2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11 - Medical Assistance for Needy Persons › 367-A - Payments; Insurance.

§  367-a.  Payments;  insurance.  1. (a) Any inconsistent provision of
this chapter or other law notwithstanding, no assignment of the claim of
any supplier of medical assistance shall be  valid  and  enforceable  as
against  any social services district or the department, and any payment
with respect to any medical assistance shall  be  made  to  the  person,
institution,  state  department or agency or municipality supplying such
medical assistance  at  rates  established  by  the  appropriate  social
services  district  and  contained  in  its approved local medical plan,
except as otherwise permitted or  required  by  applicable  federal  and
state provisions, including the regulations of the department; provided,
however,  that  for  those districts for whom the department has assumed
payment responsibilities pursuant to section three hundred sixty-seven-b
of this chapter, rates shall be established by the department, except as
otherwise required by applicable provisions of federal or state  law.  A
social   services  official  may  apply  to  the  department  for  local
variations in rates to be applicable, upon approval by  the  department,
to  recipients for whom such district is responsible. Claims for payment
shall be made in such form and manner as the department shall determine.
(b) Where an applicant  for  or  recipient  of  public  assistance  or
medical assistance has health insurance in force, is enrolled in a group
health  insurance  plan  or  group  health  plan covering care and other
medical benefits provided under this title, payment or  part-payment  of
the premium, co-insurance, any deductible amounts and other cost-sharing
obligations   for   such   insurance   may  also  be  made  when  deemed
cost-effective pursuant to the regulations of the department.
(c)  Any  inconsistent  provisions  of  this  title   or   other   law
notwithstanding  and  to the extent that federal financial participation
is available therefor and in accordance  with  the  regulations  of  the
commissioner,  payment  of the premium for coverage under a group health
insurance plan or group health  plan  may  be  made  under  the  medical
assistance  program  on  behalf  of  a  person not otherwise entitled to
public assistance or medical assistance if the social services  official
determines  that  the savings in expenditures to the program as a result
of such coverage are likely to exceed the amount of  the  premiums  paid
and such person has:
(i)  income  (as determined in accordance with the methodology used to
determine  eligibility  for  benefits  under  the  federal  supplemental
security  income program) in an amount less than or equal to one hundred
per cent of the federal income official poverty  line  (as  defined  and
annually  revised  by  the  federal  office  of  management  and budget)
applicable to the person's family size;
(ii) resources (as determined in accordance with the methodology  used
to  determine  eligibility  for  benefits under the federal supplemental
security income program) less than or equal to twice the maximum  amount
an  individual is permitted to have to obtain benefits under the federal
supplemental security income program; and
(iii) coverage available under a group health  insurance  plan  or  an
employer-based  group health plan provided pursuant to title XXII of the
federal public  health  services  act,  section  4980B  of  the  federal
internal  revenue  code  of 1986, or title VI of the employee retirement
income security act of 1974.
(d) (i) Amounts payable under this title for  medical  assistance  for
items   and   services   provided  to  eligible  persons  who  are  also
beneficiaries under part A of title XVIII of the federal social security
act and items and services provided to qualified medicare  beneficiaries
under part A of title XVIII of the federal social security act shall not
be  less than the amount of any deductible and co-insurance liability of
such eligible persons  or  for  which  such  eligible  persons  or  such

qualified  medicare beneficiaries would be liable under federal law were
they not eligible for medical assistance  or  were  they  not  qualified
medicare beneficiaries with respect to such benefits under such part A.
(ii) Amounts payable under this title for medical assistance for items
and  services  provided  to  eligible persons who are also beneficiaries
under part B of title XVIII of the federal social security act and items
and services provided to qualified medicare beneficiaries under  part  B
of title XVIII of the federal social security act shall not be less than
the  amount  of any deductible liability of such eligible persons or for
which such eligible persons or  such  qualified  medicare  beneficiaries
would  be  liable  under  federal law were they not eligible for medical
assistance or  were  they  not  qualified  medicare  beneficiaries  with
respect to such benefits under such part B.
(iii)  With respect to items and services provided to eligible persons
who are also beneficiaries under part B of title XVIII  of  the  federal
social  security  act  and  items  and  services  provided  to qualified
medicare beneficiaries under part B of title XVIII of the federal social
security act, the amount payable for services covered under  this  title
shall  be  the  amount  of  any  co-insurance liability of such eligible
persons pursuant to federal law  were  they  not  eligible  for  medical
assistance  or  were  they  not  qualified  medicare  beneficiaries with
respect to such benefits under such part B, but  shall  not  exceed  the
amount  that  otherwise would be made under this title if provided to an
eligible person other than a person who is also a beneficiary under part
B or is a qualified medicare beneficiary minus the amount payable  under
part  B;  provided,  however, amounts payable under this title for items
and services provided to eligible persons  who  are  also  beneficiaries
under  part  B  or  to  qualified medicare beneficiaries by an ambulance
service under the authority of an operating certificate issued  pursuant
to  article  thirty  of  the  public health law, a psychologist licensed
under article one  hundred  fifty-three  of  the  education  law,  or  a
facility under the authority of an operating certificate issued pursuant
to  article  sixteen, thirty-one or thirty-two of the mental hygiene law
and with respect to outpatient hospital and clinic  items  and  services
provided  by  a facility under the authority of an operating certificate
issued pursuant to article twenty-eight of the public health law,  shall
not  be  less  than  the  amount  of  any co-insurance liability of such
eligible persons or such qualified medicare beneficiaries, or for  which
such  eligible persons or such qualified medicare beneficiaries would be
liable under federal law were they not eligible for  medical  assistance
or  were  they not qualified medicare beneficiaries with respect to such
benefits under part B.
(iv) If a health plan participating in part C of title  XVIII  of  the
federal  social  security  act  pays  for items and services provided to
eligible persons who are also beneficiaries under part B of title  XVIII
of   the   federal   social   security  act  or  to  qualified  medicare
beneficiaries, the amount payable for services under this title shall be
eighty-five percent of the amount of any co-insurance liability of  such
eligible  persons  pursuant to federal law if they were not eligible for
medical assistance or were not  qualified  medicare  beneficiaries  with
respect  to  such benefits under such part B; provided, however, amounts
payable under this title for items and  services  provided  to  eligible
persons who are also beneficiaries under part B or to qualified medicare
beneficiaries  by  an  ambulance  service  under  the  authority  of  an
operating certificate issued pursuant to article thirty  of  the  public
health  law,  or  a  psychologist  licensed  under  article  one hundred
fifty-three of the education law, shall not be less than the  amount  of
any  co-insurance  liability  of such eligible persons or such qualified

medicare beneficiaries, or for  which  such  eligible  persons  or  such
qualified  medicare beneficiaries would be liable under federal law were
they not eligible for medical assistance  or  were  they  not  qualified
medicare beneficiaries with respect to such benefits under part B.
(e)  Amounts  payable  under  this title for medical assistance in the
form of clinic services pursuant to article twenty-eight of  the  public
health  law,  article  sixteen of the mental hygiene law and independent
practitioner services for individuals  with  developmental  disabilities
provided  to  eligible persons diagnosed with a developmental disability
who are also beneficiaries under part B of title XVIII  of  the  federal
social   security   act,   or  provided  to  persons  diagnosed  with  a
developmental disability who are qualified medicare beneficiaries  under
part  B  of  title XVIII of such act shall not be less than the approved
medical assistance payment level less the amount payable under part B.
(f) Amounts payable under this title for  medical  assistance  in  the
form  of  outpatient  mental health services under article thirty-one or
outpatient  chemical  dependence  services  including  opioid  treatment
services  under article thirty-two of the mental hygiene law provided to
eligible persons who are also beneficiaries under part B of title  XVIII
of  the  federal  social  security act or provided to qualified medicare
beneficiaries under part B of title XVIII of such act shall not be  less
than  the  approved  medical  assistance  payment  level less the amount
payable under part B.
(g) Notwithstanding any provision of this  section  to  the  contrary,
amounts  payable  under this title for medical assistance in the form of
hospital outpatient services or diagnostic and treatment center services
pursuant to article twenty-eight of the public health  law  provided  to
eligible  persons who are also beneficiaries under part B of title XVIII
of the federal social security act or  provided  to  qualified  medicare
beneficiaries  under  part B of title XVIII of such act shall not exceed
the approved medical assistance payment level less  the  amount  payable
under part B.
(h)  Amounts  payable  under  this title for medical assistance in the
form of freestanding clinic services pursuant to article twenty-eight of
the public health law provided to eligible persons participating in  the
New   York   traumatic   brain   injury  waiver  program  who  are  also
beneficiaries under part B of title XVIII of the federal social security
act or who are qualified medicare beneficiaries under part  B  of  title
XVIII of such act shall not be less than the approved medical assistance
payment level less the amount payable under part B.
2.  (a)  Any  inconsistent  provision of this chapter notwithstanding,
provision for medical care and other medical  benefits  available  under
this  title may be made, in whole or in part, either under this title or
other appropriate provisions of this chapter, through insurance or other
prepaid plans, in accordance with the regulations of the department.
(b)  Any  inconsistent  provision  of  this  chapter  or   other   law
notwithstanding,  upon  furnishing  assistance  under  this title to any
applicant or recipient of medical assistance, the local social  services
district  or  the  department  shall be subrogated, to the extent of the
expenditures by such district or department for medical care  furnished,
to  any  rights such person may have to medical support or reimbursement
from liable third parties, including but not limited to health insurers,
self-insured plans, group health plans, service benefit  plans,  managed
care  organizations,  pharmacy  benefit  managers, or other parties that
are, by statute, contract, or agreement, legally responsible for payment
of a claim for a health care item  or  service.  For  purposes  of  this
section,  the  term  medical  support  shall  mean  the right to support
specified as support for the purpose of  medical  care  by  a  court  or

