§ 248 — Cost-sharing responsibilities of eligible program participants for catastrophic coverage

New York § 248

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

Text

§ 248. Cost-sharing responsibilities of eligible program participants\nfor catastrophic coverage. 1. Deductible. Eligible individuals meeting\nthe deductible requirements of this section may purchase prescribed\ncovered drugs for an amount specified by subdivision three of this\nsection, subject to the limits on point of sale co-payments specified by\nsubdivision four of this section.\n 2. Deductible schedule. Eligible individuals electing to meet the\nrequirements of this subdivision shall incur an amount of personal\ncovered drug expenditures during any annual coverage period which are\nnot reimbursed by any other public or private third party payment source\nor insurance plan, and shall be deemed to have met their deductible\nrequirements for the remainder of such annual coverage period. The\namount of personal covered drug expenditures to be incurred by eligible\nprogram participants for catastrophic coverage under this option shall\nbe in accordance with the following schedule:\n (a) Annual personal covered drug expenditures for unmarried individual\neligible program participants:\nindividual income of $20,001 to $21,000 $530\nindividual income of $21,001 to $22,000 $550\nindividual income of $22,001 to $23,000 $580\nindividual income of $23,001 to $24,000 $720\nindividual income of $24,001 to $25,000 $750\nindividual income of $25,001 to $26,000 $780\nindividual income of $26,001 to $27,000 $810\nindividual income of $27,001 to $28,000 $840\nindividual income of $28,001 to $29,000 $870\nindividual income of $29,001 to $30,000 $900\nindividual income of $30,001 to $31,000 $930\nindividual income of $31,001 to $32,000 $960\nindividual income of $32,001 to $33,000 $1,160\nindividual income of $33,001 to $34,000 $1,190\nindividual income of $34,001 to $35,000 $1,230\nindividual income of $35,001 to $36,000 $1,260\nindividual income of $36,001 to $37,000 $1,290\nindividual income of $37,001 to $38,000 $1,320\nindividual income of $38,001 to $39,000 $1,350\nindividual income of $39,001 to $40,000 $1,380\nindividual income of $40,001 to $41,000 $1,410\nindividual income of $41,001 to $42,000 $1,440\nindividual income of $42,001 to $43,000 $1,470\nindividual income of $43,001 to $44,000 $1,500\nindividual income of $44,001 to $45,000 $1,530\nindividual income of $45,001 to $46,000 $1,560\nindividual income of $46,001 to $47,000 $1,590\nindividual income of $47,001 to $48,000 $1,620\nindividual income of $48,001 to $49,000 $1,650\nindividual income of $49,001 to $50,000 $1,680\nindividual income of $50,001 to $51,000 $1,710\nindividual income of $51,001 to $52,000 $1,740\nindividual income of $52,001 to $53,000 $1,770\nindividual income of $53,001 to $54,000 $1,800\nindividual income of $54,001 to $55,000 $1,830\nindividual income of $55,001 to $56,000 $1,860\nindividual income of $56,001 to $57,000 $1,890\nindividual income of $57,001 to $58,000 $1,920\nindividual income of $58,001 to $59,000 $1,950\nindividual income of $59,001 to $60,000 $1,980\nindividual income of $60,001 to $61,000 $2,010\nindividual income of $61,001 to $62,000 $2,040\nindividual income of $62,001 to $63,000 $2,070\nindividual income of $63,001 to $64,000 $2,100\nindividual income of $64,001 to $65,000 $2,130\nindividual income of $65,001 to $66,000 $2,160\nindividual income of $66,001 to $67,000 $2,190\nindividual income of $67,001 to $68,000 $2,220\nindividual income of $68,001 to $69,000 $2,250\nindividual income of $69,001 to $70,000 $2,280\nindividual income of $70,001 to $71,000 $2,310\nindividual income of $71,001 to $72,000 $2,340\nindividual income of $72,001 to $73,000 $2,370\nindividual income of $73,001 to $74,000 $2,400\nindividual income of $74,001 to $75,000 $2,430\n (b) Annual personal covered drug expenditures for each married\nindividual eligible program participant:\njoint income of $26,001 to $27,000 $650\njoint income of $27,001 to $28,000 $675\njoint income of $28,001 to $29,000 $700\njoint income of $29,001 to $30,000 $725\njoint income of $30,001 to $31,000 $900\njoint income of $31,001 to $32,000 $930\njoint income of $32,001 to $33,000 $960\njoint income of $33,001 to $34,000 $990\njoint income of $34,001 to $35,000 $1,020\njoint income of $35,001 to $36,000 $1,050\njoint income of $36,001 to $37,000 $1,080\njoint income of $37,001 