NY A04135

Repeals specific physician qualification requirements for utilization review determinations involving medically fragile children and replaces them with standards established in new sections 4406-i (public health law) and 3217-j (insurance law).

Establishes comprehensive utilization review standards for medically fragile children including requirements to consider services necessary for reaching maximum functional capacity, avoid using adult-only review standards, accommodate prolonged discharge plans, and ensure network providers can meet specialized needs.

Defines "medically fragile child" as individuals under 21 years old with chronic debilitating conditions who are technologically dependent, require complex medication regimens, or need ongoing assessment to prevent health deterioration; includes specific conditions like cerebral palsy, congenital heart disease, and traumatic brain injury.

Requires health maintenance organizations and insurers to contract with providers with demonstrated expertise in caring for medically fragile children and authorizes them to seek out-of-network providers when in-network providers cannot meet the child's needs.

For Medicaid managed care, requires health plans to continue paying for inpatient or residential facility care when specialized home services are unavailable or the child is awaiting placement in an appropriate residential facility with specialized services.