDENTIAL HEALTH CARE FACIL-
 ITY  CARE AT A 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. 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  MUST COOPERATE WITH THE HEALTH MAINTENANCE ORGANIZATION'S PLACE-
 MENT EFFORTS.
   7. IN THE EVENT  A  HEALTH  MAINTENANCE  ORGANIZATION  ENTERS  INTO  A
 PARTICIPATION AGREEMENT WITH A SPECIALTY CARE CENTER FOR MEDICALLY FRAG-
 ILE  CHILDREN  IN THIS STATE, AND THE TERMS OF THAT PARTICIPATION AGREE-
 MENT EXTEND TO ONE OR MORE OTHER  HEALTH  MAINTENANCE  ORGANIZATIONS  OR
 INSURERS  (INCLUDING HEALTH MAINTENANCE ORGANIZATIONS AND INSURERS OPER-
 ATING IN OTHER STATES) BY VIRTUE OF AFFILIATION WITH (OR CONTRACTS WITH)
 THE HEALTH MAINTENANCE ORGANIZATION, THE REQUIREMENTS  OF  THIS  ARTICLE
 REGARDING  PROCEDURES  FOR UTILIZATION REVIEW OF MEDICALLY FRAGILE CHIL-
 DREN SHALL APPLY TO THOSE  OTHER  HEALTH  MAINTENANCE  ORGANIZATIONS  OR
 INSURERS.
   8. (A) THE COMMISSIONER SHALL DESIGNATE A SINGLE SET OF CLINICAL STAN-
 DARDS  APPLICABLE  TO  ALL UTILIZATION REVIEW AGENTS REGARDING PEDIATRIC
 EXTENDED ACUTE CARE STAYS (DEFINED FOR THE PURPOSES OF THIS  SECTION  AS
 DISCHARGE  FROM  ONE ACUTE CARE HOSPITAL FOLLOWED BY IMMEDIATE ADMISSION
 TO A SECOND ACUTE CARE HOSPITAL; NOT INCLUDING TRANSFERS OF CASE PAYMENT
 CASES AS DEFINED IN SECTION TWENTY-EIGHT HUNDRED SEVEN-C OF  THIS  CHAP-
 TER).  THE STANDARDS SHALL BE ADAPTED FROM NATIONAL LONG TERM ACUTE CARE
 HOSPITAL STANDARDS FOR ADULTS AND SHALL BE APPROVED BY THE COMMISSIONER,
 AFTER CONSULTATION WITH ONE OR MORE SPECIALTY CARE CENTERS FOR MEDICALLY
 FRAGILE CHILDREN.  THE STANDARDS SHALL INCLUDE, BUT NOT BE  LIMITED  TO,
 SPECIFICATIONS OF THE LEVEL OF CARE SUPPORTS IN THE PATIENT'S HOME, AT A
 SKILLED  NURSING  FACILITY  OR  OTHER  SETTING, THAT MUST BE IN PLACE IN
 ORDER TO SAFELY AND ADEQUATELY CARE FOR A MEDICALLY FRAGILE CHILD BEFORE
 MEDICALLY COMPLEX ACUTE CARE CAN BE DEEMED NO  LONGER  MEDICALLY  NECES-
 SARY.    THE STANDARDS DESIGNATED BY THE COMMISSIONER SHALL PRE-EMPT THE
 CLINICAL STANDARDS, IF ANY, FOR PEDIATRIC EXTENDED ACUTE CARE SET  FORTH
 IN THE UTILIZATION REVIEW PLAN BY THE UTILIZATION REVIEW AGENT.
   (B)  THE  COMMISSIONER  SHALL  DESIGNATE  A SINGLE SET OF SUPPLEMENTAL
 CLINICAL STANDARDS (IN ADDITION TO THE CLINICAL  STANDARDS  SELECTED  BY
 THE  UTILIZATION  REVIEW  AGENT)  APPLICABLE  TO  ALL UTILIZATION REVIEW
 AGENTS  REGARDING  ACUTE  AND  SUB-ACUTE  INPATIENT  REHABILITATION  FOR
 MEDICALLY FRAGILE CHILDREN. THE SUPPLEMENTAL STANDARDS SHALL SPECIFY THE
 LEVEL  OF  CARE  SUPPORTS  IN  THE  PATIENT'S HOME, AT A SKILLED NURSING
 FACILITY OR OTHER SETTING, THAT MUST BE IN PLACE IN ORDER TO SAFELY  AND
 ADEQUATELY  CARE FOR A MEDICALLY FRAGILE CHILD BEFORE ACUTE OR SUB-ACUTE
 INPATIENT REHABILITATION CAN BE DEEMED NO  LONGER  MEDICALLY  NECESSARY.
