§ 2510 — Definitions

§ 2510. Definitions. For the purpose of this title, unless the context\nclearly requires otherwise:\n 1. "Applicant" means an eligible organization which submits a proposal\nunder subdivision six of section two thousand five hundred eleven of\nthis title.\n 1-a. "Applicant for insurance" means the person or persons applying\nfor insurance coverage for a child pursuant to this title.\n 2. "Approved organization" means an eligible organization approved by\nthe commissioner under subdivision seven of section two thousand five\nhundred eleven of this title to underwrite a child health insurance plan\nand an organization approved by the commissioner under subdivision\nseven-a of section two thousand five hundred eleven of this title.\n 3. "Eligible organization" means:\n (a) a commercial insurer;\n (b) a corporation or health maintenance organization licensed under\narticle forty-three of the insurance law;\n (c) a health maintenance organization certified under article\nforty-four of this chapter; or\n (d) a comprehensive health services plan operating pursuant to\nregulations of the department of social services or the department of\nhealth.\n 4. "Eligible child" or "eligible children" means a person or persons\nunder the age of thirteen years for the period January first, nineteen\nhundred ninety-one through December thirty-first, nineteen hundred\nninety-three; born on or after June first, nineteen hundred eighty and\nunder the age of sixteen for a period commencing on or after January\nfirst, nineteen hundred ninety-four through December thirty-first,\nnineteen hundred ninety-six; and for a person or persons enrolled in the\nprogram on the day before they are sixteen years of age, under the age\nof seventeen for a period commencing on or after June first, nineteen\nhundred ninety-five through December thirty-first, nineteen hundred\nninety-six; and under the age of nineteen for periods commencing on or\nafter January first, nineteen hundred ninety-seven, who meets or meet\nthe criteria in section two thousand five hundred eleven of this title.\n 5. "Child health insurance plan" means the written undertaking of an\napproved organization to provide coverage for covered health care\nservices to eligible children under this title.\n 6. "Period of eligibility" means that period commencing on the first\nday of the month during which a child is an eligible child and enrolled\nor recertified for enrollment on an annual basis based on all required\ninformation and documentation and ending on the last day of the twelfth\nmonth following such date, provided, however:\n (a) the period of eligibility for a child who ceases to be eligible\nbecause he or she no longer resides in New York state or has access to\nor obtained other health insurance coverage, as defined by the\ncommissioner in consultation with the superintendent pursuant to\nparagraph (c) of subdivision two of section twenty-five hundred eleven\nof this article, shall end the last day of the month in which the child\nceases to be an eligible child; and\n (b) the period of eligibility for a child who becomes eligible for\nmedical assistance shall end the last day of the third month after the\nchild becomes eligible for medical assistance; and\n (c) the period of eligibility for a child for whom an applicable\npremium payment has not been paid shall end in accordance with time\nframes and procedures determined by the commissioner.\n (d) effective on or after March first, two thousand twenty-three\nthrough March thirty-first, two thousand twenty-seven, subject to\nextension under Title XXI of the federal social security act, the period\nof eligibility for pregnant individuals enrolled in the child health\ninsurance plan shall include twelve months postpartum coverage\ncommencing on the first day of the month following the last day of\npregnancy and ending on the last day of the month in which the\ntwelve-month postpartum period ends; provided, however, such postpartum\ncoverage may end prior to the end of the twelve-month period only under\nthe following circumstances: (i) the individual requests voluntary\ntermination; (ii) the individual ceases to be a state resident; (iii)\neligibility was determined incorrectly because of error, fraud, abuse,\nor perjury attributed to the individual; or (iv) the individual dies.\n (e) an eligible child under six years of age shall, consistent with\napplicable federal requirements, remain continuously enrolled until the\nlater of:\n (i) the last day of the twelfth month following the date of enrollment\nor recertification in the child health insurance plan; or\n (ii) the last day of the month in which the child reaches the age of\nsix.