NY A08604

Expands utilization review requirements for health maintenance organizations and insurers to explicitly cover inpatient, outpatient, and community-based services for medically fragile children, including skilled nursing, private duty nursing, personal care, home health aide, and various therapies

Prohibits medical necessity reviews for private duty nursing services when prescribed for children requiring tracheostomy, respiratory support, suctioning, feeding tubes, central lines, or total parenteral nutrition

Requires that informal care by family members be voluntary and cannot be assumed or required when determining authorization of private duty nursing services

Mandates continuation of home health services for at least 90 days when services are deemed no longer medically necessary, and requires Medicaid managed care plans to continue coverage pending appeals when providers demonstrate 70% or more of their denials have been overturned

Allows parents and caregivers of medically fragile children to appear virtually or telephonically for fair hearings, and makes telehealth and remote patient monitoring reimbursable services for children meeting medically fragile criteria