§ 367-A — Payments; insurance

New York § 367-A

• Jurisdiction: New York
• Law SOS: Social Services
• Title 11: Medical Assistance For Needy Persons
• Art. 5: Assistance and Care

Text

§ 367-a. Payments; insurance. 1. (a) Any inconsistent provision of\nthis chapter or other law notwithstanding, no assignment of the claim of\nany supplier of medical assistance shall be valid and enforceable as\nagainst any social services district or the department, and any payment\nwith respect to any medical assistance shall be made to the person,\ninstitution, state department or agency or municipality supplying such\nmedical assistance at rates established by the appropriate social\nservices district and contained in its approved local medical plan,\nexcept as otherwise permitted or required by applicable federal and\nstate provisions, including the regulations of the department; provided,\nhowever, that for those districts for whom the department has assumed\npayment responsibilities pursuant to section three hundred sixty-seven-b\nof this chapter, rates shall be established by the department, except as\notherwise required by applicable provisions of federal or state law. A\nsocial services official may apply to the department for local\nvariations in rates to be applicable, upon approval by the department,\nto recipients for whom such district is responsible. Claims for payment\nshall be made in such form and manner as the department shall determine.\n (b) Where an applicant for or recipient of public assistance or\nmedical assistance has health insurance in force, is enrolled in a group\nhealth insurance plan or group health plan covering care and other\nmedical benefits provided under this title, payment or part-payment of\nthe premium, co-insurance, any deductible amounts and other cost-sharing\nobligations for such insurance may also be made when deemed\ncost-effective pursuant to the regulations of the department.\n (c) Any inconsistent provisions of this title or other law\nnotwithstanding and to the extent that federal financial participation\nis available therefor and in accordance with the regulations of the\ncommissioner, payment of the premium for coverage under a group health\ninsurance plan or group health plan may be made under the medical\nassistance program on behalf of a person not otherwise entitled to\npublic assistance or medical assistance if the social services official\ndetermines that the savings in expenditures to the program as a result\nof such coverage are likely to exceed the amount of the premiums paid\nand such person has:\n (i) income (as determined in accordance with the methodology used to\ndetermine eligibility for benefits under the federal supplemental\nsecurity income program) in an amount less than or equal to one hundred\nper cent of the federal income official poverty line (as defined and\nannually revised by the federal office of management and budget)\napplicable to the person's family size;\n (ii) resources (as determined in accordance with the methodology used\nto determine eligibility for benefits under the federal supplemental\nsecurity income program) less than or equal to twice the maximum amount\nan individual is permitted to have to obtain benefits under the federal\nsupplemental security income program; and\n (iii) coverage available under a group health insurance plan or an\nemployer-based group health plan provided pursuant to title XXII of the\nfederal public health services act, section 4980B of the federal\ninternal revenue code of 1986, or title VI of the employee retirement\nincome security act of 1974.\n (d) (i) Amounts payable under this title for medical assistance for\nitems and services provided to eligible persons who are also\nbeneficiaries under part A of title XVIII of the federal social security\nact and items and services provided to qualified medicare beneficiaries\nunder part A of title XVIII of the federal social security act shall not\nbe less than the amount of any deductible and co-insurance liability of\nsuch eligible persons or for which such eligible persons or such\nqualified medicare beneficiaries would be liable under federal law were\nthey not eligible for medical assistance or were they not qualified\nmedicare beneficiaries with respect to such benefits under such part A.\n (ii) Amounts payable under this title for medical assistance for items\nand services provided to eligible persons who are also beneficiaries\nunder part B of title XVIII of the federal social security act and items\nand services provided to qualified medicare beneficiaries under part B\nof title XVIII of the federal social security act shall not be less than\nthe amount of any deductible liability of such eligible persons or for\nwhich such eligible persons or such qualified medicare beneficiaries\nwould be liable under federal law were they not eligible for medical\nassistance or were they not qualified medicare beneficiaries with\nrespect to such benefits under such part B.\n (iii) With respect to items and services provided to eligible persons\nwho are also beneficiaries under part B of title XVIII of the federal\nsocial security act and items and services provided to qualified\nmedicare beneficiaries under part B of title XVIII of the federal social\nsecurity act, the amount payable for services covered under this title\nshall be the amount of any co-insurance liability of such eligible\npersons pursuant to federal law were they not eligible for medical\nassistance or were they not qualified medicare beneficiaries with\nrespect to such benefits under such part B, but shall not exceed the\namount that otherwise would be made under this title if provided to an\neligible person other than a person who is also a beneficiary under part\nB or is a qualified medicare beneficiary minus the amount payable under\npart B; provided, however, amounts payable under this title for items\nand services provided to eligible persons who are also beneficiaries\nunder part B or to qualified medicare beneficiaries by an ambulance\nservice under the authority of an operating certificate issued pursuant\nto article thirty of the public health law, a psychologist licensed\nunder article one hundred fifty-three of the education law, or a\nfacility under the authority of an operating certificate issued pursuant\nto article sixteen, thirty-one or thirty-two of the mental hygiene law\nand with respect to outpatient hospital and clinic items and services\nprovided by a facility under the authority of an operating certificate\nissued pursuant to article twenty-eight of the public health law, shall\nnot be less than the amount of any co-insurance liability of such\neligible persons or such qualified medicare beneficiaries, or for which\nsuch eligible persons or such qualified medicare beneficiaries would be\nliable under federal law were they not eligible for medical assistance\nor were they not qualified medicare beneficiaries with respect to such\nbenefits under part B.\n (iv) If a health plan participating in part C of title XVIII of the\nfederal social security act pays for items and services provided to\neligible persons who are also beneficiaries under part B of title XVIII\nof the federal social security act or to qualified medicare\nbeneficiaries, the amount payable for services under this title shall be\neighty-five percent of the amount of any co-insurance liability of such\neligible persons pursuant to federal law if they were not eligible for\nmedical assistance or were not qualified medicare beneficiaries with\nrespect to such benefits under such part B; provided, however, amounts\npayable under this title for items and services provided to eligible\npersons who are also beneficiaries under part B or to qualified medicare\nbeneficiaries by an ambulance service under the authority of an\noperating certificate issued pursuant to article thirty of the public\nhealth law, or a psychologist licensed under article one hundred\nfifty-three of the education law, shall not be less than the amount of\nany co-insurance liability of such eligible persons or such qualified\nmedicare beneficiaries, or for which such eligible persons or such\nqualified medicare beneficiaries would be liable under federal law were\nthey not eligible for medical assistance or were they not qualified\nmedicare beneficiaries with respect to such benefits under part B.\n (e) Amounts payable under this title for medical assistance in the\nform of clinic services pursuant to article twenty-eight of the public\nhealth law, article sixteen of the mental hygiene law and independent\npractitioner services for individuals with developmental disabilities\nprovided to eligible persons diagnosed with a developmental disability\nwho are also beneficiaries under part B of title XVIII of the federal\nsocial security act, or provided to persons diagnosed with a\ndevelopmental disability who are qualified medicare beneficiaries under\npart B of title XVIII of such act shall not be less than the approved\nmedical assistance payment level less the amount payable under part B.