Bill > A08604

This bill provides comprehensive support for medically fragile children by establishing new requirements for health maintenance organizations (HMOs) and insurers in managing services for these vulnerable patients. The legislation mandates that health plans must consider medical necessity for medically fragile children more holistically, taking into account the specific needs of each child's growth and development, rather than applying adult-oriented review standards. Key provisions include requiring HMOs and insurers to cover a wide range of community-based and home health services such as skilled nursing, home-based private duty nursing, personal care services, and various therapies, and to determine service levels on a case-by-case basis considering the child's long-term care needs. The bill also prohibits medical necessity reviews for certain complex private duty nursing services, ensures continuity of care by requiring services to be maintained for at least 90 days during transitions, and allows parents and caregivers to participate in fair hearings virtually or by telephone. Additionally, the legislation requires health plans to work closely with specialty care centers, accommodate complex discharge plans, and consider family circumstances when determining care, with the ultimate goal of helping medically fragile children reach their maximum functional capacity while supporting their families' needs.

Health and Social Services

https://www.nysenate.gov/legislation/bills/2025/A8604