NY Soc Serv L § 367-A (2021)
2021 New York Laws SOS - Social Services Article 5 - Assistance and Care Title 11 - Medical Assistance for Needy Persons 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.  (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.  (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) 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  for  persons who would be qualified medicare beneficiaries except that  their  incomes  exceed  one  hundred percent  of  the  federal income poverty line applicable to the person's family size but, in calendar years  nineteen  hundred  ninety-three  and nineteen  hundred  ninety-four,  is less than one hundred ten percent of such poverty line and, in calendar year beginning  in  nineteen  hundred ninety-five,  is  less  than  one hundred twenty percent of such poverty  line 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.  (b)   (1)  For  purposes  of  this  subdivision,  "qualified  medicare beneficiaries" are those persons who are entitled to hospital  insurance benefits under part A of title XVIII of the federal social security act, whose income does not exceed one hundred 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.  (2)  Notwithstanding  any  provision  of  subparagraph  one  of   this paragraph  to  the  contrary,  to  the  extent  that  federal  financial participation is available, a person whose resources are  in  excess  of the   amount   specified   but   otherwise  meets  the  requirements  of subparagraph one of this paragraph  shall  be  considered  a  "qualified medicare   beneficiary"  for  the  purposes  of  this  subdivision.  The commissioner is authorized to submit amendments to the  state  plan  for medical assistance and/or submit one or more applications for waivers of the  federal  social  security  act,  to  obtain  the  federal approvals necessary to implement this subparagraph.  (c) (1) For purposes of  this  subdivision,  "qualified  disabled  and working  individuals" are individuals who are not otherwise eligible for medical assistance and:  (i) who are 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.  (2)   For  purposes  of  this  paragraph,  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.  (d) (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 individuals (referred to as qualified  individuals  1)  who are  entitled to hospital insurance benefits under part A of title XVIII of the federal social security act and whose income exceeds  the  income level  established  by  the  state  and  is  at least one hundred twenty percent, but less than one hundred thirty-five percent, of  the  federal poverty  level,  for  a  family  of  the  size  involved and who are not otherwise eligible for medical assistance under the state plan;  (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) 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.  (e)  (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, 2026  (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,  mental  retardation  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-three, 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, 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.  (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, 2026   * (f) (1) The department may require manufacturers of drugs other than single source drugs and innovator multiple source drugs, as  such  terms are  defined  in  42  U.S.C.  §  1396r-8(k),  to  provide rebates to the department for any drug that  has  increased  more  than  three  hundred percent  of  its state maximum acquisition cost (SMAC) during the period April 1, 2016 through March thirty-first,  two  thousand  seventeen,  or that  has  increased  more  than  seventy-five percent of its SMAC on or after April first, two thousand seventeen, in comparison to its SMAC  at any  time during the course of the preceding twelve months. The required rebate shall be limited to the amount by which the current SMAC for  the drug  exceeds the applicable percentage of the SMAC for the same drug at any time during the course of the preceding twelve months. Such  rebates shall  be  in addition to any rebates payable to the department pursuant to any other provision of federal or state  law.  Nothing  herein  shall affect  the  department's obligation to reimburse for covered outpatient drugs pursuant to paragraph (d) of this subdivision.  (2) Except as provided in subparagraph three of  this  paragraph,  the commissioner  shall  not  determine  any  further  rebates to be payable pursuant to this paragraph once the Centers for  Medicare  and  Medicaid Services  has  adopted a final methodology for determining the amount of additional rebates under the federal generic drug price increase  rebate program  pursuant  to  42 U.S.C. § 1396r-8 (c)(3), as amended by section 602 of the Bipartisan Budget Act of 2015.  (3) During state fiscal year 2016-2017, if the  Centers  for  Medicare and  Medicaid  Services  has adopted a final methodology for determining the amount of additional rebates under the federal  generic  drug  price increase  rebate  program  pursuant  to  42  U.S.C. § 1396r-8 (c)(3), as amended by section 602  of  the  Bipartisan  Budget  Act  of  2015,  the department  may  collect  for  a  given  drug  the portion of the rebate determined under this paragraph that is in excess of the rebate required by such federal rebate program.  (4) The additional rebates authorized pursuant to this paragraph shall apply to generic prescription drugs dispensed to  enrollees  of  managed care  providers  pursuant  to section three hundred sixty-four-j of this title and to generic prescription drugs dispensed to Medicaid recipients who are not enrollees of such providers.  (5) Beginning in two thousand seventeen, the department shall  provide an annual report to the legislature no later than February first setting forth:  (i) The number of drugs that exceeded the ceiling price established in this  paragraph during the preceding year in comparison to the number of drugs that experienced at least a three hundred percent  price  increase during  two  thousand  fourteen  and two thousand fifteen, or at least a seventy-five percent price increase during two thousand fifteen and  two thousand sixteen;  (ii)  The average percent amount above the ceiling price of drugs that exceeded the ceiling price in the preceding year in  comparison  to  the number  of  drugs  that  experienced  a  price  increase more than three hundred percent during two thousand fourteen and two  thousand  fifteen, or  at  least  a seventy-five percent price increase during two thousand fifteen and two thousand sixteen;  (iii) The number of generic drugs available to enrollees  in  Medicaid fee  for  service  or  Medicaid  managed care, by fiscal quarter, in the preceding year in comparison to the drugs available, by fiscal  quarter, during  two  thousand  fourteen,  two thousand fifteen, and two thousand sixteen; and  (iv) The total drug spend on generic drugs for the preceding  year  in comparison  to the total drug spend on generic drugs during two thousand fourteen, two thousand fifteen, and two thousand sixteen.   * NB Repealed March 31, 2022   * 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, 2024   * 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, 2024   * 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 actual cost of the drugs to the practitioners; and  (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,  less three and three-tenths percent thereof; 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 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.   * NB Effective until March 31, 2023   * 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, 2023   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.