§ 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
capacity, taking into account the appropriate functional capacities of
children of the same age. In the case of Medicaid managed care, health
maintenance organizations shall continue to cover services until that
child achieves age-appropriate functional capacity.

(b) 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.

(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
Medicaid managed care, 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.

(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
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 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
organization 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.

4. In the case of Medicaid managed care, the health maintenance
organization shall pay for all days of inpatient hospital 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, or the patient is awaiting discharge
to a residential health care facility when no residential health care
facility 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 Medicaid 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
fragile 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.