N.Y.
Public Health Law Section 4401
Definitions
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 § 4406 (Health maintenance organizations)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 § 4403-C (Comprehensive HIV special needs plan certification)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 Social Services Law § 365-A (Character and adequacy of assistance)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, 2025 * 7. “HIV Center of excellence” is defined as a health care facility certified to operate under article 28 (Hospitals)article twenty-eight of this chapter that offers specialized treatment expertise in HIV care services as defined by the commissioner. * NB Repealed March 31, 2025 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.
Source:
Section 4401 — Definitions, https://www.nysenate.gov/legislation/laws/PBH/4401 (updated Sep. 8, 2023; accessed Apr. 13, 2024).
