2023 New York Laws › ELD - Elder › Article 2 - Programs for the Elderly › Title 3 - Program for Elderly Pharmaceutical Insurance Coverage › 242 - Program Eligibility.

§  242.  Program  eligibility.   1. Persons eligible for comprehensive
coverage under section two  hundred  forty-seven  of  this  title  shall
include:
(a) any unmarried resident who is at least sixty-five years of age and
whose  income  for the calendar year immediately preceding the effective
date of the annual coverage period beginning on or after January  first,
two  thousand  five,  is  less than or equal to twenty thousand dollars.
After the initial determination of eligibility, each eligible individual
must be redetermined eligible at least every twenty-four months; and
(b) any married resident who is at least sixty-five years of  age  and
whose  income  for the calendar year immediately preceding the effective
date of the annual coverage period when combined with the income in  the
same calendar year of such married person's spouse beginning on or after
January  first,  two  thousand  one, is less than or equal to twenty-six
thousand dollars. After the initial determination of  eligibility,  each
eligible  individual  must  be  redetermined  eligible  at  least  every
twenty-four months.
2. Persons  eligible  for  catastrophic  coverage  under  section  two
hundred forty-eight of this title shall include:
(a) any unmarried resident who is at least sixty-five years of age and
whose  income  for the calendar year immediately preceding the effective
date of the annual coverage period beginning on or after January  first,
two thousand one, is more than twenty thousand and less than or equal to
seventy-five  thousand  dollars.  After  the  initial  determination  of
eligibility, each eligible individual must be redetermined  eligible  at
least every twenty-four months; and
(b)  any  married resident who is at least sixty-five years of age and
whose income for the calendar year immediately preceding  the  effective
date  of the annual coverage period when combined with the income in the
same calendar year of such married person's spouse beginning on or after
January first, two  thousand  one,  is  more  than  twenty-six  thousand
dollars  and  less  than or equal to one hundred thousand dollars. After
the initial determination of eligibility, each eligible individual  must
be redetermined eligible at least every twenty-four months.
3.  (a)  Eligibility  for  assistance  under  this  title shall not be
granted to any person  who  at  the  time  an  application  is  made  is
receiving  medical  assistance  under section three hundred sixty-six of
the social services law, or to any person receiving equivalent or better
coverage from any other public or private third party payment source  or
insurance plan than those benefits provided for under this title.
(b) An individual who is determined eligible for assistance under this
title  whose  prescription  costs  are  covered in part by any public or
private plan may receive reduced assistance under this  title.  In  such
cases, benefits provided through this title shall be considered payments
of last resort.
(c)  The  participant  registration  fee  charged  to eligible program
participants for comprehensive coverage pursuant to section two  hundred
forty-seven  of this title shall be waived for the portion of the annual
coverage period that the participant is also enrolled as a full  subsidy
individual  in  a  prescription drug or MA-PD plan under part D of title
XVIII of the federal social security act.
(e) As a condition of eligibility for benefits under this title, if  a
program  participant's  income  indicates  that the participant could be
eligible for an income-related subsidy under  section  1860D-14  of  the
federal  social  security  act by either applying for such subsidy or by
enrolling  in  a  medicare  savings  program  as  a  qualified  medicare
beneficiary  (QMB),  a specified low-income medicare beneficiary (SLMB),
or a qualifying individual (QI), a program participant  is  required  to

provide,  and to authorize the elderly pharmaceutical insurance coverage
program  to  obtain,  any  information  or  documentation  required   to
establish  the  participant's  eligibility  for  such  subsidy,  and  to
authorize the elderly pharmaceutical insurance coverage program to apply
on  behalf  of  the  participant for the subsidy or the medicare savings
program. The elderly pharmaceutical  insurance  coverage  program  shall
make a reasonable effort to notify the program participant of his or her
need  to  provide  any  of  the  above  required  information.  After  a
reasonable  effort  has  been  made  to  contact  the   participant,   a
participant  shall  be notified in writing that he or she has sixty days
to provide  such  required  information.  If  such  information  is  not
provided  within the sixty day period, the participant's coverage may be
terminated.
(f) As a condition of eligibility for benefits  under  this  title,  a
program participant is required to be enrolled in Medicare part D and to
maintain  such  enrollment.  For  unmarried participants with individual
annual income less than or equal to twenty-three  thousand  dollars  and
married  participants  with  joint  annual  income less than or equal to
twenty-nine  thousand  dollars,  the  elderly  pharmaceutical  insurance
coverage program shall pay for the portion of the part D monthly premium
that  is  the  responsibility  of the participant. Such payment shall be
limited to the low-income benchmark premium amount  established  by  the
federal  centers for medicare and medicaid services and any other amount
which such agency establishes under its de minimus premium policy.
(h)  The  elderly  pharmaceutical  insurance   coverage   program   is
authorized  to  represent  program  participants  under  this title with
respect to their Medicare part D coverage.
(i) An individual who is determined  to  be  eligible  for  assistance
under  this article shall not become ineligible based upon income solely
because of an increase in either a  public  or  private  pension  or  an
increase in social security benefits as provided under federal law where
such increase does not exceed the consumer price index (all items United
States  city  average) for such year. This provision shall be limited to
one subsequent calendar year.
4. As a condition  of  eligibility  for  benefits  under  this  title,
participants  must  be  enrolled  in  medicare  part D and maintain such
enrollment.  For  persons  who  meet  the  eligibility  requirements  to
participate  in  the  elderly pharmaceutical insurance coverage program,
the program will pay for a drug covered by the person's medicare part  D
plan  or  a drug in a medicare part D excluded drug class, as defined in
subdivision eight of  section  two  hundred  forty-one  of  this  title,
provided that such drug is a covered drug, as defined in subdivision one
of section two hundred forty-one of this title, and that the participant
complies  with  the  point  of sale co-payment requirements set forth in
sections two hundred forty-seven and two  hundred  forty-eight  of  this
title. No payment shall be made for medicare part D plan deductibles.