S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1319
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                             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:
 
   Section  1. Subparagraphs (iv) and (v) of paragraph (a) of subdivision
 2 of section 4900 of the public health law, subparagraph (iv) as amended
 and subparagraph (v) as added by a chapter of the laws of 2022  amending
 the public health law and the insurance law relating to enhancing cover-
 age  and care for medically fragile children, as proposed in legislative
 bills numbers S.2121-C and A.289-C, are amended 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; [or

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

 S. 1319                             2

   (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
   § 2. Paragraph (b) of subdivision 2 of  section  4900  of  the  public
 health  law,  as  amended  by 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, 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
 amended  by 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, is amended to read as follows:
 S. 1319                             3
 
   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] FORTY-FOUR HUNDRED SIX-I of this [article]
 CHAPTER.
   § 4. Paragraph (c) of subdivision 10 of section  4900  of  the  public
 health  law,  as  amended  by 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, 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]
 FORTY-FOUR HUNDRED SIX-I of this [article] CHAPTER;
   § 5. Subdivision 11 of section 4900 of the public health law as  added
 by  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 is REPEALED.
   § 6. Section 4401 of the public health law is amended by adding a  new
 subdivision 9 to read as follows:
   9.  "MEDICALLY FRAGILE CHILD" MEANS AN INDIVIDUAL WHO IS UNDER TWENTY-
 ONE YEARS OF AGE AND HAS A CHRONIC DEBILITATING CONDITION OR CONDITIONS,
 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 COMPLI-
 CATIONS THAT PLACE THEIR LIFE, HEALTH OR DEVELOPMENT  AT  RISK.  CHRONIC
 DEBILITATING  CONDITIONS  INCLUDE  BRONCHOPULMONARY  DYSPLASIA, CEREBRAL
 PALSY, CONGENITAL HEART DISEASE, MICROCEPHALY,  PULMONARY  HYPERTENSION,
 AND  MUSCULAR  DYSTROPHY.  THE TERM "MEDICALLY FRAGILE CHILD" SHALL ALSO
 INCLUDE TRAUMATIC BRAIN INJURY, THE NATURE OF WHICH  TYPICALLY  REQUIRES
 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.  NOTWITHSTANDING
 THE DEFINITIONS SET FORTH IN THIS SUBDIVISION,  ANY  PATIENT  WHICH  HAS
 RECEIVED  PRIOR  APPROVAL  FROM  A  HEALTH  MAINTENANCE ORGANIZATION 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.
   § 7. Subdivision 1 of section 4902 of the public health law is amended
 by adding a new paragraph (l) to read as follows:
   (L) THE COMMISSIONER,  IN  CONSULTATION  WITH  THE  SUPERINTENDENT  OF
 FINANCIAL  SERVICES, MAY, AS NECESSARY, PROMULGATE BY REGULATION SPECIAL
 CONSIDERATIONS AND PROCESSES FOR UTILIZATION REVIEW RELATED TO MEDICALLY
 FRAGILE CHILDREN. SUCH REGULATIONS MAY INCLUDE, AT A MINIMUM,  CONSIDER-
 ATIONS AND PROCESSES RELATED TO:
   (I)  MEDICALLY  NECESSARY  COVERED SERVICES TO MEDICALLY FRAGILE CHIL-
 DREN;
   (II) DETERMINATIONS SPECIFIC TO THE NEEDS OF MEDICALLY  FRAGILE  CHIL-
 DREN;
   (III) STABILIZATION AND DISCHARGE PLANS; AND
 S. 1319                             4
 
