N.Y. Social Services Law § 367-a: Payments; insurance

§ 367-a. Payments; insurance. 1. (a) Any inconsistent provision of

this chapter or other law notwithstanding, no assignment of the claim of

any supplier of medical assistance shall be valid and enforceable as

against any social services district or the department, and any payment

with respect to any medical assistance shall be made to the person,

institution, state department or agency or municipality supplying such

medical assistance at rates established by the appropriate social

services district and contained in its approved local medical plan,

except as otherwise permitted or required by applicable federal and

state provisions, including the regulations of the department; provided,

however, that for those districts for whom the department has assumed

payment responsibilities pursuant to section three hundred sixty-seven-b

of this chapter, rates shall be established by the department, except as

otherwise required by applicable provisions of federal or state law. A

social services official may apply to the department for local

variations in rates to be applicable, upon approval by the department,

to recipients for whom such district is responsible. Claims for payment

shall be made in such form and manner as the department shall determine.

(b) Where an applicant for or recipient of public assistance or

medical assistance has health insurance in force, is enrolled in a group

health insurance plan or group health plan covering care and other

medical benefits provided under this title, payment or part-payment of

the premium, co-insurance, any deductible amounts and other cost-sharing

obligations for such insurance may also be made when deemed

cost-effective pursuant to the regulations of the department.

(c) Any inconsistent provisions of this title or other law

notwithstanding and to the extent that federal financial participation

is available therefor and in accordance with the regulations of the

commissioner, payment of the premium for coverage under a group health

insurance plan or group health plan may be made under the medical

assistance program on behalf of a person not otherwise entitled to

public assistance or medical assistance if the social services official

determines that the savings in expenditures to the program as a result

of such coverage are likely to exceed the amount of the premiums paid

and such person has:

(i) income (as determined in accordance with the methodology used to

determine eligibility for benefits under the federal supplemental

security income program) in an amount less than or equal to one hundred

per cent of the federal income official poverty line (as defined and

annually revised by the federal office of management and budget)

applicable to the person's family size;

(ii) resources (as determined in accordance with the methodology used

to determine eligibility for benefits under the federal supplemental

security income program) less than or equal to twice the maximum amount

an individual is permitted to have to obtain benefits under the federal

supplemental security income program; and

(iii) coverage available under a group health insurance plan or an

employer-based group health plan provided pursuant to title XXII of the

federal public health services act, section 4980B of the federal

internal revenue code of 1986, or title VI of the employee retirement

income security act of 1974.

(d) (i) Amounts payable under this title for medical assistance for

items and services provided to eligible persons who are also

beneficiaries under part A of title XVIII of the federal social security

act and items and services provided to qualified medicare beneficiaries

under part A of title XVIII of the federal social security act shall not

be less than the amount of any deductible and co-insurance liability of

such eligible persons or for which such eligible persons or such

qualified medicare beneficiaries would be liable under federal law were

they not eligible for medical assistance or were they not qualified

medicare beneficiaries with respect to such benefits under such part A.

(ii) Amounts payable under this title for medical assistance for items

and services provided to eligible persons who are also beneficiaries

under part B of title XVIII of the federal social security act and items

and services provided to qualified medicare beneficiaries under part B

of title XVIII of the federal social security act shall not be less than

the amount of any deductible liability of such eligible persons or for

which such eligible persons or such qualified medicare beneficiaries

would be liable under federal law were they not eligible for medical

assistance or were they not qualified medicare beneficiaries with

respect to such benefits under such part B.

* (iii) With respect to items and services provided to eligible

persons who are also beneficiaries under part B of title XVIII of the

federal social security act and items and services provided to qualified

medicare beneficiaries under part B of title XVIII of the federal social

security act, the amount payable for services covered under this title

shall be the amount of any co-insurance liability of such eligible

persons pursuant to federal law were they not eligible for medical

assistance or were they not qualified medicare beneficiaries with

respect to such benefits under such part B, but shall not exceed the

amount that otherwise would be made under this title if provided to an

eligible person other than a person who is also a beneficiary under part

B or is a qualified medicare beneficiary minus the amount payable under

part B; provided, however, amounts payable under this title for items

and services provided to eligible persons who are also beneficiaries

under part B or to qualified medicare beneficiaries by an ambulance

service under the authority of an operating certificate issued pursuant

to article thirty of the public health law, a psychologist licensed

under article one hundred fifty-three of the education law, or a

facility under the authority of an operating certificate issued pursuant

to article sixteen, thirty-one or thirty-two of the mental hygiene law

and with respect to outpatient hospital and clinic items and services

provided by a facility under the authority of an operating certificate

issued pursuant to article twenty-eight of the public health law, shall

not be less than the amount of any co-insurance liability of such

eligible persons or such qualified medicare beneficiaries, or for which

such eligible persons or such qualified medicare beneficiaries would be

liable under federal law were they not eligible for medical assistance

or were they not qualified medicare beneficiaries with respect to such

benefits under part B.

* NB Effective until April 1, 2027

* (iii) With respect to items and services provided to eligible

persons who are also beneficiaries under part B of title XVIII of the

federal social security act and items and services provided to qualified

medicare beneficiaries under part B of title XVIII of the federal social

security act, the amount payable for services covered under this title

shall be the amount of any co-insurance liability of such eligible

persons pursuant to federal law were they not eligible for medical

assistance or were they not qualified medicare beneficiaries with

respect to such benefits under such part B, but shall not exceed the

amount that otherwise would be made under this title if provided to an

eligible person other than a person who is also a beneficiary under part

B or is a qualified medicare beneficiary minus the amount payable under

part B; provided, however, amounts payable under this title for items

and services provided to eligible persons who are also beneficiaries

under part B or to qualified medicare beneficiaries by an ambulance

service under the authority of an operating certificate issued pursuant

to article thirty of the public health law, or a facility under the

authority of an operating certificate issued pursuant to article

sixteen, thirty-one or thirty-two of the mental hygiene law and with

respect to outpatient hospital and clinic items and services provided by

a facility under the authority of an operating certificate issued

pursuant to article twenty-eight of the public health law, shall not be

less than the amount of any co-insurance liability of such eligible

persons or such qualified medicare beneficiaries, or for which such

eligible persons or such qualified medicare beneficiaries would be

liable under federal law were they not eligible for medical assistance

or were they not qualified medicare beneficiaries with respect to such

benefits under part B.

* NB Effective April 1, 2027

* (iv) If a health plan participating in part C of title XVIII of the

federal social security act pays for items and services provided to

eligible persons who are also beneficiaries under part B of title XVIII

of the federal social security act or to qualified medicare

beneficiaries, the amount payable for services under this title shall be

eighty-five percent of the amount of any co-insurance liability of such

eligible persons pursuant to federal law if they were not eligible for

medical assistance or were not qualified medicare beneficiaries with

respect to such benefits under such part B; provided, however, amounts

payable under this title for items and services provided to eligible

persons who are also beneficiaries under part B or to qualified medicare

beneficiaries by an ambulance service under the authority of an

operating certificate issued pursuant to article thirty of the public

health law, or a psychologist licensed under article one hundred

fifty-three of the education law, shall not be less than the amount of

any co-insurance liability of such eligible persons or such qualified

medicare beneficiaries, or for which such eligible persons or such

qualified medicare beneficiaries would be liable under federal law were

they not eligible for medical assistance or were they not qualified

medicare beneficiaries with respect to such benefits under part B.