\n (f) Amounts payable under this title for medical assistance in the\nform of outpatient mental health services under article thirty-one or\noutpatient chemical dependence services including opioid treatment\nservices under article thirty-two of the mental hygiene law provided to\neligible persons who are also beneficiaries under part B of title XVIII\nof the federal social security act or provided to qualified medicare\nbeneficiaries under part B of title XVIII of such act shall not be less\nthan the approved medical assistance payment level less the amount\npayable under part B.\n (g) Notwithstanding any provision of this section to the contrary,\namounts payable under this title for medical assistance in the form of\nhospital outpatient services or diagnostic and treatment center services\npursuant to article twenty-eight of the public health law provided to\neligible persons who are also beneficiaries under part B of title XVIII\nof the federal social security act or provided to qualified medicare\nbeneficiaries under part B of title XVIII of such act shall not exceed\nthe approved medical assistance payment level less the amount payable\nunder part B.\n (h) Amounts payable under this title for medical assistance in the\nform of freestanding clinic services pursuant to article twenty-eight of\nthe public health law provided to eligible persons participating in the\nNew York traumatic brain injury waiver program who are also\nbeneficiaries under part B of title XVIII of the federal social security\nact or who are qualified medicare beneficiaries under part B of title\nXVIII of such act shall not be less than the approved medical assistance\npayment level less the amount payable under part B.\n 2. (a) Any inconsistent provision of this chapter notwithstanding,\nprovision for medical care and other medical benefits available under\nthis title may be made, in whole or in part, either under this title or\nother appropriate provisions of this chapter, through insurance or other\nprepaid plans, in accordance with the regulations of the department.\n (b) Any inconsistent provision of this chapter or other law\nnotwithstanding, upon furnishing assistance under this title to any\napplicant or recipient of medical assistance, the local social services\ndistrict or the department shall be subrogated, to the extent of the\nexpenditures by such district or department for medical care furnished,\nto any rights such person may have to medical support or reimbursement\nfrom liable third parties, including but not limited to health insurers,\nself-insured plans, group health plans, service benefit plans, managed\ncare organizations, pharmacy benefit managers, or other parties that\nare, by statute, contract, or agreement, legally responsible for payment\nof a claim for a health care item or service. For purposes of this\nsection, the term medical support shall mean the right to support\nspecified as support for the purpose of medical care by a court or\nadministrative order. The right of subrogation does not attach to\ninsurance benefits paid or provided under any health insurance policy\nprior to the receipt of written notice of the exercise of subrogation\nrights by the carrier issuing such insurance, nor shall such right of\nsubrogation attach to any benefits which may be claimed by a social\nservices official or the department, by agreement or other established\nprocedure, directly from an insurance carrier. No right of subrogation\nto insurance benefits available under any health insurance policy shall\nbe enforceable unless written notice of the exercise of such subrogation\nright is received by the carrier within three years from the date\nservices for which benefits are provided under the policy or contract\nare rendered. Liable third parties shall not deny a claim made by a\nsocial services official or the department in conformance with this\nparagraph solely on the basis of the date of submission of the claim,\nthe type or format of the claim form, a failure to obtain prior\nauthorization, or a failure to present proper documentation at the\npoint-of-sale that is the basis of the claim. Liable third parties shall\nrespond to a request for payment within sixty calendar days after\nreceipt of written proof of loss or claim for payment for health care\nservices provided to a recipient of Medicaid who is covered by the third\nparty and shall not charge a fee to process or adjudicate a claim. The\nlocal social services district or the department shall also notify the\ncarrier when the exercise of subrogation rights has terminated because a\nperson is no longer receiving assistance under this title. Such carrier\nshall establish mechanisms to maintain the confidentiality of all\nindividually identifiable information or records. Such carrier shall\nlimit the use of such information or record to the specific purpose for\nwhich such disclosure is made, and shall not further disclose such\ninformation or records.\n (c) In accordance with regulations of the department and to the extent\nauthorized by federal law and regulation, the social services district\nis authorized to retain, in addition to amounts retained as repayment\nfor its share of the costs of medical assistance provided, a portion of\nthe federal share of the amount collected as medical support or third\nparty benefits assigned under paragraph (f) of subdivision four of\nsection three hundred sixty-six of this article, when such district, or\nother governmental agency pursuant to an agreement with such district,\nhas collected such medical support or third party benefits on behalf of\na person receiving medical assistance whose rights to medical support or\nthird party benefits have been assigned to the state or to the\nappropriate social services official. Where more than one district has\nbeen involved in enforcing or collecting such amounts, the federal\nincentive shall be apportioned among each such district in accordance\nwith the regulations of the department.\n 3. (a) As used in this subdivision, the following terms shall have the\nfollowing meanings:\n (1) "Qualified medicare beneficiary" means a person who is entitled to\nhospital insurance benefits under part A of title XVIII of the federal\nsocial security act, whose income does not exceed one hundred\nthirty-eight percent of the official federal poverty line applicable to\nthe person's family size and whose resources do not exceed twice the\nmaximum amount of resources a person may have in order to qualify for\nbenefits under the federal supplemental security income program of title\nXVI of the federal social security act, as determined for purposes of\nsuch program. To the extent that federal financial participation is\navailable, a person whose resources are in excess of the amount\nspecified in this subparagraph but otherwise meets the requirements\nshall be considered a "qualified medicare beneficiary".\n (2) "Qualified individual" means a person who is entitled to hospital\ninsurance benefits under part A of title XVIII of the federal social\nsecurity act and whose income is greater than one hundred thirty-eight\npercent, but less than or equal to one hundred eighty-six percent, of\nthe federal poverty line, for the applicable family size, and who is not\notherwise eligible for medical assistance under this article; referred\nto as a qualified individual.\n (3) "Qualified disabled and working individual" means an individual\nwho is not otherwise eligible for medical assistance and:\n (i) who is entitled to enroll for hospital insurance benefits under\nsection 1818A of part A of title XVIII of the federal social security\nact;\n (ii) whose income does not exceed two hundred percent of the official\nfederal poverty line applicable to the person's family size; and\n (iii) whose resources do not exceed twice the maximum amount of\nresources that an individual or a couple, in the case of a married\nindividual, may have and obtain federal supplemental security income\nbenefits under title XVI of the federal social security act, as\ndetermined for purposes of that program.\n For purposes of this subparagraph, income and resources are determined\nby the same methodology as is used for determining eligibility under the\nfederal supplemental security income benefits under title XVI of the\nfederal social security act.\n (b) Payment of premiums for enrolling qualified disabled and working\nindividuals and qualified medicare beneficiaries under Part A of title\nXVIII of the federal social security act and for enrolling such\nbeneficiaries and eligible recipients of public assistance under part B\nof title XVIII of the federal social security act, together with the\ncosts of the applicable co-insurance and deductible amounts on behalf of\nsuch beneficiaries, and recipients, and premiums under section 1839 of\nthe federal social security act shall be made and the cost thereof borne\nby the state or by the state and social services districts,\nrespectively, in accordance with the regulations of the department,\nprovided, however, that the share of the cost to be borne by a social\nservices district, if any, shall in no event exceed the proportionate\nshare borne by such district with respect to other expenditures under\nthis title. Moreover, if the director of the budget approves, payment of\npremiums for enrolling persons who have been determined to be eligible\nfor medical assistance only may be made and the cost thereof borne or\nshared pursuant to this subdivision.