S T A T E O F N E W Y O R K
________________________________________________________________________
9507
I N S E N A T E
March 18, 2026
___________
Introduced by Sen. STAVISKY -- 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 supporting medically fragile children who require community-based
and home health services
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Section 4406-i of the public health law, as added by chap-
ter 170 of the laws of 2023, is amended to read as follows:
§ 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) FOR INPATIENT,
OUTPATIENT AND COMMUNITY-BASED SERVICES 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 capaci-
ty, taking into account the appropriate functional capacities of chil-
dren of the same age. IN THE CASE OF COMMUNITY-BASED LONG-TERM SERVICES
AND SUPPORTS, THOSE SHALL INCLUDE BUT NOT BE LIMITED TO SKILLED NURSING,
HOME-BASED PRIVATE DUTY NURSING, PERSONAL CARE SERVICES, CONSUMER
DIRECTED PERSONAL ASSISTANCE PROGRAM SERVICES, HOME HEALTH AIDE, PHYS-
ICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, AND FEEDING THERAPY.
In the case of Medicaid managed care, health maintenance organizations
shall continue to cover services until that child achieves age-appropri-
ate functional capacity.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD13172-01-5
S. 9507 2
(b) Shall not base determinations solely upon review standards appli-
cable to (or designed for) adults to medically fragile children. Deter-
minations shall take into consideration the specific needs of the child
and the circumstances pertaining to their growth and development. THE
DETERMINATIONS SHALL CONSIDER THE LEVEL OF CARE REQUIRED FOR A MEDICALLY
FRAGILE CHILD, INCLUDING TWENTY-FOUR HOUR, SEVEN-DAY PER WEEK AND/OR
INSTITUTIONAL LEVEL OF CARE AND DETERMINATIONS SHALL BE MADE ON A CASE-
BY-CASE BASIS TAKING INTO ACCOUNT THE PARTICULAR NEEDS OF THE CHILD AND
FAMILY.
(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.
(C-1) IN THE CASE OF COMMUNITY-BASED LONG TERM CARE SERVICES FOR
MEDICALLY FRAGILE CHILDREN, THE HEALTH MAINTENANCE ORGANIZATION'S DETER-
MINATION ADDITIONALLY SHALL SPECIFY THE LEVEL OF CARE AND SUPPORTS THAT
SHALL BE IN PLACE IN ORDER TO SAFELY AND ADEQUATELY PROVIDE CARE FOR A
MEDICALLY FRAGILE CHILD IN THE HOME, AND CONSIDER THE CHILD'S LONG TERM
CARE NEEDS, NOT JUST WHAT IS REQUIRED TO ADDRESS THE IMMEDIATE SITU-
ATION.
(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 Medi-
caid managed care, payments shall not be denied to a discharging hospi-
tal or other facility due to lack of an available post-discharge provid-
er 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 chil-
dren. 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 organ-
ization shall inquire of, and shall consider the desires of the family
of a medically fragile child including, but not limited to, the avail-
ability and capacity of the family, the need for the family to simul-
taneously 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 organ-
ization shall pay for all days of inpatient hospital care at a partic-
ipating 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
S. 9507 3
not available or in place, or the patient is awaiting discharge to a
residential health care facility when no residential health care facili-
ty 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 Medi-
caid 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 frag-
ile 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.
§ 2. The public health law is amended by adding a new section 4406-j
to read as follows:
§ 4406-J. HOME AND COMMUNITY-BASED SERVICES FOR MEDICALLY FRAGILE
CHILDREN. 1. PRIVATE DUTY NURSING. (A) NOTWITHSTANDING ANY OTHER
PROVISION IN THIS ARTICLE, MEDICAL NECESSITY REVIEWS SHALL BE PROHIBITED
FOR PRIVATE DUTY NURSING HOURS PRESCRIBED FOR PRIVATE DUTY NURSING
SERVICES THAT INCLUDES: TRACHEOSTOMY, RESPIRATORY SUPPORT, SUCTIONING, A
NASOGASTRIC FEEDING TUBE, GASTROSTOMY FEEDING TUBE, CENTRAL LINES, OR
TOTAL PARENTERAL NUTRITION.