   (IV) PAYMENT FOR THE CARE OF MEDICALLY FRAGILE CHILDREN.
   § 8. Section 4903-a of the public health law is REPEALED.
   §  9.  The public health law is amended by adding a new section 4406-i
 to read as follows:
   § 4406-I. UTILIZATION  REVIEW  DETERMINATIONS  FOR  MEDICALLY  FRAGILE
 CHILDREN.  1.  NOTWITHSTANDING  ANY INCONSISTENT PROVISION OF THE HEALTH
 MAINTENANCE ORGANIZATION'S CLINICAL STANDARDS,  THE  HEALTH  MAINTENANCE
 ORGANIZATION,  AND ANY UTILIZATION REVIEW AGENT UNDER CONTRACT WITH SUCH
 HEALTH MAINTENANCE ORGANIZATION, 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.
   2. HEALTH MAINTENANCE ORGANIZATIONS 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:
   (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. IN THE CASE OF MEDICAID MANAGED CARE, HEALTH MAIN-
 TENANCE ORGANIZATIONS SHALL CONTINUE TO COVER SERVICES UNTIL THAT  CHILD
 ACHIEVES AGE-APPROPRIATE FUNCTIONAL CAPACITY.
   (B)  SHALL NOT BASE DETERMINATIONS SOLELY UPON REVIEW STANDARDS APPLI-
 CABLE TO (OR DESIGNED FOR) ADULTS TO MEDICALLY FRAGILE CHILDREN.  DETER-
 MINATIONS SHALL 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.  HEALTH  MAINTENANCE
 ORGANIZATIONS,  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.
   (D)  IT  IS  THE  HEALTH MAINTENANCE ORGANIZATION'S NETWORK MANAGEMENT
 RESPONSIBILITY 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. IN THE CASE  OF  MEDI-
 CAID  MANAGED CARE, PAYMENTS SHALL NOT BE DENIED TO A DISCHARGING HOSPI-
 TAL OR OTHER FACILITY DUE TO LACK OF AN AVAILABLE POST-DISCHARGE PROVID-
 ER AS LONG AS THEY HAVE WORKED WITH  THE  UTILIZATION  REVIEW  AGENT  TO
 IDENTIFY AN APPROPRIATE PROVIDER.
   (E) THIS SECTION DOES NOT LIMIT ANY OTHER RIGHTS THE 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 SUBDIVISION ONE-B OF
 SECTION FORTY-NINE HUNDRED FOUR OF THIS CHAPTER.
   (F) HEALTH MAINTENANCE ORGANIZATIONS  SHALL  CONTRACT  WITH  PROVIDERS
 WITH  DEMONSTRATED  EXPERTISE  IN CARING FOR THE MEDICALLY FRAGILE CHIL-
 DREN.  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 HEALTH MAINTENANCE ORGANIZATION FOR
 OUT-OF-NETWORK PROVIDERS WHEN PARTICIPATING PROVIDERS  CANNOT  MEET  THE
 CHILD'S NEEDS.
   3.  IN  THE CASE OF MEDICAID MANAGED CARE, WHEN RENDERING OR ARRANGING
 FOR CARE OR PAYMENT, BOTH THE PROVIDER AND THE HEALTH MAINTENANCE ORGAN-
 S. 1319                             5
 