\n 7. "Covered health care services" means: the services of physicians,\noptometrists, nurses, nurse practitioners, midwives and other related\nprofessional personnel which are provided on an outpatient basis,\nincluding routine well-child visits; diagnosis and treatment of illness\nand injury; inpatient health care services; laboratory tests; diagnostic\nx-rays; prescription and non-prescription drugs, ostomy and other\nmedical supplies and durable medical equipment; radiation therapy;\nchemotherapy; hemodialysis; outpatient blood clotting factor products\nand other treatments and services furnished in connection with the care\nof hemophilia and other blood clotting protein deficiencies; emergency\nroom services; ambulance services; hospice services; emergency,\npreventive and routine dental care, including orthodontia but excluding\ncosmetic surgery; emergency, preventive and routine vision care,\nincluding eyeglasses; speech and hearing services; inpatient and\noutpatient mental health, alcohol and substance abuse services,\nincluding children and family treatment and support services, children's\nhome and community based services, assertive community treatment\nservices and residential rehabilitation for youth services which shall\nbe reimbursed in accordance with the ambulatory patient group (APG)\nrate-setting methodology as utilized by the department of health, the\noffice of addiction services and supports, or the office of mental\nhealth for rate-setting purposes or any such other fees established\npursuant to article forty-three of the mental hygiene law; and\nhealth-related services provided by voluntary foster care agency health\nfacilities licensed pursuant to article twenty-nine-I of this chapter;\nas defined by the commissioner. "Covered health care services" shall not\ninclude drugs, procedures and supplies for the treatment of erectile\ndysfunction when provided to, or prescribed for use by, a person who is\nrequired to register as a sex offender pursuant to article six-C of the\ncorrection law, provided that any denial of coverage of such drugs,\nprocedures or supplies shall provide the patient with the means of\nobtaining additional information concerning both the denial and the\nmeans of challenging such denial.\n 8. "Subsidy payment" means a payment made to an approved organization\nfor the cost of covered health care services coverage to an eligible\nchild or children.\n 9. "Premium payment" means: a payment made on behalf of an eligible\nchild for enrollment in the child health insurance plan equal to:\n (a) for periods prior to October first, nineteen hundred ninety-seven,\ntwenty-five dollars per year for each child, but no more than one\nhundred dollars per year per family; and\n (b) for periods on or after October first, nineteen hundred\nninety-seven, amounts as follows:\n (i) no payments are required for eligible children whose family net\nhousehold income is less than one hundred twenty-six percent of the\nnon-farm federal poverty level or the gross equivalent of such net\nincome;\n (ii) nine dollars per month for each eligible child whose family net\nhousehold income is between one hundred twenty-six percent and one\nhundred thirty-two percent of the non-farm federal poverty level or the\ngross equivalent of such net income, but no more than thirty-six dollars\nper month per family; and\n (iii) thirteen dollars per month for each eligible child whose family\nnet household income is between one hundred thirty-three percent and one\nhundred eighty-five percent of the non-farm federal poverty level or the\ngross equivalent of such net income, but no more than fifty-two dollars\nper month per family.\n (c) for periods on or after January first, nineteen hundred\nninety-nine, amounts as follows:\n (i) no payments are required for eligible children whose family net\nhousehold income is less than one hundred thirty-three percent of the\nnon-farm federal poverty level or the gross equivalent of such net\nincome and, effective August first, two thousand, no payments are\nrequired for eligible children who are American Indians or Alaskan\nNatives, as defined by the U.S. Department of Health and Human Services;\nand\n (ii) nine dollars per month for each eligible child whose family net\nhousehold income is between one hundred thirty-three percent and one\nhundred eighty-five percent of the non-farm federal poverty level or the\ngross equivalent of such net income, but no more than twenty-seven\ndollars per month per family; and\n (iv) effective September first, two thousand eight, twenty dollars per\nmonth for each eligible child whose family gross household income is\nbetween two hundred fifty-one percent and three hundred percent of the\nnon-farm federal poverty level, but no more than sixty dollars per month\nper family;\n (v) effective September first, two thousand eight, thirty dollars per\nmonth for each eligible child whose family gross household income is\nbetween three hundred one percent and three hundred fifty percent of the\nnon-farm federal poverty level, but no more than ninety dollars per\nmonth per family; and\n (vi) effective September first, two thousand eight, forty dollars per\nmonth for each eligible child whose family gross household income is\nbetween three hundred fifty-one percent and four hundred percent of the\nnon-farm federal poverty level, but no more than one hundred twenty\ndollars per month per family.