§ 242. Program eligibility. 1. Persons eligible for comprehensive coverage under section two hundred forty-seven of this title shall include: (a) any unmarried resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period beginning on or after January first, two thousand five, is less than or equal to twenty thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months; and (b) any married resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period when combined with the income in the same calendar year of such married person's spouse beginning on or after January first, two thousand one, is less than or equal to twenty-six thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months. 2. Persons eligible for catastrophic coverage under section two hundred forty-eight of this title shall include: (a) any unmarried resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period beginning on or after January first, two thousand one, is more than twenty thousand and less than or equal to thirty-five thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months; and (b) any married resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period when combined with the income in the same calendar year of such married person's spouse beginning on or after January first, two thousand one, is more than twenty-six thousand dollars and less than or equal to fifty thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months. 3. (a) Eligibility for assistance under this title shall not be granted to any person who at the time an application is made is receiving medical assistance under section three hundred sixty-six of the social services law, or to any person receiving equivalent or better coverage from any other public or private third party payment source or insurance plan than those benefits provided for under this title. (b) An individual who is determined eligible for assistance under this title whose prescription costs are covered in part by any public or private plan may receive reduced assistance under this title. In such cases, benefits provided through this title shall be considered payments of last resort. (c) (1) The fact that some of an individual's prescription drug expenses are paid or reimbursable under the provisions of the medicare program shall not disqualify an individual, if he or she is otherwise eligible, from receiving assistance under this title. In such cases, the state shall pay the portion of the cost of those prescriptions for qualified drugs for which no payment or reimbursement is made by the medicare program or any federally funded prescription drug benefit, less the participant's co-payment required on the amount not paid by the medicare program. (2) Coverage under this paragraph shall be available only after the participant has first exhausted the first two levels of appeal available under Part D of title XVIII of the federal social security act and the appeal has been denied. During the coverage determination and appealperiod, the elderly pharmaceutical insurance coverage program shall provide up to a ninety day supply of the prescribed medication, or such lesser supply as specified on the prescription, if: (i) the pharmacist notifies the prescriber that the participant's Medicare Part D plan and the elderly pharmaceutical insurance coverage program have denied payment for the prescribed medication and that if the prescriber does not choose to change the prescription to a drug that is covered by the participant's Medicare Part D plan, a Medicare Part D appeal must be pursued; and (ii) the prescriber notifies the elderly pharmaceutical insurance coverage program of the prescriber's intent to provide necessary information and cooperation in the pursuit of the Medicare Part D appeal. In instances where the pharmacist is unable to immediately reach the prescriber, the elderly pharmaceutical insurance coverage program shall, upon the request of the pharmacist, authorize a three day emergency supply of the prescribed medication. The elderly pharmaceutical insurance coverage program shall authorize such additional ninety day supplies of the prescribed medication, or such lesser supply as specified on the prescription, and such additional three day emergency supplies as required to ensure coverage of the prescribed medication during the pendency of the Medicare Part D appeal. (3) The participant registration fee charged to eligible program participants for comprehensive coverage pursuant to section two hundred forty-seven of this title shall be waived for the portion of the annual coverage period that the participant is also enrolled as a full subsidy individual in a prescription drug or MA-PD plan under Part D of title XVIII of the federal social security act. (d) The elderly pharmaceutical insurance coverage program is authorized to apply for transitional assistance under the medicare prescription drug discount program with a specific drug discount card under title XVIII of the federal social security act on behalf of applicants and eligible program participants under this title. The elderly pharmaceutical insurance coverage program shall provide applicants and eligible program participants with prior written notice of, and the opportunity to decline, such automatic enrollment. (e) As a condition of continued eligibility for benefits under this title, if a program participant's income indicates that the participant could be eligible for an income-related subsidy under section 1860D-14 of the federal social security act by either applying for such subsidy or by enrolling in a medicare savings program as a qualified medicare beneficiary (QMB), a specified low-income medicare beneficiary (SLMB), or a qualifying individual (QI), a program participant is required to provide, and to authorize the elderly pharmaceutical insurance coverage program to obtain, any information or documentation required to establish the participant's eligibility for such subsidy, and to authorize the elderly pharmaceutical insurance coverage program to apply on behalf of the participant for the subsidy or the medicare savings program. The elderly pharmaceutical insurance coverage program shall make a reasonable effort to notify the program participant of his or her need to provide any of the above required information. After