NY Elder L § 247 (2021)
2021 New York Laws ELD - Elder Article 2 - Programs for the Elderly Title 3 - Program for Elderly Pharmaceutical Insurance Coverage 247 - Cost-Sharing Responsibilities of Eligible Program Participants for Comprehensive Coverage.

§  247. Cost-sharing responsibilities of eligible program participants for comprehensive coverage.   1. Registration fee. Eligible individuals meeting the registration fee requirements of this section may purchase prescribed covered  drugs  for an amount specified by subdivision three of this section, subject to the limits  on  point  of  sale co-payments specified by subdivision four of this section.   2. Registration fee schedule. Eligible individuals  electing  to  meet the  requirements of this subdivision shall pay a quarterly registration fee in a manner and form determined by the executive  director;  at  the option  of the participant, the registration fee may be paid annually in a lump sum upon the beginning of the annual coverage period. No eligible individual electing to meet the requirements of this  subdivision  shall have  his participation in the program lapse by virtue of non-payment of the applicable registration  fee  unless  the  contractor  has  provided notification  of  the  amount and due date thereof, and more than thirty days have elapsed since the due date of  the  individual's  registration fee. The registration fee to be charged to eligible program participants for comprehensive coverage under this option shall be in accordance with the following schedule:  (a)  Quarterly  registration  fees  for  unmarried  individual program participants: individual income of $5,000 or less                    $2.00 individual income of $5,001 to $6,000                  $2.00 individual income of $6,001 to $7,000                  $4.00 individual income of $7,001 to $8,000                  $5.50 individual income of $8,001 to $9,000                  $7.00 individual income of $9,001 to $10,000                 $9.00 individual income of $10,001 to $11,000                $10.00 individual income of $11,001 to $12,000                $11.50 individual income of $12,001 to $13,000                $13.50 individual income of $13,001 to $14,000                $15.00 individual income of $14,001 to $15,000                $20.00 individual income of $15,001 to $16,000                $27.50 individual income of $16,001 to $17,000                $35.00 individual income of $17,001 to $18,000                $42.50 individual income of $18,001 to $19,000                $50.00 individual income of $19,001 to $20,000                $57.50  (b) Quarterly registration fees for each  married  individual  program participant: joint income of $5,000 or less                         $2.00 joint income of $5,001 to $6,000                       $2.00 joint income of $6,001 to $7,000                       $3.00 joint income of $7,001 to $8,000                       $4.00 joint income of $8,001 to $9,000                       $5.00 joint income of $9,001 to $10,000                      $6.00 joint income of $10,001 to $11,000                     $7.00 joint income of $11,001 to $12,000                     $8.00 joint income of $12,001 to $13,000                     $9.00 joint income of $13,001 to $14,000                     $10.00 joint income of $14,001 to $15,000                     $10.00 joint income of $15,001 to $16,000                     $21.00 joint income of $16,001 to $17,000                     $26.50 joint income of $17,001 to $18,000                     $31.50 joint income of $18,001 to $19,000                     $37.50 joint income of $19,001 to $20,000                     $43.00 joint income of $20,001 to $21,000                     $48.50 joint income of $21,001 to $22,000                     $54.00  joint income of $22,001 to $23,000                     $59.50 joint income of $23,001 to $24,000                     $65.00 joint income of $24,001 to $25,000                     $68.75 joint income of $25,001 to $26,000                     $75.00  (c)  In  the event that the state expenditures per participant meeting the registration fee requirements  of  this  subdivision,  exclusive  of expenditures  for program administration, in the program year commencing October first, nineteen hundred eighty-eight, and in each  program  year thereafter,  exceed  such expenditures in the previous program year by a minimum of ten percent, the annual registration fees set forth  in  this subdivision  may,  unless  otherwise  provided  by  law,  be  increased, pro-rata, for the subsequent program year, provided that  such  increase shall   not  exceed  seven  and  one-half  percent  of  the  prior  year registration fees as may have been  adjusted  in  accordance  with  this paragraph.  (d)  In  the  event  that the state expenditures per such participant, incurred pursuant to this subdivision,  exclusive  of  expenditures  for program  administration,  in  the program year commencing October first, nineteen hundred eighty-eight, and in each program year thereafter,  are less than such expenditures in the previous program year by a minimum of ten  percent, the annual registration fees set forth in this subdivision may, unless otherwise provided by law, be decreased, pro-rata,  for  the subsequent  program  year,  provided that such decrease shall not exceed seven and one-half percent of the prior year registration  fees  as  may have been adjusted in accordance with this paragraph.  (e)  The determination to adjust annual registration fees set forth in this subdivision shall follow a review of such factors as  the  relative financial  capacity  of the state and such eligible program participants to support such adjustments and changes in the consumer price index. The frequency of such adjustments shall not exceed once in any program  year and  such  adjustments shall not become effective for individual program participants prior to the first day of the next annual  coverage  period for each participant.   3. Point of sale co-payment. (a) Upon satisfaction of the registration fee  pursuant to this section an eligible program participant must pay a point of  sale  co-payment  as  set  forth  in  paragraph  (b)  of  this subdivision  at  the  time of each purchase of a covered drug prescribed for such individual. Such co-payment shall not be waived or  reduced  in whole  or  in part subject to the limits provided by subdivision four of this section.  (b) The point of sale co-payment  amounts  which  are  to  be  charged eligible  program participants shall be in accordance with the following schedule: For each prescription of covered drugs costing $15.00 or less.....