 THE SUPPLEMENTAL STANDARDS DESIGNATED BY THE COMMISSIONER SHALL PRE-EMPT
 THE  CLINICAL  STANDARDS,  IF  ANY, REGARDING READINESS FOR DISCHARGE OF
 MEDICALLY FRAGILE CHILDREN FROM ACUTE OR SUB-ACUTE  INPATIENT  REHABILI-
 TATION,  AS  SET FORTH IN THE UTILIZATION REVIEW PLAN BY THE UTILIZATION
 REVIEW AGENT.
   9. IN ALL INSTANCES THE UTILIZATION REVIEW AGENT SHALL  DEFER  TO  THE
 RECOMMENDATIONS  OF THE REFERRING PHYSICIAN TO REFER A MEDICALLY FRAGILE

 A. 9098                             7
 
 CHILD FOR CARE AT A PARTICULAR SPECIALTY PROVIDER OF CARE  TO  MEDICALLY
 FRAGILE  CHILDREN,  OR  THE  RECOMMENDED  TREATMENT PLAN BY THE TREATING
 PHYSICIAN AT A SPECIALTY CARE CENTER  FOR  MEDICALLY  FRAGILE  CHILDREN,
 EXCEPT  WHERE  THE UTILIZATION REVIEW AGENT HAS DETERMINED, BY CLEAR AND
 CONVINCING EVIDENCE, THAT: (A)  THE  RECOMMENDED  PROVIDER  OR  PROPOSED
 TREATMENT  PLAN  IS  NOT  IN  THE BEST INTEREST OF THE MEDICALLY FRAGILE
 CHILD, OR (B) AN ALTERNATIVE PROVIDER OFFERING  SUBSTANTIALLY  THE  SAME
 LEVEL  OF  CARE IN ACCORDANCE WITH SUBSTANTIALLY THE SAME TREATMENT PLAN
 IS AVAILABLE FROM A LOWER COST PROVIDER.
   § 7. Subparagraph (D) of paragraph 1 of subsection (b) of section 4900
 of the insurance law, as added by section 36 of subpart A of part BB  of
 chapter 57 of the laws of 2019, is amended and a new subparagraph (E) is
 added to read as follows:
   (D)  for  purposes of a determination involving treatment for a mental
 health condition:
   (i) a physician who  possesses  a  current  and  valid  non-restricted
 license  to  practice  medicine and who specializes in behavioral health
 and has experience in the delivery of mental health  courses  of  treat-
 ment; or
   (ii)  a  health  care professional other than a licensed physician who
 specializes in behavioral health and has experience in the  delivery  of
 mental  health  courses  of treatment and, where applicable, possesses a
 current and valid non-restricted license, certificate,  or  registration
 or,  where  no  provision  for  a  license,  certificate or registration
 exists, is credentialed by the national accrediting body appropriate  to
 the profession; [and] OR
   (E) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT OF A MEDICALLY
 FRAGILE CHILD:
   (I)  A  PHYSICIAN  WHO  POSSESSES  A  CURRENT AND VALID NON-RESTRICTED
 LICENSE TO PRACTICE MEDICINE AND WHO IS BOARD CERTIFIED OR BOARD  ELIGI-
 BLE  IN PEDIATRIC REHABILITATION, PEDIATRIC CRITICAL CARE, OR NEONATOLO-
 GY; OR
   (II) A PHYSICIAN WHO POSSESSES  A  CURRENT  AND  VALID  NON-RESTRICTED
 LICENSE  TO  PRACTICE  MEDICINE  AND  IS  BOARD CERTIFIED IN A PEDIATRIC
 SUBSPECIALTY DIRECTLY RELEVANT TO THE PATIENT'S MEDICAL CONDITION; AND
   § 8. Paragraph 2 of subsection (b) of section 4900  of  the  insurance
 law,  as  amended by chapter 586 of the laws of 1998, is amended to read
 as follows:
   (2) for purposes of title two of this article:
   (A) a physician who:
   (i) possesses a current and valid non-restricted license  to  practice
 medicine;
   (ii)  where  applicable,  is  board certified or board eligible in the
 same or similar specialty as the  health  care  provider  who  typically
 manages  the  medical  condition  or disease or provides the health care
 service or treatment under appeal;
   (iii) has been practicing in such area of specialty for a period of at
 least five years; and
   (iv) is knowledgeable about the health care service or treatment under
 appeal; or
   (B) a health care professional other than a licensed physician who:
   (i) where applicable, possesses a  current  and  valid  non-restricted
 license, certificate or registration;
   (ii)  where  applicable,  is  credentialed by the national accrediting
 body appropriate to the profession in the same profession  and  same  or
 similar  specialty as the health care provider who typically manages the

 A. 9098                             8
 
 medical condition or disease or provides  the  health  care  service  or
 treatment under appeal;
   (iii) has been practicing in such area of specialty for a period of at
 least five years;
   (iv) is knowledgeable about the health care service or treatment under
 appeal; and
   (v) where applicable to such health care professional's scope of prac-
 tice, is clinically supported by a physician who possesses a current and
 valid non-restricted license to practice medicine; OR
   (C) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT OF A MEDICALLY
 FRAGILE CHILD:
   (I)  A  PHYSICIAN  WHO  POSSESSES  A  CURRENT AND VALID NON-RESTRICTED
 LICENSE TO PRACTICE MEDICINE AND WHO IS BOARD CERTIFIED OR BOARD  ELIGI-
 BLE  IN PEDIATRIC REHABILITATION, PEDIATRIC CRITICAL CARE, OR NEONATOLO-
 GY; OR
   (II) A PHYSICIAN WHO POSSESSES  A  CURRENT  AND  VALID  NON-RESTRICTED
 LICENSE  TO  PRACTICE  MEDICINE  AND  IS  BOARD CERTIFIED IN A PEDIATRIC
 SUBSPECIALTY DIRECTLY RELEVANT TO THE PATIENT'S MEDICAL CONDITION.