a reasonable effort has been made to contact the participant, a participant shall be notified in writing that he or she has sixty days to provide such required information. If such information is not provided within the sixty day period, the participant's coverage may be terminated. (f) As a condition of continued eligibility for benefits under this title, if a program participant is eligible for Medicare part D drug coverage under section 1860D of the federal social security act, the participant is required to enroll in Medicare part D at the firstavailable enrollment period and to maintain such enrollment. This requirement shall be waived if such enrollment would result in significant additional financial liability by the participant, including, but not limited to, individuals in a Medicare advantage plan whose cost sharing would be increased, or if such enrollment would result in the loss of any health coverage through a union or employer plan for the participant, the participant's spouse or other dependent. The elderly pharmaceutical insurance coverage program shall provide premium assistance for all participants enrolled in Medicare part D as follows: (i) for participants with comprehensive coverage under section two hundred forty-seven of this title, the elderly pharmaceutical insurance coverage program shall pay for the portion of the part D monthly premium that is the responsibility of the participant. Such payment shall be limited to the low-income benchmark premium amount established by the federal centers for Medicare and Medicaid services and any other amount which such agency establishes under its de minimus premium policy, except that such payments made on behalf of participants enrolled in a Medicare advantage plan may exceed the low-income benchmark premium amount if determined to be cost effective to the program. (ii) for participants with catastrophic coverage under section two hundred forty-eight of this title, the elderly pharmaceutical insurance coverage program shall credit the participant's annual personal covered drug expenditure amount required under this title by an amount equal to the annual low-income benchmark premium amount established by the centers for Medicare and Medicaid services, prorated for the remaining portion of the participant's elderly pharmaceutical insurance coverage program coverage period. The elderly pharmaceutical insurance coverage program shall, at appropriate times, notify participants with catastrophic coverage under section two hundred forty-seven of this title of their right to coordinate the annual coverage period with that of Medicare part D, along with the possible advantages and disadvantages of doing so. (g) The elderly pharmaceutical insurance coverage program is authorized and directed to conduct an enrollment program to facilitate, in as prompt and streamlined a fashion as possible, the enrollment into Medicare part D of program participants who are required by the provisions of this section to enroll in part D. Provided, however, that a participant shall not be prevented from receiving his or her drugs immediately at the pharmacy under the elderly pharmaceutical insurance coverage program as a result of such participant's enrollment in Medicare part D. (h) In order to maximize prescription drug coverage under Medicare part D, the elderly pharmaceutical insurance coverage program is authorized to represent program participants under this title in the pursuit of such coverage. Such representation shall not result in any additional financial liability on behalf of such program participants and shall include, but not be limited to, the following actions: (i) application for the premium and cost-sharing subsidies on behalf of eligible program participants; (ii) enrollment in a prescription drug plan or MA-PD plan; the elderly pharmaceutical insurance coverage program shall provide program participants with prior written notice of, and the opportunity to decline such facilitated enrollment subject, however, to the provisions of paragraph (f) of this subdivision; (iii) pursuit of appeals, grievances, or coverage determinations.
§ 242. Program eligibility. 1. Persons eligible for comprehensive coverage under section two hundred forty-seven of this title shall include: (a) any unmarried resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period beginning on or after January first, two thousand five, is less than or equal to twenty thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months; and (b) any married resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period when combined with the income in the same calendar year of such married person's spouse beginning on or after January first, two thousand one, is less than or equal to twenty-six thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months. 2. Persons eligible for catastrophic coverage under section two hundred forty-eight of this title shall include: (a) any unmarried resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period beginning on or after January first, two thousand one, is more than twenty thousand and less than or equal to thirty-five thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months; and (b) any married resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period when combined with the income in the same calendar year of such married person's spouse beginning on or after January first, two thousand one, is more than twenty-six thousand dollars and less than or equal to fifty thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months. 