administrative  order.  The  right  of  subrogation  does  not attach to
insurance benefits paid or provided under any  health  insurance  policy
prior  to  the  receipt of written notice of the exercise of subrogation
rights  by  the  carrier issuing such insurance, nor shall such right of
subrogation attach to any benefits which may  be  claimed  by  a  social
services  official  or the department, by agreement or other established
procedure, directly from an insurance carrier. No right  of  subrogation
to  insurance benefits available under any health insurance policy shall
be enforceable unless written notice of the exercise of such subrogation
right is received by the  carrier  within  three  years  from  the  date
services  for  which  benefits are provided under the policy or contract
are rendered. Liable third parties shall not deny  a  claim  made  by  a
social  services  official  or  the  department in conformance with this
paragraph solely on the basis of the date of submission  of  the  claim,
the  type  or  format  of  the  claim  form,  a  failure to obtain prior
authorization, or a failure  to  present  proper  documentation  at  the
point-of-sale that is the basis of the claim. Liable third parties shall
respond  to  a  request  for  payment  within  sixty calendar days after
receipt of written proof of loss or claim for payment  for  health  care
services provided to a recipient of Medicaid who is covered by the third
party  and  shall not charge a fee to process or adjudicate a claim. The
local social services district or the department shall also  notify  the
carrier when the exercise of subrogation rights has terminated because a
person  is no longer receiving assistance under this title. Such carrier
shall establish  mechanisms  to  maintain  the  confidentiality  of  all
individually  identifiable  information  or  records. Such carrier shall
limit the use of such information or record to the specific purpose  for
which  such  disclosure  is  made,  and  shall not further disclose such
information or records.
(c) In accordance with regulations of the department and to the extent
authorized by federal law and regulation, the social  services  district
is  authorized  to  retain, in addition to amounts retained as repayment
for its share of the costs of medical assistance provided, a portion  of
the  federal  share  of the amount collected as medical support or third
party benefits assigned under  paragraph  (f)  of  subdivision  four  of
section  three hundred sixty-six of this article, when such district, or
other governmental agency pursuant to an agreement with  such  district,
has  collected such medical support or third party benefits on behalf of
a person receiving medical assistance whose rights to medical support or
third party  benefits  have  been  assigned  to  the  state  or  to  the
appropriate  social  services official. Where more than one district has
been involved in enforcing  or  collecting  such  amounts,  the  federal
incentive  shall  be  apportioned among each such district in accordance
with the regulations of the department.
* 3. (a) Payment of premiums  for  enrolling  qualified  disabled  and
working individuals and qualified medicare beneficiaries under Part A of
title  XVIII  of  the federal social security act and for enrolling such
beneficiaries and eligible recipients of public assistance under part  B
of  title  XVIII  of  the federal social security act, together with the
costs of the applicable co-insurance and deductible amounts on behalf of
such beneficiaries, and recipients, and premiums under section  1839  of
the  federal  social  security  act  for  persons who would be qualified
medicare beneficiaries except that  their  incomes  exceed  one  hundred
percent  of  the  federal income poverty line applicable to the person's
family size but, in calendar years  nineteen  hundred  ninety-three  and
nineteen  hundred  ninety-four,  is less than one hundred ten percent of
such poverty line and, in calendar year beginning  in  nineteen  hundred
ninety-five,  is  less  than  one hundred twenty percent of such poverty

line shall be made and the cost thereof borne by the  state  or  by  the
state  and  social  services districts, respectively, in accordance with
the regulations of the department, provided, however, that the share  of
the  cost to be borne by a social services district, if any, shall in no
event exceed the proportionate share borne by such district with respect
to other expenditures under this title. Moreover, if the director of the
budget approves, payment of premiums for enrolling persons who have been
determined to be eligible for medical assistance only may  be  made  and
the cost thereof borne or shared pursuant to this subdivision.
(b)   (1)  For  purposes  of  this  subdivision,  "qualified  medicare
beneficiaries" are those persons who are entitled to hospital  insurance
benefits under part A of title XVIII of the federal social security act,
whose income does not exceed one hundred percent of the official federal
poverty  line applicable to the person's family size and whose resources
do not exceed twice the maximum amount of resources a person may have in
order to qualify for benefits under the  federal  supplemental  security
income  program  of  title  XVI  of  the federal social security act, as
determined for purposes of such program.
(2)  Notwithstanding  any  provision  of  subparagraph  one  of   this
paragraph  to  the  contrary,  to  the  extent  that  federal  financial
participation is available, a person whose resources are  in  excess  of
the   amount   specified   but   otherwise  meets  the  requirements  of
subparagraph one of this paragraph  shall  be  considered  a  "qualified
medicare   beneficiary"  for  the  purposes  of  this  subdivision.  The
commissioner is authorized to submit amendments to the  state  plan  for
medical assistance and/or submit one or more applications for waivers of
the  federal  social  security  act,  to  obtain  the  federal approvals
necessary to implement this subparagraph.
(c) (1) For purposes of  this  subdivision,  "qualified  disabled  and
working  individuals" are individuals who are not otherwise eligible for
medical assistance and:
(i) who are entitled to enroll for hospital insurance  benefits  under
section  1818A  of  part A of title XVIII of the federal social security
act;
(ii) whose income does not exceed two hundred percent of the  official
federal poverty line applicable to the person's family size; and
(iii)  whose  resources  do  not  exceed  twice  the maximum amount of
resources that an individual or a couple,  in  the  case  of  a  married
individual,  may  have  and  obtain federal supplemental security income
benefits under  title  XVI  of  the  federal  social  security  act,  as
determined for purposes of that program.
(2)   For  purposes  of  this  paragraph,  income  and  resources  are
determined  by  the  same  methodology  as  is  used   for   determining
eligibility  under  the  federal  supplemental  security income benefits
under title XVI of the federal social security act.
(d) (1) Beginning April first, two thousand two and to the extent that
federal financial participation is available at a  one  hundred  percent
federal  Medical  assistance percentage and subject to sections 1933 and
1902(a)(10)(E)(iv)  of  the  federal  social   security   act,   medical
assistance  shall  be  available  for  full  payment  of medicare part B
premiums for individuals (referred to as qualified  individuals  1)  who
are  entitled to hospital insurance benefits under part A of title XVIII
of the federal social security act and whose income exceeds  the  income
level  established  by  the  state  and  is  at least one hundred twenty
percent, but less than one hundred thirty-five percent, of  the  federal
poverty  level,  for  a  family  of  the  size  involved and who are not
otherwise eligible for medical assistance under the state plan;
(2) Premium payments for the individuals described in subparagraph one
of this paragraph will be one hundred percent federally funded up to the
amount of  the  federal  allotment.  The  department  shall  discontinue
enrollment  into  the  program  when  the  part  B premium payments made
pursuant  to  subparagraph one of this paragraph meet the yearly federal
allotment.
(3) The commissioner of health shall develop a simplified  application
form,  consistent  with  federal  law,  for  payments  pursuant  to this
section. The commissioner of health, in cooperation with the office  for
the aging, shall publicize the availability of such payments to medicare
beneficiaries.
(e)  (1)  Payment  of  premiums for enrolling individuals in qualified
health plans offered through a  health  insurance  exchange  established
pursuant to the federal Patient Protection and Affordable Care Act (P.L.
111-148),   as   amended  by  the  federal  Health  Care  and  Education
Reconciliation Act  of  2010  (P.L.  111-152),  shall  be  available  to
individuals who:
(i)  immediately prior to being enrolled in the qualified health plan,
were or would have been eligible under the family health plus program as
a parent or stepparent of a child under the age of twenty-one, and whose
MAGI household income, as defined in subparagraph eight of paragraph (a)
of subdivision one of section three hundred  sixty-six  of  this  title,
exceeds one hundred thirty-three percent of the federal poverty line for
the applicable family size;
(ii)  are  not  otherwise  eligible  for medical assistance under this
title; and
(iii) are enrolled in a standard health plan in the silver  level,  as
defined in 42 U.S.C. 18022.
(2)   Payment   pursuant  to  this  paragraph  shall  be  for  premium
obligations of the individual under the qualified health plan and  shall
continue  only  if  and  for  so long as the individual's MAGI household
income exceeds one hundred thirty-three percent, but does not exceed one
hundred fifty percent, of the federal poverty line  for  the  applicable
family  size,  or,  if  earlier,  until  the  individual is eligible for
enrollment in a standard health plan pursuant to section  three  hundred
sixty-nine-gg of this article.
(3)  The  commissioner  of health shall submit amendments to the state
plan for medical assistance and/or submit one or more  applications  for
waivers  of  the  federal  social  security  act  as may be necessary to
receive federal financial participation in the costs  of  payments  made
pursuant  to  this paragraph; provided further, however, that nothing in
this subparagraph shall  be  deemed  to  affect  payments  for  premiums
pursuant  to  this  paragraph  if federal financial participation in the
costs of such payments is not available.
* NB Effective until January 1,  2023  subject  to  federal  financial
participation
* 3.  (a)  As used in this subdivision, the following terms shall have
the following meanings:
(1) "Qualified medicare beneficiary" means a person who is entitled to
hospital insurance benefits under part A of title XVIII of  the  federal
social   security   act,  whose  income  does  not  exceed  one  hundred
thirty-eight percent of the official federal poverty line applicable  to
the  person's  family  size  and whose resources do not exceed twice the
maximum amount of resources a person may have in order  to  qualify  for
benefits under the federal supplemental security income program of title
XVI  of  the  federal social security act, as determined for purposes of
such program. To the extent  that  federal  financial  participation  is
available,  a  person  whose  resources  are  in  excess  of  the amount