   § 9. Subsection (b-1) of section 4900 of the insurance law,  as  added
 by chapter 586 of the laws of 1998, is amended to read as follows:
   (b-1)  "Clinical  standards"  means those guidelines and standards set
 forth in the utilization review plan by  the  utilization  review  agent
 whose adverse determination is under appeal OR, IN THE CASE OF MEDICALLY
 FRAGILE  CHILDREN  THOSE GUIDELINES AND STANDARDS AS REQUIRED BY SECTION
 FORTY-NINE HUNDRED THREE-A OF THIS ARTICLE.
   § 10. Subsection (j) of section 4900 of the insurance law, as added by
 chapter 705 of the laws of 1996, is amended to read as follows:
   (j) "Utilization review plan" means: (1) a description of the  process
 for  developing  the written clinical review criteria; (2) a description
 of the types of  written  clinical  information  which  the  plan  might
 consider  in its clinical review, including but not limited to, a set of
 specific written clinical review criteria; (3) a description of practice
 guidelines and standards used by a utilization review agent in  carrying
 out  a  determination  of  medical  necessity,  WHICH,  IN  THE  CASE OF
 MEDICALLY FRAGILE CHILDREN, SHALL INCORPORATE THE STANDARDS REQUIRED  BY
 SECTION  FORTY-NINE  HUNDRED THREE-A OF THIS ARTICLE; (4) the procedures
 for scheduled review and  evaluation  of  the  written  clinical  review
 criteria;  and (5) a description of the qualifications and experience of
 the health care  professionals  who  developed  the  criteria,  who  are
 responsible  for  periodic  evaluation of the criteria and of the health
 care professionals or others who use the written clinical review  crite-
 ria in the process of utilization review.
   §  11.  Section  4900  of the insurance law is amended by adding a new
 subsection (k) to read as follows:
   (K) "MEDICALLY FRAGILE CHILD" MEANS AN INDIVIDUAL WHO IS  UNDER  TWEN-
 TY-ONE  YEARS  OF AGE AND HAS A CHRONIC DEBILITATING CONDITION OR CONDI-
 TIONS, WHO MAY OR MAY NOT  BE  HOSPITALIZED  OR  INSTITUTIONALIZED,  AND
 MEETS  ONE  OR  MORE  OF  THE FOLLOWING CRITERIA: (1) IS TECHNOLOGICALLY
 DEPENDENT FOR LIFE  OR  HEALTH  SUSTAINING  FUNCTIONS;  (2)  REQUIRES  A
 COMPLEX  MEDICATION  REGIMEN  OR MEDICAL INTERVENTIONS TO MAINTAIN OR TO
 IMPROVE THEIR HEALTH STATUS; OR (3) IS IN NEED OF ONGOING ASSESSMENT  OR
 INTERVENTION  TO PREVENT SERIOUS DETERIORATION OF THEIR HEALTH STATUS OR
 MEDICAL COMPLICATIONS THAT PLACE THEIR LIFE, HEALTH  OR  DEVELOPMENT  AT
 RISK.  CHRONIC  DEBILITATING CONDITIONS INCLUDE, BUT ARE NOT LIMITED TO,
 BRONCHOPULMONARY DYSPLASIA, CEREBRAL PALSY,  CONGENITAL  HEART  DISEASE,
 MICROCEPHALY,  PULMONARY  HYPERTENSION, AND MUSCULAR DYSTROPHY. THE TERM

 A. 9098                             9
 
