2023 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.