to $38,000 $1,110\njoint income of $38,001 to $39,000 $1,140\njoint income of $39,001 to $40,000 $1,170\njoint income of $40,001 to $41,000 $1,200\njoint income of $41,001 to $42,000 $1,230\njoint income of $42,001 to $43,000 $1,260\njoint income of $43,001 to $44,000 $1,290\njoint income of $44,001 to $45,000 $1,320\njoint income of $45,001 to $46,000 $1,575\njoint income of $46,001 to $47,000 $1,610\njoint income of $47,001 to $48,000 $1,645\njoint income of $48,001 to $49,000 $1,680\njoint income of $49,001 to $50,000 $1,715\njoint income of $50,001 to $51,000 $1,745\njoint income of $51,001 to $52,000 $1,775\njoint income of $52,001 to $53,000 $1,805\njoint income of $53,001 to $54,000 $1,835\njoint income of $54,001 to $55,000 $1,865\njoint income of $55,001 to $56,000 $1,895\njoint income of $56,001 to $57,000 $1,925\njoint income of $57,001 to $58,000 $1,955\njoint income of $58,001 to $59,000 $1,985\njoint income of $59,001 to $60,000 $2,015\njoint income of $60,001 to $61,000 $2,045\njoint income of $61,001 to $62,000 $2,075\njoint income of $62,001 to $63,000 $2,105\njoint income of $63,001 to $64,000 $2,135\njoint income of $64,001 to $65,000 $2,165\njoint income of $65,001 to $66,000 $2,195\njoint income of $66,001 to $67,000 $2,225\njoint income of $67,001 to $68,000 $2,255\njoint income of $68,001 to $69,000 $2,285\njoint income of $69,001 to $70,000 $2,315\njoint income of $70,001 to $71,000 $2,345\njoint income of $71,001 to $72,000 $2,375\njoint income of $72,001 to $73,000 $2,405\njoint income of $73,001 to $74,000 $2,435\njoint income of $74,001 to $75,000 $2,465\njoint income of $75,001 to $76,000 $2,495\njoint income of $76,001 to $77,000 $2,525\njoint income of $77,001 to $78,000 $2,555\njoint income of $78,001 to $79,000 $2,585\njoint income of $79,001 to $80,000 $2,615\njoint income of $80,001 to $81,000 $2,645\njoint income of $81,001 to $82,000 $2,675\njoint income of $82,001 to $83,000 $2,705\njoint income of $83,001 to $84,000 $2,735\njoint income of $84,001 to $85,000 $2,765\njoint income of $85,001 to $86,000 $2,795\njoint income of $86,001 to $87,000 $2,825\njoint income of $87,001 to $88,000 $2,855\njoint income of $88,001 to $89,000 $2,885\njoint income of $89,001 to $90,000 $2,915\njoint income of $90,001 to $91,000 $2,945\njoint income of $91,001 to $92,000 $2,975\njoint income of $92,001 to $93,000 $3,005\njoint income of $93,001 to $94,000 $3,035\njoint income of $94,001 to $95,000 $3,065\njoint income of $95,001 to $96,000 $3,095\njoint income of $96,001 to $97,000 $3,125\njoint income of $97,001 to $98,000 $3,155\njoint income of $98,001 to $99,000 $3,185\njoint income of $99,001 to $100,000 $3,215\n (c) In the event that the state expenditures per participant electing\nto meet the deductible 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 personal covered drug expenditures\nset forth in this subdivision may, unless otherwise provided by law, be\nincreased, pro-rata, for the subsequent program year, provided that such\nincrease shall not exceed eight percent of the prior year personal\ncovered drug expenditures as may have been adjusted in accordance with\nthis paragraph.\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 personal covered drug expenditures set forth in\nthis subdivision may, unless otherwise provided by law, be decreased,\npro-rata, for the subsequent program year, provided that such decrease\nshall not exceed eight percent of the prior year personal covered drug\nexpenditures as may have been adjusted in accordance with this\nparagraph.\n (e) The determination to adjust annual personal covered drug\nexpenditures set forth in this subdivision, shall follow a review of\nsuch factors as the relative financial capacity of the state and such\neligible program participants to support such adjustments and changes in\nthe consumer price index. The frequency of such adjustments shall not\nexceed once in any twelve month period and such adjustments shall not\nbecome effective for individual program participants prior to the first\nday of the next annual coverage period for each participant.