§ 247 — Cost-sharing responsibilities of eligible program participants for comprehensive coverage

New York § 247

• Jurisdiction: New York
• Law ELD: Elder
• Title 3: Program For Elderly Pharmaceutical Insurance Coverage
• Art. 2: Programs For the Elderly

Text

§ 247. Cost-sharing responsibilities of eligible program participants\nfor comprehensive coverage.\n 1. Registration fee. Eligible individuals meeting the registration fee\nrequirements of this section may purchase prescribed covered drugs for\nan amount specified by subdivision three of this section, subject to the\nlimits on point of sale co-payments specified by subdivision four of\nthis section.\n 2. Registration fee schedule. Eligible individuals electing to meet\nthe requirements of this subdivision shall pay a quarterly registration\nfee in a manner and form determined by the executive director; at the\noption of the participant, the registration fee may be paid annually in\na lump sum upon the beginning of the annual coverage period. No eligible\nindividual electing to meet the requirements of this subdivision shall\nhave his participation in the program lapse by virtue of non-payment of\nthe applicable registration fee unless the contractor has provided\nnotification of the amount and due date thereof, and more than thirty\ndays have elapsed since the due date of the individual's registration\nfee. The registration fee to be charged to eligible program participants\nfor comprehensive coverage under this option shall be in accordance with\nthe following schedule:\n (a) Quarterly registration fees for unmarried individual program\nparticipants:\nindividual income of $5,000 or less $2.00\nindividual income of $5,001 to $6,000 $2.00\nindividual income of $6,001 to $7,000 $4.00\nindividual income of $7,001 to $8,000 $5.50\nindividual income of $8,001 to $9,000 $7.00\nindividual income of $9,001 to $10,000 $9.00\nindividual income of $10,001 to $11,000 $10.00\nindividual income of $11,001 to $12,000 $11.50\nindividual income of $12,001 to $13,000 $13.50\nindividual income of $13,001 to $14,000 $15.00\nindividual income of $14,001 to $15,000 $20.00\nindividual income of $15,001 to $16,000 $27.50\nindividual income of $16,001 to $17,000 $35.00\nindividual income of $17,001 to $18,000 $42.50\nindividual income of $18,001 to $19,000 $50.00\nindividual income of $19,001 to $20,000 $57.50\n (b) Quarterly registration fees for each married individual program\nparticipant:\njoint income of $5,000 or less $2.00\njoint income of $5,001 to $6,000 $2.00\njoint income of $6,001 to $7,000 $3.00\njoint income of $7,001 to $8,000 $4.00\njoint income of $8,001 to $9,000 $5.00\njoint income of $9,001 to $10,000 $6.00\njoint income of $10,001 to $11,000 $7.00\njoint income of $11,001 to $12,000 $8.00\njoint income of $12,001 to $13,000 $9.00\njoint income of $13,001 to $14,000 $10.00\njoint income of $14,001 to $15,000 $10.00\njoint income of $15,001 to $16,000 $21.00\njoint income of $16,001 to $17,000 $26.50\njoint income of $17,001 to $18,000 $31.50\njoint income of $18,001 to $19,000 $37.50\njoint income of $19,001 to $20,000 $43.00\njoint income of $20,001 to $21,000 $48.50\njoint income of $21,001 to $22,000 $54.00\njoint income of $22,001 to $23,000 $59.50\njoint income of $23,001 to $24,000 $65.00\njoint income of $24,001 to $25,000 $68.75\njoint income of $25,001 to $26,000 $75.00\n (c) In the event that the state expenditures per participant meeting\nthe registration fee requirements of this subdivision, exclusive of\nexpenditures for program administration, in the program year commencing\nOctober first, nineteen hundred eighty-eight, and in each program year\nthereafter, exceed such expenditures in the previous program year by a\nminimum of ten percent, the annual registration fees set forth in this\nsubdivision may, unless otherwise provided by law, be increased,\npro-rata, for the subsequent program year, provided that such increase\nshall not exceed seven and one-half percent of the prior year\nregistration fees as may have been adjusted in accordance with this\nparagraph.\n (d) In the event that the state expenditures per such participant,\nincurred pursuant to this subdivision, exclusive of expenditures for\nprogram administration, in the program year commencing October first,\nnineteen hundred eighty-eight, and in each program year thereafter, are\nless than such expenditures in the previous program year by a minimum of\nten percent, the annual registration fees set forth in this subdivision\nmay, unless otherwise provided by law, be decreased, pro-rata, for the\nsubsequent program year, provided that such decrease shall not exceed\nseven and one-half percent of the prior year registration fees as may\nhave been adjusted in accordance with this paragraph.\n (e) The determination to adjust annual registration fees set forth in\nthis subdivision shall follow a review of such factors as the relative\nfinancial capacity of the state and such eligible program participants\nto support such adjustments and changes in the consumer price index. The\nfrequency of such adjustments shall not exceed once in any program year\nand such adjustments shall not become effective for individual program\nparticipants prior to the first day of the next annual coverage period\nfor each participant.\n 3. Point of sale co-payment. (a) Upon satisfaction of the registration\nfee pursuant to this section an eligible program participant must pay a\npoint of sale co-payment as set forth in paragraph (b) of this\nsubdivision at the time of each purchase of a covered drug prescribed\nfor such individual. Such co-payment shall not be waived or reduced in\nwhole or in part subject to the limits provided by subdivision four of\nthis section.\n (b) The point of sale co-payment amounts which are to be charged\neligible program participants shall be in accordance with the following\nschedule:\nFor each prescription of covered drugs costing $15.00 or less.....