N.Y. Elder Law § 247: Cost-sharing responsibilities of eligible program participants for comprehensive coverage

§ 247. Cost-sharing responsibilities of eligible program participants

for comprehensive coverage.

1. Registration fee. Eligible individuals meeting the registration fee

requirements of this section may purchase prescribed covered drugs for

an amount specified by subdivision three of this section, subject to the

limits on point of sale co-payments specified by subdivision four of

this section.

2. Registration fee schedule. Eligible individuals electing to meet

the requirements of this subdivision shall pay a quarterly registration

fee in a manner and form determined by the executive director; at the

option of the participant, the registration fee may be paid annually in

a lump sum upon the beginning of the annual coverage period. No eligible

individual electing to meet the requirements of this subdivision shall

have his participation in the program lapse by virtue of non-payment of

the applicable registration fee unless the contractor has provided

notification of the amount and due date thereof, and more than thirty

days have elapsed since the due date of the individual's registration

fee. The registration fee to be charged to eligible program participants

for comprehensive coverage under this option shall be in accordance with

the following schedule:

(a) Quarterly registration fees for unmarried individual program

participants:

individual income of $5,000 or less $2.00

individual income of $5,001 to $6,000 $2.00

individual income of $6,001 to $7,000 $4.00

individual income of $7,001 to $8,000 $5.50

individual income of $8,001 to $9,000 $7.00

individual income of $9,001 to $10,000 $9.00

individual income of $10,001 to $11,000 $10.00

individual income of $11,001 to $12,000 $11.50

individual income of $12,001 to $13,000 $13.50

individual income of $13,001 to $14,000 $15.00

individual income of $14,001 to $15,000 $20.00

individual income of $15,001 to $16,000 $27.50

individual income of $16,001 to $17,000 $35.00

individual income of $17,001 to $18,000 $42.50

individual income of $18,001 to $19,000 $50.00

individual income of $19,001 to $20,000 $57.50

(b) Quarterly registration fees for each married individual program

participant:

joint income of $5,000 or less $2.00

joint income of $5,001 to $6,000 $2.00

joint income of $6,001 to $7,000 $3.00

joint income of $7,001 to $8,000 $4.00

joint income of $8,001 to $9,000 $5.00

joint income of $9,001 to $10,000 $6.00

joint income of $10,001 to $11,000 $7.00

joint income of $11,001 to $12,000 $8.00

joint income of $12,001 to $13,000 $9.00

joint income of $13,001 to $14,000 $10.00

joint income of $14,001 to $15,000 $10.00

joint income of $15,001 to $16,000 $21.00

joint income of $16,001 to $17,000 $26.50

joint income of $17,001 to $18,000 $31.50

joint income of $18,001 to $19,000 $37.50

joint income of $19,001 to $20,000 $43.00

joint income of $20,001 to $21,000 $48.50

joint income of $21,001 to $22,000 $54.00

joint income of $22,001 to $23,000 $59.50

joint income of $23,001 to $24,000 $65.00

joint income of $24,001 to $25,000 $68.75

joint income of $25,001 to $26,000 $75.00

(c) In the event that the state expenditures per participant meeting

the registration fee requirements of this subdivision, exclusive of

expenditures for program administration, in the program year commencing

October first, nineteen hundred eighty-eight, and in each program year

thereafter, exceed such expenditures in the previous program year by a

minimum of ten percent, the annual registration fees set forth in this

subdivision may, unless otherwise provided by law, be increased,

pro-rata, for the subsequent program year, provided that such increase

shall not exceed seven and one-half percent of the prior year

registration fees as may have been adjusted in accordance with this

paragraph.

(d) In the event that the state expenditures per such participant,

incurred pursuant to this subdivision, exclusive of expenditures for

program administration, in the program year commencing October first,

nineteen hundred eighty-eight, and in each program year thereafter, are

less than such expenditures in the previous program year by a minimum of

ten percent, the annual registration fees set forth in this subdivision

may, unless otherwise provided by law, be decreased, pro-rata, for the

subsequent program year, provided that such decrease shall not exceed

seven and one-half percent of the prior year registration fees as may

have been adjusted in accordance with this paragraph.

(e) The determination to adjust annual registration fees set forth in

this subdivision shall follow a review of such factors as the relative

financial capacity of the state and such eligible program participants

to support such adjustments and changes in the consumer price index. The

frequency of such adjustments shall not exceed once in any program year

and such adjustments shall not become effective for individual program

participants prior to the first day of the next annual coverage period

for each participant.

3. Point of sale co-payment. (a) Upon satisfaction of the registration

fee pursuant to this section an eligible program participant must pay a

point of sale co-payment as set forth in paragraph (b) of this

subdivision at the time of each purchase of a covered drug prescribed

for such individual. Such co-payment shall not be waived or reduced in

whole or in part subject to the limits provided by subdivision four of

this section.