3. (a) Eligibility for assistance under this title shall not be granted to any person who at the time an application is made is receiving medical assistance under section three hundred sixty-six of the social services law, or to any person receiving equivalent or better coverage from any other public or private third party payment source or insurance plan than those benefits provided for under this title. (b) An individual who is determined eligible for assistance under this title whose prescription costs are covered in part by any public or private plan may receive reduced assistance under this title. In such cases, benefits provided through this title shall be considered payments of last resort. (c) (1) The fact that some of an individual's prescription drug expenses are paid or reimbursable under the provisions of the medicare program shall not disqualify an individual, if he or she is otherwise eligible, from receiving assistance under this title. In such cases, the state shall pay the portion of the cost of those prescriptions for qualified drugs for which no payment or reimbursement is made by the medicare program or any federally funded prescription drug benefit, less the participant's co-payment required on the amount not paid by the medicare program. (2) Coverage under this paragraph shall be available only after the participant has first exhausted the first two levels of appeal available under Part D of title XVIII of the federal social security act and the appeal has been denied. During the coverage determination and appealperiod, the elderly pharmaceutical insurance coverage program shall provide up to a ninety day supply of the prescribed medication, or such lesser supply as specified on the prescription, if: (i) the pharmacist notifies the prescriber that the participant's Medicare Part D plan and the elderly pharmaceutical insurance coverage program have denied payment for the prescribed medication and that if the prescriber does not choose to change the prescription to a drug that is covered by the participant's Medicare Part D plan, a Medicare Part D appeal must be pursued; and (ii) the prescriber notifies the elderly pharmaceutical insurance coverage program of the prescriber's intent to provide necessary information and cooperation in the pursuit of the Medicare Part D appeal. In instances where the pharmacist is unable to immediately reach the prescriber, the elderly pharmaceutical insurance coverage program shall, upon the request of the pharmacist, authorize a three day emergency supply of the prescribed medication. The elderly pharmaceutical insurance coverage program shall authorize such additional ninety day supplies of the prescribed medication, or such lesser supply as specified on the prescription, and such additional three day emergency supplies as required to ensure coverage of the prescribed medication during the pendency of the Medicare Part D appeal. (3) The participant registration fee charged to eligible program participants for comprehensive coverage pursuant to section two hundred forty-seven of this title shall be waived for the portion of the annual coverage period that the participant is also enrolled as a full subsidy individual in a prescription drug or MA-PD plan under Part D of title XVIII of the federal social security act. (d) The elderly pharmaceutical insurance coverage program is authorized to apply for transitional assistance under the medicare prescription drug discount program with a specific drug discount card under title XVIII of the federal social security act on behalf of applicants and eligible program participants under this title. The elderly pharmaceutical insurance coverage program shall provide applicants and eligible program participants with prior written notice of, and the opportunity to decline, such automatic enrollment. (e) As a condition of continued eligibility for benefits under this title, if a program participant's income indicates that the participant could be eligible for an income-related subsidy under section 1860D-14 of the federal social security act by either applying for such subsidy or by enrolling in a medicare savings program as a qualified medicare beneficiary (QMB), a specified low-income medicare beneficiary (SLMB), or a qualifying individual (QI), a program participant is required to provide, and to authorize the elderly pharmaceutical insurance coverage program to obtain, any information or documentation required to establish the participant's eligibility for such subsidy, and to authorize the elderly pharmaceutical insurance coverage program to apply on behalf of the participant for the subsidy or the medicare savings program. The elderly pharmaceutical insurance coverage program shall make a reasonable effort to notify the program participant of his or her need to provide any of the above required information. After a reasonable effort has been made to contact the participant, a participant shall be notified in writing that he or she has sixty days to provide such required information. If such information is not provided within the sixty day period, the participant's coverage may be terminated. (f) As a condition of continued eligibility for benefits under this title, if a program participant is eligible for Medicare part D drug coverage under section 1860D of the federal social security act, the participant is required to enroll in Medicare part D at the firstavailable enrollment period and to maintain such enrollment. This requirement shall be waived if such enrollment would result in significant additional financial liability by the participant, including, but not limited to, individuals in a Medicare advantage plan whose cost sharing would be increased, or if such enrollment would result in the loss of any health coverage through a union or employer plan for the participant, the participant's spouse or other dependent. The elderly pharmaceutical insurance coverage program shall provide premium assistance for all participants enrolled in Medicare part D as follows: (i) for participants with comprehensive coverage under section two hundred forty-seven of this title, the elderly pharmaceutical insurance coverage program shall pay for the portion of the part D monthly premium that is the responsibility of the participant. Such payment shall be limited to the low-income benchmark premium amount established by the federal centers for Medicare and Medicaid services and any other amount which such agency establishes under its de minimus premium policy, except that such payments made on behalf of participants enrolled in a Medicare advantage plan may exceed the low-income benchmark premium amount if determined to be cost effective to the program. (ii) for participants with catastrophic coverage under section two hundred forty-eight of this title, the elderly pharmaceutical insurance coverage program shall credit the participant's annual personal covered drug expenditure amount required under this title by an amount equal to the annual low-income benchmark