specified in this subparagraph  but  otherwise  meets  the  requirements
shall be considered a "qualified medicare beneficiary".
(2)  "Qualified individual" means a person who is entitled to hospital
insurance benefits under part A of title XVIII  of  the  federal  social
security  act  and whose income is greater than one hundred thirty-eight
percent, but less than or equal to one hundred  eighty-six  percent,  of
the federal poverty line, for the applicable family size, and who is not
otherwise  eligible  for medical assistance under this article; referred
to as a qualified individual.
(3) "Qualified disabled and working individual"  means  an  individual
who is not otherwise eligible for medical assistance and:
(i)  who  is  entitled to enroll for hospital insurance benefits under
section 1818A of part A of title XVIII of the  federal  social  security
act;
(ii)  whose income does not exceed two hundred percent of the official
federal poverty line applicable to the person's family size; and
(iii) whose resources do  not  exceed  twice  the  maximum  amount  of
resources  that  an  individual  or  a  couple, in the case of a married
individual, may have and obtain  federal  supplemental  security  income
benefits  under  title  XVI  of  the  federal  social  security  act, as
determined for purposes of that program.
For purposes of this subparagraph, income and resources are determined
by the same methodology as is used for determining eligibility under the
federal supplemental security income benefits under  title  XVI  of  the
federal social security act.
(b)  Payment  of premiums for enrolling qualified disabled and working
individuals and qualified medicare beneficiaries under Part A  of  title
XVIII  of  the  federal  social  security  act  and  for  enrolling such
beneficiaries and eligible recipients of public assistance under part  B
of  title  XVIII  of  the federal social security act, together with the
costs of the applicable co-insurance and deductible amounts on behalf of
such beneficiaries, and recipients, and premiums under section  1839  of
the federal social security act shall be made and the cost thereof borne
by   the   state   or  by  the  state  and  social  services  districts,
respectively, in accordance with  the  regulations  of  the  department,
provided,  however,  that  the share of the cost to be borne by a social
services district, if any, shall in no event  exceed  the  proportionate
share  borne  by  such district with respect to other expenditures under
this title. Moreover, if the director of the budget approves, payment of
premiums for enrolling persons who have been determined to  be  eligible
for  medical  assistance  only may be made and the cost thereof borne or
shared pursuant to this subdivision.
(c) (1) Beginning April first, two thousand two and to the extent that
federal financial participation is available at a  one  hundred  percent
federal  Medical  assistance percentage and subject to sections 1933 and
1902(a)(10)(E)(iv)  of  the  federal  social   security   act,   medical
assistance  shall  be  available  for  full  payment  of medicare part B
premiums for qualified individuals.
(2) Premium payments for the individuals described in subparagraph one
of this paragraph will be one hundred percent federally funded up to the
amount of  the  federal  allotment.  The  department  shall  discontinue
enrollment  into  the  program  when  the  part  B premium payments made
pursuant to subparagraph one of this paragraph meet the  yearly  federal
allotment.
(3)  The commissioner of health shall develop a simplified application
form, consistent  with  federal  law,  for  payments  pursuant  to  this
section.  The commissioner of health, in cooperation with the office for

the aging, shall publicize the availability of such payments to medicare
beneficiaries.
(d)  (1)  Payment  of  premiums for enrolling individuals in qualified
health plans offered through a  health  insurance  exchange  established
pursuant to the federal Patient Protection and Affordable Care Act (P.L.
111-148),   as   amended  by  the  federal  Health  Care  and  Education
Reconciliation Act  of  2010  (P.L.  111-152),  shall  be  available  to
individuals who:
(i)  immediately prior to being enrolled in the qualified health plan,
were or would have been eligible under the family health plus program as
a parent or stepparent of a child under the age of twenty-one, and whose
MAGI household income, as defined in subparagraph eight of paragraph (a)
of subdivision one of section three hundred  sixty-six  of  this  title,
exceeds one hundred thirty-three percent of the federal poverty line for
the applicable family size;
(ii)  are  not  otherwise  eligible  for medical assistance under this
title; and
(iii) are enrolled in a standard health plan in the silver  level,  as
defined in 42 U.S.C. 18022.
(2)   Payment   pursuant  to  this  paragraph  shall  be  for  premium
obligations of the individual under the qualified health plan and  shall
continue  only  if  and  for  so long as the individual's MAGI household
income exceeds one hundred thirty-three percent, but does not exceed one
hundred fifty percent, of the federal poverty line  for  the  applicable
family  size,  or,  if  earlier,  until  the  individual is eligible for
enrollment in a standard health plan pursuant to section  three  hundred
sixty-nine-gg of this article.
(3)  The  commissioner  of health shall submit amendments to the state
plan for medical assistance and/or submit one or more  applications  for
waivers  of  the  federal  social  security  act  as may be necessary to
receive federal financial participation in the costs  of  payments  made
pursuant  to  this paragraph; provided further, however, that nothing in
this subparagraph shall  be  deemed  to  affect  payments  for  premiums
pursuant  to  this  paragraph  if federal financial participation in the
costs of such payments is not available.
* NB  Effective  January  1,  2023  subject   to   federal   financial
participation
4.  No  social services district shall make final payments pursuant to
title XIX of the federal social  security  act  for  benefits  available
under  title  XVIII  of  such act without documentation that title XVIII
claims have been filed and denied.
5. (a) When medical care,  services  and  supplies  are  furnished  an
eligible  person  on  behalf  of  a  social services district under this
title, such social  services  district  is  authorized  to  utilize  any
appropriate  organization  as  a  fiscal  intermediary to audit and make
payment for such district's share of the cost of such care, services and
supplies.
(b) To carry out the purposes of paragraph  (a),  the  department,  on
behalf  of  itself  and  any of the social services districts, may enter
into  agreements  with  appropriate  organizations  to  act  as   fiscal
intermediaries.
6.  (a) Notwithstanding any inconsistent provision of law, payment for
claims for services as specified in paragraph (d)  of  this  subdivision
furnished to eligible persons under this title, subject to paragraph (b)
of  this  subdivision shall be reduced in accordance with the provisions
of paragraph (c) of this subdivision by an  amount  not  to  exceed  the
maximum amount authorized by federal law and regulations as a co-payment
amount, which co-payment amount the provider of such services may charge

the  recipient, provided, however, no provider may deny such services to
an individual eligible for services based on the individual's  inability
to pay the co-payment amount.
(b)  Co-payments  shall apply to all eligible persons for the services
defined in paragraph (d) of this subdivision with the exception of:
(i) individuals under twenty-one years of age;
(ii) pregnant women;
(iii) individuals who are inpatients in a medical  facility  who  have
been  required  to  spend  all  of their income for medical care, except
their  personal  needs  allowance  or  residents  of   community   based
residential  facilities  licensed  by the office of mental health or the
office for people with developmental disabilities who have been required
to spend all of their income, except their personal needs allowance;
(iv) individuals enrolled in health maintenance organizations or other
entities which provide comprehensive health services, or  other  managed
care  programs  for  services covered by such programs, except that such
persons, other than persons otherwise exempted from co-payments pursuant
to subparagraphs (i), (ii), (iii) and (v) of this paragraph,  and  other
than  those  persons enrolled in a managed long term care program, shall
be subject to co-payments as described in subparagraph (v) of  paragraph
(d) of this subdivision;
(v)  individuals  whose family income is less than one hundred percent
of the  federal  poverty  line,  as  defined  in  subparagraph  four  of
paragraph  (a)  of subdivision one of section three hundred sixty-six of
this title, for a family of the same size; and
(vi) any other individuals required to be excluded by federal  law  or
regulations.
(b-1)  The  commissioner  is  authorized  to  submit  any  request  or
application to the Centers for Medicare and Medicaid Services as may  be
necessary  to  be granted a waiver of the requirement for the department
of  health  to  calculate  its  Medicaid  payments   to   managed   care
organizations  to  include cost sharing established under the state plan
for medical assistance for  enrollees  who  are  not  exempt  from  cost
sharing.  In the absence of such a waiver, the commissioner shall adjust
Medicaid payments to managed care organizations beginning October first,
two thousand fifteen or  on  the  date  the  Centers  for  Medicare  and
Medicaid  Services  commences enforcement of such requirement, whichever
is later.
* (c)  (i)  Co-payments  charged  pursuant  to  this  subdivision  for
non-institutional   services  shall  not  exceed  the  following  table,
provided,  however,  that  the   department   may   establish   standard
co-payments  for  services based upon the average or typical payment for
that service:
State's payment                  Maximum co-payment
for the services               chargeable to recipient
$10 or less                           $.50
$10.01 to $25                        $1.00
$25.01 to $50                        $2.00
$50.01 or more                       $3.00
(ii)  co-payments  charged  pursuant  to  this  subdivision  for  each
discharge for inpatient care shall be twenty-five dollars.
(iii)   Notwithstanding   any   other  provision  of  this  paragraph,
co-payments charged for each generic prescription drug  dispensed  shall
be  one dollar and for each brand name prescription drug dispensed shall
be two dollars and fifty cents; provided, however, that the  co-payments
charged  for  each  brand  name prescription drug reimbursed pursuant to

