1. The Laws of New York
  2. Consolidated Laws
  3. Public Health
  4. Article 2: The Department of Health
  5. Title 7: Ny State of Health


Section 268-A Definitions

Public Health (PBH)

For purposes of this title, the following definitions shall apply:

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

  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 and any other health insurance subsidy program designated as such by the commissioner.

  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 an alien 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 employer.

  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.