premium amount established by the centers for Medicare and Medicaid services, prorated for the remaining portion of the participant's elderly pharmaceutical insurance coverage program coverage period. The elderly pharmaceutical insurance coverage program shall, at appropriate times, notify participants with catastrophic coverage under section two hundred forty-seven of this title of their right to coordinate the annual coverage period with that of Medicare part D, along with the possible advantages and disadvantages of doing so. (g) The elderly pharmaceutical insurance coverage program is authorized and directed to conduct an enrollment program to facilitate, in as prompt and streamlined a fashion as possible, the enrollment into Medicare part D of program participants who are required by the provisions of this section to enroll in part D. Provided, however, that a participant shall not be prevented from receiving his or her drugs immediately at the pharmacy under the elderly pharmaceutical insurance coverage program as a result of such participant's enrollment in Medicare part D. (h) In order to maximize prescription drug coverage under Medicare part D, the elderly pharmaceutical insurance coverage program is authorized to represent program participants under this title in the pursuit of such coverage. Such representation shall not result in any additional financial liability on behalf of such program participants and shall include, but not be limited to, the following actions: (i) application for the premium and cost-sharing subsidies on behalf of eligible program participants; (ii) enrollment in a prescription drug plan or MA-PD plan; the elderly pharmaceutical insurance coverage program shall provide program participants with prior written notice of, and the opportunity to decline such facilitated enrollment subject, however, to the provisions of paragraph (f) of this subdivision; (iii) pursuit of appeals, grievances, or coverage determinations.
§ 242. Program eligibility. 1. Persons eligible for comprehensive coverage under section two hundred forty-seven of this title shall include: (a) any unmarried resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period beginning on or after January first, two thousand five, is less than or equal to twenty thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months; and (b) any married resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period when combined with the income in the same calendar year of such married person's spouse beginning on or after January first, two thousand one, is less than or equal to twenty-six thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months. 2. Persons eligible for catastrophic coverage under section two hundred forty-eight of this title shall include: (a) any unmarried resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period beginning on or after January first, two thousand one, is more than twenty thousand and less than or equal to thirty-five thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months; and (b) any married resident who is at least sixty-five years of age and whose income for the calendar year immediately preceding the effective date of the annual coverage period when combined with the income in the same calendar year of such married person's spouse beginning on or after January first, two thousand one, is more than twenty-six thousand dollars and less than or equal to fifty thousand dollars. After the initial determination of eligibility, each eligible individual must be redetermined eligible at least every twenty-four months. 3. (a) Eligibility for assistance under this title shall not be granted to any person who at the time an application is made is receiving medical assistance under section three hundred sixty-six of the social services law, or to any person receiving equivalent or better coverage from any other public or private third party payment source or insurance plan than those benefits provided for under this title. (b) An individual who is determined eligible for assistance under this title whose prescription costs are covered in part by any public or private plan may receive reduced assistance under this title. In such cases, benefits provided through this title shall be considered payments of last resort. (c) (1) The fact that some of an individual's prescription drug expenses are paid or reimbursable under the provisions of the medicare program shall not disqualify an individual, if he or she is otherwise eligible, from receiving assistance under this title. In such cases, the state shall pay the portion of the cost of those prescriptions for qualified drugs for which no payment or reimbursement is made by the medicare program or any federally funded prescription drug benefit, less the participant's co-payment required on the amount not paid by the medicare program. (2) Coverage under this paragraph shall be available only after the participant has first exhausted the first two levels of appeal available under Part D of title XVIII of the federal social security act and the appeal has been denied. During the coverage determination and appealperiod, the elderly pharmaceutical insurance coverage program shall provide up to a ninety day supply of the prescribed medication, or such lesser supply as specified on the prescription, if: (i) the pharmacist notifies the prescriber that the participant's Medicare Part D plan and the elderly pharmaceutical insurance coverage program have denied payment for the prescribed medication and that if the prescriber does not choose to change the prescription to a drug that is covered by the participant's Medicare Part D plan, a Medicare Part D appeal must be pursued; and (ii) the prescriber notifies the elderly pharmaceutical insurance coverage program of the prescriber's intent to provide necessary information and cooperation in the pursuit of the Medicare Part D appeal. In instances where the pharmacist is unable to immediately reach the prescriber, the elderly pharmaceutical insurance coverage program shall, upon the request of the pharmacist, authorize a three day emergency supply of the prescribed medication. The elderly pharmaceutical insurance coverage program shall authorize such additional ninety day supplies of the prescribed medication, or