* NB Effective until April 1, 2027

* (iv) If a health plan participating in part C of title XVIII of the

federal social security act pays for items and services provided to

eligible persons who are also beneficiaries under part B of title XVIII

of the federal social security act or to qualified medicare

beneficiaries, the amount payable for services under this title shall be

the amount of any co-insurance liability of such eligible persons

pursuant to federal law if they were not eligible for medical assistance

or were not qualified medicare beneficiaries with respect to such

benefits under such part B, but shall not exceed the amount that

otherwise would be made under this title if provided to an eligible

person other than a person who is also a beneficiary under part B or is

a qualified medicare beneficiary minus the amount payable under part B;

provided, however, amounts payable under this title for items and

services provided to eligible persons who are also beneficiaries under

part B or to qualified medicare beneficiaries by an ambulance service

under the authority of an operating certificate issued pursuant to

article thirty of the public health law shall not be less than the

amount of any coinsurance liability of such eligible persons or such

qualified medicare beneficiaries, or for which such eligible persons or

such qualified medicare beneficiaries would be liable under federal law

were they not eligible for medical assistance or were they not qualified

medicare beneficiaries with respect to such benefits under part B.

* NB Effective April 1, 2027

(e) Amounts payable under this title for medical assistance in the

form of clinic services pursuant to article twenty-eight of the public

health law, article sixteen of the mental hygiene law and independent

practitioner services for individuals with developmental disabilities

provided to eligible persons diagnosed with a developmental disability

who are also beneficiaries under part B of title XVIII of the federal

social security act, or provided to persons diagnosed with a

developmental disability who are qualified medicare beneficiaries under

part B of title XVIII of such act shall not be less than the approved

medical assistance payment level less the amount payable under part B.

(f) Amounts payable under this title for medical assistance in the

form of outpatient mental health services under article thirty-one or

outpatient chemical dependence services including opioid treatment

services under article thirty-two of the mental hygiene law provided to

eligible persons who are also beneficiaries under part B of title XVIII

of the federal social security act or provided to qualified medicare

beneficiaries under part B of title XVIII of such act shall not be less

than the approved medical assistance payment level less the amount

payable under part B.

(g) Notwithstanding any provision of this section to the contrary,

amounts payable under this title for medical assistance in the form of

hospital outpatient services or diagnostic and treatment center services

pursuant to article twenty-eight of the public health law provided to

eligible persons who are also beneficiaries under part B of title XVIII

of the federal social security act or provided to qualified medicare

beneficiaries under part B of title XVIII of such act shall not exceed

the approved medical assistance payment level less the amount payable

under part B.

(h) Amounts payable under this title for medical assistance in the

form of freestanding clinic services pursuant to article twenty-eight of

the public health law provided to eligible persons participating in the

New York traumatic brain injury waiver program who are also

beneficiaries under part B of title XVIII of the federal social security

act or who are qualified medicare beneficiaries under part B of title

XVIII of such act shall not be less than the approved medical assistance

payment level less the amount payable under part B.

2. (a) Any inconsistent provision of this chapter notwithstanding,

provision for medical care and other medical benefits available under

this title may be made, in whole or in part, either under this title or

other appropriate provisions of this chapter, through insurance or other

prepaid plans, in accordance with the regulations of the department.

(b) Any inconsistent provision of this chapter or other law

notwithstanding, upon furnishing assistance under this title to any

applicant or recipient of medical assistance, the local social services

district or the department shall be subrogated, to the extent of the

expenditures by such district or department for medical care furnished,

to any rights such person may have to medical support or reimbursement

from liable third parties, including but not limited to health insurers,

self-insured plans, group health plans, service benefit plans, managed

care organizations, pharmacy benefit managers, or other parties that

are, by statute, contract, or agreement, legally responsible for payment

of a claim for a health care item or service. For purposes of this

section, the term medical support shall mean the right to support

specified as support for the purpose of medical care by a court or

administrative order. The right of subrogation does not attach to

insurance benefits paid or provided under any health insurance policy

prior to the receipt of written notice of the exercise of subrogation

rights by the carrier issuing such insurance, nor shall such right of

subrogation attach to any benefits which may be claimed by a social

services official or the department, by agreement or other established

procedure, directly from an insurance carrier. No right of subrogation

to insurance benefits available under any health insurance policy shall

be enforceable unless written notice of the exercise of such subrogation

right is received by the carrier within three years from the date

services for which benefits are provided under the policy or contract

are rendered. Liable third parties shall not deny a claim made by a

social services official or the department in conformance with this

paragraph solely on the basis of the date of submission of the claim,

the type or format of the claim form, a failure to obtain prior

authorization, or a failure to present proper documentation at the

point-of-sale that is the basis of the claim. Liable third parties shall

respond to a request for payment within sixty calendar days after

receipt of written proof of loss or claim for payment for health care

services provided to a recipient of Medicaid who is covered by the third

party and shall not charge a fee to process or adjudicate a claim. The

local social services district or the department shall also notify the

carrier when the exercise of subrogation rights has terminated because a

person is no longer receiving assistance under this title. Such carrier

shall establish mechanisms to maintain the confidentiality of all

individually identifiable information or records. Such carrier shall

limit the use of such information or record to the specific purpose for

which such disclosure is made, and shall not further disclose such

information or records.

(c) In accordance with regulations of the department and to the extent

authorized by federal law and regulation, the social services district

is authorized to retain, in addition to amounts retained as repayment

for its share of the costs of medical assistance provided, a portion of

the federal share of the amount collected as medical support or third

party benefits assigned under paragraph (f) of subdivision four of

section three hundred sixty-six of this article, when such district, or

other governmental agency pursuant to an agreement with such district,

has collected such medical support or third party benefits on behalf of

a person receiving medical assistance whose rights to medical support or

third party benefits have been assigned to the state or to the

appropriate social services official. Where more than one district has

been involved in enforcing or collecting such amounts, the federal

incentive shall be apportioned among each such district in accordance

with the regulations of the department.

3. (a) As used in this subdivision, the following terms shall have the

following meanings:

(1) "Qualified medicare beneficiary" means a person who is entitled to

hospital insurance benefits under part A of title XVIII of the federal

social security act, whose income does not exceed one hundred

thirty-eight percent of the official federal poverty line applicable to

the person's family size and whose resources do not exceed twice the

maximum amount of resources a person may have in order to qualify for

benefits under the federal supplemental security income program of title

XVI of the federal social security act, as determined for purposes of

such program. To the extent that federal financial participation is

available, a person whose resources are in excess of the amount

specified in this subparagraph but otherwise meets the requirements

shall be considered a "qualified medicare beneficiary".

(2) "Qualified individual" means a person who is entitled to hospital

insurance benefits under part A of title XVIII of the federal social

security act and whose income is greater than one hundred thirty-eight

percent, but less than or equal to one hundred eighty-six percent, of

the federal poverty line, for the applicable family size, and who is not

otherwise eligible for medical assistance under this article; referred

to as a qualified individual.

(3) "Qualified disabled and working individual" means an individual

who is not otherwise eligible for medical assistance and:

(i) who is entitled to enroll for hospital insurance benefits under

section 1818A of part A of title XVIII of the federal social security

act;

(ii) whose income does not exceed two hundred percent of the official

federal poverty line applicable to the person's family size; and

(iii) whose resources do not exceed twice the maximum amount of

resources that an individual or a couple, in the case of a married

individual, may have and obtain federal supplemental security income

benefits under title XVI of the federal social security act, as

determined for purposes of that program.

