NY Pub Health L § 2510 (2021)
2021 New York Laws PBH - Public Health Article 25 - Maternal and Child Health Title 1-A - Child Health Insurance Plan 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.   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 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; hospice services; emergency,  preventive  and  routine  dental care,  including  medically necessary orthodontia but excluding cosmetic surgery;  emergency,  preventive  and  routine  vision  care,  including eyeglasses;  speech  and hearing services; and, inpatient and outpatient mental health, alcohol and substance abuse services as  defined  by  the commissioner  in  consultation  with the superintendent. "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    *(iii)  fifteen dollars per month for each eligible child whose family net household income is between one hundred eighty-six percent  and  one hundred  ninety-two percent of the non-farm federal poverty level or the gross equivalent of such net income, but no more than forty-five dollars per  month  per family, and, effective July first, two thousand, fifteen dollars per month for each eligible child  whose  family  net  household income  is  between one hundred eighty-six percent and two hundred eight percent of the non-farm federal poverty level or the gross equivalent of such net income, but no more  than  forty-five  dollars  per  month  per family; and   * NB Expires July 1, 2023  (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.   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.