such lesser supply as specified on the prescription, and such additional three day emergency supplies as required to ensure coverage of the prescribed medication during the pendency of the Medicare Part D appeal. (3) The participant registration fee charged to eligible program participants for comprehensive coverage pursuant to section two hundred forty-seven of this title shall be waived for the portion of the annual coverage period that the participant is also enrolled as a full subsidy individual in a prescription drug or MA-PD plan under Part D of title XVIII of the federal social security act. (d) The elderly pharmaceutical insurance coverage program is authorized to apply for transitional assistance under the medicare prescription drug discount program with a specific drug discount card under title XVIII of the federal social security act on behalf of applicants and eligible program participants under this title. The elderly pharmaceutical insurance coverage program shall provide applicants and eligible program participants with prior written notice of, and the opportunity to decline, such automatic enrollment. (e) As a condition of continued eligibility for benefits under this title, if a program participant's income indicates that the participant could be eligible for an income-related subsidy under section 1860D-14 of the federal social security act by either applying for such subsidy or by enrolling in a medicare savings program as a qualified medicare beneficiary (QMB), a specified low-income medicare beneficiary (SLMB), or a qualifying individual (QI), a program participant is required to provide, and to authorize the elderly pharmaceutical insurance coverage program to obtain, any information or documentation required to establish the participant's eligibility for such subsidy, and to authorize the elderly pharmaceutical insurance coverage program to apply on behalf of the participant for the subsidy or the medicare savings program. The elderly pharmaceutical insurance coverage program shall make a reasonable effort to notify the program participant of his or her need to provide any of the above required information. After a reasonable effort has been made to contact the participant, a participant shall be notified in writing that he or she has sixty days to provide such required information. If such information is not provided within the sixty day period, the participant's coverage may be terminated. (f) As a condition of continued eligibility for benefits under this title, if a program participant is eligible for Medicare part D drug coverage under section 1860D of the federal social security act, the participant is required to enroll in Medicare part D at the firstavailable enrollment period and to maintain such enrollment. This requirement shall be waived if such enrollment would result in significant additional financial liability by the participant, including, but not limited to, individuals in a Medicare advantage plan whose cost sharing would be increased, or if such enrollment would result in the loss of any health coverage through a union or employer plan for the participant, the participant's spouse or other dependent. The elderly pharmaceutical insurance coverage program shall provide premium assistance for all participants enrolled in Medicare part D as follows: (i) for participants with comprehensive coverage under section two hundred forty-seven of this title, the elderly pharmaceutical insurance coverage program shall pay for the portion of the part D monthly premium that is the responsibility of the participant. Such payment shall be limited to the low-income benchmark premium amount established by the federal centers for Medicare and Medicaid services and any other amount which such agency establishes under its de minimus premium policy, except that such payments made on behalf of participants enrolled in a Medicare advantage plan may exceed the low-income benchmark premium amount if determined to be cost effective to the program. (ii) for participants with catastrophic coverage under section two hundred forty-eight of this title, the elderly pharmaceutical insurance coverage program shall credit the participant's annual personal covered drug expenditure amount required under this title by an amount equal to the annual low-income benchmark premium amount established by the centers for Medicare and Medicaid services, prorated for the remaining portion of the participant's elderly pharmaceutical insurance coverage program coverage period. The elderly pharmaceutical insurance coverage program shall, at appropriate times, notify participants with catastrophic coverage under section two hundred forty-seven of this title of their right to coordinate the annual coverage period with that of Medicare part D, along with the possible advantages and disadvantages of doing so. (g) The elderly pharmaceutical insurance coverage program is authorized and directed to conduct an enrollment program to facilitate, in as prompt and streamlined a fashion as possible, the enrollment into Medicare part D of program participants who are required by the provisions of this section to enroll in part D. Provided, however, that a participant shall not be prevented from receiving his or her drugs immediately at the pharmacy under the elderly pharmaceutical insurance coverage program as a result of such participant's enrollment in Medicare part D. (h) In order to maximize prescription drug coverage under Medicare part D, the elderly pharmaceutical insurance coverage program is authorized to represent program participants under this title in the pursuit of such coverage. Such representation shall not result in any additional financial liability on behalf of such program participants and shall include, but not be limited to, the following actions: (i) application for the premium and cost-sharing subsidies on behalf of eligible program participants; (ii) enrollment in a prescription drug plan or MA-PD plan; the elderly pharmaceutical insurance coverage program shall provide program participants with prior written notice of, and the opportunity to decline such facilitated enrollment subject, however, to the provisions of paragraph (f) of this subdivision; (iii) pursuit of appeals, grievances, or coverage determinations.