For purposes of this subparagraph, income and resources are determined

by the same methodology as is used for determining eligibility under the

federal supplemental security income benefits under title XVI of the

federal social security act.

(b) Payment of premiums for enrolling qualified disabled and working

individuals and qualified medicare beneficiaries under Part A of title

XVIII of the federal social security act and for enrolling such

beneficiaries and eligible recipients of public assistance under part B

of title XVIII of the federal social security act, together with the

costs of the applicable co-insurance and deductible amounts on behalf of

such beneficiaries, and recipients, and premiums under section 1839 of

the federal social security act shall be made and the cost thereof borne

by the state or by the state and social services districts,

respectively, in accordance with the regulations of the department,

provided, however, that the share of the cost to be borne by a social

services district, if any, shall in no event exceed the proportionate

share borne by such district with respect to other expenditures under

this title. Moreover, if the director of the budget approves, payment of

premiums for enrolling persons who have been determined to be eligible

for medical assistance only may be made and the cost thereof borne or

shared pursuant to this subdivision.

(c) (1) Beginning April first, two thousand two and to the extent that

federal financial participation is available at a one hundred percent

federal Medical assistance percentage and subject to sections 1933 and

1902(a)(10)(E)(iv) of the federal social security act, medical

assistance shall be available for full payment of medicare part B

premiums for qualified individuals.

(2) Premium payments for the individuals described in subparagraph one

of this paragraph will be one hundred percent federally funded up to the

amount of the federal allotment. The department shall discontinue

enrollment into the program when the part B premium payments made

pursuant to subparagraph one of this paragraph meet the yearly federal

allotment.

(3) (i) The commissioner of health shall develop a simplified

application form, consistent with federal law, for payments pursuant to

this section. The commissioner of health, in cooperation with the office

for the aging, shall publicize the availability of such payments to

medicare beneficiaries.

(ii) Low-income subsidy data transmitted from the social security

administration to local departments of social services in accordance

with section 1144(c)(3) of the federal social security act shall be

treated as an application for the medicare savings program, without

requiring submission of another application. Any information verified by

the social security administration shall be accepted without further

verification, if the information provided through low-income subsidy

data supports a determination of eligibility under this subdivision. The

commissioner of health shall report on an annual basis on the status of

the medicare savings program and the number of applications received by

local social services districts under this article.

(d) (1) Payment of premiums for enrolling individuals in qualified

health plans offered through a health insurance exchange established

pursuant to the federal Patient Protection and Affordable Care Act (P.L.

111-148), as amended by the federal Health Care and Education

Reconciliation Act of 2010 (P.L. 111-152), shall be available to

individuals who:

(i) immediately prior to being enrolled in the qualified health plan,

were or would have been eligible under the family health plus program as

a parent or stepparent of a child under the age of twenty-one, and whose

MAGI household income, as defined in subparagraph eight of paragraph (a)

of subdivision one of section three hundred sixty-six of this title,

exceeds one hundred thirty-three percent of the federal poverty line for

the applicable family size;

(ii) are not otherwise eligible for medical assistance under this

title; and

(iii) are enrolled in a standard health plan in the silver level, as

defined in 42 U.S.C. 18022.

(2) Payment pursuant to this paragraph shall be for premium

obligations of the individual under the qualified health plan and shall

continue only if and for so long as the individual's MAGI household

income exceeds one hundred thirty-three percent, but does not exceed one

hundred fifty percent, of the federal poverty line for the applicable

family size, or, if earlier, until the individual is eligible for

enrollment in a standard health plan pursuant to section three hundred

sixty-nine-gg of this article.

(3) The commissioner of health shall submit amendments to the state

plan for medical assistance and/or submit one or more applications for

waivers of the federal social security act as may be necessary to

receive federal financial participation in the costs of payments made

pursuant to this paragraph; provided further, however, that nothing in

this subparagraph shall be deemed to affect payments for premiums

pursuant to this paragraph if federal financial participation in the

costs of such payments is not available.

4. No social services district shall make final payments pursuant to

title XIX of the federal social security act for benefits available

under title XVIII of such act without documentation that title XVIII

claims have been filed and denied.

5. (a) When medical care, services and supplies are furnished an

eligible person on behalf of a social services district under this

title, such social services district is authorized to utilize any

appropriate organization as a fiscal intermediary to audit and make

payment for such district's share of the cost of such care, services and

supplies.

(b) To carry out the purposes of paragraph (a), the department, on

behalf of itself and any of the social services districts, may enter

into agreements with appropriate organizations to act as fiscal

intermediaries.

6. (a) Notwithstanding any inconsistent provision of law, payment for

claims for services as specified in paragraph (d) of this subdivision

furnished to eligible persons under this title, subject to paragraph (b)

of this subdivision shall be reduced in accordance with the provisions

of paragraph (c) of this subdivision by an amount not to exceed the

maximum amount authorized by federal law and regulations as a co-payment

amount, which co-payment amount the provider of such services may charge

the recipient, provided, however, no provider may deny such services to

an individual eligible for services based on the individual's inability

to pay the co-payment amount.

(b) Co-payments shall apply to all eligible persons for the services

defined in paragraph (d) of this subdivision with the exception of:

(i) individuals under twenty-one years of age;

(ii) pregnant women;

(iii) individuals who are inpatients in a medical facility who have

been required to spend all of their income for medical care, except

their personal needs allowance or residents of community based

residential facilities licensed by the office of mental health or the

office for people with developmental disabilities who have been required

to spend all of their income, except their personal needs allowance;

(iv) individuals enrolled in health maintenance organizations or other

entities which provide comprehensive health services, or other managed

care programs for services covered by such programs, except that such

persons, other than persons otherwise exempted from co-payments pursuant

to subparagraphs (i), (ii), (iii) and (v) of this paragraph, and other

than those persons enrolled in a managed long term care program, shall

be subject to co-payments as described in subparagraph (v) of paragraph

(d) of this subdivision;

(v) individuals whose family income is less than one hundred percent

of the federal poverty line, as defined in subparagraph four of

paragraph (a) of subdivision one of section three hundred sixty-six of

this title, for a family of the same size; and

(vi) any other individuals required to be excluded by federal law or

regulations.

(b-1) The commissioner is authorized to submit any request or

application to the Centers for Medicare and Medicaid Services as may be

necessary to be granted a waiver of the requirement for the department

of health to calculate its Medicaid payments to managed care

organizations to include cost sharing established under the state plan

for medical assistance for enrollees who are not exempt from cost

sharing. In the absence of such a waiver, the commissioner shall adjust

Medicaid payments to managed care organizations beginning October first,

two thousand fifteen or on the date the Centers for Medicare and

Medicaid Services commences enforcement of such requirement, whichever

is later.

* (c) (i) Co-payments charged pursuant to this subdivision for

non-institutional services shall not exceed the following table,

provided, however, that the department may establish standard

co-payments for services based upon the average or typical payment for

that service:

State's payment Maximum co-payment

for the services chargeable to recipient

$10 or less $.50

$10.01 to $25 $1.00

$25.01 to $50 $2.00

$50.01 or more $3.00

(ii) co-payments charged pursuant to this subdivision for each

discharge for inpatient care shall be twenty-five dollars.