\n (d) for periods on or after July first, two thousand nine, amounts as\nfollows:\n (i) no payments are required for eligible children whose family\nhousehold income is less than one hundred sixty percent of the non-farm\nfederal poverty level and for eligible children who are American Indians\nor Alaskan Natives, as defined by the U.S. Department of Health and\nHuman Services, whose family household income is less than two hundred\nfifty-one percent of the non-farm federal poverty level; and\n (ii) nine dollars per month for each eligible child whose family\nhousehold income is between one hundred sixty percent and two hundred\ntwenty-two percent of the non-farm federal poverty level, but no more\nthan twenty-seven dollars per month per family; and\n (iii) fifteen dollars per month for each eligible child whose family\nhousehold income is between two hundred twenty-three percent and two\nhundred fifty percent of the non-farm federal poverty level, but no more\nthan forty-five dollars per month per family; and\n (iv) thirty dollars per month for each eligible child whose family\nhousehold income is between two hundred fifty-one percent and three\nhundred percent of the non-farm federal poverty level, but no more than\nninety dollars per month per family;\n (v) forty-five dollars per month for each eligible child whose family\nhousehold income is between three hundred one percent and three hundred\nfifty percent of the non-farm federal poverty level, but no more than\none hundred thirty-five dollars per month per family; and\n (vi) sixty dollars per month for each eligible child whose family\nhousehold income is between three hundred fifty-one percent and four\nhundred percent of the non-farm federal poverty level, but no more than\none hundred eighty dollars per month per family.\n (e) for periods on or after October first, two thousand twenty-two,\namounts as follows:\n (i) no payments are required for eligible children whose family\nhousehold income is less than two hundred twenty-three percent of the\nnon-farm federal poverty level and for eligible children who are\nAmerican Indians or Alaskan Natives, as defined by the United States\ndepartment of health and human services, whose family household income\nis less than two hundred fifty-one percent of the non-farm federal\npoverty level; and\n (ii) fifteen dollars per month for each eligible child whose family\nhousehold income is between two hundred twenty-three percent and two\nhundred fifty percent of the non-farm federal poverty level, but no more\nthan forty-five dollars per month per family; and\n (iii) thirty dollars per month for each eligible child whose family\nhousehold income is between two hundred fifty-one percent and three\nhundred percent of the non-farm federal poverty level, but no more than\nninety dollars per month per family; and\n (iv) forty-five dollars per month for each eligible child whose family\nhousehold income is between three hundred one percent and three hundred\nfifty percent of the non-farm federal poverty level, but no more than\none hundred thirty-five dollars per month per family; and\n (v) sixty dollars per month for each eligible child whose family\nhousehold income is between three hundred fifty-one percent and four\nhundred percent of the non-farm federal poverty level, but no more than\none hundred eighty dollars per month per family.\n 10. "Superintendent" means the superintendent of financial services.\n 11. "Inpatient health care services" means: inpatient hospital\nservices provided by a general hospital, as defined in article\ntwenty-eight of this chapter, a facility operated by the office of\nmental health under section 7.17 of the mental hygiene law, a facility\nissued an operating certificate pursuant to the provisions of article\ntwenty-three or thirty-one of the mental hygiene law and services\nprovided by physicians and other professional personnel on an inpatient\nbasis for covered inpatient services; as defined by the commissioner in\nconsultation with the superintendent.\n 12. "Group health plan" or "health insurance coverage" shall have the\nsame meanings as set forth in section twenty-one hundred ten of the\nfederal social security act.\n 13. "Household income" means the sum of the modified adjusted gross\nincome of every individual included in a child's household calculated in\naccordance with applicable federal law and regulations, as may be\namended.\n 14. "State enrollment center" means the centralized system and\noperation of eligibility determinations by the state or its contractor\nfor all insurance affordability programs, including the child health\ninsurance program established pursuant to this title.\n 15. "Insurance affordability programs" means those programs set forth\nin section 435.4 of title 42 of the code of federal regulations.\n