 IZATION SHALL INQUIRE OF, AND SHALL CONSIDER THE DESIRES OF  THE  FAMILY
 OF  A  MEDICALLY FRAGILE CHILD INCLUDING, BUT NOT LIMITED TO, THE AVAIL-
 ABILITY AND CAPACITY OF THE FAMILY, THE NEED FOR THE  FAMILY  TO  SIMUL-
 TANEOUSLY CARE FOR THE FAMILY'S OTHER CHILDREN, AND THE NEED FOR PARENTS
 TO CONTINUE EMPLOYMENT.
   4. IN THE CASE OF MEDICAID MANAGED CARE, THE HEALTH MAINTENANCE ORGAN-
 IZATION  SHALL  PAY FOR ALL DAYS OF INPATIENT HOSPITAL CARE AT A PARTIC-
 IPATING 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
 RESIDENTIAL HEALTH CARE FACILITY WHEN NO RESIDENTIAL HEALTH CARE FACILI-
 TY BED IS AVAILABLE GIVEN THE SPECIALIZED NEEDS OF THE MEDICALLY FRAGILE
 CHILD. IN THE CASE OF MEDICAID  MANAGED  CARE,  THE  HEALTH  MAINTENANCE
 ORGANIZATION SHALL PAY, FOR ALL DAYS OF RESIDENTIAL HEALTH CARE FACILITY
 CARE  AT  A  PARTICIPATING  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. IN THE CASE  OF  MEDI-
 CAID  MANAGED  CARE, 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 SHALL  FACILITATE
 PLACEMENT EFFORTS TO EFFECTUATE THE DISCHARGE.
   5.  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, THE REQUIREMENTS OF THIS SECTION SHALL APPLY
 TO SUCH PARTICIPATION AGREEMENT AND  TO  ALL  CLAIMS  SUBMITTED  TO,  OR
 PAYMENTS  MADE  BY, ANY OTHER HEALTH MAINTENANCE ORGANIZATIONS, INSURERS
 OR PAYORS MAKING PAYMENT TO THE SPECIALTY CARE CENTER  PURSUANT  TO  THE
 PROVISIONS OF THAT PARTICIPATION AGREEMENT.
   § 10. Subdivision 9 of section 4403 of the public health law, as added
 by  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, is amended to read as follows:
   9. A health maintenance organization shall have procedures for  cover-
 age of medically fragile children including[, but not limited to,] those
 necessary  to  implement section [forty-nine hundred three-a] FORTY-FOUR
 HUNDRED SIX-I of this article.
   § 11. Subparagraphs (D) and (E) of paragraph 1 of  subsection  (b)  of
 section  4900  of  the  insurance  law,  subparagraph (D) as amended and
 subparagraph (E) as added by 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, are amended 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
 S. 1319                             6
 
 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; [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
   § 12. Paragraph 2 of subsection (b) of section 4900 of  the  insurance
 law,  as  amended  by  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, 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
 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].
   § 13. Subsection (b-1) of  section  4900  of  the  insurance  law,  as
 amended  by a chapter of the laws of 2022 amending the public health law
 S. 1319                             7
 
 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, 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] THREE THOUSAND TWO HUNDRED SEVENTEEN-J  AND
 FOUR THOUSAND THREE HUNDRED SIX-I of this [article] CHAPTER.
   §  14. Subsection (j) of section 4900 of the insurance law, as amended
 by 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, 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 prac-
 tice  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] SECTIONS THREE THOUSAND TWO HUNDRED
 SEVENTEEN-J  AND  FOUR  THOUSAND  THREE  HUNDRED SIX-I of this [article]
 CHAPTER; (4) the procedures for scheduled review and evaluation  of  the
 written  clinical  review  criteria; and (5) a description of the quali-
 fications and experience of the health care professionals who  developed
 the  criteria, who are responsible for periodic evaluation of the crite-
 ria and of the health care professionals or others who use  the  written
 clinical review criteria in the process of utilization review.
   § 15. Subsection (k) of section 4900 of the insurance law, as added by
 a  chapter of the laws of 2022 amending the public health and the insur-
 ance law relating to enhancing coverage and care for  medically  fragile
 children,  as  proposed  in  legislative  bills numbers S. 2121-C and A.
 289-C, is REPEALED.
   § 16. Subsection (a) of section 107 of the insurance law is amended by
 adding a new paragraph 55 to read as follows:
   (55) "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 BRONCHOPULMONARY DYSPLA-
 SIA, CEREBRAL PALSY, CONGENITAL HEART DISEASE,  MICROCEPHALY,  PULMONARY
 HYPERTENSION, AND MUSCULAR DYSTROPHY. THE TERM "MEDICALLY FRAGILE CHILD"
 SHALL ALSO INCLUDE TRAUMATIC BRAIN INJURY, THE NATURE OF 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.  NOTWITHSTAND-
 ING  THE DEFINITIONS SET FORTH IN THIS SUBSECTION, ANY PATIENT WHICH HAS
 RECEIVED PRIOR APPROVAL FROM AN INSURER FOR  ADMISSION  TO  A  SPECIALTY
 CARE  FACILITY  FOR  MEDICALLY  FRAGILE  CHILDREN  SHALL BE CONSIDERED A
 S. 1319                             8
 