(iii) Notwithstanding any other provision of this paragraph,

co-payments charged for each generic prescription drug dispensed shall

be one dollar and for each brand name prescription drug dispensed shall

be two dollars and fifty cents; provided, however, that the co-payments

charged for each brand name prescription drug reimbursed pursuant to

subparagraph (ii) of paragraph (a-1) of subdivision four of section

three hundred sixty-five-a of this title shall be one dollar.

(iv) When an individual is initially dispensed or prescribed a seven

or fewer days supply of an opioid pursuant to paragraph (b) of

subdivision five of section three thousand three hundred thirty-one of

the public health law, and is subsequently dispensed or prescribed an

additional supply of such opioid for the same underlying condition, the

total co-payment that may be charged to such an individual for the

initial prescription plus all subsequent prescriptions for the same

underlying condition for up to a total of thirty-days supply of such

opioid shall not exceed the amount set forth in subparagraph (iii) of

this paragraph.

* NB Repealed March 31, 2029

(d) Co-payments shall apply to the following services, subject to such

exceptions for subcategories of these services as recognized by the

commissioner in regulations, provided in accordance with section three

hundred sixty-five-a of this article and the regulations of the

department, to the extent permitted by title XIX of the federal social

security act:

(i) in-patient care in a general hospital, as defined in subdivision

ten of section twenty-eight hundred one of the public health law;

(ii) out-patient hospital and clinic services except for mental health

services, and developmental disability services, alcohol and substance

abuse services and methadone maintenance services;

(iii) home health services, including services provided under the long

term home health care program, provided however, home health providers

shall not require employees providing services in the home to collect

the co-payment amount;

(iv) sickroom supplies;

(v) drugs, excepting psychotropic drugs and drugs with FDA approved

indications for the treatment of tuberculosis as specified by the

department and those drugs intended for use by residents of adult care

facilities licensed by the department of health who have been required

to spend all of their income, except their personal needs allowance;

(vi) clinical laboratory services;

(vii) x-rays;

(viii) emergency room services provided for non-urgent or

non-emergency medical care, provided however, co-payments shall not be

required for emergency services or family planning services and

supplies;

(e) In the period from January first, nineteen hundred ninety-three to

March thirty-first, nineteen hundred ninety-three no recipient shall be

required to pay more than a total of fifty dollars in co-payments

required by this subdivision for drugs, nor shall reductions in payments

as a result of such co-payments exceed fifty dollars for any recipient.

(f) (i) In the year commencing April first, nineteen hundred

ninety-three and for each year thereafter, and ending in the year

concluding on March thirty-first, two thousand five, no recipient shall

be required to pay more than a total of one hundred dollars in

co-payments required by this subdivision, nor shall reductions in

payments as a result of such co-payments exceed one hundred dollars for

any recipient.

(ii) In the year commencing April first, two thousand five and for

each year thereafter, no recipient shall be required to pay more than a

total of two hundred dollars in co-payments required by this

subdivision, nor shall reductions in payments as a result of such

co-payments exceed two hundred dollars for any recipient.

(g) The commissioner shall promptly:

(i) promulgate a regulation making it an unacceptable practice under

the medical assistance program for a provider to deny services to an

individual eligible for services based on the individual's inability to

pay the co-pay amount required by this subdivision;

(ii) establish and maintain a toll-free hotline which may be used to

report a violation of the regulation promulgated pursuant to

subparagraph (i) of this paragraph; and

(iii) provide notice to all recipients summarizing their rights and

obligations under this subdivision.

7. (a) Every manufacturer or wholesaler of drugs, prescriptions or

poisons registered under the provisions of section sixty-eight hundred

eight of the education law, shall, upon request of the department for

any information pertaining to wholesale prices charged to pharmacists

for any drugs available under the medical assistance program, make the

requested information available to the department on a monthly basis, or

such other periodic basis as the department shall request.

(b) The department shall provide for financial arrangements with any

manufacturer or wholesaler of drugs, prescriptions or poisons as may be

necessary to reimburse such manufacturer or wholesaler for its actual

and necessary costs included in furnishing the requested information.

(c) Any information obtained pursuant to the provisions of this

subdivision shall not be made available for public inspection or copying

under the provisions of article six of the public officers law. The

department shall not disclose such information to any person, firm,

department or agency, except any state agency or department as may be

necessary for the administration of the medical assistance program under

the provisions of this chapter or any other law.

(d) Notwithstanding any inconsistent provision of law, if a

manufacturer (as defined under section 1927 of the federal social

security act) has entered into a rebate agreement with the department or

with the federal secretary of health and human services on behalf of the

department under section 1927 of the federal social security act, the

department shall reimburse for covered outpatient drugs which are

dispensed under the medical assistance program to all persons in receipt

of medical assistance benefits as a result of their eligibility having

been established under subparagraph one or nine of paragraph (a) of

subdivision one of section three hundred sixty-six of this title, and

which are dispensed to all persons eligible for health care services as

a result of their eligibility having been established under subdivision

two of section three hundred sixty-nine-ee of this article, only

pursuant to the terms of the rebate agreement between the department and

such manufacturer; provided, however, that any agreement between the

department and a manufacturer entered into before August first, nineteen

hundred ninety-one, shall be deemed to have been entered into on April

first, nineteen hundred ninety-one; and provided further, that if a

manufacturer has not entered into an agreement with the department

before August first, nineteen hundred ninety-one, such agreement shall

not be effective until April first, nineteen hundred ninety-two, unless

such agreement provides that rebates will be retroactively calculated as

if the agreement had been in effect on April first, nineteen hundred

ninety-one. The rebate agreement between such manufacturer and the

department shall utilize for single source drugs and innovator multiple

source drugs the identical formula used to determine the basic rebate

for federal financial participation single source drugs and innovator

multiple source drugs, pursuant to paragraph one of subdivision (c) of

section 1927 of the federal social security act, to determine the amount

of the rebate pursuant to this paragraph. The rebate agreement between

such manufacturer and the department shall utilize for non-innovator

multiple source drugs the identical formula used to determine the basic

rebate for federal financial participation non-innovator multiple source

drugs, pursuant to paragraphs three and four of subdivision (c) of

section 1927 of the federal social security act, to determine the amount

of the rebate pursuant to this paragraph. The terms and conditions of

such rebate agreement with respect to periodic payment of the rebate,

provision of information by the department, audits, manufacturer

provision of information verification of surveys, penalties,

confidentiality of information, and length of the agreement shall apply

to drugs of the manufacturer dispensed under the medical assistance

program to all persons in receipt of medical assistance benefits as a

result of their eligibility having been established under subparagraph

one or nine of paragraph (a) of subdivision one of section three hundred

sixty-six of this title, and which are dispensed to all persons eligible

for health care services as a result of their eligibility having been

established under subdivision two of section three hundred sixty-nine-ee

of this article. The department in providing utilization data to a

manufacturer (as provided for under section 1927.4(b)(1)(A) of the

federal social security act) shall provide such data by zip code, if

requested, for drugs covered under a rebate agreement.