(b) The point of sale co-payment amounts which are to be charged

eligible program participants shall be in accordance with the following

schedule:

For each prescription of covered drugs costing $15.00 or less.....$3.00

For each prescription of covered drugs costing $15.01 to $35.00...$7.00

For each prescription of covered drugs costing $35.01 to $55.00..$15.00

For each prescription of covered drugs costing $55.01 or more....$20.00

(c) For the purposes of the foregoing schedule of point of sale

co-payments, "costing" shall mean the amount of reimbursement which

shall be paid by the state to a participating provider pharmacy in

accordance with section two hundred fifty of this title plus the point

of sale co-payment, calculated as of the date of sale.

4. Limits on point of sale co-payments. During each annual coverage

period no point of sale co-payment as set forth in subdivision three of

this section shall be required to be made for the remainder of such

period by any eligible program participant who has already incurred

co-payments in excess of the limits set forth in the following schedule:

(a) Limits on co-payments by unmarried individual eligible program

participants:

individual income of $5,000 or less no more than $340

individual income of $5,001 to $6,000 no more than $408

individual income of $6,001 to $7,000 no more than $476

individual income of $7,001 to $8,000 no more than $544

individual income of $8,001 to $9,000 no more than $612

individual income of $9,001 to $10,000 no more than $700

individual income of $10,001 to $11,000 no more than $720

individual income of $11,001 to $12,000 no more than $827

individual income of $12,001 to $13,000 no more than $896

individual income of $13,001 to $14,000 no more than $964

individual income of $14,001 to $15,000 no more than $1,016

individual income of $15,001 to $16,000 no more than $1,034

individual income of $16,001 to $17,000 no more than $1,052

individual income of $17,001 to $18,000 no more than $1,070

individual income of $18,001 to $19,000 no more than $1,088

individual income of $19,001 to $20,000 no more than $1,160

(b) Limits on co-payments by each married individual eligible program

participant:

joint income of $5,000 or less no more than $291

joint income of $5,001 to $6,000 no more than $342

joint income of $6,001 to $7,000 no more than $399

joint income of $7,001 to $8,000 no more than $456

joint income of $8,001 to $9,000 no more than $513

joint income of $9,001 to $10,000 no more than $570

joint income of $10,001 to $11,000 no more than $622

joint income of $11,001 to $12,000 no more than $641

joint income of $12,001 to $13,000 no more than $660

joint income of $13,001 to $14,000 no more than $684

joint income of $14,001 to $15,000 no more than $710

joint income of $15,001 to $16,000 no more than $826

joint income of $16,001 to $17,000 no more than $877

joint income of $17,001 to $18,000 no more than $928

joint income of $18,001 to $19,000 no more than $980

joint income of $19,001 to $20,000 no more than $990

joint income of $20,001 to $21,000 no more than $1,008

joint income of $21,001 to $22,000 no more than $1,026

joint income of $22,001 to $23,000 no more than $1,044

joint income of $23,001 to $24,000 no more than $1,062

joint income of $24,001 to $25,000 no more than $1,080

joint income of $25,001 to $26,000 no more than $1,150

(c) Effective October first, nineteen hundred eighty-eight, the limits

on point of sale co-payments as set forth in this subdivision may be

adjusted by the panel on the anniversary date of each program

participant's annual coverage period, and such adjustment shall be in

effect for the duration of that annual coverage period. Any such annual

adjustment shall be made using a percentage adjustment factor which

shall not exceed one-half of the difference between the year-to-year

percentage increase in the consumer price index for all urban consumers,

as published by the United States Department of Labor, and, if larger,

the year-to-year percentage increase in the aggregate average cost of

covered drugs purchased under this title, which year-to-year percentage

increase in such cost shall be determined by comparison of such cost in

the same month of each of the appropriate successive years; provided,

however, that for any such adjustment based wholly on experience in the

program year commencing October first, nineteen hundred eighty-seven,

the year-to-year percentage increase in such cost shall be determined by

comparison of such cost in each of two months no less than five months

apart and within such program year, which comparison shall be

annualized. Such percentage adjustment factor shall be the same as that

used to determine any similar annual adjustment for the same annual

coverage periods pursuant to the provisions of subdivision four of

section two hundred forty-eight of this title.

(d) Such annual adjustments shall be calculated by multiplying the

percentage adjustment factor by (1) ten percent and applying the

resulting percentage to the upper income limitation of each income level

for unmarried individuals contained in this subdivision, and by (2)

seven and one-half percent and applying the resulting percentage to the

upper income limitation of each income level for married individuals

contained in this subdivision; each result of such calculations, minus

any applicable registration fee increases made pursuant to subdivision

two of this section and plus the result of applying the percentage

adjustment factor to the sum of any such annual adjustments applicable

thereto for any prior annual coverage period, shall be the amount by

which the limit on co-payments for each such income level may be

adjusted, and such amount shall be in addition to any such amount or

amounts applicable to prior annual coverage periods.

(e) The determination to adjust the limits on point of sale

co-payments set forth in this subdivision shall follow a review of such

factors as the relative financial capacity of the state and such

eligible program participants to support such adjustments.