N.Y. Public Health Law § 4401: Definitions

§ 4401. Definitions. For the purpose of this article: 1. "Health

maintenance organization" or "organization" means any person, natural or

corporate, or any groups of such persons who enter into an arrangement,

agreement or plan or any combination of arrangements or plans which

propose to provide or offer, or which do provide or offer, a

comprehensive health services plan.

2. "Comprehensive health services plan" or "plan" means a plan through

which each member of an enrolled population is entitled to receive

comprehensive health services in consideration for a basic advance or

periodic charge. A plan may include the provision of health care

services which are covered by the organization at the election of

enrollees by health care providers not participating in the plan

pursuant to a contract, employment or other association to the extent

authorized in section forty-four hundred six of this article; provided,

however, that in no event shall an enrollee elect to have a

non-participating provider serve as the enrollee's primary care

practitioner responsible for supervising and coordinating the care of

the enrollee.

3. "Comprehensive health services" means all those health services

which an enrolled population might require in order to be maintained in

good health, and shall include, but shall not be limited to, physician

services (including consultant and referral services), in-patient and

out-patient hospital services, diagnostic laboratory and therapeutic and

diagnostic radiologic services, and emergency and preventive health

services. Such term may be further defined by agreement with enrolled

populations providing additional benefits necessary, desirable or

appropriate to meet their health care needs.

4. "Enrolled population" means a group of persons, defined as to

probable age, sex and family composition, which receives comprehensive

health services from a health maintenance organization in consideration

for a basic advance or periodic charge.

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

the state of New York.

* 6. "Comprehensive HIV special needs plan" means a health maintenance

organization certified pursuant to section forty-four hundred three-c of

this article which, in addition to providing or arranging for the

provision of comprehensive health services on a capitated basis,

including those for which medical assistance payment is authorized

pursuant to section three hundred sixty-five-a of the social services

law, also provides or arranges for the provision of HIV care to HIV

positive persons eligible to receive benefits under title XIX of the

federal social security act or other public programs.

* NB Repealed March 31, 2030

* 7. "HIV Center of excellence" is defined as a health care facility

certified to operate under article twenty-eight of this chapter that

offers specialized treatment expertise in HIV care services as defined

by the commissioner.

* NB Repealed March 31, 2030

8. "Special needs managed care plan" shall mean a combination of

persons natural or corporate, or any groups of such persons, or a county

or counties, who enter into an arrangement, agreement or plan, or

combination of arrangements, agreements or plans, to provide health and

behavioral health services to enrollees with significant behavioral

health needs.

9. "Medically fragile child" means an individual who is under

twenty-one years of age and has a chronic debilitating condition or

conditions, who may or may not be hospitalized or institutionalized, and

meets one or more of the following criteria (a) is technologically

dependent for life or health sustaining functions, (b) requires a

complex medication regimen or medical interventions to maintain or to

improve their health status, or (c) is in need of ongoing assessment or

intervention to prevent serious deterioration of their health status or

medical complications that place their life, health or development at

risk. Chronic debilitating conditions include bronchopulmonary

dysplasia, cerebral palsy, congenital heart disease, microcephaly,

pulmonary hypertension, and muscular dystrophy. The term "medically

fragile child" shall also include traumatic brain injury, the nature of

which typically requires care in a specialty care center for medically

fragile children, even though the child does not have a chronic

debilitating condition or also meet one of the three conditions of this

subdivision. Notwithstanding the definitions set forth in this

subdivision, any patient which has received prior approval from a health

maintenance organization for admission to a specialty care facility for

medically fragile children shall be considered a medically fragile child

at least until discharge from that facility occurs.