* (e) During the period from April first, two thousand fifteen through

March thirty-first, two thousand twenty-nine, the commissioner may, in

lieu of a managed care provider or pharmacy benefit manager, negotiate

directly and enter into an arrangement with a pharmaceutical

manufacturer for the provision of supplemental rebates relating to

pharmaceutical utilization by enrollees of managed care providers

pursuant to section three hundred sixty-four-j of this title and may

also negotiate directly and enter into such an agreement relating to

pharmaceutical utilization by medical assistance recipients not so

enrolled. Such rebate arrangements shall be limited to the following:

antiretrovirals approved by the FDA for the treatment of HIV/AIDS,

accelerated approval drugs established pursuant to this paragraph,

opioid dependence agents and opioid antagonists listed in a statewide

formulary established pursuant to subparagraph (vii) of this paragraph,

hepatitis C agents, high cost drugs as provided for in subparagraph

(viii) of this paragraph, gene therapies as provided for in subparagraph

(ix) of this paragraph, and any other class or drug designated by the

commissioner for which the pharmaceutical manufacturer has in effect a

rebate arrangement with the federal secretary of health and human

services pursuant to 42 U.S.C. § 1396r-8, and for which the state has

established standard clinical criteria. No agreement entered into

pursuant to this paragraph shall have an initial term or be extended

beyond the expiration or repeal of this paragraph. For purposes of this

paragraph, an "accelerated approval" is a drug or labeled indication of

a drug authorized by the Federal Food, Drug and Cosmetic Act for drugs

approved under Subpart H of 21 CFR Part 314 and Subpart E of 21 CFR Part

601 for serious conditions that fill an unmet medical need based on

whether the drug has an effect on a surrogate clinical endpoint, and is

pending verification of clinical benefit in confirmatory trials.

(i) The manufacturer shall not enter into any rebate arrangements with

a managed care provider, or any of a managed care provider's agents,

including but not limited to any pharmacy benefit manager on the gene

therapy, drug, or drug classes subject to this paragraph when the state

has a rebate arrangement in place and standard clinical criteria are

imposed on the managed care provider.

(ii) The commissioner shall establish adequate rates of reimbursement

which shall take into account both the impact of the commissioner

negotiating such arrangements and any limitations imposed on the managed

care provider's ability to establish clinical criteria relating to the

utilization of such drugs. In developing the managed care provider's

reimbursement rate, the commissioner shall identify the amount of

reimbursement for such drugs as a separate and distinct component from

the reimbursement otherwise made for prescription drugs as prescribed by

this section.

(iii) The commissioner shall submit a report to the temporary

president of the senate and the speaker of the assembly annually by

December thirty-first. The report shall analyze the adequacy of rates to

managed care providers for drug expenditures related to the classes

under this paragraph.

(iv) Nothing in this paragraph shall be construed to require a

pharmaceutical manufacturer to enter into a rebate arrangement

satisfactory to the commissioner relating to pharmaceutical utilization

by enrollees of managed care providers pursuant to section three hundred

sixty-four-j of this title or relating to pharmaceutical utilization by

medical assistance recipients not so enrolled.

(v) All clinical criteria, including requirements for prior approval,

and all utilization review determinations established by the state as

described in this paragraph for the gene therapies, drugs, or drug

classes subject to this paragraph shall be developed using

evidence-based and peer-reviewed clinical review criteria in accordance

with article two-A of the public health law, as applicable.

(vi) All prior authorization and utilization review determinations

related to the coverage of any drug subject to this paragraph shall be

subject to article forty-nine of the public health law, section three

hundred sixty-four-j of this title, and article forty-nine of the

insurance law, as applicable. Nothing in this paragraph shall diminish

any rights relating to access, prior authorization, or appeal relating

to any drug class or drug afforded to a recipient under any other

provision of law.

(vii) The department shall publish a statewide formulary of opioid

dependence agents and opioid antagonists, which shall include as

"preferred drugs" all drugs in such classes, which shall include all

subclasses of a given drug that have a different pharmacological route

of administration, provided that:

(A) for all drugs that are included as of the date of the enactment of

this subparagraph on a formulary of a managed care provider, as defined

in section three hundred sixty-four-j of this title, or in the Medicaid

fee-for-service preferred drug program pursuant to section two hundred

seventy-two of the public health law, the cost to the department for

such drug is equal to or less than the lowest cost paid for the drug by

any managed care provider or by the Medicaid fee-for-service program

after the application of any rebates, as of the date that the department

implements the statewide formulary established by this subparagraph.

Where there is a generic version of the drug approved by the Food and

Drug Administration as bioequivalent to a brand name drug pursuant to 21

U.S.C. § 355(j)(8)(B), the cost to the department for the brand and

generic versions shall be equal to or less than the lower of the two

maximum costs determined pursuant to the previous sentence; and

(B) for all drugs that are not included as of the date of the

enactment of this subparagraph on a formulary of a managed care

provider, as defined in section three hundred sixty-four-j of this

title, or in the Medicaid fee-for-service preferred drug program

pursuant to section two hundred seventy-two of the public health law,

the department is able to obtain the drug at a cost that is equal to or

less than the lowest cost to the department of other comparable drugs in

the class, after the application of any rebates. Where there is a

generic version of the drug approved by the Food and Drug Administration

as bioequivalent to a brand name drug pursuant to 21 U.S.C. §

355(j)(8)(B), the cost to the department for the brand and generic

versions shall be equal to or less than the lower of the two maximum

costs determined pursuant to the previous sentence.

(viii) The commissioner may identify and refer high cost drugs, as

defined in clause (D) of this subparagraph, that are not included as of

the date of the enactment of this subparagraph on a formulary of a

managed care provider or covered by the Medicaid fee for service of

program to the drug utilization review board established by section

three hundred sixty-nine-bb of this article for a recommendation as to

whether a target supplemental Medicaid rebate should be paid by the

manufacturer of the drug to the department and the target amount of the

rebate.

(A) If the commissioner intends to refer a high cost drug to the drug

utilization review board pursuant to this subparagraph, the commissioner

shall notify the manufacturer of such drug and shall attempt to reach

agreement with the manufacturer on a rebate arrangement satisfactory to

the commissioner for the drug prior to referring the drug to the drug

utilization review board for review. Such arrangement may be based on

evidence based research, including, but not limited to, such research

operated or conducted by or for other state governments, the federal

government, the governments of other nations, and third party payers or

multi-state coalitions, provided however that the department shall

account for the effectiveness of the drug in treating the conditions for

which it is prescribed or in improving a patient's health, quality of

life, or overall health outcomes, and the likelihood that use of the

drug will reduce the need for other medical care, including

hospitalization.

(B) In the event that the commissioner and the manufacturer have

previously agreed to a rebate arrangement for a drug pursuant to this

paragraph, the drug shall not be referred to the drug utilization review

board for any further rebate agreement for the duration of the previous

rebate agreement, provided however, the commissioner may refer a drug to

the drug utilization review board if the commissioner determines there

are significant and substantiated utilization or market changes, new

evidence-based research, or statutory or federal regulatory changes that

warrant additional rebates. In such cases, the department shall notify

the manufacturer and provide evidence of the changes or research that

would warrant additional rebates, and shall attempt to reach agreement

with the manufacturer on a rebate for the drug prior to referring the

drug to the drug utilization review board for review.

(C) If the commissioner is unsuccessful in entering into a rebate

arrangement with the manufacturer of the drug satisfactory to the

department, the drug manufacturer shall in that event be required to

provide to the department, on a standard reporting form developed by the

department, the information as described in subdivision six of section

two hundred eighty of the public health law. All information disclosed

pursuant to this clause shall be considered confidential and shall not

be disclosed by the department in a form that identifies a specific

manufacturer or prices charged for drugs by such manufacturer.