subparagraph (ii) of paragraph (a-1)  of  subdivision  four  of  section
three hundred sixty-five-a of this title shall be one dollar.
(iv)  When  an individual is initially dispensed or prescribed a seven
or fewer  days  supply  of  an  opioid  pursuant  to  paragraph  (b)  of
subdivision  five  of section three thousand three hundred thirty-one of
the public health law, and is subsequently dispensed  or  prescribed  an
additional  supply of such opioid for the same underlying condition, the
total co-payment that may be charged  to  such  an  individual  for  the
initial  prescription  plus  all  subsequent  prescriptions for the same
underlying condition for up to a total of  thirty-days  supply  of  such
opioid  shall  not  exceed the amount set forth in subparagraph (iii) of
this paragraph.
* NB Repealed March 31, 2026
(d) Co-payments shall apply to the following services, subject to such
exceptions for subcategories of these  services  as  recognized  by  the
commissioner  in  regulations, provided in accordance with section three
hundred  sixty-five-a  of  this  article  and  the  regulations  of  the
department,  to  the extent permitted by title XIX of the federal social
security act:
(i) in-patient care in a general hospital, as defined  in  subdivision
ten of section twenty-eight hundred one of the public health law;
(ii) out-patient hospital and clinic services except for mental health
services,  and  developmental disability services, alcohol and substance
abuse services and methadone maintenance services;
(iii) home health services, including services provided under the long
term home health care program, provided however, home  health  providers
shall  not  require  employees providing services in the home to collect
the co-payment amount;
(iv) sickroom supplies;
(v) drugs, excepting psychotropic drugs and drugs  with  FDA  approved
indications  for  the  treatment  of  tuberculosis  as  specified by the
department and those drugs intended for use by residents of  adult  care
facilities  licensed  by the department of health who have been required
to spend all of their income, except their personal needs allowance;
(vi) clinical laboratory services;
(vii) x-rays;
(viii)  emergency   room   services   provided   for   non-urgent   or
non-emergency  medical  care, provided however, co-payments shall not be
required  for  emergency  services  or  family  planning  services   and
supplies;
(e) In the period from January first, nineteen hundred ninety-three to
March  thirty-first, nineteen hundred ninety-three no recipient shall be
required to pay more than  a  total  of  fifty  dollars  in  co-payments
required by this subdivision for drugs, nor shall reductions in payments
as a result of such co-payments exceed fifty dollars for any recipient.
(f)   (i)  In  the  year  commencing  April  first,  nineteen  hundred
ninety-three and for each  year  thereafter,  and  ending  in  the  year
concluding  on March thirty-first, two thousand five, no recipient shall
be required to  pay  more  than  a  total  of  one  hundred  dollars  in
co-payments  required  by  this  subdivision,  nor  shall  reductions in
payments as a result of such co-payments exceed one hundred dollars  for
any recipient.
(ii)  In  the  year  commencing April first, two thousand five and for
each year thereafter, no recipient shall be required to pay more than  a
total   of   two   hundred  dollars  in  co-payments  required  by  this
subdivision, nor shall reductions  in  payments  as  a  result  of  such
co-payments exceed two hundred dollars for any recipient.
(g) The commissioner shall promptly:
(i)  promulgate  a regulation making it an unacceptable practice under
the medical assistance program for a provider to  deny  services  to  an
individual  eligible for services based on the individual's inability to
pay the co-pay amount required by this subdivision;
(ii)  establish  and maintain a toll-free hotline which may be used to
report  a  violation  of  the   regulation   promulgated   pursuant   to
subparagraph (i) of this paragraph; and
(iii)  provide  notice  to all recipients summarizing their rights and
obligations under this subdivision.
7. (a) Every manufacturer or wholesaler  of  drugs,  prescriptions  or
poisons  registered  under the provisions of section sixty-eight hundred
eight of the education law, shall, upon request of  the  department  for
any  information  pertaining  to wholesale prices charged to pharmacists
for any drugs available under the medical assistance program,  make  the
requested information available to the department on a monthly basis, or
such other periodic basis as the department shall request.
(b)  The  department shall provide for financial arrangements with any
manufacturer or wholesaler of drugs, prescriptions or poisons as may  be
necessary  to  reimburse  such manufacturer or wholesaler for its actual
and necessary costs included in furnishing the requested information.
(c) Any information  obtained  pursuant  to  the  provisions  of  this
subdivision shall not be made available for public inspection or copying
under  the  provisions  of  article  six of the public officers law. The
department shall not disclose such  information  to  any  person,  firm,
department  or  agency,  except any state agency or department as may be
necessary for the administration of the medical assistance program under
the provisions of this chapter or any other law.
(d)  Notwithstanding  any  inconsistent  provision  of   law,   if   a
manufacturer  (as  defined  under  section  1927  of  the federal social
security act) has entered into a rebate agreement with the department or
with the federal secretary of health and human services on behalf of the
department under section 1927 of the federal social  security  act,  the
department  shall  reimburse  for  covered  outpatient  drugs  which are
dispensed under the medical assistance program to all persons in receipt
of medical assistance benefits as a result of their  eligibility  having
been  established  under  subparagraph  one  or nine of paragraph (a) of
subdivision one of section three hundred sixty-six of  this  title,  and
which  are dispensed to all persons eligible for health care services as
a result of their eligibility having been established under  subdivision
two  of  section  three  hundred  sixty-nine-ee  of  this  article, only
pursuant to the terms of the rebate agreement between the department and
such manufacturer; provided, however, that  any  agreement  between  the
department and a manufacturer entered into before August first, nineteen
hundred  ninety-one,  shall be deemed to have been entered into on April
first, nineteen hundred ninety-one; and  provided  further,  that  if  a
manufacturer  has  not  entered  into  an  agreement with the department
before August first, nineteen hundred ninety-one, such  agreement  shall
not  be effective until April first, nineteen hundred ninety-two, unless
such agreement provides that rebates will be retroactively calculated as
if the agreement had been in effect on  April  first,  nineteen  hundred
ninety-one.  The  rebate  agreement  between  such  manufacturer and the
department shall utilize for single source drugs and innovator  multiple
source  drugs  the  identical formula used to determine the basic rebate
for federal financial participation single source  drugs  and  innovator
multiple  source  drugs, pursuant to paragraph one of subdivision (c) of
section 1927 of the federal social security act, to determine the amount
of the rebate pursuant to this paragraph. The rebate  agreement  between
such  manufacturer  and  the  department shall utilize for non-innovator

