§ 4401 — Definitions

§ 4401. Definitions. For the purpose of this article: 1. "Health\nmaintenance organization" or "organization" means any person, natural or\ncorporate, or any groups of such persons who enter into an arrangement,\nagreement or plan or any combination of arrangements or plans which\npropose to provide or offer, or which do provide or offer, a\ncomprehensive health services plan.\n 2. "Comprehensive health services plan" or "plan" means a plan through\nwhich each member of an enrolled population is entitled to receive\ncomprehensive health services in consideration for a basic advance or\nperiodic charge. A plan may include the provision of health care\nservices which are covered by the organization at the election of\nenrollees by health care providers not participating in the plan\npursuant to a contract, employment or other association to the extent\nauthorized in section forty-four hundred six of this article; provided,\nhowever, that in no event shall an enrollee elect to have a\nnon-participating provider serve as the enrollee's primary care\npractitioner responsible for supervising and coordinating the care of\nthe enrollee.\n 3. "Comprehensive health services" means all those health services\nwhich an enrolled population might require in order to be maintained in\ngood health, and shall include, but shall not be limited to, physician\nservices (including consultant and referral services), in-patient and\nout-patient hospital services, diagnostic laboratory and therapeutic and\ndiagnostic radiologic services, and emergency and preventive health\nservices. Such term may be further defined by agreement with enrolled\npopulations providing additional benefits necessary, desirable or\nappropriate to meet their health care needs.\n 4. "Enrolled population" means a group of persons, defined as to\nprobable age, sex and family composition, which receives comprehensive\nhealth services from a health maintenance organization in consideration\nfor a basic advance or periodic charge.\n 5. "Superintendent" means the superintendent of financial services of\nthe state of New York.\n * 6. "Comprehensive HIV special needs plan" means a health maintenance\norganization certified pursuant to section forty-four hundred three-c of\nthis article which, in addition to providing or arranging for the\nprovision of comprehensive health services on a capitated basis,\nincluding those for which medical assistance payment is authorized\npursuant to section three hundred sixty-five-a of the social services\nlaw, also provides or arranges for the provision of HIV care to HIV\npositive persons eligible to receive benefits under title XIX of the\nfederal social security act or other public programs.\n * NB Repealed March 31, 2030\n * 7. "HIV Center of excellence" is defined as a health care facility\ncertified to operate under article twenty-eight of this chapter that\noffers specialized treatment expertise in HIV care services as defined\nby the commissioner.\n * NB Repealed March 31, 2030\n 8. "Special needs managed care plan" shall mean a combination of\npersons natural or corporate, or any groups of such persons, or a county\nor counties, who enter into an arrangement, agreement or plan, or\ncombination of arrangements, agreements or plans, to provide health and\nbehavioral health services to enrollees with significant behavioral\nhealth needs.\n 9. "Medically fragile child" means an individual who is under\ntwenty-one years of age and has a chronic debilitating condition or\nconditions, who may or may not be hospitalized or institutionalized, and\nmeets one or more of the following criteria (a) is technologically\ndependent for life or health sustaining functions, (b) requires a\ncomplex medication regimen or medical interventions to maintain or to\nimprove their health status, or (c) is in need of ongoing assessment or\nintervention to prevent serious deterioration of their health status or\nmedical complications that place their life, health or development at\nrisk. Chronic debilitating conditions include bronchopulmonary\ndysplasia, cerebral palsy, congenital heart disease, microcephaly,\npulmonary hypertension, and muscular dystrophy. The term "medically\nfragile child" shall also include traumatic brain injury, the nature of\nwhich typically requires care in a specialty care center for medically\nfragile children, even though the child does not have a chronic\ndebilitating condition or also meet one of the three conditions of this\nsubdivision. Notwithstanding the definitions set forth in this\nsubdivision, any patient which has received prior approval from a health\nmaintenance organization for admission to a specialty care facility for\nmedically fragile children shall be considered a medically fragile child\nat least until discharge from that facility occurs.\n