 "MEDICALLY FRAGILE CHILD" SHALL ALSO INCLUDE SEVERE CONDITIONS,  INCLUD-
 ING  BUT  NOT LIMITED TO TRAUMATIC BRAIN INJURY, WHICH TYPICALLY REQUIRE
 CARE IN A SPECIALTY CARE CENTER FOR  MEDICALLY  FRAGILE  CHILDREN,  EVEN
 THOUGH  THE CHILD DOES NOT HAVE A CHRONIC DEBILITATING CONDITION OR ALSO
 MEET ONE OF THE THREE CONDITIONS OF THIS SUBSECTION. IN ORDER TO FACILI-
 TATE THE PROMPT AND CONVENIENT IDENTIFICATION OF PARTICULAR PATIENT CARE
 SITUATIONS MEETING THE DEFINITIONS OF THIS SUBSECTION,  THE  SUPERINTEN-
 DENT,  AFTER CONSULTING WITH THE COMMISSIONER OF HEALTH, MAY ISSUE WRIT-
 TEN GUIDANCE LISTING (BY DIAGNOSIS  CODES,  UTILIZATION  THRESHOLDS,  OR
 OTHER  AVAILABLE  CODING  OR  COMMONLY USED MEDICAL CLASSIFICATIONS) THE
 TYPES OF PATIENT CARE NEEDS WHICH ARE DEEMED TO  MEET  THIS  DEFINITION.
 NOTWITHSTANDING  THE  DEFINITIONS  SET  FORTH  IN  THIS  SUBSECTION, ANY
 PATIENT WHICH HAS RECEIVED PRIOR  APPROVAL  FROM  A  UTILIZATION  REVIEW
 AGENT  FOR  ADMISSION TO A SPECIALTY CARE FACILITY FOR MEDICALLY FRAGILE
 CHILDREN SHALL BE CONSIDERED A MEDICALLY FRAGILE CHILD  AT  LEAST  UNTIL
 DISCHARGE FROM THAT FACILITY OCCURS.
   §  12.  The insurance law is amended by adding a new section 4903-a to
 read as follows:
   § 4903-A. UTILIZATION  REVIEW  DETERMINATIONS  FOR  MEDICALLY  FRAGILE
 CHILDREN. (A) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF THE UTILIZA-
 TION  REVIEW  AGENT'S  CLINICAL  STANDARDS, THE UTILIZATION REVIEW AGENT
 SHALL ADMINISTER AND APPLY THE CLINICAL  STANDARDS  (AND  MAKE  DETERMI-
 NATIONS  OF  MEDICAL  NECESSITY) REGARDING MEDICALLY FRAGILE CHILDREN IN
 ACCORDANCE WITH THE REQUIREMENTS OF THIS  SECTION.  IF  THE  UTILIZATION
 REVIEW  AGENT IS A SEPARATE ENTITY FROM THE HEALTH CARE PLAN, THE HEALTH
 CARE PLAN SHALL MAKE CONTRACTUAL  OR  OTHER  ARRANGEMENTS  IN  ORDER  TO
 FACILITATE THE UTILIZATION REVIEW AGENT'S COMPLIANCE WITH THIS SECTION.
   (B)  IN  THE  CASE  OF  A MEDICALLY FRAGILE CHILD, THE TERM "MEDICALLY
 NECESSARY" SHALL MEAN HEALTH CARE AND SERVICES  THAT  ARE  NECESSARY  TO
 PROMOTE  NORMAL  GROWTH  AND  DEVELOPMENT  AND PREVENT, DIAGNOSE, TREAT,
 AMELIORATE OR PALLIATE THE EFFECTS OF A  PHYSICAL,  MENTAL,  BEHAVIORAL,
 GENETIC, OR CONGENITAL CONDITION, INJURY OR DISABILITY.  WHEN APPLIED TO
 THE  CIRCUMSTANCES  OF  ANY PARTICULAR MEDICALLY FRAGILE CHILD, THE TERM
 "MEDICALLY NECESSARY" SHALL INCLUDE: (1) THE CARE OR SERVICES  THAT  ARE
 ESSENTIAL  TO  PREVENT, DIAGNOSE, PREVENT THE WORSENING OF, ALLEVIATE OR
 AMELIORATE THE EFFECTS OF AN ILLNESS, INJURY,  DISABILITY,  DISORDER  OR
 CONDITION;  (2)  THE  CARE OR SERVICES THAT ARE ESSENTIAL TO THE OVERALL
 PHYSICAL, COGNITIVE AND MENTAL GROWTH AND  DEVELOPMENTAL  NEEDS  OF  THE
 CHILD;  AND  (3)  THE  CARE  OR  SERVICES  THAT WILL ASSIST THE CHILD TO