multiple source drugs the identical formula used to determine the  basic
rebate for federal financial participation non-innovator multiple source
drugs,  pursuant  to  paragraphs  three  and  four of subdivision (c) of
section 1927 of the federal social security act, to determine the amount
of  the  rebate  pursuant to this paragraph. The terms and conditions of
such rebate agreement with respect to periodic payment  of  the  rebate,
provision   of  information  by  the  department,  audits,  manufacturer
provision   of   information   verification   of   surveys,   penalties,
confidentiality  of information, and length of the agreement shall apply
to drugs of the manufacturer  dispensed  under  the  medical  assistance
program  to  all  persons in receipt of medical assistance benefits as a
result of their eligibility having been established  under  subparagraph
one or nine of paragraph (a) of subdivision one of section three hundred
sixty-six of this title, and which are dispensed to all persons eligible
for  health  care  services as a result of their eligibility having been
established under subdivision two of section three hundred sixty-nine-ee
of this article. The department  in  providing  utilization  data  to  a
manufacturer  (as  provided  for  under  section  1927.4(b)(1)(A) of the
federal social security act) shall provide such data  by  zip  code,  if
requested, for drugs covered under a rebate agreement.
* (e)  ** During  the  period  from  April first, two thousand fifteen
through March thirty-first, two thousand  twenty-six,  the  commissioner
may,  in  lieu  of  a managed care provider or pharmacy benefit manager,
negotiate directly and enter into an arrangement with  a  pharmaceutical
manufacturer  for  the  provision  of  supplemental  rebates relating to
pharmaceutical  utilization  by  enrollees  of  managed  care  providers
pursuant  to  section  three  hundred sixty-four-j of this title and may
also negotiate directly and enter into such  an  agreement  relating  to
pharmaceutical  utilization  by  medical  assistance  recipients  not so
enrolled. Such rebate arrangements shall be limited  to  the  following:
antiretrovirals  approved  by  the  FDA  for  the treatment of HIV/AIDS,
opioid dependence agents and opioid antagonists listed  in  a  statewide
formulary  established pursuant to subparagraph (vii) of this paragraph,
hepatitis C agents, high cost drugs  as  provided  for  in  subparagraph
(viii) of this paragraph, gene therapies as provided for in subparagraph
(ix)  of  this  paragraph, and any other class or drug designated by the
commissioner for which the pharmaceutical manufacturer has in  effect  a
rebate  arrangement  with  the  federal  secretary  of  health and human
services pursuant to 42 U.S.C. § 1396r-8, and for which  the  state  has
established  standard  clinical  criteria.  No  agreement  entered  into
pursuant to this paragraph shall have an initial  term  or  be  extended
beyond the expiration or repeal of this paragraph.
** NB Effective until October 1, 2024
** During  the  period  from April first, two thousand fifteen through
March thirty-first, two thousand twenty-six, the  commissioner  may,  in
lieu  of  a managed care provider or pharmacy benefit manager, negotiate
directly  and  enter  into  an   arrangement   with   a   pharmaceutical
manufacturer  for  the  provision  of  supplemental  rebates relating to
pharmaceutical  utilization  by  enrollees  of  managed  care  providers
pursuant  to  section  three  hundred sixty-four-j of this title and may
also negotiate directly and enter into such  an  agreement  relating  to
pharmaceutical  utilization  by  medical  assistance  recipients  not so
enrolled. Such rebate arrangements shall be limited  to  the  following:
antiretrovirals  approved  by  the  FDA  for  the treatment of HIV/AIDS,
accelerated approval  drugs  established  pursuant  to  this  paragraph,
opioid  dependence  agents  and opioid antagonists listed in a statewide
formulary established pursuant to subparagraph (vii) of this  paragraph,
hepatitis  C  agents,  high  cost  drugs as provided for in subparagraph

(viii) of this paragraph, gene therapies as provided for in subparagraph
(ix) of this paragraph, and any other class or drug  designated  by  the
commissioner  for  which the pharmaceutical manufacturer has in effect a
rebate  arrangement  with  the  federal  secretary  of  health and human
services pursuant to 42 U.S.C. § 1396r-8, and for which  the  state  has
established  standard  clinical  criteria.  No  agreement  entered  into
pursuant to this paragraph shall have an initial  term  or  be  extended
beyond  the expiration or repeal of this paragraph. For purposes of this
paragraph, an "accelerated approval" is a drug or labeled indication  of
a  drug  authorized by the Federal Food, Drug and Cosmetic Act for drugs
approved under Subpart H of 21 CFR Part 314 and Subpart E of 21 CFR Part
601 for serious conditions that fill an  unmet  medical  need  based  on
whether  the drug has an effect on a surrogate clinical endpoint, and is
pending verification of clinical benefit in confirmatory trials.
** NB Effective October 1, 2024
(i) The manufacturer shall not enter into any rebate arrangements with
a managed care provider, or any of a  managed  care  provider's  agents,
including  but  not  limited to any pharmacy benefit manager on the gene
therapy, drug, or drug classes subject to this paragraph when the  state
has  a  rebate  arrangement  in place and standard clinical criteria are
imposed on the managed care provider.
(ii) The commissioner shall establish adequate rates of  reimbursement
which  shall  take  into  account  both  the  impact of the commissioner
negotiating such arrangements and any limitations imposed on the managed
care provider's ability to establish clinical criteria relating  to  the
utilization  of  such  drugs.  In developing the managed care provider's
reimbursement rate,  the  commissioner  shall  identify  the  amount  of
reimbursement  for  such drugs as a separate and distinct component from
the reimbursement otherwise made for prescription drugs as prescribed by
this section.
(iii)  The  commissioner  shall  submit  a  report  to  the  temporary
president  of  the  senate  and  the speaker of the assembly annually by
December thirty-first. The report shall analyze the adequacy of rates to
managed care providers for drug  expenditures  related  to  the  classes
under this paragraph.
(iv)  Nothing  in  this  paragraph  shall  be  construed  to require a
pharmaceutical  manufacturer  to  enter  into   a   rebate   arrangement
satisfactory  to the commissioner relating to pharmaceutical utilization
by enrollees of managed care providers pursuant to section three hundred
sixty-four-j of this title or relating to pharmaceutical utilization  by
medical assistance recipients not so enrolled.
(v)  All clinical criteria, including requirements for prior approval,
and all utilization review determinations established by  the  state  as
described  in  this  paragraph  for  the  gene therapies, drugs, or drug
classes  subject  to   this   paragraph   shall   be   developed   using
evidence-based  and peer-reviewed clinical review criteria in accordance
with article two-A of the public health law, as applicable.
(vi) All prior authorization  and  utilization  review  determinations
related  to  the coverage of any drug subject to this paragraph shall be
subject to article forty-nine of the public health  law,  section  three
hundred  sixty-four-j  of  this  title,  and  article  forty-nine of the
insurance law, as applicable. Nothing in this paragraph  shall  diminish
any  rights  relating to access, prior authorization, or appeal relating
to any drug class or drug  afforded  to  a  recipient  under  any  other
provision of law.
(vii)  The  department  shall  publish a statewide formulary of opioid
dependence  agents  and  opioid  antagonists,  which  shall  include  as
"preferred  drugs"  all  drugs  in such classes, which shall include all

subclasses of a given drug that have a different  pharmacological  route
of administration, provided that:
(A) for all drugs that are included as of the date of the enactment of
this  subparagraph on a formulary of a managed care provider, as defined
in section three hundred sixty-four-j of this title, or in the  Medicaid
fee-for-service  preferred  drug program pursuant to section two hundred
seventy-two of the public health law, the cost  to  the  department  for
such  drug is equal to or less than the lowest cost paid for the drug by
any managed care provider or by  the  Medicaid  fee-for-service  program
after the application of any rebates, as of the date that the department
implements  the  statewide  formulary  established by this subparagraph.
Where there is a generic version of the drug approved by  the  Food  and
Drug Administration as bioequivalent to a brand name drug pursuant to 21
U.S.C.  §  355(j)(8)(B),  the  cost  to the department for the brand and
generic versions shall be equal to or less than the  lower  of  the  two
maximum costs determined pursuant to the previous sentence; and
(B)  for  all  drugs  that  are  not  included  as  of the date of the
enactment of  this  subparagraph  on  a  formulary  of  a  managed  care
provider,  as  defined  in  section  three  hundred sixty-four-j of this
title,  or  in  the  Medicaid  fee-for-service  preferred  drug  program
pursuant  to  section  two hundred seventy-two of the public health law,
the department is able to obtain the drug at a cost that is equal to  or
less than the lowest cost to the department of other comparable drugs in
the  class,  after  the  application  of  any  rebates. Where there is a
generic version of the drug approved by the Food and Drug Administration
as  bioequivalent  to  a  brand  name  drug  pursuant  to  21  U.S.C.  §
355(j)(8)(B),  the  cost  to  the  department  for the brand and generic
versions shall be equal to or less than the lower  of  the  two  maximum
costs determined pursuant to the previous sentence.
(viii)  The  commissioner  may  identify and refer high cost drugs, as
defined in clause (D) of this subparagraph, that are not included as  of
the  date  of  the  enactment  of  this subparagraph on a formulary of a
managed care provider or covered by the  Medicaid  fee  for  service  of
program  to  the  drug  utilization  review board established by section
three hundred sixty-nine-bb of this article for a recommendation  as  to
whether  a  target  supplemental  Medicaid  rebate should be paid by the
manufacturer of the drug to the department and the target amount of  the
rebate.
(A)  If the commissioner intends to refer a high cost drug to the drug
utilization review board pursuant to this subparagraph, the commissioner
shall notify the manufacturer of such drug and shall  attempt  to  reach
agreement  with the manufacturer on a rebate arrangement satisfactory to
the commissioner for the drug prior to referring the drug  to  the  drug
utilization  review  board  for review. Such arrangement may be based on
evidence based research, including, but not limited  to,  such  research
operated  or  conducted  by  or for other state governments, the federal
government, the governments of other nations, and third party payers  or
multi-state  coalitions,  provided  however  that  the  department shall
account for the effectiveness of the drug in treating the conditions for
which it is prescribed or in improving a patient's  health,  quality  of
life,  or  overall  health  outcomes, and the likelihood that use of the
drug  will  reduce  the  need  for   other   medical   care,   including
hospitalization.
(B)  In  the  event  that  the  commissioner and the manufacturer have
previously agreed to a rebate arrangement for a drug  pursuant  to  this
paragraph, the drug shall not be referred to the drug utilization review
board  for any further rebate agreement for the duration of the previous
rebate agreement, provided however, the commissioner may refer a drug to