(B) PRIVATE DUTY NURSING AUTHORIZATION SHALL BE DETERMINED BY CONSID-
ERING AN INSTITUTIONAL LEVEL OF CARE THAT WOULD OTHERWISE BE NEEDED AND
SHALL BE INDIVIDUALIZED BASED ON THE ASSESSMENT OF THE PARTICULAR CHILD,
CONSISTENT WITH SECTION FORTY-FOUR HUNDRED SIX-I OF THIS ARTICLE,
REVIEWED ON A CASE BY CASE BASIS WITH CONSIDERATION TO SKILLED CARE
NEEDS, INCLUSIVE OF TRACHEOSTOMY, RESPIRATORY SUPPORT, NASOGASTRIC FEED-
ING TUBE, GASTROSTOMY FEEDING TUBE, CENTRAL LINES, OR TOTAL PARENTERAL
NUTRITION.
(C) INFORMAL CARE BY FAMILY MEMBERS SHALL BE VOLUNTARY AND CANNOT BE
ASSUMED OR REQUIRED WHEN DETERMINING AUTHORIZATION OF PRIVATE DUTY NURS-
ING SERVICES.
2. HOME HEALTH SERVICES. (A) MEDICAID MANAGED CARE ORGANIZATIONS SHALL
REIMBURSE REGISTERED NURSES FOR COMPLETING PROCESSES TO RECERTIFY
SERVICES.
(B) IF A CHILD MEETS THE LEVEL OF CARE CRITERIA BASED UPON THE
MEDICALLY FRAGILE CHILD SUBGROUP OF THE CHILDREN'S HOME AND COMMUNITY
BASED SERVICES WAIVER AND IS APPROVED UNDER SUCH SUBGROUP FOR SUCH WAIV-
ER, PROVIDED THE MEDICAID MANAGED CARE PLANS AND FEE FOR SERVICES, MEDI-
CAID SHALL NOT DENY, REDUCE, SUSPEND OR DISCONTINUE HOME AND COMMUNITY
BASED WAIVER SERVICES, UNLESS SUCH SERVICES ARE SUBSEQUENTLY DEEMED
MEDICALLY UNNECESSARY BY THE PRESCRIBING PHYSICIAN, AND DEPENDENT ON
CONTINUING FEDERAL FINANCIAL PARTICIPATION.
(C) WHERE A PROVIDER CAN DEMONSTRATE THAT APPEALS OF DENIALS FOR HOME
HEALTH CARE SERVICES HAVE BEEN UPHELD BY SEVENTY PERCENT OR MORE OVER
THE PAST TWELVE MONTHS, THE MEDICAID MANAGED CARE PLAN SHALL CONTINUE
COVERING THE SERVICES PENDING COMPLETION OF THE APPEALS PROCESS.
S. 9507 4
(D) IN ORDER TO ENSURE APPROPRIATE TRANSITIONS OF CARE, HOME HEALTH
SERVICES SHALL BE CONTINUED FOR NO LESS THAN NINETY DAYS WHERE HOME
HEALTH SERVICES ARE DEEMED TO NO LONGER BE MEDICALLY NECESSARY OR APPRO-
PRIATE.
(E) TELEHEALTH AND REMOTE PATIENT MONITORING FOR CHILDREN WHO MEET
MEDICALLY FRAGILE CRITERIA WHEN PRESCRIBED BY A PHYSICIAN SHALL BE REIM-
BURSABLE SERVICES.
§ 3. The public health law is amended by adding a new section 4406-k
to read as follows:
§ 4406-K. FAIR HEARINGS INVOLVING SERVICES FOR MEDICALLY FRAGILE CHIL-
DREN. PARENTS AND CAREGIVERS OF MEDICALLY FRAGILE CHILDREN SHALL BE
GIVEN AN OPTION TO APPEAR VIRTUALLY OR TELEPHONICALLY FOR ANY FAIR HEAR-
ING INVOLVING A MEDICALLY FRAGILE CHILD.