(D) For the purposes of this subparagraph, the term "high cost drug"

shall mean a brand name drug or biologic that has a launch wholesale

acquisition cost of thirty thousand dollars or more per year or course

of treatment, or a biosimilar drug that has a launch wholesale

acquisition cost that is not at least fifteen percent lower than the

referenced brand biologic at the time the biosimilar is launched, or a

generic drug that has a wholesale acquisition cost of one hundred

dollars or more for a thirty day supply or recommended dosage approved

for labeling by the federal Food and Drug Administration, or a brand

name drug or biologic that has a wholesale acquisition cost increase of

three thousand dollars or more in any twelve-month period, or course of

treatment if less than twelve months.

(ix) For purposes of this paragraph, a "gene therapy" is a drug (A)

approved under section 505 of the Federal Food, Drug and Cosmetics Act

or licensed under subsection (a) or (k) of section 351 of the Public

Health Services Act; (B) that treats a rare disease or condition, as

defined in 21 USC § 360bb(a)(2), that is life-threatening, as defined in

42 CFR 321.18; (C) is considered a gene therapy by the federal Food and

Drug Administration for which a biologics license pursuant to 21 CFR

600-680 is held; (D) if administered in accordance with the labeling of

such drug, is expected to result in either the cure of such disease or

condition or a reduction in the symptoms of such disease or condition

that materially improves the patient's length or quality of life; and

(E) is expected to achieve the result described in clause (D) of this

subparagraph after not more than three administrations.

* NB Repealed March 31, 2032

* 8. No government agency shall purchase, pay for, or make

reimbursement or grants-in-aid for any service in a residential

treatment facility for children and youth or a comprehensive psychiatric

emergency program unless at the time such service was provided, the

residential treatment facility for children and youth or comprehensive

psychiatric emergency program possessed a valid operating certificate

authorizing such service. Notwithstanding any inconsistent provision of

law, no government agency shall make payments pursuant to this title or

title nineteen of the federal social security act to a residential

treatment facility for children and youth for service to a person whose

need for care and treatment in such a facility was not certified

pursuant to section 9.51 of the mental hygiene law.

* NB Effective until July 1, 2027

* 8. No government agency shall purchase, pay for, or make

reimbursement or grants-in-aid for any service in a residential

treatment facility for children and youth unless at the time such

service was provided, the residential treatment facility for children

and youth possessed a valid operating certificate authorizing such

service. Notwithstanding any inconsistent provision of law, no

government agency shall make payments pursuant to this title or title

nineteen of the federal social security act to a residential treatment

facility for children and youth for service to a person whose need for

care and treatment in such a facility was not certified pursuant to

section 9.51 of the mental hygiene law.

* NB Effective July 1, 2027

* 9. Notwithstanding any inconsistent provision of law or regulation

to the contrary, for those drugs which may not be dispensed without a

prescription as required by section sixty-eight hundred ten of the

education law and for which payment is authorized pursuant to paragraph

(g) of subdivision two of section three hundred sixty-five-a of this

title, and for those drugs that are available without a prescription as

required by section sixty-eight hundred ten of the education law but are

reimbursed as items of medical assistance pursuant to paragraph (a) of

subdivision four of section three hundred sixty-five-a of this title,

payments under this title shall be made at the following amounts:

(a) for drugs provided by medical practitioners and claimed separately

by the practitioners the lower of:

(i) (1) an amount equal to the national average drug acquisition cost

set by the federal centers for medicare and medicaid services for the

drug, if any, or if such amount is not available, the wholesale

acquisition cost of the drug based on the package size dispensed from,

as reported by the prescription drug pricing service used by the

department, (2) the federal upper limit, if any, established by the

federal centers for medicare and medicaid services; (3) the state

maximum acquisition cost, if any, established pursuant to paragraph (e)

of this subdivision; or (4) the actual cost of the drug to the

practitioner.

(ii) Notwithstanding subparagraph (i) of this paragraph and paragraph

(e) of this subdivision, for the Medicaid fee-for-service program, if a

drug has been purchased from a manufacturer by a covered entity pursuant

to section 340B of the federal public health service act (42 USCA §

256b), the actual amount paid by such covered entity. For purposes of

this subparagraph, a "covered entity" is an entity that meets the

requirements of paragraph four of subdivision (a) of such section that

elects to participate in the program established by such section, and

that causes claims for payment for drugs covered by this subparagraph to

be submitted to the medical assistance program, either directly or

through an authorized contract pharmacy. No medical assistance payments

may be made to a covered entity or to an authorized contract pharmacy of

a covered entity for drugs that are eligible for purchase under the

section 340B program and are dispensed on an outpatient basis to

patients of the covered entity, other than under the provisions of this

subparagraph. Medical practitioners submitting claims for reimbursement

of drugs purchased pursuant to section 340B of the public health service

act shall notify the department that the claim is eligible for purchase

under the 340B program, consistent with claiming instructions issued by

the department to identify such claims.

(iii) In no event shall a medical practitioner be reimbursed at an

amount that is lower than the state maximum acquisition cost, or for

drugs that do not have a state maximum acquisition cost, the wholesale

acquisition cost of the drug based on the package size.

(b) for drugs dispensed by pharmacies:

(i) (A) if the drug dispensed is a generic prescription drug, the

lower of: (1) an amount equal to the national average drug acquisition

cost set by the federal centers for medicare and medicaid services for

the drug, if any, or if such amount if not available, the wholesale

acquisition cost of the drug based on the package size dispensed from,

as reported by the prescription drug pricing service used by the

department, less seventeen and one-half percent thereof; (2) the federal

upper limit, if any, established by the federal centers for medicare and

medicaid services; (3) the state maximum acquisition cost, if any,

established pursuant to paragraph (e) of this subdivision; or (4) the

dispensing pharmacy's usual and customary price charged to the general

public; (B) if the drug dispensed is available without a prescription as

required by section sixty-eight hundred ten of the education law but is

reimbursed as an item of medical assistance pursuant to paragraph (a) of

subdivision four of section three hundred sixty-five-a of this title,

the lower of (1) an amount equal to the national average drug

acquisition cost set by the federal centers for medicare and medicaid

services for the drug, if any, or if such amount is not available, the

wholesale acquisition cost of the drug based on the package size

dispensed from, as reported by the prescription drug pricing service

used by the department, (2) the federal upper limit, if any, established

by the federal centers for medicare and medicaid services; (3) the state

maximum acquisition cost if any, established pursuant to paragraph (e)

of this subdivision; or (4) the dispensing pharmacy's usual and

customary price charged to the general public;

(ii) if the drug dispensed is a brand-name prescription drug, the

lower of:

(A) an amount equal to the national average drug acquisition cost set

by the federal centers for medicare and medicaid services for the drug,

if any, or if such amount is not available, the wholesale acquisition

cost of the drug based on the package size dispensed from, as reported

by the prescription drug pricing service used by the department; or (B)

the dispensing pharmacy's usual and customary price charged to the

general public; and

(iii) notwithstanding subparagraphs (i) and (ii) of this paragraph and

paragraphs (d) and (e) of this subdivision, if the drug dispensed is a

drug that has been purchased from a manufacturer by a covered entity

pursuant to section 340B of the federal public health service act (42

USCA § 256b), the actual amount paid by such covered entity pursuant to

such section, plus the reasonable administrative costs, as determined by

the commissioner, incurred by the covered entity or by an authorized

contract pharmacy in connection with the purchase and dispensing of such

drug and the tracking of such transactions. For purposes of this

subparagraph, a "covered entity" is an entity that meets the

requirements of paragraph four of subsection (a) of such section, that

elects to participate in the program established by such section, and

that causes claims for payment for drugs covered by this subparagraph to

be submitted to the medical assistance program, either directly or

through an authorized contract pharmacy. No medical assistance payments

may be made to a covered entity or to an authorized contract pharmacy of

a covered entity for drugs that are eligible for purchase under the

section 340B program and are dispensed on an outpatient basis to

patients of the covered entity, other than under the provisions of this

subparagraph. Pharmacies submitting claims for reimbursement of drugs

purchased pursuant to section 340B of the public health service act

shall notify the department that the claim is eligible for purchase

under the 340B program, consistent with claiming instructions issued by

the department to identify such claims.