\n (c) (1) Beginning April first, two thousand two and to the extent that\nfederal financial participation is available at a one hundred percent\nfederal Medical assistance percentage and subject to sections 1933 and\n1902(a)(10)(E)(iv) of the federal social security act, medical\nassistance shall be available for full payment of medicare part B\npremiums for qualified individuals.\n (2) Premium payments for the individuals described in subparagraph one\nof this paragraph will be one hundred percent federally funded up to the\namount of the federal allotment. The department shall discontinue\nenrollment into the program when the part B premium payments made\npursuant to subparagraph one of this paragraph meet the yearly federal\nallotment.\n * (3) The commissioner of health shall develop a simplified\napplication form, consistent with federal law, for payments pursuant to\nthis section. The commissioner of health, in cooperation with the office\nfor the aging, shall publicize the availability of such payments to\nmedicare beneficiaries.\n * NB Effective until April 1, 2026\n * (3) (i) The commissioner of health shall develop a simplified\napplication form, consistent with federal law, for payments pursuant to\nthis section. The commissioner of health, in cooperation with the office\nfor the aging, shall publicize the availability of such payments to\nmedicare beneficiaries.\n (ii) Low-income subsidy data transmitted from the social security\nadministration to local departments of social services in accordance\nwith section 1144(c)(3) of the federal social security act shall be\ntreated as an application for the medicare savings program, without\nrequiring submission of another application. Any information verified by\nthe social security administration shall be accepted without further\nverification, if the information provided through low-income subsidy\ndata supports a determination of eligibility under this subdivision. The\ncommissioner of health shall report on an annual basis on the status of\nthe medicare savings program and the number of applications received by\nlocal social services districts under this article.\n * NB Effective April 1, 2026\n (d) (1) Payment of premiums for enrolling individuals in qualified\nhealth plans offered through a health insurance exchange established\npursuant to the federal Patient Protection and Affordable Care Act (P.L.\n111-148), as amended by the federal Health Care and Education\nReconciliation Act of 2010 (P.L. 111-152), shall be available to\nindividuals who:\n (i) immediately prior to being enrolled in the qualified health plan,\nwere or would have been eligible under the family health plus program as\na parent or stepparent of a child under the age of twenty-one, and whose\nMAGI household income, as defined in subparagraph eight of paragraph (a)\nof subdivision one of section three hundred sixty-six of this title,\nexceeds one hundred thirty-three percent of the federal poverty line for\nthe applicable family size;\n (ii) are not otherwise eligible for medical assistance under this\ntitle; and\n (iii) are enrolled in a standard health plan in the silver level, as\ndefined in 42 U.S.C. 18022.\n (2) Payment pursuant to this paragraph shall be for premium\nobligations of the individual under the qualified health plan and shall\ncontinue only if and for so long as the individual's MAGI household\nincome exceeds one hundred thirty-three percent, but does not exceed one\nhundred fifty percent, of the federal poverty line for the applicable\nfamily size, or, if earlier, until the individual is eligible for\nenrollment in a standard health plan pursuant to section three hundred\nsixty-nine-gg of this article.\n (3) The commissioner of health shall submit amendments to the state\nplan for medical assistance and/or submit one or more applications for\nwaivers of the federal social security act as may be necessary to\nreceive federal financial participation in the costs of payments made\npursuant to this paragraph; provided further, however, that nothing in\nthis subparagraph shall be deemed to affect payments for premiums\npursuant to this paragraph if federal financial participation in the\ncosts of such payments is not available.\n 4. No social services district shall make final payments pursuant to\ntitle XIX of the federal social security act for benefits available\nunder title XVIII of such act without documentation that title XVIII\nclaims have been filed and denied.\n 5. (a) When medical care, services and supplies are furnished an\neligible person on behalf of a social services district under this\ntitle, such social services district is authorized to utilize any\nappropriate organization as a fiscal intermediary to audit and make\npayment for such district's share of the cost of such care, services and\nsupplies.\n (b) To carry out the purposes of paragraph (a), the department, on\nbehalf of itself and any of the social services districts, may enter\ninto agreements with appropriate organizations to act as fiscal\nintermediaries.\n 6. (a) Notwithstanding any inconsistent provision of law, payment for\nclaims for services as specified in paragraph (d) of this subdivision\nfurnished to eligible persons under this title, subject to paragraph (b)\nof this subdivision shall be reduced in accordance with the provisions\nof paragraph (c) of this subdivision by an amount not to exceed the\nmaximum amount authorized by federal law and regulations as a co-payment\namount, which co-payment amount the provider of such services may charge\nthe recipient, provided, however, no provider may deny such services to\nan individual eligible for services based on the individual's inability\nto pay the co-payment amount.\n (b) Co-payments shall apply to all eligible persons for the services\ndefined in paragraph (d) of this subdivision with the exception of:\n (i) individuals under twenty-one years of age;\n (ii) pregnant women;\n (iii) individuals who are inpatients in a medical facility who have\nbeen required to spend all of their income for medical care, except\ntheir personal needs allowance or residents of community based\nresidential facilities licensed by the office of mental health or the\noffice for people with developmental disabilities who have been required\nto spend all of their income, except their personal needs allowance;\n (iv) individuals enrolled in health maintenance organizations or other\nentities which provide comprehensive health services, or other managed\ncare programs for services covered by such programs, except that such\npersons, other than persons otherwise exempted from co-payments pursuant\nto subparagraphs (i), (ii), (iii) and (v) of this paragraph, and other\nthan those persons enrolled in a managed long term care program, shall\nbe subject to co-payments as described in subparagraph (v) of paragraph\n(d) of this subdivision;\n (v) individuals whose family income is less than one hundred percent\nof the federal poverty line, as defined in subparagraph four of\nparagraph (a) of subdivision one of section three hundred sixty-six of\nthis title, for a family of the same size; and\n (vi) any other individuals required to be excluded by federal law or\nregulations.\n (b-1) The commissioner is authorized to submit any request or\napplication to the Centers for Medicare and Medicaid Services as may be\nnecessary to be granted a waiver of the requirement for the department\nof health to calculate its Medicaid payments to managed care\norganizations to include cost sharing established under the state plan\nfor medical assistance for enrollees who are not exempt from cost\nsharing. In the absence of such a waiver, the commissioner shall adjust\nMedicaid payments to managed care organizations beginning October first,\ntwo thousand fifteen or on the date the Centers for Medicare and\nMedicaid Services commences enforcement of such requirement, whichever\nis later.\n * (c) (i) Co-payments charged pursuant to this subdivision for\nnon-institutional services shall not exceed the following table,\nprovided, however, that the department may establish standard\nco-payments for services based upon the average or typical payment for\nthat service:\n State's payment Maximum co-payment\n for the services chargeable to recipient\n $10 or less $.50\n $10.01 to $25 $1.00\n $25.01 to $50 $2.00\n $50.01 or more $3.00\n (ii) co-payments charged pursuant to this subdivision for each\ndischarge for inpatient care shall be twenty-five dollars.\n (iii) Notwithstanding any other provision of this paragraph,\nco-payments charged for each generic prescription drug dispensed shall\nbe one dollar and for each brand name prescription drug dispensed shall\nbe two dollars and fifty cents; provided, however, that the co-payments\ncharged for each brand name prescription drug reimbursed pursuant to\nsubparagraph (ii) of paragraph (a-1) of subdivision four of section\nthree hundred sixty-five-a of this title shall be one dollar.\n (iv) When an individual is initially dispensed or prescribed a seven\nor fewer days supply of an opioid pursuant to paragraph (b) of\nsubdivision five of section three thousand three hundred thirty-one of\nthe public health law, and is subsequently dispensed or prescribed an\nadditional supply of such opioid for the same underlying condition, the\ntotal co-payment that may be charged to such an individual for the\ninitial prescription plus all subsequent prescriptions for the same\nunderlying condition for up to a total of thirty-days supply of such\nopioid shall not exceed the amount set forth in subparagraph (iii) of\nthis paragraph.