 ACHIEVE OR MAINTAIN MAXIMUM  FUNCTIONAL  CAPACITY  IN  PERFORMING  DAILY
 ACTIVITIES,  TAKING  INTO  ACCOUNT  BOTH  THE FUNCTIONAL CAPACITY OF THE
 CHILD AND THOSE FUNCTIONAL CAPACITIES THAT ARE APPROPRIATE FOR  INDIVID-
 UALS  OF  THE  SAME AGE AS THE CHILD. THE UTILIZATION REVIEW AGENT SHALL
 BASE  ITS  DETERMINATION  ON  MEDICAL  AND  OTHER  RELEVANT  INFORMATION
 PROVIDED BY THE CHILD'S PRIMARY CARE PROVIDER, OTHER HEALTH CARE PROVID-
 ERS, SCHOOL, LOCAL SOCIAL SERVICES, AND/OR LOCAL PUBLIC HEALTH OFFICIALS
 THAT  HAVE  EVALUATED  THE  CHILD, AND THE UTILIZATION REVIEW AGENT WILL
 ENSURE THE CARE AND SERVICES ARE PROVIDED IN SUFFICIENT AMOUNT, DURATION
 AND SCOPE TO REASONABLY BE EXPECTED TO PRODUCE THE INTENDED RESULTS  AND
 TO  HAVE  THE  EXPECTED  BENEFITS  THAT  OUTWEIGH  THE POTENTIAL HARMFUL
 EFFECTS.
   (C) UTILIZATION REVIEW  AGENTS  SHALL  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  CAPACI-
 TY,  TAKING  INTO ACCOUNT THE APPROPRIATE FUNCTIONAL CAPACITIES OF CHIL-

 A. 9098                            10
 
 DREN OF THE SAME AGE.  UTILIZATION REVIEW AGENTS MUST CONTINUE TO  COVER
 SERVICES UNTIL THAT CHILD ACHIEVES AGE-APPROPRIATE FUNCTIONAL CAPACITY.
   (2)  SHALL NOT BASE DETERMINATIONS SOLELY UPON REVIEW STANDARDS APPLI-
 CABLE TO (OR DESIGNED FOR) ADULTS TO MEDICALLY FRAGILE  CHILDREN.  ADULT
 STANDARDS INCLUDE, BUT ARE NOT LIMITED TO, MEDICARE REHABILITATION STAN-
 DARDS  AND THE "MEDICARE 3 HOUR RULE."  DETERMINATIONS HAVE TO 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. AREA UTILIZATION  REVIEW
 AGENTS  MUST  CONSIDER  WHEN  DEVELOPING  AND  APPROVING DISCHARGE PLANS
 INCLUDE, BUT ARE NOT  LIMITED  TO:  SUDDEN  REVERSALS  OF  CONDITION  OR
 PROGRESS, WHICH MAY MAKE DISCHARGE DECISIONS UNCERTAIN OR MORE PROLONGED
 THAN  FOR  OTHER  CHILDREN  OR  ADULTS; NECESSARY TRAINING OF PARENTS OR
 OTHER ADULTS TO CARE FOR MEDICALLY FRAGILE  CHILDREN  AT  HOME;  UNUSUAL
 DISCHARGE  DELAYS  ENCOUNTERED  IF  PARENTS  OR OTHER RESPONSIBLE ADULTS
 DECLINE OR ARE  SLOW  TO  ASSUME  FULL  RESPONSIBILITY  FOR  CARING  FOR
 MEDICALLY  FRAGILE  CHILDREN;  THE  NEED TO AWAIT AN APPROPRIATE HOME OR
 HOME-LIKE ENVIRONMENT RATHER THAN DISCHARGE  TO  A  HOUSING  SHELTER  OR
 OTHER  INAPPROPRIATE SETTING FOR MEDICALLY FRAGILE CHILDREN, THE NEED TO
 AWAIT CONSTRUCTION ADAPTATIONS TO THE HOME (SUCH AS THE INSTALLATION  OF
 GENERATORS  OR OTHER EQUIPMENT); AND LACK OF AVAILABLE SUITABLE SPECIAL-
 IZED CARE (SUCH AS UNAVAILABILITY OF PEDIATRIC NURSING HOME BEDS, PEDIA-
 TRIC VENTILATOR UNITS, PEDIATRIC PRIVATE DUTY NURSING IN  THE  HOME,  OR
 SPECIALIZED  PEDIATRIC  HOME CARE SERVICES).   UTILIZATION REVIEW AGENTS
 MUST DEVELOP A PERSON CENTERED DISCHARGE PLAN FOR THE CHILD  TAKING  THE
 ABOVE SITUATIONS INTO CONSIDERATION.