$3.00 For each prescription of covered drugs costing $15.01 to $35.00...$7.00 For each prescription of covered drugs costing $35.01 to $55.00..$15.00 For each prescription of covered drugs costing $55.01 or more....$20.00  (c) For the purposes of  the  foregoing  schedule  of  point  of  sale co-payments,  "costing"  shall  mean  the  amount of reimbursement which shall be paid by the state  to  a  participating  provider  pharmacy  in accordance  with  section two hundred fifty of this title plus the point of sale co-payment, calculated as of the date of sale.   4. Limits on point of sale co-payments. During  each  annual  coverage period  no point of sale co-payment as set forth in subdivision three of this section shall be required to be made  for  the  remainder  of  such period  by  any  eligible  program  participant who has already incurred co-payments in excess of the limits set forth in the following schedule:  (a) Limits on co-payments by  unmarried  individual  eligible  program participants: individual income of $5,000 or less                 no more than $340 individual income of $5,001 to $6,000               no more than $408 individual income of $6,001 to $7,000               no more than $476 individual income of $7,001 to $8,000               no more than $544 individual income of $8,001 to $9,000               no more than $612 individual income of $9,001 to $10,000              no more than $700 individual income of $10,001 to $11,000             no more than $720 individual income of $11,001 to $12,000             no more than $827 individual income of $12,001 to $13,000             no more than $896 individual income of $13,001 to $14,000             no more than $964 individual income of $14,001 to $15,000             no more than $1,016 individual income of $15,001 to $16,000             no more than $1,034 individual income of $16,001 to $17,000             no more than $1,052 individual income of $17,001 to $18,000             no more than $1,070 individual income of $18,001 to $19,000             no more than $1,088 individual income of $19,001 to $20,000             no more than $1,160  (b)  Limits on co-payments by each married individual eligible program participant: joint income of $5,000 or less                      no more than $291 joint income of $5,001 to $6,000                    no more than $342 joint income of $6,001 to $7,000                    no more than $399 joint income of $7,001 to $8,000                    no more than $456 joint income of $8,001 to $9,000                    no more than $513 joint income of $9,001 to $10,000                   no more than $570 joint income of $10,001 to $11,000                  no more than $622 joint income of $11,001 to $12,000                  no more than $641 joint income of $12,001 to $13,000                  no more than $660 joint income of $13,001 to $14,000                  no more than $684 joint income of $14,001 to $15,000                  no more than $710 joint income of $15,001 to $16,000                  no more than $826 joint income of $16,001 to $17,000                  no more than $877 joint income of $17,001 to $18,000                  no more than $928 joint income of $18,001 to $19,000                  no more than $980 joint income of $19,001 to $20,000                  no more than $990 joint income of $20,001 to $21,000                  no more than $1,008 joint income of $21,001 to $22,000                  no more than $1,026 joint income of $22,001 to $23,000                  no more than $1,044 joint income of $23,001 to $24,000                  no more than $1,062 joint income of $24,001 to $25,000                  no more than $1,080 joint income of $25,001 to $26,000                  no more than $1,150  (c) Effective October first, nineteen hundred eighty-eight, the limits on point of sale co-payments as set forth in  this  subdivision  may  be adjusted   by  the  panel  on  the  anniversary  date  of  each  program participant's annual coverage period, and such adjustment  shall  be  in effect  for the duration of that annual coverage period. Any such annual adjustment shall be made using  a  percentage  adjustment  factor  which shall  not  exceed  one-half  of the difference between the year-to-year percentage increase in the consumer price index for all urban consumers, as published by the United States Department of Labor, and,  if  larger, the  year-to-year  percentage  increase in the aggregate average cost of covered drugs purchased under this title, which year-to-year  percentage increase  in such cost shall be determined by comparison of such cost in the same month of each of the appropriate  successive  years;  provided, however,  that for any such adjustment based wholly on experience in the program year commencing October first,  nineteen  hundred  eighty-seven, the year-to-year percentage increase in such cost shall be determined by  comparison  of  such cost in each of two months no less than five months apart  and  within  such  program  year,  which  comparison   shall   be annualized.  Such percentage adjustment factor shall be the same as that used  to  determine  any  similar  annual adjustment for the same annual coverage periods pursuant to  the  provisions  of  subdivision  four  of section two hundred forty-eight of this title.  (d)  Such  annual  adjustments  shall be calculated by multiplying the percentage adjustment  factor  by  (1)  ten  percent  and  applying  the resulting percentage to the upper income limitation of each income level for  unmarried  individuals  contained  in  this subdivision, and by (2) seven and one-half percent and applying the resulting percentage to  the upper  income  limitation  of  each income level for married individuals contained in this subdivision; each result of such  calculations,  minus any  applicable  registration fee increases made pursuant to subdivision two of this section and plus  the  result  of  applying  the  percentage adjustment  factor  to the sum of any such annual adjustments applicable thereto for any prior annual coverage period, shall  be  the  amount  by which  the  limit  on  co-payments  for  each  such  income level may be adjusted, and such amount shall be in addition to  any  such  amount  or amounts applicable to prior annual coverage periods.  (e)   The  determination  to  adjust  the  limits  on  point  of  sale co-payments set forth in this subdivision shall follow a review of  such factors  as  the  relative  financial  capacity  of  the  state and such eligible program participants to support such adjustments.