\n * NB Repealed March 31, 2026\n (d) Co-payments shall apply to the following services, subject to such\nexceptions for subcategories of these services as recognized by the\ncommissioner in regulations, provided in accordance with section three\nhundred sixty-five-a of this article and the regulations of the\ndepartment, to the extent permitted by title XIX of the federal social\nsecurity act:\n (i) in-patient care in a general hospital, as defined in subdivision\nten of section twenty-eight hundred one of the public health law;\n (ii) out-patient hospital and clinic services except for mental health\nservices, and developmental disability services, alcohol and substance\nabuse services and methadone maintenance services;\n (iii) home health services, including services provided under the long\nterm home health care program, provided however, home health providers\nshall not require employees providing services in the home to collect\nthe co-payment amount;\n (iv) sickroom supplies;\n (v) drugs, excepting psychotropic drugs and drugs with FDA approved\nindications for the treatment of tuberculosis as specified by the\ndepartment and those drugs intended for use by residents of adult care\nfacilities licensed by the department of health who have been required\nto spend all of their income, except their personal needs allowance;\n (vi) clinical laboratory services;\n (vii) x-rays;\n (viii) emergency room services provided for non-urgent or\nnon-emergency medical care, provided however, co-payments shall not be\nrequired for emergency services or family planning services and\nsupplies;\n (e) In the period from January first, nineteen hundred ninety-three to\nMarch thirty-first, nineteen hundred ninety-three no recipient shall be\nrequired to pay more than a total of fifty dollars in co-payments\nrequired by this subdivision for drugs, nor shall reductions in payments\nas a result of such co-payments exceed fifty dollars for any recipient.\n (f) (i) In the year commencing April first, nineteen hundred\nninety-three and for each year thereafter, and ending in the year\nconcluding on March thirty-first, two thousand five, no recipient shall\nbe required to pay more than a total of one hundred dollars in\nco-payments required by this subdivision, nor shall reductions in\npayments as a result of such co-payments exceed one hundred dollars for\nany recipient.\n (ii) In the year commencing April first, two thousand five and for\neach year thereafter, no recipient shall be required to pay more than a\ntotal of two hundred dollars in co-payments required by this\nsubdivision, nor shall reductions in payments as a result of such\nco-payments exceed two hundred dollars for any recipient.\n (g) The commissioner shall promptly:\n (i) promulgate a regulation making it an unacceptable practice under\nthe medical assistance program for a provider to deny services to an\nindividual eligible for services based on the individual's inability to\npay the co-pay amount required by this subdivision;\n (ii) establish and maintain a toll-free hotline which may be used to\nreport a violation of the regulation promulgated pursuant to\nsubparagraph (i) of this paragraph; and\n (iii) provide notice to all recipients summarizing their rights and\nobligations under this subdivision.\n 7. (a) Every manufacturer or wholesaler of drugs, prescriptions or\npoisons registered under the provisions of section sixty-eight hundred\neight of the education law, shall, upon request of the department for\nany information pertaining to wholesale prices charged to pharmacists\nfor any drugs available under the medical assistance program, make the\nrequested information available to the department on a monthly basis, or\nsuch other periodic basis as the department shall request.\n (b) The department shall provide for financial arrangements with any\nmanufacturer or wholesaler of drugs, prescriptions or poisons as may be\nnecessary to reimburse such manufacturer or wholesaler for its actual\nand necessary costs included in furnishing the requested information.\n (c) Any information obtained pursuant to the provisions of this\nsubdivision shall not be made available for public inspection or copying\nunder the provisions of article six of the public officers law. The\ndepartment shall not disclose such information to any person, firm,\ndepartment or agency, except any state agency or department as may be\nnecessary for the administration of the medical assistance program under\nthe provisions of this chapter or any other law.\n (d) Notwithstanding any inconsistent provision of law, if a\nmanufacturer (as defined under section 1927 of the federal social\nsecurity act) has entered into a rebate agreement with the department or\nwith the federal secretary of health and human services on behalf of the\ndepartment under section 1927 of the federal social security act, the\ndepartment shall reimburse for covered outpatient drugs which are\ndispensed under the medical assistance program to all persons in receipt\nof medical assistance benefits as a result of their eligibility having\nbeen established under subparagraph one or nine of paragraph (a) of\nsubdivision one of section three hundred sixty-six of this title, and\nwhich are dispensed to all persons eligible for health care services as\na result of their eligibility having been established under subdivision\ntwo of section three hundred sixty-nine-ee of this article, only\npursuant to the terms of the rebate agreement between the department and\nsuch manufacturer; provided, however, that any agreement between the\ndepartment and a manufacturer entered into before August first, nineteen\nhundred ninety-one, shall be deemed to have been entered into on April\nfirst, nineteen hundred ninety-one; and provided further, that if a\nmanufacturer has not entered into an agreement with the department\nbefore August first, nineteen hundred ninety-one, such agreement shall\nnot be effective until April first, nineteen hundred ninety-two, unless\nsuch agreement provides that rebates will be retroactively calculated as\nif the agreement had been in effect on April first, nineteen hundred\nninety-one. The rebate agreement between such manufacturer and the\ndepartment shall utilize for single source drugs and innovator multiple\nsource drugs the identical formula used to determine the basic rebate\nfor federal financial participation single source drugs and innovator\nmultiple source drugs, pursuant to paragraph one of subdivision (c) of\nsection 1927 of the federal social security act, to determine the amount\nof the rebate pursuant to this paragraph. The rebate agreement between\nsuch manufacturer and the department shall utilize for non-innovator\nmultiple source drugs the identical formula used to determine the basic\nrebate for federal financial participation non-innovator multiple source\ndrugs, pursuant to paragraphs three and four of subdivision (c) of\nsection 1927 of the federal social security act, to determine the amount\nof the rebate pursuant to this paragraph. The terms and conditions of\nsuch rebate agreement with respect to periodic payment of the rebate,\nprovision of information by the department, audits, manufacturer\nprovision of information verification of surveys, penalties,\nconfidentiality of information, and length of the agreement shall apply\nto drugs of the manufacturer dispensed under the medical assistance\nprogram to all persons in receipt of medical assistance benefits as a\nresult of their eligibility having been established under subparagraph\none or nine of paragraph (a) of subdivision one of section three hundred\nsixty-six of this title, and which are dispensed to all persons eligible\nfor health care services as a result of their eligibility having been\nestablished under subdivision two of section three hundred sixty-nine-ee\nof this article. The department in providing utilization data to a\nmanufacturer (as provided for under section 1927.4(b)(1)(A) of the\nfederal social security act) shall provide such data by zip code, if\nrequested, for drugs covered under a rebate agreement.\n * (e) During the period from April first, two thousand fifteen through\nMarch thirty-first, two thousand twenty-six, the commissioner may, in\nlieu of a managed care provider or pharmacy benefit manager, negotiate\ndirectly and enter into an arrangement with a pharmaceutical\nmanufacturer for the provision of supplemental rebates relating to\npharmaceutical utilization by enrollees of managed care providers\npursuant to section three hundred sixty-four-j of this title and may\nalso negotiate directly and enter into such an agreement relating to\npharmaceutical utilization by medical assistance recipients not so\nenrolled. Such rebate arrangements shall be limited to the following:\nantiretrovirals approved by the FDA for the treatment of HIV/AIDS,\naccelerated approval drugs established pursuant to this paragraph,\nopioid dependence agents and opioid antagonists listed in a statewide\nformulary established pursuant to subparagraph (vii) of this paragraph,\nhepatitis C agents, high cost drugs as provided for in subparagraph\n(viii) of this paragraph, gene therapies as provided for in subparagraph\n(ix) of this paragraph, and any other class or drug designated by the\ncommissioner for which the pharmaceutical manufacturer has in effect a\nrebate arrangement with the federal secretary of health and human\nservices pursuant to 42 U.S.C. § 1396r-8, and for which the state has\nestablished standard clinical criteria. No agreement entered into\npursuant to this paragraph shall have an initial term or be extended\nbeyond the expiration or repeal of this paragraph. For purposes of this\nparagraph, an "accelerated approval" is a drug or labeled indication of\na drug authorized by the Federal Food, Drug and Cosmetic Act for drugs\napproved under Subpart H of 21 CFR Part 314 and Subpart E of 21 CFR Part\n601 for serious conditions that fill an unmet medical need based on\nwhether the drug has an effect on a surrogate clinical endpoint, and is\npending verification of clinical benefit in confirmatory trials.