   (4)  IT  IS THE UTILIZATION REVIEW AGENTS NETWORK MANAGEMENT RESPONSI-
 BILITY 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; 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.  UTILIZATION REVIEW
 AGENTS ARE REQUIRED TO APPROVE THE USE OF  OUT-OF-NETWORK  PROVIDERS  IF
 THEY  DO  NOT  HAVE A PARTICIPATING PROVIDER TO ADDRESS THE NEEDS OF THE
 CHILD.
   (5) UTILIZATION REVIEW AGENTS MUST ENSURE THAT MEDICALLY FRAGILE CHIL-
 DREN RECEIVE SERVICES FROM APPROPRIATE PROVIDERS THAT HAVE THE EXPERTISE
 TO EFFECTIVELY TREAT THE CHILD AND MUST  CONTRACT  WITH  PROVIDERS  WITH
 DEMONSTRATED  EXPERTISE  IN  CARING  FOR THE MEDICALLY FRAGILE CHILDREN.
 NETWORK PROVIDERS SHALL  REFER  TO  APPROPRIATE  NETWORK  COMMUNITY  AND
 FACILITY  PROVIDERS TO MEET THE NEEDS OF THE CHILD OR SEEK AUTHORIZATION
 FROM THE UTILIZATION REVIEW  AGENT  FOR  OUT-OF-NETWORK  PROVIDERS  WHEN
 PARTICIPATING  PROVIDERS  CANNOT MEET THE CHILD'S NEEDS. THE UTILIZATION
 REVIEW AGENT MUST AUTHORIZE SERVICES AS FAST AS THE INSURED'S  CONDITION
 REQUIRES  AND IN ACCORDANCE WITH ESTABLISHED TIMEFRAMES IN THE CONTRACTS
 OR POLICY FORMS.
   (D) A UTILIZATION REVIEW AGENT SHALL HAVE  A  PROCEDURE  BY  WHICH  AN
 INSURED  WHO  IS  A  MEDICALLY  FRAGILE  CHILD  WHO REQUIRES SPECIALIZED
 MEDICAL CARE OVER A PROLONGED PERIOD OF TIME, MAY RECEIVE A REFERRAL  TO
 A  SPECIALTY CARE CENTER FOR MEDICALLY FRAGILE CHILDREN. IF THE UTILIZA-
 TION REVIEW AGENT, OR THE PRIMARY CARE PROVIDER OR THE SPECIALIST TREAT-
 ING THE PATIENT, IN CONSULTATION WITH A MEDICAL DIRECTOR OF THE UTILIZA-
 TION REVIEW  AGENT,  DETERMINES  THAT  THE  INSURED'S  CARE  WOULD  MOST
 APPROPRIATELY  BE PROVIDED BY SUCH A SPECIALTY CARE CENTER, THE UTILIZA-

 A. 9098                            11
 
 TION REVIEW AGENT SHALL REFER THE INSURED TO SUCH CENTER.  IN  NO  EVENT
 SHALL  A  UTILIZATION  REVIEW  AGENT BE REQUIRED TO PERMIT AN INSURED TO
 ELECT TO HAVE A NON-PARTICIPATING  SPECIALTY  CARE  CENTER,  UNLESS  THE
 HEALTH  CARE  PLAN DOES NOT HAVE AN APPROPRIATE SPECIALTY CARE CENTER TO
 TREAT THE INSURED'S DISEASE OR CONDITION WITHIN ITS NETWORK. SUCH REFER-
 RAL SHALL BE PURSUANT TO A TREATMENT PLAN  DEVELOPED  BY  THE  SPECIALTY
 CARE  CENTER  AND APPROVED BY THE UTILIZATION REVIEW AGENT, IN CONSULTA-
 TION WITH THE PRIMARY CARE PROVIDER, IF ANY, OR  A  SPECIALIST  TREATING
 THE PATIENT, AND THE INSURED OR THE INSURED'S DESIGNEE. IF A UTILIZATION
 REVIEW  AGENT REFERS AN INSURED TO A SPECIALTY CARE CENTER THAT DOES NOT
 PARTICIPATE IN THE HEALTH CARE PLAN'S NETWORK, SERVICES PROVIDED  PURSU-
 ANT  TO  THE  APPROVED TREATMENT PLAN SHALL BE PROVIDED AT NO ADDITIONAL
 COST TO THE INSURED BEYOND WHAT THE  INSURED  WOULD  OTHERWISE  PAY  FOR
 SERVICES  RECEIVED  WITHIN  THE NETWORK. FOR PURPOSES OF THIS SECTION, A
 SPECIALTY CARE CENTER FOR MEDICALLY FRAGILE CHILDREN SHALL MEAN A  CHIL-
 DREN'S  HOSPITAL  AS  DEFINED PURSUANT TO SUBPARAGRAPH (IV) OF PARAGRAPH
 (E-2) OF SUBDIVISION FOUR OF SECTION TWO THOUSAND EIGHT HUNDRED  SEVEN-C
 OF  THE PUBLIC HEALTH LAW, A RESIDENTIAL HEALTH CARE FACILITY AFFILIATED
 WITH SUCH A CHILDREN'S HOSPITAL, ANY RESIDENTIAL  HEALTH  CARE  FACILITY
 WITH  A SPECIALTY PEDIATRIC BED AVERAGE DAILY CENSUS DURING TWO THOUSAND
 SEVENTEEN OF FIFTY OR MORE PATIENTS, OR A FACILITY WHICH SATISFIES  SUCH
 OTHER CRITERIA AS THE COMMISSIONER OF HEALTH MAY DESIGNATE.
