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This entry was published on 2022-12-16
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Public Health (PBH) CHAPTER 45, ARTICLE 2, TITLE 7
§ 268-a. Definitions. For purposes of this title, the following
definitions shall apply:

1. "Commissioner" means the commissioner of health of the state of New

2. "Marketplace" means the "NY State of Health, The official health
plan Marketplace" or "Marketplace" established as a health benefit
exchange or "marketplace" within the department of health pursuant to
Executive Order 42 (Cuomo) issued April 12, 2012 and this title.

3. "Federal act" means the patient protection and affordable care act,
public law 111-148, as amended by the health care and education
reconciliation act of 2010, public law 111-152, and any regulations or
guidance issued thereunder.

4. "Health plan" means a policy, contract or certificate, offered or
issued by an insurer to provide, deliver, arrange for, pay for or
reimburse any of the costs of health care services. Health plan shall
not include the following:

(a) accident insurance or disability income insurance, or any
combination thereof;

(b) coverage issued as a supplement to liability insurance;

(c) liability insurance, including general liability insurance and
automobile liability insurance;

(d) workers' compensation or similar insurance;

(e) automobile no-fault insurance;

(f) credit insurance;

(g) other similar insurance coverage, as specified in federal
regulations, under which benefits for medical care are secondary or
incidental to other insurance benefits;

(h) limited scope dental or vision benefits, benefits for long-term
care insurance, nursing home insurance, home care insurance, or any
combination thereof, or such other similar, limited benefits health
insurance as specified in federal regulations, if the benefits are
provided under a separate policy, certificate or contract of insurance
or are otherwise not an integral part of the plan;

(i) coverage only for a specified disease or illness, hospital
indemnity, or other fixed indemnity coverage;

(j) Medicare supplemental insurance as defined in section 1882(g)(1)
of the federal social security act, coverage supplemental to the
coverage provided under chapter 55 of title 10 of the United States
Code, or similar supplemental coverage provided under a group health
plan if it is offered as a separate policy, certificate or contract of
insurance; or

(k) the New York state medical indemnity fund established pursuant to
title four of article twenty-nine-D of the public health law.

5. "Insurer" means an insurance company subject to article forty-two
or a corporation subject to article forty-three of the insurance law, or
a health maintenance organization certified pursuant to article
forty-four of the public health law that contracts or offers to contract
to provide, deliver, arrange, pay or reimburse any of the costs of
health care services.

6. "Stand-Alone dental plan" means a dental services plan that has
been issued pursuant to applicable law and certified by the Marketplace
in accordance with section two hundred sixty-eight-d of this title.

7. "Qualified health plan" means a health plan that is issued pursuant
to applicable law and certified by the Marketplace in accordance with
section two hundred sixty-eight-d of this title, including a stand-alone
dental plan.

8. "Insurance affordability program" means Medicaid, child health
plus, the basic health program, post-partum extended coverage and any
other health insurance subsidy program designated as such by the

9. "Eligible individual" means an individual, including a minor, who
is eligible to enroll in an insurance affordability program or other
health insurance program as determined by the commissioner.

10. "Qualified individual" means, with respect to qualified health
plans, an individual, including a minor, who:

(a) is eligible to enroll in a qualified health plan offered to
individuals through the Marketplace;

(b) resides in this state;

(c) at the time of enrollment, is not incarcerated, other than
incarceration pending the disposition of charges; and

(d) is, and is reasonably expected to be, for the entire period for
which enrollment is sought, a citizen or national of the United States
or a noncitizen lawfully present in the United States.

11. "Secretary" means the secretary of the United States department of
health and human services.

12. "SHOP" means the small business health options program operated by
the Marketplace to assist eligible small employers in this state in
selecting qualified health plans and/or other or additional health plans
certified by the Marketplace and to determine small employer eligibility
for purposes of small employer tax credits in accordance with applicable
federal and state laws and regulations.

13. "Small employer" means an employer which offers coverage where the
coverage such employer offers would be considered small group coverage
under the insurance law and regulations promulgated thereunder, provided
that it is not otherwise prohibited under the federal act.

14. "Small group market" means the health insurance market under which
individuals receive health insurance coverage on behalf of themselves
and their dependents through a group health plan maintained by a small

15. "Superintendent" means the superintendent of financial services.

16. "Essential health benefits" shall mean the categories of benefits
defined in subsection (a) of section three thousand two hundred
seventeen-i and subsection (a) of section four thousand three hundred
six-h of the insurance law.