N.Y. Insurance Law Section 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 § 4801 (Application)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 § 4904 (Appeal of adverse determinations by utilization review agents)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.

Source: Section 3217-J — Utilization review determinations for medically fragile children, https://www.­nysenate.­gov/legislation/laws/ISC/3217-J (updated Sep. 8, 2023; accessed Jun. 15, 2024).

3201
Approval of life, accident and health, credit unemployment, and annuity policy forms
3202
Withdrawal of approval of policy forms
3203
Individual life insurance policies
3204
Policy to contain entire contract
3205
Insurable interest in the person
3206
Policies which provide for an adjustable maximum rate of interest on policy loans
3207
Life insurance contracts by or for the benefit of minors
3208
Antedating of life insurance policies and burial agreements prohibited
3209
Life insurance, annuities and funding agreements disclosure requirements
3210
Incontestability after reinstatement
3211
Notice of premium due under life or disability insurance policy
3212
Exemption of proceeds and avails of certain insurance and annuity contracts
3213
Payment of proceeds
3214
Interest upon proceeds of life insurance policies and annuity contracts
3215
Disability benefits in connection with life insurance and annuities
3216
Individual accident and health insurance policy provisions
3217
Minimum standards in the form, content and sale of accident and health insurance
3217‑A
Disclosure of information
3217‑B
Prohibitions
3217‑C
Primary and preventive obstetric and gynecologic care
3217‑D
Grievance procedure and access to specialty care
3217‑E
Choice of health care provider
3217‑F
Prohibition on lifetime and annual limits
3217‑G
Maternal depression screenings
3217‑H
Telehealth delivery of services
3217‑I
Essential health benefits package and limit on cost-sharing
3217‑J
Utilization review determinations for medically fragile children
3218
Medicare supplemental insurance policies
3219
Annuity and pure endowment contracts and certain group annuity certificates
3220
Group life insurance policies
3221
Group or blanket accident and health insurance policies
3222
Funding agreements
3223
Group annuity contracts
3224
Standard claim forms
3224‑A
Standards for prompt, fair and equitable settlement of claims for health care and payments for health care services
3224‑B
Rules relating to the processing of health claims and overpayments to physicians
3224‑C
Coordination of benefits
3224‑D
Prescription synchronization
3225
Eligibility for health insurance in cases of exposure to DES
3226
Reinsurance contracts excepted
3227
Interest upon surrenders, policy loans and other funds
3228
Individual accident and health insurance policies
3229
Minimum benefit standards for certain long term care plans
3230
Accelerated payment of the death benefit or special surrender value under a life insurance policy
3231
Rating of individual and small group health insurance policies
3231*2
Health insurance policies and subscriber contracts
3232
Pre-existing condition provisions in health policies
3232‑A
Certification of creditable coverage
3233
Stabilization of health insurance markets and premium rates
3234
Pre-existing condition provisions in group and blanket disability policies
3234*2
Limitations on administrative services and stop-loss coverage
3235
Explanation of benefits forms relating to claims under medicare supplemental insurance policies and limited benefits health insurance pol...
3236
Public health law assessments
3237
Health insurance coverage for full-time students on medical leaves of absence
3238
Pre-authorization of health care services
3239
Wellness programs
3240
Unclaimed benefits
3240*2
Student accident and health insurance
3241
Network coverage
3242
Prescription drug coverage
3243
Discrimination because of sex or marital status in hospital, surgical or medical expense insurance
3244
Explanation of benefits forms relating to claims under certain accident and health insurance policies
3245
Liability to providers in the event of an insolvency

Accessed:
Jun. 15, 2024

Last modified:
Sep. 8, 2023

§ 3217-J’s source at nysenate​.gov

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