\n (i) The manufacturer shall not enter into any rebate arrangements with\na managed care provider, or any of a managed care provider's agents,\nincluding but not limited to any pharmacy benefit manager on the gene\ntherapy, drug, or drug classes subject to this paragraph when the state\nhas a rebate arrangement in place and standard clinical criteria are\nimposed on the managed care provider.\n (ii) The commissioner shall establish adequate rates of reimbursement\nwhich shall take into account both the impact of the commissioner\nnegotiating such arrangements and any limitations imposed on the managed\ncare provider's ability to establish clinical criteria relating to the\nutilization of such drugs. In developing the managed care provider's\nreimbursement rate, the commissioner shall identify the amount of\nreimbursement for such drugs as a separate and distinct component from\nthe reimbursement otherwise made for prescription drugs as prescribed by\nthis section.\n (iii) The commissioner shall submit a report to the temporary\npresident of the senate and the speaker of the assembly annually by\nDecember thirty-first. The report shall analyze the adequacy of rates to\nmanaged care providers for drug expenditures related to the classes\nunder this paragraph.\n (iv) Nothing in this paragraph shall be construed to require a\npharmaceutical manufacturer to enter into a rebate arrangement\nsatisfactory to the commissioner relating to pharmaceutical utilization\nby enrollees of managed care providers pursuant to section three hundred\nsixty-four-j of this title or relating to pharmaceutical utilization by\nmedical assistance recipients not so enrolled.\n (v) All clinical criteria, including requirements for prior approval,\nand all utilization review determinations established by the state as\ndescribed in this paragraph for the gene therapies, drugs, or drug\nclasses subject to this paragraph shall be developed using\nevidence-based and peer-reviewed clinical review criteria in accordance\nwith article two-A of the public health law, as applicable.\n (vi) All prior authorization and utilization review determinations\nrelated to the coverage of any drug subject to this paragraph shall be\nsubject to article forty-nine of the public health law, section three\nhundred sixty-four-j of this title, and article forty-nine of the\ninsurance law, as applicable. Nothing in this paragraph shall diminish\nany rights relating to access, prior authorization, or appeal relating\nto any drug class or drug afforded to a recipient under any other\nprovision of law.\n (vii) The department shall publish a statewide formulary of opioid\ndependence agents and opioid antagonists, which shall include as\n"preferred drugs" all drugs in such classes, which shall include all\nsubclasses of a given drug that have a different pharmacological route\nof administration, provided that:\n (A) for all drugs that are included as of the date of the enactment of\nthis subparagraph on a formulary of a managed care provider, as defined\nin section three hundred sixty-four-j of this title, or in the Medicaid\nfee-for-service preferred drug program pursuant to section two hundred\nseventy-two of the public health law, the cost to the department for\nsuch drug is equal to or less than the lowest cost paid for the drug by\nany managed care provider or by the Medicaid fee-for-service program\nafter the application of any rebates, as of the date that the department\nimplements the statewide formulary established by this subparagraph.\nWhere there is a generic version of the drug approved by the Food and\nDrug Administration as bioequivalent to a brand name drug pursuant to 21\nU.S.C. § 355(j)(8)(B), the cost to the department for the brand and\ngeneric versions shall be equal to or less than the lower of the two\nmaximum costs determined pursuant to the previous sentence; and\n (B) for all drugs that are not included as of the date of the\nenactment of this subparagraph on a formulary of a managed care\nprovider, as defined in section three hundred sixty-four-j of this\ntitle, or in the Medicaid fee-for-service preferred drug program\npursuant to section two hundred seventy-two of the public health law,\nthe department is able to obtain the drug at a cost that is equal to or\nless than the lowest cost to the department of other comparable drugs in\nthe class, after the application of any rebates. Where there is a\ngeneric version of the drug approved by the Food and Drug Administration\nas bioequivalent to a brand name drug pursuant to 21 U.S.C. §\n355(j)(8)(B), the cost to the department for the brand and generic\nversions shall be equal to or less than the lower of the two maximum\ncosts determined pursuant to the previous sentence.\n (viii) The commissioner may identify and refer high cost drugs, as\ndefined in clause (D) of this subparagraph, that are not included as of\nthe date of the enactment of this subparagraph on a formulary of a\nmanaged care provider or covered by the Medicaid fee for service of\nprogram to the drug utilization review board established by section\nthree hundred sixty-nine-bb of this article for a recommendation as to\nwhether a target supplemental Medicaid rebate should be paid by the\nmanufacturer of the drug to the department and the target amount of the\nrebate.\n (A) If the commissioner intends to refer a high cost drug to the drug\nutilization review board pursuant to this subparagraph, the commissioner\nshall notify the manufacturer of such drug and shall attempt to reach\nagreement with the manufacturer on a rebate arrangement satisfactory to\nthe commissioner for the drug prior to referring the drug to the drug\nutilization review board for review. Such arrangement may be based on\nevidence based research, including, but not limited to, such research\noperated or conducted by or for other state governments, the federal\ngovernment, the governments of other nations, and third party payers or\nmulti-state coalitions, provided however that the department shall\naccount for the effectiveness of the drug in treating the conditions for\nwhich it is prescribed or in improving a patient's health, quality of\nlife, or overall health outcomes, and the likelihood that use of the\ndrug will reduce the need for other medical care, including\nhospitalization.\n (B) In the event that the commissioner and the manufacturer have\npreviously agreed to a rebate arrangement for a drug pursuant to this\nparagraph, the drug shall not be referred to the drug utilization review\nboard for any further rebate agreement for the duration of the previous\nrebate agreement, provided however, the commissioner may refer a drug to\nthe drug utilization review board if the commissioner determines there\nare significant and substantiated utilization or market changes, new\nevidence-based research, or statutory or federal regulatory changes that\nwarrant additional rebates. In such cases, the department shall notify\nthe manufacturer and provide evidence of the changes or research that\nwould warrant additional rebates, and shall attempt to reach agreement\nwith the manufacturer on a rebate for the drug prior to referring the\ndrug to the drug utilization review board for review.\n (C) If the commissioner is unsuccessful in entering into a rebate\narrangement with the manufacturer of the drug satisfactory to the\ndepartment, the drug manufacturer shall in that event be required to\nprovide to the department, on a standard reporting form developed by the\ndepartment, the information as described in subdivision six of section\ntwo hundred eighty of the public health law. All information disclosed\npursuant to this clause shall be considered confidential and shall not\nbe disclosed by the department in a form that identifies a specific\nmanufacturer or prices charged for drugs by such manufacturer.\n (D) For the purposes of this subparagraph, the term "high cost drug"\nshall mean a brand name drug or biologic that has a launch wholesale\nacquisition cost of thirty thousand dollars or more per year or course\nof treatment, or a biosimilar drug that has a launch wholesale\nacquisition cost that is not at least fifteen percent lower than the\nreferenced brand biologic at the time the biosimilar is launched, or a\ngeneric drug that has a wholesale acquisition cost of one hundred\ndollars or more for a thirty day supply or recommended dosage approved\nfor labeling by the federal Food and Drug Administration, or a brand\nname drug or biologic that has a wholesale acquisition cost increase of\nthree thousand dollars or more in any twelve-month period, or course of\ntreatment if less than twelve months.