(c) Notwithstanding subparagraph (i) of paragraph (b) of this

subdivision, if a qualified prescriber certifies "brand medically

necessary" or "brand necessary" in his or her own handwriting directly

on the face of a prescription, or in the case of electronic

prescriptions, inserts an electronic direction to clarify "brand

medically necessary" or "brand necessary", for a multiple source drug

for which a specific upper limit of reimbursement has been established

by the federal agency, in addition to writing "d a w" in the box

provided for such purpose on the prescription form, payment under this

title for such drug must be made under the provisions of subparagraph

(ii) of such paragraph.

(d) In addition to the amounts paid pursuant to paragraph (b) of this

subdivision, the department shall pay a professional pharmacy dispensing

fee for each such drug dispensed in the amount of ten dollars and eight

cents per prescription or written order of a practitioner; provided,

however that this professional dispensing fee will not apply to drugs

that are available without a prescription as required by section

sixty-eight hundred ten of the education law but do not meet the

definition of a covered outpatient drug pursuant to Section 1927K of the

Social Security Act.

(e) For a multiple source generic drug for which no specific upper

payment limit has been established by the federal centers for medicare

and medicaid services, the commissioner of health may establish a

maximum acquisition cost for such drug which shall be effective until

such time as a specific federal upper payment limit has been established

for such drug. The department shall use a similar methodology in

establishing such an interim price as that utilized by the centers for

medicare and Medicaid services in establishing the federal upper payment

limit. For this purpose, the department is authorized to enter into a

contract with an entity to provide technical and administrative support

to the commissioner of health.

(g) Notwithstanding any other provision of this subdivision to the

contrary, the department is authorized to implement a specialty pharmacy

program for the purpose of procuring certain specialty drugs at reduced

cost. The department is authorized to enter into contracts with one or

more contractors in order to obtain certain specialty drugs from a

limited number of sources at reduced prices. For purposes of this

paragraph, specialty drugs include, but are not limited to, chemotherapy

agents, hydration therapy agents, pain therapy agents, intravenous

administration of antibiotics or other drugs, and total parenteral

nutrition. All contracts entered into by the department to effectuate

the provisions of this section shall require the contractors to take

steps to assure that drugs provided pursuant to such contracts will be

readily accessible to consumers in a fashion that is no more restrictive

than that which was in effect prior to the implementation of the

specialty pharmacy program. This paragraph shall be effective only to

the extent that federal financial participation is available in the cost

of drugs obtained pursuant to this paragraph. The commissioner of health

is authorized to submit amendments to the state plan for medical

assistance and to submit applications for waivers under the social

security act to obtain the federal approvals necessary to implement this

paragraph. However, any pharmacy owned and operated by a not-for-profit

organization solely for the purpose of providing drugs to individuals

diagnosed with cystic fibrosis as part of a comprehensive clinical care

program approved by the national organization that accredits cystic

fibrosis care centers and maintains a national registry of cystic

fibrosis clinical data shall be exempt from the specialty pharmacy

program.

(h) The commissioner of health is authorized to establish a medication

therapy management pilot program in one or more counties or regions of

the state for the purpose of improving compliance with drug therapies

and improving clinical outcomes. Payments under such program may be made

to retail pharmacies for the provision of one-on-one medication regimen

counseling services for persons determined by the commissioner to be

eligible to receive such services. The commissioner is authorized to

establish fees for such counseling services, subject to the approval of

the director of the division of the budget. The provisions of this

paragraph shall not take effect unless all necessary approvals under

federal law and regulation have been obtained to receive federal

financial participation in the costs of services provided under this

paragraph.

(i)(i) The department of health shall establish a program for

synchronization of medications. Under the synchronization program, a

health care practitioner may prescribe a refill of one or more of the

patient's medications for a shorter period than would ordinarily be

provided, for the purpose of synchronizing refill dates of one or more

of the patient's medications subject to the synchronization when it is

agreed among the recipient, the health care practitioner and a

pharmacist that synchronization of multiple prescriptions for the

treatment of a chronic illness is in the best interest of the patient

for the management or treatment of a chronic illness provided that the

following apply to such medications:

(A) are covered by the department of health pursuant to this title;

(B) are used for treatment and management of a chronic illness that

are subject to refills;

(C) are not a schedule II controlled substance, nor a schedule III

controlled substance that contains hydrocodone or other opioid

medication as scheduled in section thirty-three hundred six of the

public health law, or a controlled substance under the federal

Controlled Substances Act;

(D) meet all prior authorization criteria specific to the medications

at the time of the synchronization request;

(E) are of a formulation that can be effectively and lawfully aligned

over required short fill periods to achieve synchronization; and

(F) do not have quantity limits or dose optimization criteria or state

or federal requirements that would be violated in fulfilling

synchronization.

(ii) The department of health shall not deny coverage for the

dispensing of a medication by a pharmacy for a partial supply when it is

for the purpose of synchronizing the patient's medications. When

applicable to permit synchronization, the department of health shall

allow a pharmacy to override any denial codes indicating that a

prescription is being refilled too soon for the purposes of medication

synchronization.

(iii) The dispensing fee paid to the pharmacy contracted to provide

services pursuant to this section for a partial supply associated with

medication synchronization shall be paid in accordance with the Medicaid

state plan as approved by the Centers for Medicare and Medicaid

Services.

(iv) The requirement of this paragraph applies only once for each

prescription drug subject to medication synchronization except when

either of the following occurs:

(I) the prescriber changes the dosage or frequency of administration

of the prescription drug subject to a medication synchronization; or

(II) the prescriber prescribes a different drug.

(v) Nothing in this paragraph shall be deemed to require health care

practitioners and pharmacists to synchronize the refilling of multiple

prescriptions for a recipient.

(vi) The provisions of this paragraph are subject to compliance with

all applicable federal and state laws and regulations, including the

Centers for Medicare and Medicaid Services approved Medicaid state plan.

The commissioner shall apply for waivers and submit state Medicaid plan

amendments as are necessary to implement the program for synchronization

of medications.

