2023 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.
(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.
* (e)  an eligible child under six years of age shall, consistent with
applicable federal requirements, remain continuously enrolled until  the
later of:
(i) the last day of the twelfth month following the date of enrollment
or recertification in the child health insurance plan; or
(ii)  the  last day of the month in which the child reaches the age of
six.
* NB Effective January 1, 2025
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
*(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, 2025
(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.