N.Y. Public Health Law § 2510: Definitions

§ 2510. Definitions. For the purpose of this title, unless the context

clearly requires otherwise:

1. "Applicant" means an eligible organization which submits a proposal

under subdivision six of section two thousand five hundred eleven of

this title.

1-a. "Applicant for insurance" means the person or persons applying

for insurance coverage for a child pursuant to this title.

2. "Approved organization" means an eligible organization approved by

the commissioner under subdivision seven of section two thousand five

hundred eleven of this title to underwrite a child health insurance plan

and an organization approved by the commissioner under subdivision

seven-a of section two thousand five hundred eleven of this title.

3. "Eligible organization" means:

(a) a commercial insurer;

(b) a corporation or health maintenance organization licensed under

article forty-three of the insurance law;

(c) a health maintenance organization certified under article

forty-four of this chapter; or

(d) a comprehensive health services plan operating pursuant to

regulations of the department of social services or the department of

health.

4. "Eligible child" or "eligible children" means a person or persons

under the age of thirteen years for the period January first, nineteen

hundred ninety-one through December thirty-first, nineteen hundred

ninety-three; born on or after June first, nineteen hundred eighty and

under the age of sixteen for a period commencing on or after January

first, nineteen hundred ninety-four through December thirty-first,

nineteen hundred ninety-six; and for a person or persons enrolled in the

program on the day before they are sixteen years of age, under the age

of seventeen for a period commencing on or after June first, nineteen

hundred ninety-five through December thirty-first, nineteen hundred

ninety-six; and under the age of nineteen for periods commencing on or

after January first, nineteen hundred ninety-seven, who meets or meet

the criteria in section two thousand five hundred eleven of this title.

5. "Child health insurance plan" means the written undertaking of an

approved organization to provide coverage for covered health care

services to eligible children under this title.

6. "Period of eligibility" means that period commencing on the first

day of the month during which a child is an eligible child and enrolled

or recertified for enrollment on an annual basis based on all required

information and documentation and ending on the last day of the twelfth

month following such date, provided, however:

(a) the period of eligibility for a child who ceases to be eligible

because he or she no longer resides in New York state or has access to

or obtained other health insurance coverage, as defined by the

commissioner in consultation with the superintendent pursuant to

paragraph (c) of subdivision two of section twenty-five hundred eleven

of this article, shall end the last day of the month in which the child

ceases to be an eligible child; and

(b) the period of eligibility for a child who becomes eligible for

medical assistance shall end the last day of the third month after the

child becomes eligible for medical assistance; and

(c) the period of eligibility for a child for whom an applicable

premium payment has not been paid shall end in accordance with time

frames and procedures determined by the commissioner.

(d) effective on or after March first, two thousand twenty-three

through March thirty-first, two thousand twenty-seven, subject to

extension under Title XXI of the federal social security act, the period

of eligibility for pregnant individuals enrolled in the child health

insurance plan shall include twelve months postpartum coverage

commencing on the first day of the month following the last day of

pregnancy and ending on the last day of the month in which the

twelve-month postpartum period ends; provided, however, such postpartum

coverage may end prior to the end of the twelve-month period only under

the following circumstances: (i) the individual requests voluntary

termination; (ii) the individual ceases to be a state resident; (iii)

eligibility was determined incorrectly because of error, fraud, abuse,

or perjury attributed to the individual; or (iv) the individual dies.

7. "Covered health care services" means: the services of physicians,

optometrists, nurses, nurse practitioners, midwives and other related

professional personnel which are provided on an outpatient basis,

including routine well-child visits; diagnosis and treatment of illness

and injury; inpatient health care services; laboratory tests; diagnostic

x-rays; prescription and non-prescription drugs, ostomy and other

medical supplies and durable medical equipment; radiation therapy;

chemotherapy; hemodialysis; outpatient blood clotting factor products

and other treatments and services furnished in connection with the care

of hemophilia and other blood clotting protein deficiencies; emergency

room services; ambulance services; hospice services; emergency,

preventive and routine dental care, including orthodontia but excluding

cosmetic surgery; emergency, preventive and routine vision care,

including eyeglasses; speech and hearing services; inpatient and

outpatient mental health, alcohol and substance abuse services,

including children and family treatment and support services, children's

home and community based services, assertive community treatment

services and residential rehabilitation for youth services which shall

be reimbursed in accordance with the ambulatory patient group (APG)

rate-setting methodology as utilized by the department of health, the

office of addiction services and supports, or the office of mental

health for rate-setting purposes or any such other fees established

pursuant to article forty-three of the mental hygiene law; and

health-related services provided by voluntary foster care agency health

facilities licensed pursuant to article twenty-nine-I of this chapter;

as defined by the commissioner. "Covered health care services" shall not

include drugs, procedures and supplies for the treatment of erectile

dysfunction when provided to, or prescribed for use by, a person who is

required to register as a sex offender pursuant to article six-C of the

correction law, provided that any denial of coverage of such drugs,

procedures or supplies shall provide the patient with the means of

obtaining additional information concerning both the denial and the

means of challenging such denial.

8. "Subsidy payment" means a payment made to an approved organization

for the cost of covered health care services coverage to an eligible

child or children.

