2023 New York Laws › PBH - Public Health › Article 44 - Health Maintenance Organizations › 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.