\n (ix) For purposes of this paragraph, a "gene therapy" is a drug (A)\napproved under section 505 of the Federal Food, Drug and Cosmetics Act\nor licensed under subsection (a) or (k) of section 351 of the Public\nHealth Services Act; (B) that treats a rare disease or condition, as\ndefined in 21 USC § 360bb(a)(2), that is life-threatening, as defined in\n42 CFR 321.18; (C) is considered a gene therapy by the federal Food and\nDrug Administration for which a biologics license pursuant to 21 CFR\n600-680 is held; (D) if administered in accordance with the labeling of\nsuch drug, is expected to result in either the cure of such disease or\ncondition or a reduction in the symptoms of such disease or condition\nthat materially improves the patient's length or quality of life; and\n(E) is expected to achieve the result described in clause (D) of this\nsubparagraph after not more than three administrations.\n * NB Repealed March 31, 2029\n * 8. No government agency shall purchase, pay for, or make\nreimbursement or grants-in-aid for any service in a residential\ntreatment facility for children and youth or a comprehensive psychiatric\nemergency program unless at the time such service was provided, the\nresidential treatment facility for children and youth or comprehensive\npsychiatric emergency program possessed a valid operating certificate\nauthorizing such service. Notwithstanding any inconsistent provision of\nlaw, no government agency shall make payments pursuant to this title or\ntitle nineteen of the federal social security act to a residential\ntreatment facility for children and youth for service to a person whose\nneed for care and treatment in such a facility was not certified\npursuant to section 9.51 of the mental hygiene law.\n * NB Effective until July 1, 2027\n * 8. No government agency shall purchase, pay for, or make\nreimbursement or grants-in-aid for any service in a residential\ntreatment facility for children and youth unless at the time such\nservice was provided, the residential treatment facility for children\nand youth possessed a valid operating certificate authorizing such\nservice. Notwithstanding any inconsistent provision of law, no\ngovernment agency shall make payments pursuant to this title or title\nnineteen of the federal social security act to a residential treatment\nfacility for children and youth for service to a person whose need for\ncare and treatment in such a facility was not certified pursuant to\nsection 9.51 of the mental hygiene law.\n * NB Effective July 1, 2027\n * 9. Notwithstanding any inconsistent provision of law or regulation\nto the contrary, for those drugs which may not be dispensed without a\nprescription as required by section sixty-eight hundred ten of the\neducation law and for which payment is authorized pursuant to paragraph\n(g) of subdivision two of section three hundred sixty-five-a of this\ntitle, and for those drugs that are available without a prescription as\nrequired by section sixty-eight hundred ten of the education law but are\nreimbursed as items of medical assistance pursuant to paragraph (a) of\nsubdivision four of section three hundred sixty-five-a of this title,\npayments under this title shall be made at the following amounts:\n (a) for drugs provided by medical practitioners and claimed separately\nby the practitioners the lower of:\n (i) (1) an amount equal to the national average drug acquisition cost\nset by the federal centers for medicare and medicaid services for the\ndrug, if any, or if such amount is not available, the wholesale\nacquisition cost of the drug based on the package size dispensed from,\nas reported by the prescription drug pricing service used by the\ndepartment, (2) the federal upper limit, if any, established by the\nfederal centers for medicare and medicaid services; (3) the state\nmaximum acquisition cost, if any, established pursuant to paragraph (e)\nof this subdivision; or (4) the actual cost of the drug to the\npractitioner.\n (ii) Notwithstanding subparagraph (i) of this paragraph and paragraph\n(e) of this subdivision, for the Medicaid fee-for-service program, if a\ndrug has been purchased from a manufacturer by a covered entity pursuant\nto section 340B of the federal public health service act (42 USCA §\n256b), the actual amount paid by such covered entity. For purposes of\nthis subparagraph, a "covered entity" is an entity that meets the\nrequirements of paragraph four of subdivision (a) of such section that\nelects to participate in the program established by such section, and\nthat causes claims for payment for drugs covered by this subparagraph to\nbe submitted to the medical assistance program, either directly or\nthrough an authorized contract pharmacy. No medical assistance payments\nmay be made to a covered entity or to an authorized contract pharmacy of\na covered entity for drugs that are eligible for purchase under the\nsection 340B program and are dispensed on an outpatient basis to\npatients of the covered entity, other than under the provisions of this\nsubparagraph. Medical practitioners submitting claims for reimbursement\nof drugs purchased pursuant to section 340B of the public health service\nact shall notify the department that the claim is eligible for purchase\nunder the 340B program, consistent with claiming instructions issued by\nthe department to identify such claims.\n (iii) In no event shall a medical practitioner be reimbursed at an\namount that is lower than the state maximum acquisition cost, or for\ndrugs that do not have a state maximum acquisition cost, the wholesale\nacquisition cost of the drug based on the package size.\n (b) for drugs dispensed by pharmacies:\n (i) (A) if the drug dispensed is a generic prescription drug, the\nlower of: (1) an amount equal to the national average drug acquisition\ncost set by the federal centers for medicare and medicaid services for\nthe drug, if any, or if such amount if not available, the wholesale\nacquisition cost of the drug based on the package size dispensed from,\nas reported by the prescription drug pricing service used by the\ndepartment, less seventeen and one-half percent thereof; (2) the federal\nupper limit, if any, established by the federal centers for medicare and\nmedicaid services; (3) the state maximum acquisition cost, if any,\nestablished pursuant to paragraph (e) of this subdivision; or (4) the\ndispensing pharmacy's usual and customary price charged to the general\npublic; (B) if the drug dispensed is available without a prescription as\nrequired by section sixty-eight hundred ten of the education law but is\nreimbursed as an item of medical assistance pursuant to paragraph (a) of\nsubdivision four of section three hundred sixty-five-a of this title,\nthe lower of (1) an amount equal to the national average drug\nacquisition cost set by the federal centers for medicare and medicaid\nservices for the drug, if any, or if such amount is not available, the\nwholesale acquisition cost of the drug based on the package size\ndispensed from, as reported by the prescription drug pricing service\nused by the department, (2) the federal upper limit, if any, established\nby the federal centers for medicare and medicaid services; (3) the state\nmaximum acquisition cost if any, established pursuant to paragraph (e)\nof this subdivision; or (4) the dispensing pharmacy's usual and\ncustomary price charged to the general public;\n (ii) if the drug dispensed is a brand-name prescription drug, the\nlower of:\n (A) an amount equal to the national average drug acquisition cost set\nby the federal centers for medicare and medicaid services for the drug,\nif any, or if such amount is not available, the wholesale acquisition\ncost of the drug based on the package size dispensed from, as reported\nby the prescription drug pricing service used by the department; or (B)\nthe dispensing pharmacy's usual and customary price charged to the\ngeneral public; and\n (iii) notwithstanding subparagraphs (i) and (ii) of this paragraph and\nparagraphs (d) and (e) of this subdivision, if the drug dispensed is a\ndrug that has been purchased from a manufacturer by a covered entity\npursuant to section 340B of the federal public health service act (42\nUSCA § 256b), the actual amount paid by such covered entity pursuant to\nsuch section, plus the reasonable administrative costs, as determined by\nthe commissioner, incurred by the covered entity or by an authorized\ncontract pharmacy in connection with the purchase and dispensing of such\ndrug and the tracking of such transactions. For purposes of this\nsubparagraph, a "covered entity" is an entity that meets the\nrequirements of paragraph four of subsection (a) of such section, that\nelects to participate in the program established by such section, and\nthat causes claims for payment for drugs covered by this subparagraph to\nbe submitted to the medical assistance program, either directly or\nthrough an authorized contract pharmacy. No medical assistance payments\nmay be made to a covered entity or to an authorized contract pharmacy of\na covered entity for drugs that are eligible for purchase under the\nsection 340B program and are dispensed on an outpatient basis to\npatients of the covered entity, other than under the provisions of this\nsubparagraph. Pharmacies submitting claims for reimbursement of drugs\npurchased pursuant to section 340B of the public health service act\nshall notify the department that the claim is eligible for purchase\nunder the 340B program, consistent with claiming instructions issued by\nthe department to identify such claims.