N.Y.
Public Health Law Section 2510
Definitions
1.
“Applicant” means an eligible organization which submits a proposal under subdivision six of § 2511 (Child health insurance plan 1)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 § 2511 (Child health insurance plan 1)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 § 2511 (Child health insurance plan 1)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 44 (Health Maintenance Organizations)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 § 2511 (Child health insurance plan 1)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 § 2511 (Child health insurance plan 1)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 29-I (Medical Services For Foster Children)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 28 (Hospitals)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.
Source:
Section 2510 — Definitions, https://www.nysenate.gov/legislation/laws/PBH/2510 (updated May 3, 2024; accessed Oct. 26, 2024).