   (E) WHEN RENDERING OR ARRANGING FOR CARE OR PAYMENT, BOTH THE PROVIDER
 AND  THE  HEALTH  CARE  PLAN  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.
   (F)  THE HEALTH CARE PLAN MUST PAY AT LEAST EIGHTY-FIVE PERCENT OF THE
 FACILITY'S ACUTE CARE RATE, UNLESS A DIFFERENT RATE  HAS  BEEN  MUTUALLY
 NEGOTIATED,  FOR ALL DAYS OF INPATIENT HOSPITAL CARE AT A SPECIALTY CARE
 CENTER FOR MEDICALLY FRAGILE CHILDREN WHEN THE INSURER 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  RESI-
 DENTIAL  HEALTH  CARE  FACILITY  BED  IS AVAILABLE GIVEN THE SPECIALIZED
 NEEDS OF THE MEDICALLY FRAGILE CHILD. THE HEALTH CARE PLAN MUST  PAY  AT
 LEAST  THE  FACILITY'S  SKILLED NURSING MEDICAID FACILITY RATE, UNLESS A
 DIFFERENT RATE HAS BEEN MUTUALLY NEGOTIATED, FOR ALL DAYS OF RESIDENTIAL
 HEALTH CARE FACILITY CARE AT A SPECIALTY CARE CENTER FOR MEDICALLY FRAG-
 ILE CHILDREN WHEN THE INSURER 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.  SUCH  REQUIREMENTS SHALL APPLY UNTIL THE
 HEALTH CARE PLAN CAN IDENTIFY  AND  SECURE  ADMISSION  TO  AN  ALTERNATE
 PROVIDER  RENDERING  THE NECESSARY LEVEL OF SERVICES. THE SPECIALTY CARE
 CENTER MUST COOPERATE WITH THE HEALTH CARE PLAN'S PLACEMENT EFFORTS.
   (G) IN THE EVENT A HEALTH CARE PLAN ENTERS INTO A PARTICIPATION AGREE-
 MENT WITH A SPECIALTY CARE CENTER FOR MEDICALLY FRAGILE CHILDREN IN THIS
 STATE, AND THE TERMS OF THAT PARTICIPATION AGREEMENT EXTEND  TO  ONE  OR
 MORE  OTHER  HEALTH  CARE PLANS OR INSURERS (INCLUDING HEALTH CARE PLANS
 AND INSURERS OPERATING IN OTHER STATES) BY VIRTUE  OF  AFFILIATION  WITH
 (OR  CONTRACTS  WITH)  THE  HEALTH  CARE  PLAN, THE REQUIREMENTS OF THIS
 SECTION REGARDING PROCEDURES FOR UTILIZATION REVIEW OF MEDICALLY FRAGILE
 CHILDREN SHALL APPLY TO THOSE OTHER HEALTH CARE PLANS OR INSURERS.

 A. 9098                            12
 
   (H) (1) THE SUPERINTENDENT, AFTER CONSULTING WITH THE COMMISSIONER  OF
 HEALTH, SHALL DESIGNATE A SINGLE SET OF CLINICAL STANDARDS APPLICABLE TO
 ALL  UTILIZATION  REVIEW  AGENTS REGARDING PEDIATRIC EXTENDED ACUTE CARE
 STAYS (DEFINED FOR THE PURPOSES OF THIS SECTION AS  DISCHARGE  FROM  ONE
 ACUTE  CARE  HOSPITAL  FOLLOWED BY IMMEDIATE ADMISSION TO A SECOND ACUTE
 CARE HOSPITAL; NOT INCLUDING TRANSFERS OF CASE PAYMENT CASES AS  DEFINED
 IN SECTION TWO THOUSAND EIGHT HUNDRED SEVEN-C OF THE PUBLIC HEALTH LAW).