* NB Effective until March 31, 2029

* 9. Notwithstanding any inconsistent provision of law or regulation

to the contrary, for those drugs which may not be dispensed without a

prescription as required by section sixty-eight hundred ten of the

education law and for which payment is authorized pursuant to paragraph

(g) of subdivision two of section three hundred sixty-five-a of this

title, payments under this title shall be made at the following amounts:

(a) for drugs provided by medical practitioners and claimed separately

by the practitioners, the actual cost of the drugs to the practitioners;

and

(b) for drugs dispensed by pharmacies:

(i) if the drug dispensed is a multiple source prescription drug for

which an upper limit has been set by the federal health care financing

administration, an amount equal to the specific upper limit set by such

federal agency for the multiple source prescription drug, and

(ii) if the drug dispensed is a multiple source prescription drug or a

brand-name prescription drug for which no specific upper limit has been

set by such federal agency, the lower of the estimated acquisition cost

of such drug to pharmacies, or the dispensing pharmacy's usual and

customary price charged to the general public. Estimated acquisition

cost means the average wholesale price of a prescription drug based upon

the package size dispensed from, as reported by the prescription drug

pricing service used by the department, less ten percent thereof, and

updated monthly by the department.

(c) Notwithstanding subparagraph (i) of paragraph (b) of this

subdivision, if a qualified prescriber certifies "brand medically

necessary" or "brand necessary" in his or her own handwriting directly

on the face of a prescription for a multiple source drug for which a

specific upper limit of reimbursement has been established by the

federal agency, in addition to writing "d a w" in the box provided for

such purpose on the prescription form, payment under this title for such

drug must be made under the provisions of subparagraph (ii) of such

paragraph.

(d) In addition to the amounts paid pursuant to paragraph (b) of this

subdivision to pharmacies for those drugs which may not be dispensed

without a prescription, as required by section sixty-eight hundred ten

of the education law and for which payment is authorized pursuant to

paragraph (g) of subdivision two of section three hundred sixty-five-a

of this title, the department shall pay a pharmacy dispensing fee for

each such prescription drug dispensed, which dispensing fee shall not be

less than the following amounts:

(i) for prescription drugs categorized as generic by the prescription

drug pricing service used by the department, five dollars and fifty

cents per prescription; and

(ii) for prescription drugs categorized as brand-name prescription

drug by the prescription drug pricing service used by the department,

four dollars and fifty cents per prescription.

* NB Effective March 31, 2029

10. Any provider except for those providers certified under article

twenty-eight of the public health law, of ordered services or supplies

under the medical assistance program may be required to provide

financial security to assure that funds are available to repay any

overpayments made to the provider under this title and to assure the

financial security of the medical assistance program. For the purposes

of this subdivision, "ordered services or supplies" shall mean those

services or supplies described in paragraphs (g), (i) and (j) of

subdivision two of section three hundred sixty-five-a of this title.

(a) Any financial security required by this subdivision must meet the

requirements of this paragraph. Financial security may be provided

through a bond with a corporate surety, from a company authorized to do

business in this state, or an irrevocable letter of credit or

certificate of deposit from a New York state or federally chartered

bank, trust company, savings bank or savings and loan association

qualified to do business in New York state and insured by the federal

deposit insurance corporation.

(b) The bond, letter of credit or certificate of deposit shall be

payable in favor of the people of the state of New York for the purpose

of indemnifying the medical assistance program against any overpayments

made to the provider.

(c) The bond, letter of credit or certificate of deposit filed and

maintained pursuant to this section shall not be cancelled, revoked or

terminated except after notice to, and with the consent of, the

department at least forty-five days in advance of such cancellation,

revocation or termination.

(d) The department may bring and maintain an action against the

provider and the surety or bank, trust company, savings bank or savings

and loan association for any claimed overpayments made to the provider.

(e) Financial security shall not be required for providers which do

not submit claims for payment under the medical assistance program

exceeding five hundred thousand dollars per annum or forty-two thousand

dollars per month.

(f) Financial security shall be in an amount equal to the provider's

estimated claims for payment for a one year period and may be adjusted

bi-annually in accordance with the dollar amount of claims actually

submitted. If the commissioner is satisfied from an investigation of the

financial condition of a provider that the provider is solvent and

possessed of sufficient assets to provide reasonable assurance of

recovery of any overpayments, the commissioner may modify the amount of

financial security to be provided by such provider.

(g) Financial security must be submitted by a provider upon initial

application for enrollment as a provider of medical assistance and with

each subsequent enrollment. A change in ownership of a provider shall

not release, cancel or terminate liability under this section under any

bond, letter of credit or certificate of deposit filed for a provider

while such bond, letter of credit or certificate of deposit is in effect

unless the transferee, purchaser, successor or assignee of such provider

obtains a bond, letter of credit or certificate of deposit under this

section for the benefit of such new owner. All providers enrolled in the

medical assistance program on the effective date of this subdivision

will be required to submit financial security within ninety days of

notice of such requirements by the department.

(h) The department may make the submission of the financial security

required by this subdivision a condition of participation in the medical

assistance program.

11. (a) Any inconsistent provisions of this title or other law

notwithstanding, no health insurer, self-insured plan, managed care

organization, pharmacy benefit manager, or other party that is, by

statute, contract, or agreement, legally responsible for payment of a

claim for a health care item or service, employer or organization who

has a plan, including an employee retirement income security act or

service benefit plan, providing care and other medical benefits for

persons, whether by insurance or otherwise, shall exclude a person from

eligibility, coverage or entitlement to medical benefits by reason of

the eligibility of such person for medical assistance under this title,

or by reason of the fact that such person would, except for such plan,

be eligible for benefits under this title.

(b) Any inconsistent provisions of this title or other law

notwithstanding, no insurer may impose requirements on the department or

a social services district which has been assigned the rights of an

individual who is eligible for medical assistance under this title and

who is covered for health benefits from the insurer, that are different

from requirements applicable to an agent or assignee of any other

individual so covered.

(c) Any inconsistent provisions of this title or other law

notwithstanding, the department may, to the extent necessary to

reimburse the department and the social services districts for

expenditures under this title, certify to the commissioner of taxation

and finance pursuant to section one hundred seventy-one-f of the tax law

amounts to be withheld from tax refunds otherwise due to any individual

who is required by court order to provide medical support in the form of

health insurance benefits for a child who is eligible for medical

assistance under this title and who has received payment from a

third-party for the cost of such services for such child but has not

used such payments to reimburse either the other parent or guardian of

such child or the provider of such services or the appropriate social

services district; provided however, that any claims for current or

past-due child support shall take priority over any such claims for the

costs of such services and care. Such amounts shall be withheld pursuant

to section one hundred seventy-one-f of the tax law, and shall be

credited to unreimbursed medical assistance incurred on behalf of such

child. The department shall by regulation establish procedures

consistent with paragraphs (a) and (b) of subdivision four of section

one hundred seventy-one-c of the tax law by which any individual who is

the subject of a certification may contest such certification.

12. Prior to receiving medical assistance under subparagraphs five and

six of paragraph (c) of subdivision one of section three hundred

sixty-six of this title, a person whose net available income is at least

one hundred fifty percent of the applicable federal income official

poverty line, as defined and updated by the United States department of

health and human services, must pay a monthly premium, in accordance

with a procedure to be established by the commissioner. The amount of

such premium shall be twenty-five dollars for an individual who is

otherwise eligible for medical assistance under such subparagraphs, and

fifty dollars for a couple, both of whom are otherwise eligible for

medical assistance under such subparagraphs. No premium shall be

required from a person whose net available income is less than one

hundred fifty percent of the applicable federal income official poverty

line, as defined and updated by the United States department of health

and human services.