the drug utilization review board if the commissioner  determines  there
are  significant  and  substantiated  utilization or market changes, new
evidence-based research, or statutory or federal regulatory changes that
warrant  additional  rebates. In such cases, the department shall notify
the manufacturer and provide evidence of the changes  or  research  that
would  warrant  additional rebates, and shall attempt to reach agreement
with the manufacturer on a rebate for the drug prior  to  referring  the
drug to the drug utilization review board for review.
(C)  If  the  commissioner  is  unsuccessful in entering into a rebate
arrangement with the  manufacturer  of  the  drug  satisfactory  to  the
department,  the  drug  manufacturer  shall in that event be required to
provide to the department, on a standard reporting form developed by the
department, the information as described in subdivision six  of  section
two  hundred  eighty of the public health law. All information disclosed
pursuant to this clause shall be considered confidential and  shall  not
be  disclosed  by  the  department  in a form that identifies a specific
manufacturer or prices charged for drugs by such manufacturer.
(D) For the purposes of this subparagraph, the term "high  cost  drug"
shall  mean  a  brand  name drug or biologic that has a launch wholesale
acquisition cost of thirty thousand dollars or more per year  or  course
of  treatment,  or  a  biosimilar  drug  that  has  a  launch  wholesale
acquisition cost that is not at least fifteen  percent  lower  than  the
referenced  brand  biologic at the time the biosimilar is launched, or a
generic drug that has  a  wholesale  acquisition  cost  of  one  hundred
dollars  or  more for a thirty day supply or recommended dosage approved
for labeling by the federal Food and Drug  Administration,  or  a  brand
name  drug or biologic that has a wholesale acquisition cost increase of
three thousand dollars or more in any twelve-month period, or course  of
treatment if less than twelve months.
(ix)  For  purposes  of this paragraph, a "gene therapy" is a drug (A)
approved under section 505 of the Federal Food, Drug and  Cosmetics  Act
or  licensed  under  subsection  (a) or (k) of section 351 of the Public
Health Services Act; (B) that treats a rare  disease  or  condition,  as
defined in 21 USC § 360bb(a)(2), that is life-threatening, as defined in
42  CFR 321.18; (C) is considered a gene therapy by the federal Food and
Drug Administration for which a biologics license  pursuant  to  21  CFR
600-680  is held; (D) if administered in accordance with the labeling of
such drug, is expected to result in either the cure of such  disease  or
condition  or  a  reduction in the symptoms of such disease or condition
that materially improves the patient's length or quality  of  life;  and
(E)  is  expected  to achieve the result described in clause (D) of this
subparagraph after not more than three administrations.
* NB Repealed March 31, 2029
* 8.  No  government  agency  shall  purchase,  pay   for,   or   make
reimbursement   or  grants-in-aid  for  any  service  in  a  residential
treatment facility for children and youth or a comprehensive psychiatric
emergency program unless at the time  such  service  was  provided,  the
residential  treatment  facility for children and youth or comprehensive
psychiatric emergency program possessed a  valid  operating  certificate
authorizing  such service. Notwithstanding any inconsistent provision of
law, no government agency shall make payments pursuant to this title  or
title  nineteen  of  the  federal  social  security act to a residential
treatment facility for children and youth for service to a person  whose
need  for  care  and  treatment  in  such  a  facility was not certified
pursuant to section 9.51 of the mental hygiene law.
* NB Effective until July 1, 2027
* 8.  No  government  agency  shall  purchase,  pay   for,   or   make
reimbursement   or  grants-in-aid  for  any  service  in  a  residential

treatment facility for children  and  youth  unless  at  the  time  such
service  was  provided,  the residential treatment facility for children
and youth possessed  a  valid  operating  certificate  authorizing  such
service.   Notwithstanding   any   inconsistent  provision  of  law,  no
government agency shall make payments pursuant to this  title  or  title
nineteen  of  the federal social security act to a residential treatment
facility for children and youth for service to a person whose  need  for
care  and  treatment  in  such  a facility was not certified pursuant to
section 9.51 of the mental hygiene law.
* NB Effective July 1, 2027
* 9. Notwithstanding any inconsistent provision of law  or  regulation
to  the  contrary,  for those drugs which may not be dispensed without a
prescription as required by  section  sixty-eight  hundred  ten  of  the
education  law and for which payment is authorized pursuant to paragraph
(g) of subdivision two of section three  hundred  sixty-five-a  of  this
title,  and for those drugs that are available without a prescription as
required by section sixty-eight hundred ten of the education law but are
reimbursed as items of medical assistance pursuant to paragraph  (a)  of
subdivision  four  of  section three hundred sixty-five-a of this title,
payments under this title shall be made at the following amounts:
** (a)  for  drugs  provided  by  medical  practitioners  and  claimed
separately  by  the  practitioners,  the actual cost of the drugs to the
practitioners; and
** NB Effective until October 1, 2024
** (a)  for  drugs  provided  by  medical  practitioners  and  claimed
separately by the practitioners the lower of:
(i)  (1) an amount equal to the national average drug acquisition cost
set by the federal centers for medicare and medicaid  services  for  the
drug,  if  any,  or  if  such  amount  is  not  available, the wholesale
acquisition cost of the drug based on the package size  dispensed  from,
as  reported  by  the  prescription  drug  pricing  service  used by the
department, (2) the federal upper limit,  if  any,  established  by  the
federal  centers  for  medicare  and  medicaid  services;  (3) the state
maximum acquisition cost, if any, established pursuant to paragraph  (e)
of  this  subdivision;  or  (4)  the  actual  cost  of  the  drug to the
practitioner.
(ii) Notwithstanding subparagraph (i) of this paragraph and  paragraph
(e)  of this subdivision, for the Medicaid fee-for-service program, if a
drug has been purchased from a manufacturer by a covered entity pursuant
to section 340B of the federal public health  service  act  (42  USCA  §
256b),  the  actual  amount paid by such covered entity. For purposes of
this subparagraph, a "covered  entity"  is  an  entity  that  meets  the
requirements  of  paragraph four of subdivision (a) of such section that
elects to participate in the program established by  such  section,  and
that causes claims for payment for drugs covered by this subparagraph to
be  submitted  to  the  medical  assistance  program, either directly or
through an authorized contract pharmacy. No medical assistance  payments
may be made to a covered entity or to an authorized contract pharmacy of
a  covered  entity  for  drugs  that are eligible for purchase under the
section 340B program  and  are  dispensed  on  an  outpatient  basis  to
patients  of the covered entity, other than under the provisions of this
subparagraph. Medical practitioners submitting claims for  reimbursement
of drugs purchased pursuant to section 340B of the public health service
act  shall notify the department that the claim is eligible for purchase
under the 340B program, consistent with claiming instructions issued  by
the department to identify such claims.
(iii)  In  no  event  shall a medical practitioner be reimbursed at an
amount that is lower than the state maximum  acquisition  cost,  or  for

drugs  that  do not have a state maximum acquisition cost, the wholesale
acquisition cost of the drug based on the package size.
** NB Effective October 1, 2024
** (b) for drugs dispensed by pharmacies:
(i)  (A)  if  the  drug  dispensed is a generic prescription drug, the
lower of: (1) an amount equal to the national average  drug  acquisition
cost  set  by the federal centers for medicare and medicaid services for
the drug, if any, or if such amount  if  not  available,  the  wholesale
acquisition  cost  of the drug based on the package size dispensed from,
as reported by  the  prescription  drug  pricing  service  used  by  the
department, less seventeen and one-half percent thereof; (2) the federal
upper limit, if any, established by the federal centers for medicare and
medicaid  services;  (3)  the  state  maximum  acquisition cost, if any,
established pursuant to paragraph (e) of this subdivision;  or  (4)  the
dispensing  pharmacy's  usual and customary price charged to the general
public; (B) if the drug dispensed is available without a prescription as
required by section sixty-eight hundred ten of the education law but  is
reimbursed as an item of medical assistance pursuant to paragraph (a) of
subdivision  four  of  section three hundred sixty-five-a of this title,
the  lower  of  (1)  an  amount  equal  to  the  national  average  drug
acquisition  cost  set  by the federal centers for medicare and medicaid
services for the drug, if any, or if such amount is not  available,  the
wholesale  acquisition  cost  of  the  drug  based  on  the package size
dispensed from, as reported by the  prescription  drug  pricing  service
used by the department, (2) the federal upper limit, if any, established
by the federal centers for medicare and medicaid services; (3) the state
maximum  acquisition  cost if any, established pursuant to paragraph (e)
of  this  subdivision;  or  (4)  the  dispensing  pharmacy's  usual  and
customary price charged to the general public;
(ii)  if  the  drug  dispensed  is a brand-name prescription drug, the
lower of:
(A) an amount equal to the national average drug acquisition cost  set
by  the federal centers for medicare and medicaid services for the drug,
if any, or if such amount is not available,  the  wholesale  acquisition
cost  of  the drug based on the package size dispensed from, as reported
by the prescription drug pricing service used by  the  department,  less
three and three-tenths percent thereof; or (B) the dispensing pharmacy's
usual and customary price charged to the general public; and
(iii) notwithstanding subparagraphs (i) and (ii) of this paragraph and
paragraphs  (d)  and (e) of this subdivision, if the drug dispensed is a
drug that has been purchased from a manufacturer  by  a  covered  entity
pursuant  to  section  340B of the federal public health service act (42
USCA § 256b), the actual amount paid by such covered entity pursuant  to
such section, plus the reasonable administrative costs, as determined by
the  commissioner,  incurred  by  the covered entity or by an authorized
contract pharmacy in connection with the purchase and dispensing of such
drug and the  tracking  of  such  transactions.  For  purposes  of  this
subparagraph,   a   "covered   entity"  is  an  entity  that  meets  the
requirements of paragraph four of subsection (a) of such  section,  that
elects  to  participate  in the program established by such section, and
that causes claims for payment for drugs covered by this subparagraph to
be submitted to the  medical  assistance  program,  either  directly  or
through  an authorized contract pharmacy. No medical assistance payments
may be made to a covered entity or to an authorized contract pharmacy of
a covered entity for drugs that are  eligible  for  purchase  under  the
section  340B  program  and  are  dispensed  on  an  outpatient basis to
patients of the covered entity, other than under the provisions of  this
subparagraph.  Pharmacies  submitting  claims for reimbursement of drugs

