NY Elder L § 243 (2021)
2021 New York Laws ELD - Elder Article 2 - Programs for the Elderly Title 3 - Program for Elderly Pharmaceutical Insurance Coverage 243 - Pharmaceutical Insurance Contract.

§  243.  Pharmaceutical  insurance  contract.  1.  The commissioner of health shall, subject to the approval of the  director  of  the  budget, enter into a contract with one or more contractors to assist in carrying out the provisions of this title. Such contractual arrangements shall be made  subject to a competitive process pursuant to the state finance law and shall ensure that state payments for the contractor's necessary  and legitimate  expenses  for the administration of this program are limited to the amount specified in advance, and that  such  payments  shall  not exceed  the  amount  appropriated  therefor  in  any  fiscal  year.  The commissioner shall review the contract pricing provisions to assure that the level of contract payments are in the best interest  of  the  state, giving  consideration  to  the  total  level  of  participant enrollment achieved, the volume of claims processed, and such other factors as  may be  relevant  in  order to contain state expenditures. In the event that the commissioner determines that the contract payment provisions do  not protect  the  interest  of  the  state,  the commissioner shall initiate contract negotiations for the purpose  of  modifying  contract  payments and/or scope requirements.   2.  The  responsibilities  of  the  contractor  or  contractors  shall include, but need not be limited to:  (a) providing for a method of determining, on an annual basis and upon their application therefor,  the  eligibility  of  persons  pursuant  to section  two  hundred forty-two of this title within a reasonable period of  time,  including  alternative  methods  for  such  determination  of eligibility,  such  as through the mail or home visits, where reasonable and/or necessary, and  for  notifying  applicants  of  such  eligibility determinations;  (b)  notifying  each  eligible program participant in writing upon the commencement  of  the  annual  coverage  period  of  such  participant's cost-sharing   responsibilities   pursuant   to   section   two  hundred forty-seven of  this  title.  The  contractor  shall  also  notify  each eligible  program  participant  of  any  adjustment  of  the  co-payment schedule by mail no less than thirty days prior to the effective date of such adjustments and shall inform such eligible program participants  of the date such adjustments shall take effect;  (c)   issuing   an   identification  card  to  each  eligible  program participant;  (d) processing of claims for reimbursement to  participating  provider pharmacies pursuant to section two hundred fifty of this title;  (e) performing or causing to be performed utilization reviews for such purposes as may be required by the commissioner of health;  (f) conducting audits and surveys of participating provider pharmacies as specified pursuant to the terms and conditions of the contract; and  (g)  coordinating  coverage  with insurance companies and other public and private organizations offering  such  coverage  for  those  eligible program  participants  having partial coverage for covered drugs through third-party sources, and  providing  for  recoupment  of  any  duplicate reimbursement  paid  by  the  state  on  behalf of such eligible program participants.   3. The contractor or contractors shall be  required  to  provide  such reports  as  may  be  deemed necessary by the commissioner of health and shall  maintain  files  in  a  manner  and  format   approved   by   the commissioner.   4.   The   contractor   or   contractors  may  contract  with  private not-for-profit or proprietary corporations, or with  entities  of  local government  within the state of New York, to perform such obligations of the contractor or  contractors  as  the  commissioner  of  health  shall permit.