N.Y. Elder Law § 243: Pharmaceutical insurance contract

§ 243. Pharmaceutical insurance contract. 1. The commissioner of

health shall, subject to the approval of the director of the budget,

enter into a contract with one or more contractors to assist in carrying

out the provisions of this title. Such contractual arrangements shall be

made subject to a competitive process pursuant to the state finance law

and shall ensure that state payments for the contractor's necessary and

legitimate expenses for the administration of this program are limited

to the amount specified in advance, and that such payments shall not

exceed the amount appropriated therefor in any fiscal year. The

commissioner shall review the contract pricing provisions to assure that

the level of contract payments are in the best interest of the state,

giving consideration to the total level of participant enrollment

achieved, the volume of claims processed, and such other factors as may

be relevant in order to contain state expenditures. In the event that

the commissioner determines that the contract payment provisions do not

protect the interest of the state, the commissioner shall initiate

contract negotiations for the purpose of modifying contract payments

and/or scope requirements.

2. The responsibilities of the contractor or contractors shall

include, but need not be limited to:

(a) providing for a method of determining, on an annual basis and upon

their application therefor, the eligibility of persons pursuant to

section two hundred forty-two of this title within a reasonable period

of time, including alternative methods for such determination of

eligibility, such as through the mail or home visits, where reasonable

and/or necessary, and for notifying applicants of such eligibility

determinations;

(b) notifying each eligible program participant in writing upon the

commencement of the annual coverage period of such participant's

cost-sharing responsibilities pursuant to section two hundred

forty-seven of this title. The contractor shall also notify each

eligible program participant of any adjustment of the co-payment

schedule by mail no less than thirty days prior to the effective date of

such adjustments and shall inform such eligible program participants of

the date such adjustments shall take effect;

(c) issuing an identification card to each eligible program

participant;

(d) processing of claims for reimbursement to participating provider

pharmacies pursuant to section two hundred fifty of this title;

(e) performing or causing to be performed utilization reviews for such

purposes as may be required by the commissioner of health;

(f) conducting audits and surveys of participating provider pharmacies

as specified pursuant to the terms and conditions of the contract; and

(g) coordinating coverage with insurance companies and other public

and private organizations offering such coverage for those eligible

program participants having partial coverage for covered drugs through

third-party sources, and providing for recoupment of any duplicate

reimbursement paid by the state on behalf of such eligible program

participants.

3. The contractor or contractors shall be required to provide such

reports as may be deemed necessary by the commissioner of health and

shall maintain files in a manner and format approved by the

commissioner.

4. The contractor or contractors may contract with private

not-for-profit or proprietary corporations, or with entities of local

government within the state of New York, to perform such obligations of

the contractor or contractors as the commissioner of health shall

permit.