 MEDICALLY FRAGILE CHILD AT LEAST  UNTIL  DISCHARGE  FROM  THAT  FACILITY
 OCCURS.
   §  17.  Subsection (a) of section 4902 of the insurance law is amended
 by adding a new paragraph 14 to read as follows:
   (14) THE SUPERINTENDENT, IN  CONSULTATION  WITH  THE  COMMISSIONER  OF
 HEALTH,  MAY,  AS  NECESSARY, PROMULGATE BY REGULATION SPECIAL CONSIDER-
 ATIONS AND PROCESSES FOR UTILIZATION REVIEW RELATED TO MEDICALLY FRAGILE
 CHILDREN. SUCH REGULATIONS MAY INCLUDE, AT A MINIMUM, CONSIDERATIONS AND
 PROCESSES RELATED TO:
   (I) MEDICALLY NECESSARY COVERED SERVICES TO  MEDICALLY  FRAGILE  CHIL-
 DREN;
   (II)  DETERMINATIONS  SPECIFIC TO THE NEEDS OF MEDICALLY FRAGILE CHIL-
 DREN;
   (III) STABILIZATION AND DISCHARGE PLANS; AND
   (IV) PAYMENT FOR THE CARE OF MEDICALLY FRAGILE CHILDREN.
   § 18. Section 4903-a of the insurance law, as added by  a  chapter  of
 the laws of 2022 amending the public health and the insurance law relat-
 ing  to  enhancing  coverage and care for medically fragile children, as
 proposed in legislative  bills  numbers  S.  2121-C  and  A.  289-C,  is
 REPEALED.
   §  19.  Section  3217-j of the insurance law, as added by 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,  is
 REPEALED and a new section 3217-j is added to read as follows:
   §  3217-J.  UTILIZATION  REVIEW  DETERMINATIONS  FOR MEDICALLY FRAGILE
 CHILDREN. (A) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF  THE  INSUR-
 ER'S  CLINICAL  STANDARDS, THE INSURER, AND ANY UTILIZATION REVIEW AGENT
 UNDER CONTRACT WITH SUCH INSURER, SHALL ADMINISTER AND APPLY  THE  CLIN-
 ICAL  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  CAPACI-
 TY,  TAKING  INTO ACCOUNT THE APPROPRIATE FUNCTIONAL CAPACITIES OF CHIL-
 DREN OF THE SAME AGE.
   (2) SHALL NOT BASE DETERMINATIONS SOLELY UPON REVIEW STANDARDS  APPLI-
 CABLE TO (OR DESIGNED FOR) ADULTS TO MEDICALLY FRAGILE CHILDREN.  DETER-
 MINATIONS  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 APPLI-
 CABLE 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
 S. 1319                             9
 
 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 PROVID-
 ERS 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 PARTIC-
 IPATION AGREEMENT.
   § 20. Section 4306-i of the insurance law, as added by  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, is
 amended to read as follows:
   § 4306-i. Coverage for medically fragile children. A corporation  that
 is  subject  to the provisions of this article shall have procedures for
 coverage of medically fragile children [including, but not  limited  to,
 those necessary to implement section four thousand nine hundred three-a]
 CONSISTENT  WITH  SECTION THREE THOUSAND TWO HUNDRED SEVENTEEN-J of this
 chapter.
   § 21. Section 17 of 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, is amended to read as follows:
   § 17. This act shall take effect on the first day of [January] SEPTEM-
 BER after it becomes a law.
   § 22. Sections three, four, six, seven, nine, ten, thirteen, fourteen,
 sixteen,  seventeen,  nineteen and twenty of this act shall not apply to
 any qualified health plans in the individual and small group  market  on
 and  after  the  date, if any, when the federal department of health and
 human services determines in writing  that  such  provisions  constitute
 state-required benefits in addition to essential health benefits, pursu-
 ant to the federal Affordable Care Act and regulations promulgated ther-
 eunder.
   §  23.  This act shall take effect immediately; provided that sections
 one through twenty of this act shall take effect on the same date and in
 the same manner as 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, takes effect.