§ 4. Section 3217-j of the insurance law, as added by chapter 170 of
the laws of 2023, is amended to read as follows:
§ 3217-j. Utilization review determinations for medically fragile
children. (a) Notwithstanding any inconsistent provision of the insur-
er's clinical standards, the insurer, and any utilization review agent
under contract with such insurer, shall administer and apply the clin-
ical standards (and make determinations of medical necessity) FOR INPA-
TIENT, OUTPATIENT AND COMMUNITY-BASED SERVICES regarding medically frag-
ile 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 capaci-
ty, taking into account the appropriate functional capacities of chil-
dren of the same age. IN THE CASE OF COMMUNITY-BASED LONG-TERM SERVICES
AND SUPPORTS, THOSE SHALL INCLUDE BUT NOT BE LIMITED TO HOME-BASED
PRIVATE DUTY NURSING, PERSONAL CARE SERVICES, CONSUMER DIRECTED PERSONAL
ASSISTANCE PROGRAM SERVICES, HOME HEALTH AIDE, PHYSICAL THERAPY, OCCUPA-
TIONAL THERAPY, SPEECH THERAPY, AND FEEDING THERAPY.
(2) Shall not base determinations solely upon review standards appli-
cable to (or designed for) adults to medically fragile children. Deter-
minations shall take into consideration the specific needs of the child
and the circumstances pertaining to their growth and development. THE
DETERMINATIONS ALSO SHALL CONSIDER THE LEVEL OF CARE REQUIRED FOR A
MEDICALLY FRAGILE CHILD, INCLUDING TWENTY-FOUR HOUR, SEVEN-DAY PER WEEK
AND/OR INSTITUTIONAL LEVEL OF CARE AND DETERMINATIONS SHALL BE MADE ON A
CASE-BY-CASE BASIS TAKING INTO ACCOUNT THE PARTICULAR NEEDS OF THE CHILD
AND FAMILY.
(3) Accommodate unusual stabilization and prolonged discharge plans
for medically fragile children, as appropriate. Insurers, and as appli-
cable 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) IN THE CASE OF COMMUNITY-BASED LONG-TERM CARE SERVICES FOR
MEDICALLY FRAGILE CHILDREN, THE HEALTH MAINTENANCE ORGANIZATION'S DETER-
MINATION ADDITIONALLY SHALL SPECIFY THE LEVEL OF CARE AND SUPPORTS THAT
SHALL BE IN PLACE IN ORDER TO SAFELY AND ADEQUATELY PROVIDE CARE FOR A
MEDICALLY FRAGILE CHILD IN THE HOME, AND CONSIDER THE CHILD'S LONG TERM
S. 9507 5
CARE NEEDS, NOT JUST WHAT IS REQUIRED TO ADDRESS THE IMMEDIATE SITU-
ATION.
(5) It is the insurer's network management responsibility under a
managed care health insurance contract as defined in subsection (c) of
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)] (6) 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 appropri-
ate in-network provider is not available pursuant to subsection [a-two]
(A-TWO) of section four thousand nine hundred four of this chapter.
[(6)] (7) Insurers shall contract with providers with demonstrated
expertise in caring for the medically fragile children. Network provid-
ers shall refer to appropriate network community and facility providers
for covered services to meet the needs of the child or seek authori-
zation 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 OR PROVIDER OF COMMUNITY-BASED LONG-TERM CARE
FOR MEDICALLY FRAGILE CHILDREN pursuant to the provisions of that
participation agreement.
§ 5. Sections one and four of this act shall not apply to any quali-
fied health plans in the individual and small group market on and after
the date, if any, when the federal department of health and human
services determines in writing that such provisions constitute state-re-
quired benefits in addition to essential health benefits, pursuant to
the federal Affordable Care Act and regulations promulgated thereunder.
§ 6. This act shall take effect on the first day of January after it
shall have become a law.