 THE STANDARDS SHALL BE ADAPTED FROM NATIONAL LONG TERM ACUTE CARE HOSPI-
 TAL  STANDARDS  FOR  ADULTS AND SHALL BE APPROVED BY THE SUPERINTENDENT,
 AFTER CONSULTATION WITH ONE OR MORE SPECIALTY CARE CENTERS FOR MEDICALLY
 FRAGILE CHILDREN. THE STANDARDS SHALL INCLUDE, BUT NOT  BE  LIMITED  TO,
 SPECIFICATIONS OF THE LEVEL OF CARE SUPPORTS IN THE PATIENT'S HOME, AT A
 SKILLED  NURSING  FACILITY  OR  OTHER  SETTING, THAT MUST BE IN PLACE IN
 ORDER TO SAFELY AND ADEQUATELY CARE FOR A MEDICALLY FRAGILE CHILD BEFORE
 MEDICALLY COMPLEX ACUTE CARE CAN BE DEEMED NO  LONGER  MEDICALLY  NECES-
 SARY.  THE  STANDARDS  DESIGNATED BY THE COMMISSIONER SHALL PRE-EMPT THE
 CLINICAL STANDARDS, IF ANY, FOR PEDIATRIC EXTENDED ACUTE CARE SET  FORTH
 IN THE UTILIZATION REVIEW PLAN BY THE UTILIZATION REVIEW AGENT.
   (2)  THE  SUPERINTENDENT,  AFTER  CONSULTING  WITH THE COMMISSIONER OF
 HEALTH, SHALL DESIGNATE A SINGLE SET OF SUPPLEMENTAL CLINICAL  STANDARDS
 (IN  ADDITION  TO  THE  CLINICAL  STANDARDS  SELECTED BY THE UTILIZATION
 REVIEW AGENT) APPLICABLE TO  ALL  UTILIZATION  REVIEW  AGENTS  REGARDING
 ACUTE AND SUB-ACUTE INPATIENT REHABILITATION FOR MEDICALLY FRAGILE CHIL-
 DREN.  THE  STANDARDS  SHALL  SPECIFY  THE LEVEL OF CARE SUPPORTS IN THE
 PATIENT'S HOME, AT A SKILLED NURSING FACILITY  OR  OTHER  SETTING,  THAT
 MUST  BE IN PLACE IN ORDER TO SAFELY AND ADEQUATELY CARE FOR A MEDICALLY
 FRAGILE CHILD BEFORE ACUTE OR SUB-ACUTE INPATIENT REHABILITATION CAN  BE
 DEEMED  NO LONGER MEDICALLY NECESSARY. THE SUPPLEMENTAL STANDARDS DESIG-
 NATED BY THE SUPERINTENDENT SHALL PRE-EMPT THE  CLINICAL  STANDARDS,  IF
 ANY,  REGARDING  READINESS  FOR  DISCHARGE OF MEDICALLY FRAGILE CHILDREN
 FROM ACUTE OR SUB-ACUTE INPATIENT REHABILITATION, AS SET  FORTH  IN  THE
 UTILIZATION REVIEW PLAN BY THE UTILIZATION REVIEW AGENT.
   (I)  IN  ALL INSTANCES THE UTILIZATION REVIEW AGENT SHALL DEFER TO THE
 RECOMMENDATIONS OF THE REFERRING PHYSICIAN TO REFER A MEDICALLY  FRAGILE
 CHILD  FOR  CARE AT A PARTICULAR SPECIALTY PROVIDER OF CARE TO MEDICALLY
 FRAGILE CHILDREN, OR THE RECOMMENDED  TREATMENT  PLAN  BY  THE  TREATING
 PHYSICIAN  AT  A  SPECIALTY  CARE CENTER FOR MEDICALLY FRAGILE CHILDREN,
 EXCEPT WHERE THE UTILIZATION REVIEW AGENT HAS DETERMINED, BY  CLEAR  AND
 CONVINCING  EVIDENCE,  THAT:  (1)  THE  RECOMMENDED PROVIDER OR PROPOSED
 TREATMENT PLAN IS NOT IN THE BEST  INTEREST  OF  THE  MEDICALLY  FRAGILE
 CHILD;  OR  (2)  AN ALTERNATIVE PROVIDER OFFERING SUBSTANTIALLY THE SAME
 LEVEL OF CARE IN ACCORDANCE WITH SUBSTANTIALLY THE SAME  TREATMENT  PLAN
 IS AVAILABLE FROM A LOWER COST PROVIDER.
   § 13. This act shall take effect January 1, 2021.