purchased pursuant to section 340B of  the  public  health  service  act
shall  notify  the  department  that  the claim is eligible for purchase
under the 340B program, consistent with claiming instructions issued  by
the department to identify such claims.
** NB Effective until October 1, 2024
** (b) for drugs dispensed by pharmacies:
(i)  (A)  if  the  drug  dispensed is a generic prescription drug, the
lower of: (1) an amount equal to the national average  drug  acquisition
cost  set  by the federal centers for medicare and medicaid services for
the drug, if any, or if such amount  if  not  available,  the  wholesale
acquisition  cost  of the drug based on the package size dispensed from,
as reported by  the  prescription  drug  pricing  service  used  by  the
department, less seventeen and one-half percent thereof; (2) the federal
upper limit, if any, established by the federal centers for medicare and
medicaid  services;  (3)  the  state  maximum  acquisition cost, if any,
established pursuant to paragraph (e) of this subdivision;  or  (4)  the
dispensing  pharmacy's  usual and customary price charged to the general
public; (B) if the drug dispensed is available without a prescription as
required by section sixty-eight hundred ten of the education law but  is
reimbursed as an item of medical assistance pursuant to paragraph (a) of
subdivision  four  of  section three hundred sixty-five-a of this title,
the  lower  of  (1)  an  amount  equal  to  the  national  average  drug
acquisition  cost  set  by the federal centers for medicare and medicaid
services for the drug, if any, or if such amount is not  available,  the
wholesale  acquisition  cost  of  the  drug  based  on  the package size
dispensed from, as reported by the  prescription  drug  pricing  service
used by the department, (2) the federal upper limit, if any, established
by the federal centers for medicare and medicaid services; (3) the state
maximum  acquisition  cost if any, established pursuant to paragraph (e)
of  this  subdivision;  or  (4)  the  dispensing  pharmacy's  usual  and
customary price charged to the general public;
(ii)  if  the  drug  dispensed  is a brand-name prescription drug, the
lower of:
(A) an amount equal to the national average drug acquisition cost  set
by  the federal centers for medicare and medicaid services for the drug,
if any, or if such amount is not available,  the  wholesale  acquisition
cost  of  the drug based on the package size dispensed from, as reported
by the prescription drug pricing service used by the department; or  (B)
the  dispensing  pharmacy's  usual  and  customary  price charged to the
general public; and
(iii) notwithstanding subparagraphs (i) and (ii) of this paragraph and
paragraphs (d) and (e) of this subdivision, if the drug dispensed  is  a
drug  that  has  been  purchased from a manufacturer by a covered entity
pursuant to section 340B of the federal public health  service  act  (42
USCA  § 256b), the actual amount paid by such covered entity pursuant to
such section, plus the reasonable administrative costs, as determined by
the commissioner, incurred by the covered entity  or  by  an  authorized
contract pharmacy in connection with the purchase and dispensing of such
drug  and  the  tracking  of  such  transactions.  For  purposes of this
subparagraph,  a  "covered  entity"  is  an  entity   that   meets   the
requirements  of  paragraph four of subsection (a) of such section, that
elects to participate in the program established by  such  section,  and
that causes claims for payment for drugs covered by this subparagraph to
be  submitted  to  the  medical  assistance  program, either directly or
through an authorized contract pharmacy. No medical assistance  payments
may be made to a covered entity or to an authorized contract pharmacy of
a  covered  entity  for  drugs  that are eligible for purchase under the
section 340B program  and  are  dispensed  on  an  outpatient  basis  to

patients  of the covered entity, other than under the provisions of this
subparagraph. Pharmacies submitting claims for  reimbursement  of  drugs
purchased  pursuant  to  section  340B  of the public health service act
shall  notify  the  department  that  the claim is eligible for purchase
under the 340B program, consistent with claiming instructions issued  by
the department to identify such claims.
** NB Effective October 1, 2024
** (c)  Notwithstanding  subparagraph  (i)  of  paragraph  (b) of this
subdivision,  if  a  qualified  prescriber  certifies  "brand  medically
necessary"  or  "brand necessary" in his or her own handwriting directly
on the face of a prescription for a multiple source  drug  for  which  a
specific  upper  limit  of  reimbursement  has  been  established by the
federal agency, in addition to writing "d a w" in the box  provided  for
such purpose on the prescription form, payment under this title for such
drug  must  be  made  under  the provisions of subparagraph (ii) of such
paragraph.
** NB Effective until October 1, 2024
** (c) Notwithstanding subparagraph  (i)  of  paragraph  (b)  of  this
subdivision,  if  a  qualified  prescriber  certifies  "brand  medically
necessary" or "brand necessary" in his or her own  handwriting  directly
on   the   face  of  a  prescription,  or  in  the  case  of  electronic
prescriptions,  inserts  an  electronic  direction  to  clarify   "brand
medically  necessary"  or  "brand necessary", for a multiple source drug
for which a specific upper limit of reimbursement has  been  established
by  the  federal  agency,  in  addition  to  writing  "d a w" in the box
provided for such purpose on the prescription form, payment  under  this
title  for  such  drug must be made under the provisions of subparagraph
(ii) of such paragraph.
** NB Effective October 1, 2024
(d) In addition to the amounts paid pursuant to paragraph (b) of  this
subdivision, the department shall pay a professional pharmacy dispensing
fee  for each such drug dispensed in the amount of ten dollars and eight
cents per prescription or written order  of  a  practitioner;  provided,
however  that  this  professional dispensing fee will not apply to drugs
that are  available  without  a  prescription  as  required  by  section
sixty-eight  hundred  ten  of  the  education  law  but  do not meet the
definition of a covered outpatient drug pursuant to Section 1927K of the
Social Security Act.
(e) For a multiple source generic drug for  which  no  specific  upper
payment  limit  has been established by the federal centers for medicare
and medicaid services,  the  commissioner  of  health  may  establish  a
maximum  acquisition  cost  for such drug which shall be effective until
such time as a specific federal upper payment limit has been established
for such drug.  The  department  shall  use  a  similar  methodology  in
establishing  such  an interim price as that utilized by the centers for
medicare and Medicaid services in establishing the federal upper payment
limit. For this purpose, the department is authorized to  enter  into  a
contract  with an entity to provide technical and administrative support
to the commissioner of health.
(g) Notwithstanding any other provision of  this  subdivision  to  the
contrary, the department is authorized to implement a specialty pharmacy
program  for the purpose of procuring certain specialty drugs at reduced
cost. The department is authorized to enter into contracts with  one  or
more  contractors  in  order  to  obtain  certain specialty drugs from a
limited number of sources  at  reduced  prices.  For  purposes  of  this
paragraph, specialty drugs include, but are not limited to, chemotherapy
agents,  hydration  therapy  agents,  pain  therapy  agents, intravenous
administration of antibiotics  or  other  drugs,  and  total  parenteral