\n 3. Point of sale co-payment. (a) Upon satisfaction of the deductible\nrequirements pursuant to subdivision two of this section, an eligible\nprogram participant shall pay a point of sale co-payment as set forth in\nparagraph (b) of this subdivision at the time of each purchase of a\ncovered drug prescribed for such individual. Such co-payment shall not\nbe waived or reduced in whole or in part, subject to the limits provided\nby subdivision four of this 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\ndrugs costing $15.00 or less $3.00\nFor each prescription of covered\ndrugs costing $15.01 to $35.00 $7.00\nFor each prescription of covered\ndrugs costing $35.01 to $55.00 $15.00\nFor each prescription of covered\ndrugs 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. Annual limits on point of sale co-payments. During each annual\ncoverage period, no point of sale co-payments as set forth in\nsubdivision three of this section shall be required to be made for the\nremainder of such period by any eligible program participant meeting the\npersonal covered drug expenditure requirements of subdivision two of\nthis section in excess of the limits set forth in the following\nschedule:\n (a) Limits on co-payments by unmarried individual eligible program\nparticipants:\nindividual income of $20,001 to $21,000 no more than $1,050\nindividual income of $21,001 to $22,000 no more than $1,100\nindividual income of $22,001 to $23,000 no more than $1,150\nindividual income of $23,001 to $24,000 no more than $1,200\nindividual income of $24,001 to $25,000 no more than $1,250\nindividual income of $25,001 to $26,000 no more than $1,300\nindividual income of $26,001 to $27,000 no more than $1,350\nindividual income of $27,001 to $28,000 no more than $1,400\nindividual income of $28,001 to $29,000 no more than $1,450\nindividual income of $29,001 to $30,000 no more than $1,500\nindividual income of $30,001 to $31,000 no more than $1,550\nindividual income of $31,001 to $32,000 no more than $1,600\nindividual income of $32,001 to $33,000 no more than $1,650\nindividual income of $33,001 to $34,000 no more than $1,700\nindividual income of $34,001 to $75,000 no more than $1,750\n (b) Limits on co-payments by each married individual eligible program\nparticipant:\njoint income of $26,001 to $27,000 no more than $1,080\njoint income of $27,001 to $28,000 no more than $1,120\njoint income of $28,001 to $29,000 no more than $1,160\njoint income of $29,001 to $30,000 no more than $1,200\njoint income of $30,001 to $31,000 no more than $1,240\njoint income of $31,001 to $32,000 no more than $1,280\njoint income of $32,001 to $33,000 no more than $1,320\njoint income of $33,001 to $34,000 no more than $1,360\njoint income of $34,001 to $35,000 no more than $1,400\njoint income of $35,001 to $36,000 no more than $1,440\njoint income of $36,001 to $37,000 no more than $1,480\njoint income of $37,001 to $38,000 no more than $1,520\njoint income of $38,001 to $39,000 no more than $1,560\njoint income of $39,001 to $40,000 no more than $1,600\njoint income of $40,001 to $41,000 no more than $1,640\njoint income of $41,001 to $42,000 no more than $1,680\njoint income of $42,001 to $43,000 no more than $1,720\njoint income of $43,001 to $44,000 no more than $1,760\njoint income of $44,001 to $45,000 no more than $1,800\njoint income of $45,001 to $46,000 no more than $1,840\njoint income of $46,001 to $47,000 no more than $1,880\njoint income of $47,001 to $48,000 no more than $1,920\njoint income of $48,001 to $49,000 no more than $1,960\njoint income of $49,001 to $100,000 no more than $2,000\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 commissioner 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-seven of this title. Such annual adjustments\nshall be calculated by multiplying the percentage adjustment factor by\n(1) ten percent and applying the resulting percentage to the upper\nincome limitation of each income level for unmarried individuals\ncontained in this subdivision, and by (2) seven and one-half percent and\napplying the resulting percentage to the upper income limitation of each\nincome level for married individuals contained in this subdivision; each\nresult of such calculations, minus any applicable deductible increases\nmade pursuant to subdivision two of this section and plus the result of\napplying the percentage adjustment factor to the sum of any such annual\nadjustments applicable thereto for any prior annual coverage period,\nshall be the amount by which the limit on co-payments for each such\nincome level may be adjusted, and such amount shall be in addition to\nany such amount or amounts applicable to prior annual coverage periods.\n (d) 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 participant to support such adjustments.\n