2023 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.