\n (c) Notwithstanding subparagraph (i) of paragraph (b) of this\nsubdivision, if a qualified prescriber certifies "brand medically\nnecessary" or "brand necessary" in his or her own handwriting directly\non the face of a prescription, or in the case of electronic\nprescriptions, inserts an electronic direction to clarify "brand\nmedically necessary" or "brand necessary", for a multiple source drug\nfor which a specific upper limit of reimbursement has been established\nby the federal agency, in addition to writing "d a w" in the box\nprovided for such purpose on the prescription form, payment under this\ntitle for such drug must be made under the provisions of subparagraph\n(ii) of such paragraph.\n (d) In addition to the amounts paid pursuant to paragraph (b) of this\nsubdivision, the department shall pay a professional pharmacy dispensing\nfee for each such drug dispensed in the amount of ten dollars and eight\ncents per prescription or written order of a practitioner; provided,\nhowever that this professional dispensing fee will not apply to drugs\nthat are available without a prescription as required by section\nsixty-eight hundred ten of the education law but do not meet the\ndefinition of a covered outpatient drug pursuant to Section 1927K of the\nSocial Security Act.\n (e) For a multiple source generic drug for which no specific upper\npayment limit has been established by the federal centers for medicare\nand medicaid services, the commissioner of health may establish a\nmaximum acquisition cost for such drug which shall be effective until\nsuch time as a specific federal upper payment limit has been established\nfor such drug. The department shall use a similar methodology in\nestablishing such an interim price as that utilized by the centers for\nmedicare and Medicaid services in establishing the federal upper payment\nlimit. For this purpose, the department is authorized to enter into a\ncontract with an entity to provide technical and administrative support\nto the commissioner of health.\n (g) Notwithstanding any other provision of this subdivision to the\ncontrary, the department is authorized to implement a specialty pharmacy\nprogram for the purpose of procuring certain specialty drugs at reduced\ncost. The department is authorized to enter into contracts with one or\nmore contractors in order to obtain certain specialty drugs from a\nlimited number of sources at reduced prices. For purposes of this\nparagraph, specialty drugs include, but are not limited to, chemotherapy\nagents, hydration therapy agents, pain therapy agents, intravenous\nadministration of antibiotics or other drugs, and total parenteral\nnutrition. All contracts entered into by the department to effectuate\nthe provisions of this section shall require the contractors to take\nsteps to assure that drugs provided pursuant to such contracts will be\nreadily accessible to consumers in a fashion that is no more restrictive\nthan that which was in effect prior to the implementation of the\nspecialty pharmacy program. This paragraph shall be effective only to\nthe extent that federal financial participation is available in the cost\nof drugs obtained pursuant to this paragraph. The commissioner of health\nis authorized to submit amendments to the state plan for medical\nassistance and to submit applications for waivers under the social\nsecurity act to obtain the federal approvals necessary to implement this\nparagraph. However, any pharmacy owned and operated by a not-for-profit\norganization solely for the purpose of providing drugs to individuals\ndiagnosed with cystic fibrosis as part of a comprehensive clinical care\nprogram approved by the national organization that accredits cystic\nfibrosis care centers and maintains a national registry of cystic\nfibrosis clinical data shall be exempt from the specialty pharmacy\nprogram.\n (h) The commissioner of health is authorized to establish a medication\ntherapy management pilot program in one or more counties or regions of\nthe state for the purpose of improving compliance with drug therapies\nand improving clinical outcomes. Payments under such program may be made\nto retail pharmacies for the provision of one-on-one medication regimen\ncounseling services for persons determined by the commissioner to be\neligible to receive such services. The commissioner is authorized to\nestablish fees for such counseling services, subject to the approval of\nthe director of the division of the budget. The provisions of this\nparagraph shall not take effect unless all necessary approvals under\nfederal law and regulation have been obtained to receive federal\nfinancial participation in the costs of services provided under this\nparagraph.\n (i)(i) The department of health shall establish a program for\nsynchronization of medications. Under the synchronization program, a\nhealth care practitioner may prescribe a refill of one or more of the\npatient's medications for a shorter period than would ordinarily be\nprovided, for the purpose of synchronizing refill dates of one or more\nof the patient's medications subject to the synchronization when it is\nagreed among the recipient, the health care practitioner and a\npharmacist that synchronization of multiple prescriptions for the\ntreatment of a chronic illness is in the best interest of the patient\nfor the management or treatment of a chronic illness provided that the\nfollowing apply to such medications:\n (A) are covered by the department of health pursuant to this title;\n (B) are used for treatment and management of a chronic illness that\nare subject to refills;\n (C) are not a schedule II controlled substance, nor a schedule III\ncontrolled substance that contains hydrocodone or other opioid\nmedication as scheduled in section thirty-three hundred six of the\npublic health law, or a controlled substance under the federal\nControlled Substances Act;\n (D) meet all prior authorization criteria specific to the medications\nat the time of the synchronization request;\n (E) are of a formulation that can be effectively and lawfully aligned\nover required short fill periods to achieve synchronization; and\n (F) do not have quantity limits or dose optimization criteria or state\nor federal requirements that would be violated in fulfilling\nsynchronization.\n (ii) The department of health shall not deny coverage for the\ndispensing of a medication by a pharmacy for a partial supply when it is\nfor the purpose of synchronizing the patient's medications. When\napplicable to permit synchronization, the department of health shall\nallow a pharmacy to override any denial codes indicating that a\nprescription is being refilled too soon for the purposes of medication\nsynchronization.\n (iii) The dispensing fee paid to the pharmacy contracted to provide\nservices pursuant to this section for a partial supply associated with\nmedication synchronization shall be paid in accordance with the Medicaid\nstate plan as approved by the Centers for Medicare and Medicaid\nServices.\n (iv) The requirement of this paragraph applies only once for each\nprescription drug subject to medication synchronization except when\neither of the following occurs:\n (I) the prescriber changes the dosage or frequency of administration\nof the prescription drug subject to a medication synchronization; or\n (II) the prescriber prescribes a different drug.\n (v) Nothing in this paragraph shall be deemed to require health care\npractitioners and pharmacists to synchronize the refilling of multiple\nprescriptions for a recipient.\n (vi) The provisions of this paragraph are subject to compliance with\nall applicable federal and state laws and regulations, including the\nCenters for Medicare and Medicaid Services approved Medicaid state plan.\nThe commissioner shall apply for waivers and submit state Medicaid plan\namendments as are necessary to implement the program for synchronization\nof medications.\n * NB Effective until March 31, 2029\n * 9. Notwithstanding any inconsistent provision of law or regulation\nto the contrary, for those drugs which may not be dispensed without a\nprescription as required by section sixty-eight hundred ten of the\neducation law and for which payment is authorized pursuant to paragraph\n(g) of subdivision two of section three hundred sixty-five-a of this\ntitle, payments under this title shall be made at the following amounts:\n (a) for drugs provided by medical practitioners and claimed separately\nby the practitioners, the actual cost of the drugs to the practitioners;\nand\n (b) for drugs dispensed by pharmacies:\n (i) if the drug dispensed is a multiple source prescription drug for\nwhich an upper limit has been set by the federal health care financing\nadministration, an amount equal to the specific upper limit set by such\nfederal agency for the multiple source prescription drug, and\n (ii) if the drug dispensed is a multiple source prescription drug or a\nbrand-name prescription drug for which no specific upper limit has been\nset by such federal agency, the lower of the estimated acquisition cost\nof such drug to pharmacies, or the dispensing pharmacy's usual and\ncustomary price charged to the general public. Estimated acquisition\ncost means the average wholesale price of a prescription drug based upon\nthe package size dispensed from, as reported by the prescription drug\npricing service used by the department, less ten percent thereof, and\nupdated monthly by the department.