9. "Premium payment" means: a payment made on behalf of an eligible

child for enrollment in the child health insurance plan equal to:

(a) for periods prior to October first, nineteen hundred ninety-seven,

twenty-five dollars per year for each child, but no more than one

hundred dollars per year per family; and

(b) for periods on or after October first, nineteen hundred

ninety-seven, amounts as follows:

(i) no payments are required for eligible children whose family net

household income is less than one hundred twenty-six percent of the

non-farm federal poverty level or the gross equivalent of such net

income;

(ii) nine dollars per month for each eligible child whose family net

household income is between one hundred twenty-six percent and one

hundred thirty-two percent of the non-farm federal poverty level or the

gross equivalent of such net income, but no more than thirty-six dollars

per month per family; and

(iii) thirteen dollars per month for each eligible child whose family

net household income is between one hundred thirty-three percent and one

hundred eighty-five percent of the non-farm federal poverty level or the

gross equivalent of such net income, but no more than fifty-two dollars

per month per family.

(c) for periods on or after January first, nineteen hundred

ninety-nine, amounts as follows:

(i) no payments are required for eligible children whose family net

household income is less than one hundred thirty-three percent of the

non-farm federal poverty level or the gross equivalent of such net

income and, effective August first, two thousand, no payments are

required for eligible children who are American Indians or Alaskan

Natives, as defined by the U.S. Department of Health and Human Services;

and

(ii) nine dollars per month for each eligible child whose family net

household income is between one hundred thirty-three percent and one

hundred eighty-five percent of the non-farm federal poverty level or the

gross equivalent of such net income, but no more than twenty-seven

dollars per month per family; and

(iv) effective September first, two thousand eight, twenty dollars per

month for each eligible child whose family gross household income is

between two hundred fifty-one percent and three hundred percent of the

non-farm federal poverty level, but no more than sixty dollars per month

per family;

(v) effective September first, two thousand eight, thirty dollars per

month for each eligible child whose family gross household income is

between three hundred one percent and three hundred fifty percent of the

non-farm federal poverty level, but no more than ninety dollars per

month per family; and

(vi) effective September first, two thousand eight, forty dollars per

month for each eligible child whose family gross household income is

between three hundred fifty-one percent and four hundred percent of the

non-farm federal poverty level, but no more than one hundred twenty

dollars per month per family.

(d) for periods on or after July first, two thousand nine, amounts as

follows:

(i) no payments are required for eligible children whose family

household income is less than one hundred sixty percent of the non-farm

federal poverty level and for eligible children who are American Indians

or Alaskan Natives, as defined by the U.S. Department of Health and

Human Services, whose family household income is less than two hundred

fifty-one percent of the non-farm federal poverty level; and

(ii) nine dollars per month for each eligible child whose family

household income is between one hundred sixty percent and two hundred

twenty-two percent of the non-farm federal poverty level, but no more

than twenty-seven dollars per month per family; and

(iii) fifteen dollars per month for each eligible child whose family

household income is between two hundred twenty-three percent and two

hundred fifty percent of the non-farm federal poverty level, but no more

than forty-five dollars per month per family; and

(iv) thirty dollars per month for each eligible child whose family

household income is between two hundred fifty-one percent and three

hundred percent of the non-farm federal poverty level, but no more than

ninety dollars per month per family;

(v) forty-five dollars per month for each eligible child whose family

household income is between three hundred one percent and three hundred

fifty percent of the non-farm federal poverty level, but no more than

one hundred thirty-five dollars per month per family; and

(vi) sixty dollars per month for each eligible child whose family

household income is between three hundred fifty-one percent and four

hundred percent of the non-farm federal poverty level, but no more than

one hundred eighty dollars per month per family.

(e) for periods on or after October first, two thousand twenty-two,

amounts as follows:

(i) no payments are required for eligible children whose family

household income is less than two hundred twenty-three percent of the

non-farm federal poverty level and for eligible children who are

American Indians or Alaskan Natives, as defined by the United States

department of health and human services, whose family household income

is less than two hundred fifty-one percent of the non-farm federal

poverty level; and

(ii) fifteen dollars per month for each eligible child whose family

household income is between two hundred twenty-three percent and two

hundred fifty percent of the non-farm federal poverty level, but no more

than forty-five dollars per month per family; and

(iii) thirty dollars per month for each eligible child whose family

household income is between two hundred fifty-one percent and three

hundred percent of the non-farm federal poverty level, but no more than

ninety dollars per month per family; and

(iv) forty-five dollars per month for each eligible child whose family

household income is between three hundred one percent and three hundred

fifty percent of the non-farm federal poverty level, but no more than

one hundred thirty-five dollars per month per family; and

(v) sixty dollars per month for each eligible child whose family

household income is between three hundred fifty-one percent and four

hundred percent of the non-farm federal poverty level, but no more than

one hundred eighty dollars per month per family.

10. "Superintendent" means the superintendent of financial services.

11. "Inpatient health care services" means: inpatient hospital

services provided by a general hospital, as defined in article

twenty-eight of this chapter, a facility operated by the office of

mental health under section 7.17 of the mental hygiene law, a facility

issued an operating certificate pursuant to the provisions of article

twenty-three or thirty-one of the mental hygiene law and services

provided by physicians and other professional personnel on an inpatient

basis for covered inpatient services; as defined by the commissioner in

consultation with the superintendent.

12. "Group health plan" or "health insurance coverage" shall have the

same meanings as set forth in section twenty-one hundred ten of the

federal social security act.

13. "Household income" means the sum of the modified adjusted gross

income of every individual included in a child's household calculated in

accordance with applicable federal law and regulations, as may be

amended.

14. "State enrollment center" means the centralized system and

operation of eligibility determinations by the state or its contractor

for all insurance affordability programs, including the child health

insurance program established pursuant to this title.

15. "Insurance affordability programs" means those programs set forth

in section 435.4 of title 42 of the code of federal regulations.