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This entry was published on 2023-09-08
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Utilization review determinations for medically fragile children
Insurance (ISC) CHAPTER 28, ARTICLE 32
§ 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.