\n (c) Notwithstanding subparagraph (i) of paragraph (b) of this\nsubdivision, if a qualified prescriber certifies "brand medically\nnecessary" or "brand necessary" in his or her own handwriting directly\non the face of a prescription for a multiple source drug for which a\nspecific upper limit of reimbursement has been established by the\nfederal agency, in addition to writing "d a w" in the box provided for\nsuch purpose on the prescription form, payment under this title for such\ndrug must be made under the provisions of subparagraph (ii) of such\nparagraph.\n (d) In addition to the amounts paid pursuant to paragraph (b) of this\nsubdivision to pharmacies for those drugs which may not be dispensed\nwithout a prescription, as required by section sixty-eight hundred ten\nof the education law and for which payment is authorized pursuant to\nparagraph (g) of subdivision two of section three hundred sixty-five-a\nof this title, the department shall pay a pharmacy dispensing fee for\neach such prescription drug dispensed, which dispensing fee shall not be\nless than the following amounts:\n (i) for prescription drugs categorized as generic by the prescription\ndrug pricing service used by the department, five dollars and fifty\ncents per prescription; and\n (ii) for prescription drugs categorized as brand-name prescription\ndrug by the prescription drug pricing service used by the department,\nfour dollars and fifty cents per prescription.\n * NB Effective March 31, 2029\n 10. Any provider except for those providers certified under article\ntwenty-eight of the public health law, of ordered services or supplies\nunder the medical assistance program may be required to provide\nfinancial security to assure that funds are available to repay any\noverpayments made to the provider under this title and to assure the\nfinancial security of the medical assistance program. For the purposes\nof this subdivision, "ordered services or supplies" shall mean those\nservices or supplies described in paragraphs (g), (i) and (j) of\nsubdivision two of section three hundred sixty-five-a of this title.\n (a) Any financial security required by this subdivision must meet the\nrequirements of this paragraph. Financial security may be provided\nthrough a bond with a corporate surety, from a company authorized to do\nbusiness in this state, or an irrevocable letter of credit or\ncertificate of deposit from a New York state or federally chartered\nbank, trust company, savings bank or savings and loan association\nqualified to do business in New York state and insured by the federal\ndeposit insurance corporation.\n (b) The bond, letter of credit or certificate of deposit shall be\npayable in favor of the people of the state of New York for the purpose\nof indemnifying the medical assistance program against any overpayments\nmade to the provider.\n (c) The bond, letter of credit or certificate of deposit filed and\nmaintained pursuant to this section shall not be cancelled, revoked or\nterminated except after notice to, and with the consent of, the\ndepartment at least forty-five days in advance of such cancellation,\nrevocation or termination.\n (d) The department may bring and maintain an action against the\nprovider and the surety or bank, trust company, savings bank or savings\nand loan association for any claimed overpayments made to the provider.\n (e) Financial security shall not be required for providers which do\nnot submit claims for payment under the medical assistance program\nexceeding five hundred thousand dollars per annum or forty-two thousand\ndollars per month.\n (f) Financial security shall be in an amount equal to the provider's\nestimated claims for payment for a one year period and may be adjusted\nbi-annually in accordance with the dollar amount of claims actually\nsubmitted. If the commissioner is satisfied from an investigation of the\nfinancial condition of a provider that the provider is solvent and\npossessed of sufficient assets to provide reasonable assurance of\nrecovery of any overpayments, the commissioner may modify the amount of\nfinancial security to be provided by such provider.\n (g) Financial security must be submitted by a provider upon initial\napplication for enrollment as a provider of medical assistance and with\neach subsequent enrollment. A change in ownership of a provider shall\nnot release, cancel or terminate liability under this section under any\nbond, letter of credit or certificate of deposit filed for a provider\nwhile such bond, letter of credit or certificate of deposit is in effect\nunless the transferee, purchaser, successor or assignee of such provider\nobtains a bond, letter of credit or certificate of deposit under this\nsection for the benefit of such new owner. All providers enrolled in the\nmedical assistance program on the effective date of this subdivision\nwill be required to submit financial security within ninety days of\nnotice of such requirements by the department.\n (h) The department may make the submission of the financial security\nrequired by this subdivision a condition of participation in the medical\nassistance program.\n 11. (a) Any inconsistent provisions of this title or other law\nnotwithstanding, no health insurer, self-insured plan, managed care\norganization, pharmacy benefit manager, or other party that is, by\nstatute, contract, or agreement, legally responsible for payment of a\nclaim for a health care item or service, employer or organization who\nhas a plan, including an employee retirement income security act or\nservice benefit plan, providing care and other medical benefits for\npersons, whether by insurance or otherwise, shall exclude a person from\neligibility, coverage or entitlement to medical benefits by reason of\nthe eligibility of such person for medical assistance under this title,\nor by reason of the fact that such person would, except for such plan,\nbe eligible for benefits under this title.\n (b) Any inconsistent provisions of this title or other law\nnotwithstanding, no insurer may impose requirements on the department or\na social services district which has been assigned the rights of an\nindividual who is eligible for medical assistance under this title and\nwho is covered for health benefits from the insurer, that are different\nfrom requirements applicable to an agent or assignee of any other\nindividual so covered.\n (c) Any inconsistent provisions of this title or other law\nnotwithstanding, the department may, to the extent necessary to\nreimburse the department and the social services districts for\nexpenditures under this title, certify to the commissioner of taxation\nand finance pursuant to section one hundred seventy-one-f of the tax law\namounts to be withheld from tax refunds otherwise due to any individual\nwho is required by court order to provide medical support in the form of\nhealth insurance benefits for a child who is eligible for medical\nassistance under this title and who has received payment from a\nthird-party for the cost of such services for such child but has not\nused such payments to reimburse either the other parent or guardian of\nsuch child or the provider of such services or the appropriate social\nservices district; provided however, that any claims for current or\npast-due child support shall take priority over any such claims for the\ncosts of such services and care. Such amounts shall be withheld pursuant\nto section one hundred seventy-one-f of the tax law, and shall be\ncredited to unreimbursed medical assistance incurred on behalf of such\nchild. The department shall by regulation establish procedures\nconsistent with paragraphs (a) and (b) of subdivision four of section\none hundred seventy-one-c of the tax law by which any individual who is\nthe subject of a certification may contest such certification.\n 12. Prior to receiving medical assistance under subparagraphs five and\nsix of paragraph (c) of subdivision one of section three hundred\nsixty-six of this title, a person whose net available income is at least\none hundred fifty percent of the applicable federal income official\npoverty line, as defined and updated by the United States department of\nhealth and human services, must pay a monthly premium, in accordance\nwith a procedure to be established by the commissioner. The amount of\nsuch premium shall be twenty-five dollars for an individual who is\notherwise eligible for medical assistance under such subparagraphs, and\nfifty dollars for a couple, both of whom are otherwise eligible for\nmedical assistance under such subparagraphs. No premium shall be\nrequired from a person whose net available income is less than one\nhundred fifty percent of the applicable federal income official poverty\nline, as defined and updated by the United States department of health\nand human services.\n