2006 New York Code - 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.
    * NB Effective until July 1, 2007
    * 5. "Child health insurance plan" means the written undertaking of an
  approved organization to provide coverage  for  primary  and  preventive
  health  care  services, and on and after January first, nineteen hundred
  ninety-seven inpatient health care services, to eligible children  under
  this title.
    * NB Effective July 1, 2007
    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  and  durable  medical
  equipment; radiation therapy; chemotherapy; hemodialysis; emergency room
  services;  hospice  services;  emergency,  preventive and routine dental
  care, except orthodontia and 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.
    * NB Effective until July 1, 2007
    * 7.  a.  "Primary  and  preventive  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; laboratory tests; diagnostic x-rays;
  prescription  drugs;  radiation  therapy;  chemotherapy;   hemodialysis;
  emergency  room  services; hospice services; and, outpatient alcohol and
  substance abuse services as defined by the commissioner in  consultation
  with the superintendent.
    b.  "Optional  primary  and  preventive  health  care services" means:
  dental,  vision,  speech  and  hearing  services  as  defined   by   the
  commissioner in consultation with the superintendent.
    * NB Effective July 1, 2007
    * 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.
    * NB Effective until July 1, 2007
    * 8.  "Subsidy  payment"  means  a  payment  made   to   an   approved
  organization for the cost of primary and preventive health care services
  coverage  and  inpatient  health  care  services coverage to an eligible
  child or children.
    * NB Effective July 1, 2007
    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.
    * NB Expires July 1, 2007
    10. "Superintendent" means the superintendent of insurance.
    * 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.
    * NB Effective until July 1, 2007
    * 11.  "Inpatient  health  care  services"  means:  inpatient hospital
  services  provided  by  a  general  hospital,  as  defined  in   article
  twenty-eight   of   this  chapter,  excluding  mental  health  services,
  substance abuse services, and alcohol treatment services;  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.
    * NB Effective July 1, 2007