$3.00\nFor each prescription of covered drugs costing $15.01 to $35.00...$7.00\nFor each prescription of covered drugs costing $35.01 to $55.00..$15.00\nFor each prescription of covered drugs costing $55.01 or more....$20.00\n (c) For the purposes of the foregoing schedule of point of sale\nco-payments, "costing" shall mean the amount of reimbursement which\nshall be paid by the state to a participating provider pharmacy in\naccordance with section two hundred fifty of this title plus the point\nof sale co-payment, calculated as of the date of sale.\n 4. Limits on point of sale co-payments. During each annual coverage\nperiod no point of sale co-payment as set forth in subdivision three of\nthis section shall be required to be made for the remainder of such\nperiod by any eligible program participant who has already incurred\nco-payments in excess of the limits set forth in the following schedule:\n (a) Limits on co-payments by unmarried individual eligible program\nparticipants:\nindividual income of $5,000 or less no more than $340\nindividual income of $5,001 to $6,000 no more than $408\nindividual income of $6,001 to $7,000 no more than $476\nindividual income of $7,001 to $8,000 no more than $544\nindividual income of $8,001 to $9,000 no more than $612\nindividual income of $9,001 to $10,000 no more than $700\nindividual income of $10,001 to $11,000 no more than $720\nindividual income of $11,001 to $12,000 no more than $827\nindividual income of $12,001 to $13,000 no more than $896\nindividual income of $13,001 to $14,000 no more than $964\nindividual income of $14,001 to $15,000 no more than $1,016\nindividual income of $15,001 to $16,000 no more than $1,034\nindividual income of $16,001 to $17,000 no more than $1,052\nindividual income of $17,001 to $18,000 no more than $1,070\nindividual income of $18,001 to $19,000 no more than $1,088\nindividual income of $19,001 to $20,000 no more than $1,160\n (b) Limits on co-payments by each married individual eligible program\nparticipant:\njoint income of $5,000 or less no more than $291\njoint income of $5,001 to $6,000 no more than $342\njoint income of $6,001 to $7,000 no more than $399\njoint income of $7,001 to $8,000 no more than $456\njoint income of $8,001 to $9,000 no more than $513\njoint income of $9,001 to $10,000 no more than $570\njoint income of $10,001 to $11,000 no more than $622\njoint income of $11,001 to $12,000 no more than $641\njoint income of $12,001 to $13,000 no more than $660\njoint income of $13,001 to $14,000 no more than $684\njoint income of $14,001 to $15,000 no more than $710\njoint income of $15,001 to $16,000 no more than $826\njoint income of $16,001 to $17,000 no more than $877\njoint income of $17,001 to $18,000 no more than $928\njoint income of $18,001 to $19,000 no more than $980\njoint income of $19,001 to $20,000 no more than $990\njoint income of $20,001 to $21,000 no more than $1,008\njoint income of $21,001 to $22,000 no more than $1,026\njoint income of $22,001 to $23,000 no more than $1,044\njoint income of $23,001 to $24,000 no more than $1,062\njoint income of $24,001 to $25,000 no more than $1,080\njoint income of $25,001 to $26,000 no more than $1,150\n (c) Effective October first, nineteen hundred eighty-eight, the limits\non point of sale co-payments as set forth in this subdivision may be\nadjusted by the panel on the anniversary date of each program\nparticipant's annual coverage period, and such adjustment shall be in\neffect for the duration of that annual coverage period. Any such annual\nadjustment shall be made using a percentage adjustment factor which\nshall not exceed one-half of the difference between the year-to-year\npercentage increase in the consumer price index for all urban consumers,\nas published by the United States Department of Labor, and, if larger,\nthe year-to-year percentage increase in the aggregate average cost of\ncovered drugs purchased under this title, which year-to-year percentage\nincrease in such cost shall be determined by comparison of such cost in\nthe same month of each of the appropriate successive years; provided,\nhowever, that for any such adjustment based wholly on experience in the\nprogram year commencing October first, nineteen hundred eighty-seven,\nthe year-to-year percentage increase in such cost shall be determined by\ncomparison of such cost in each of two months no less than five months\napart and within such program year, which comparison shall be\nannualized. Such percentage adjustment factor shall be the same as that\nused to determine any similar annual adjustment for the same annual\ncoverage periods pursuant to the provisions of subdivision four of\nsection two hundred forty-eight of this title.\n (d) Such annual adjustments shall be calculated by multiplying the\npercentage adjustment factor by (1) ten percent and applying the\nresulting percentage to the upper income limitation of each income level\nfor unmarried individuals contained in this subdivision, and by (2)\nseven and one-half percent and applying the resulting percentage to the\nupper income limitation of each income level for married individuals\ncontained in this subdivision; each result of such calculations, minus\nany applicable registration fee increases made pursuant to subdivision\ntwo of this section and plus the result of applying the percentage\nadjustment factor to the sum of any such annual adjustments applicable\nthereto for any prior annual coverage period, shall be the amount by\nwhich the limit on co-payments for each such income level may be\nadjusted, and such amount shall be in addition to any such amount or\namounts applicable to prior annual coverage periods.\n (e) The determination to adjust the limits on point of sale\nco-payments set forth in this subdivision shall follow a review of such\nfactors as the relative financial capacity of the state and such\neligible program participants to support such adjustments.\n