What's happening
This bill enhances health insurance coverage and care standards for medically fragile children in New York, setting specific requirements for treatment, provider qualifications, and discharge planning.
Why it matters
Defines “medically fragile children”. with a broad and specific set of criteria, ensuring that children with chronic, severe, or complex medical needs—including those dependent on technology or requiring intensive care—are explicitly recognized and protected under the law.
Mandates expert involvement in care decisions. , requiring that insurance determinations for medically fragile children must be made by pediatric subspecialists with relevant board certifications, rather than generalists or adult-focused providers, increasing the likelihood that decisions reflect best pediatric practices.
Prioritizes individualized, developmentally appropriate care. by requiring that medical necessity and discharge planning consider the child’s age, unique developmental needs, family situation, and home environment, and by rejecting the use of adult-centered standards (e.g., Medicare “3 hour rule”) for pediatric cases.
Strengthens protections for continuity and quality of care. , including requirements for referral to specialty care centers, coverage of out-of-network providers when necessary, continued payment for hospital or facility stays due to lack of appropriate discharge options, and deference to the child’s treating physician unless clear evidence supports an alternative—aiming to prevent gaps in care and reduce administrative denials.
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Who cares
Medically fragile children and their families
The bill would require coverage decisions to account for children's growth and development and care planning to consider families' caregiving capacity and parents' need to work.
Health insurers, HMOs and utilization review agents
The bill would impose child-specific medical necessity standards, require out-of-network care when suitable network providers are unavailable and limit departures from physicians' recommendations.
Children's hospitals and specialty pediatric care facilities
The bill would establish payment requirements for specified stays prolonged by unavailable home services or appropriate placement, unless different rates are mutually negotiated.
State health and insurance regulators
The bill would require them to designate clinical standards for pediatric extended acute care and supplemental standards for inpatient rehabilitation discharge readiness.
Headline styles
Protect Medically Fragile Children
Plain English, a few words. Used as the page title.
Sponsors
History
- Referred to health
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Improve Care for Fragile Kids
In Assembly Committee · Insurance · Sponsor Richard Gottfried
Full text
12 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
7208
IN SENATE
January 10, 2020
Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Health
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 Assembly, 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 treatment; 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 eligible in pediatric rehabilitation, pediatric critical care, or neonatology; 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
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§ 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 practice, 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 eligible in pediatric rehabilitation, pediatric critical care, or neonatology, 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 incorporate 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:
S. 7208 3
11. "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 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, including 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 facilitate the prompt and convenient identification of particular patient care situations meeting the definitions of this subdivision, the commissioner may issue written 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 subdivision, 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.
§ 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 utilization review agent's clinical standards, the utilization review agent 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. If the utilization review agent is a separate entity from the health maintenance organization 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 individuals of the same age as the child. The utilization review agent shall
S. 7208 4
base its determination on medical and other relevant information provided by the child's primary care provider, other health care providers, 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 capacity, taking into account the appropriate functional capacities of children 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 Periodic Screening, Diagnosis, and Treatment ("EPSDT") standards, as specified by the commissioner of health.
(b) Shall not base determinations solely upon review standards applicable to (or designed for) adults to medically fragile children. Adult standards include, but are not limited to, Medicare rehabilitation standards 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 specialized care (such as unavailability of pediatric nursing home beds, pediatric 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 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; payments shall not be denied to a discharging hospital or other facility due to lack of an available postdischarge 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.
S. 7208 5
(e) Utilization review agents must ensure that medically fragile children 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.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the public health law and the insurance law, in relation to enhancing coverage and care for medically fragile children
Purpose or general idea of bill
To ensure that medically fragile children receive appropriate care and treatment, and that health plans adopt policies and procedures tailored to the unique healthcare needs of this population.
Summary of provisions
Section 1 amends Public Health Law § 4900 (2) (a) to require that during an internal appeal of a medical necessity denial regarding a medically fragile child, the health plan reviewer must be a physician with exper- tise in pediatric rehabilitation, pediatric critical care, neonatology, or a comparable specialty relevant to the medically fragile child's condition.
Read the full memo (608 words)
Section 2 amends Public Health Law § 4900 (2) (b) to require that during an external appeal of the medical necessity denial regarding a medically fragile child, the independent, external reviewer must be a physician with expertise in pediatric rehabilitation, pediatric critical care, neonatology, or a comparable specialty relevant to the childs' condi- tion.
Section 3 amends Public Health Law § 4900 (2-a) to require that the clinical standards adopted by the utilization review agent must include the special accommodations for medically fragile children as added by this bill.
Section 4 amends Public Health Law § 4900 (10) (c) to require that the utilization review plan adopted by the utilization review agent must include the special accommodations for medically fragile children as added by this bill.
Section 5 adds a new subdivision 11 to Public Health Law § 4900 to add a new definition of "medically fragile child," based on the definition currently employed by the Department of Health.
Section 6 amends Public Health Law Article 49 to add a new § 4903-a which specifies important new protections for medically fragile children during the health plan utilization review process, as administered by utilization review agents subject to Article 49.
Sections 7 to 12 institutes identical changes (same as sections 1-6 above) to Article 49 of the Insurance Law which governs health insurer utilization review procedures.
Section 13 is the effective date.
Justification
Medically fragile children constitute an extremely small percentage of all children whose health care needs are often extensive, unusual, and prolonged. Their care should be specially tailored to meet their unique healthcare needs, but insurance companies frequently stand in the way of this. Standard, by-the-book medical necessity guidelines intended for adults or children with more routine medical needs do not reflect the extraordinary medical and developmental needs of these children. Given the relatively small number of medically fragile child cases at any one health plan, health plan medical staff members may not be familiar with their unique needs, and in some instances, this lack of familiarity has resulted in inappropriate denials of care. The Department of Health and certain health plans have responded to this challenge by identifying situations where special accommodations must be made. The purpose of this bill is to ensure that these best practices are followed by all state-regulated health plans, including commercial insurance, Child Health Plus, Medicaid managed care plans, and the state public employee health plan, all of which are covered by Art. 49 of the Public Health Law and Insurance Law. (Local public employee s elf-insured plans are not.)
Prior legislative history
New bill.
Fiscal implications for state and local governments
None. Many of the provisions in this bill already apply to the fee-for- service Medicaid program and Medicaid Managed Care pursuant to federal mandates or current Department of Health policy would generally not result in additional costs to the State.
Effective date
January 1, 2021.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.