nutrition.  All  contracts  entered into by the department to effectuate
the provisions of this section shall require  the  contractors  to  take
steps  to  assure that drugs provided pursuant to such contracts will be
readily accessible to consumers in a fashion that is no more restrictive
than  that  which  was  in  effect  prior  to  the implementation of the
specialty pharmacy program. This paragraph shall be  effective  only  to
the extent that federal financial participation is available in the cost
of drugs obtained pursuant to this paragraph. The commissioner of health
is  authorized  to  submit  amendments  to  the  state  plan for medical
assistance and to submit  applications  for  waivers  under  the  social
security act to obtain the federal approvals necessary to implement this
paragraph.  However, any pharmacy owned and operated by a not-for-profit
organization solely for the purpose of providing  drugs  to  individuals
diagnosed  with cystic fibrosis as part of a comprehensive clinical care
program approved by the  national  organization  that  accredits  cystic
fibrosis  care  centers  and  maintains  a  national  registry of cystic
fibrosis clinical data shall  be  exempt  from  the  specialty  pharmacy
program.
(h) The commissioner of health is authorized to establish a medication
therapy  management  pilot program in one or more counties or regions of
the state for the purpose of improving compliance  with  drug  therapies
and improving clinical outcomes. Payments under such program may be made
to  retail pharmacies for the provision of one-on-one medication regimen
counseling services for persons determined by  the  commissioner  to  be
eligible  to  receive  such  services. The commissioner is authorized to
establish fees for such counseling services, subject to the approval  of
the  director  of  the  division  of  the budget. The provisions of this
paragraph shall not take effect unless  all  necessary  approvals  under
federal  law  and  regulation  have  been  obtained  to  receive federal
financial participation in the costs of  services  provided  under  this
paragraph.
(i)(i)  The  department  of  health  shall  establish  a  program  for
synchronization of medications. Under  the  synchronization  program,  a
health  care  practitioner  may prescribe a refill of one or more of the
patient's medications for a shorter  period  than  would  ordinarily  be
provided,  for  the purpose of synchronizing refill dates of one or more
of the patient's medications subject to the synchronization when  it  is
agreed   among  the  recipient,  the  health  care  practitioner  and  a
pharmacist  that  synchronization  of  multiple  prescriptions  for  the
treatment  of  a  chronic illness is in the best interest of the patient
for the management or treatment of a chronic illness provided  that  the
following apply to such medications:
(A) are covered by the department of health pursuant to this title;
(B)  are  used  for treatment and management of a chronic illness that
are subject to refills;
(C) are not a schedule II controlled substance,  nor  a  schedule  III
controlled   substance   that   contains  hydrocodone  or  other  opioid
medication as scheduled in  section  thirty-three  hundred  six  of  the
public   health  law,  or  a  controlled  substance  under  the  federal
Controlled Substances Act;
(D) meet all prior authorization criteria specific to the  medications
at the time of the synchronization request;
(E)  are of a formulation that can be effectively and lawfully aligned
over required short fill periods to achieve synchronization; and
(F) do not have quantity limits or dose optimization criteria or state
or  federal  requirements  that  would   be   violated   in   fulfilling
synchronization.
(ii)  The  department  of  health  shall  not  deny  coverage  for the
dispensing of a medication by a pharmacy for a partial supply when it is
for  the  purpose  of  synchronizing  the  patient's  medications.  When
applicable  to  permit  synchronization,  the department of health shall
allow  a  pharmacy  to  override  any  denial  codes  indicating  that a
prescription is being refilled too soon for the purposes  of  medication
synchronization.
(iii)  The  dispensing  fee paid to the pharmacy contracted to provide
services pursuant to this section for a partial supply  associated  with
medication synchronization shall be paid in accordance with the Medicaid
state  plan  as  approved  by  the  Centers  for  Medicare  and Medicaid
Services.
(iv) The requirement of this paragraph  applies  only  once  for  each
prescription  drug  subject  to  medication  synchronization except when
either of the following occurs:
(I) the prescriber changes the dosage or frequency  of  administration
of the prescription drug subject to a medication synchronization; or
(II) the prescriber prescribes a different drug.
(v)  Nothing  in this paragraph shall be deemed to require health care
practitioners and pharmacists to synchronize the refilling  of  multiple
prescriptions for a recipient.
(vi)  The  provisions of this paragraph are subject to compliance with
all applicable federal and state laws  and  regulations,  including  the
Centers for Medicare and Medicaid Services approved Medicaid state plan.
The  commissioner shall apply for waivers and submit state Medicaid plan
amendments as are necessary to implement the program for synchronization
of medications.
* NB Effective until March 31, 2025
* 9. Notwithstanding any inconsistent provision of law  or  regulation
to  the  contrary,  for those drugs which may not be dispensed without a
prescription as required by  section  sixty-eight  hundred  ten  of  the
education  law and for which payment is authorized pursuant to paragraph
(g) of subdivision two of section three  hundred  sixty-five-a  of  this
title, payments under this title shall be made at the following amounts:
(a) for drugs provided by medical practitioners and claimed separately
by the practitioners, the actual cost of the drugs to the practitioners;
and
(b) for drugs dispensed by pharmacies:
(i)  if  the drug dispensed is a multiple source prescription drug for
which an upper limit has been set by the federal health  care  financing
administration,  an amount equal to the specific upper limit set by such
federal agency for the multiple source prescription drug, and
(ii) if the drug dispensed is a multiple source prescription drug or a
brand-name prescription drug for which no specific upper limit has  been
set  by such federal agency, the lower of the estimated acquisition cost
of such drug to pharmacies,  or  the  dispensing  pharmacy's  usual  and
customary  price  charged  to  the general public. Estimated acquisition
cost means the average wholesale price of a prescription drug based upon
the package size dispensed from, as reported by  the  prescription  drug
pricing  service  used  by the department, less ten percent thereof, and
updated monthly by the department.
(c)  Notwithstanding  subparagraph  (i)  of  paragraph  (b)  of   this
subdivision,  if  a  qualified  prescriber  certifies  "brand  medically
necessary" or "brand necessary" in his or her own  handwriting  directly
on  the  face  of  a prescription for a multiple source drug for which a
specific upper limit  of  reimbursement  has  been  established  by  the
federal  agency,  in addition to writing "d a w" in the box provided for
such purpose on the prescription form, payment under this title for such

drug must be made under the provisions  of  subparagraph  (ii)  of  such
paragraph.
(d)  In addition to the amounts paid pursuant to paragraph (b) of this
subdivision to pharmacies for those drugs which  may  not  be  dispensed
without  a  prescription, as required by section sixty-eight hundred ten
of the education law and for which payment  is  authorized  pursuant  to
paragraph  (g)  of subdivision two of section three hundred sixty-five-a
of this title, the department shall pay a pharmacy  dispensing  fee  for
each such prescription drug dispensed, which dispensing fee shall not be
less than the following amounts:
(i)  for prescription drugs categorized as generic by the prescription
drug pricing service used by the  department,  five  dollars  and  fifty
cents per prescription; and
(ii)  for  prescription  drugs  categorized as brand-name prescription
drug by the prescription drug pricing service used  by  the  department,
four dollars and fifty cents per prescription.
* NB Effective March 31, 2025
10.  Any  provider  except for those providers certified under article
twenty-eight of the public health law, of ordered services  or  supplies
under  the  medical  assistance  program  may  be  required  to  provide
financial security to assure that  funds  are  available  to  repay  any
overpayments  made  to  the  provider under this title and to assure the
financial security of the medical assistance program. For  the  purposes
of  this  subdivision,  "ordered  services or supplies" shall mean those
services or supplies  described  in  paragraphs  (g),  (i)  and  (j)  of
subdivision two of section three hundred sixty-five-a of this title.
(a)  Any financial security required by this subdivision must meet the
requirements of this  paragraph.  Financial  security  may  be  provided
through  a bond with a corporate surety, from a company authorized to do
business  in  this  state,  or  an  irrevocable  letter  of  credit   or
certificate  of  deposit  from  a  New York state or federally chartered
bank, trust company,  savings  bank  or  savings  and  loan  association
qualified  to  do  business in New York state and insured by the federal
deposit insurance corporation.
(b) The bond, letter of credit or  certificate  of  deposit  shall  be
payable  in favor of the people of the state of New York for the purpose
of indemnifying the medical assistance program against any  overpayments
made to the provider.
(c)  The  bond,  letter  of credit or certificate of deposit filed and
maintained pursuant to this section shall not be cancelled,  revoked  or
terminated  except  after  notice  to,  and  with  the  consent  of, the
department at least forty-five days in  advance  of  such  cancellation,
revocation or termination.
(d)  The  department  may  bring  and  maintain  an action against the
provider and the surety or bank, trust company, savings bank or  savings
and loan association for any claimed overpayments made to the provider.
(e)  Financial  security  shall not be required for providers which do
not submit claims for  payment  under  the  medical  assistance  program
exceeding  five hundred thousand dollars per annum or forty-two thousand
dollars per month.
(f) Financial security shall be in an amount equal to  the  provider's
estimated  claims  for payment for a one year period and may be adjusted
bi-annually in accordance with the  dollar  amount  of  claims  actually
submitted. If the commissioner is satisfied from an investigation of the
financial  condition  of  a  provider  that  the provider is solvent and
possessed of  sufficient  assets  to  provide  reasonable  assurance  of
recovery  of any overpayments, the commissioner may modify the amount of
financial security to be provided by such provider.
(g) Financial security must be submitted by a  provider  upon  initial
application  for enrollment as a provider of medical assistance and with
each subsequent enrollment. A change in ownership of  a  provider  shall
not  release, cancel or terminate liability under this section under any
bond,  letter  of  credit or certificate of deposit filed for a provider
while such bond, letter of credit or certificate of deposit is in effect
unless the transferee, purchaser, successor or assignee of such provider
obtains a bond, letter of credit or certificate of  deposit  under  this
section for the benefit of such new owner. All providers enrolled in the
medical  assistance  program  on  the effective date of this subdivision
will be required to submit financial  security  within  ninety  days  of
notice of such requirements by the department.
(h)  The  department may make the submission of the financial security
required by this subdivision a condition of participation in the medical
assistance program.
11. (a) Any  inconsistent  provisions  of  this  title  or  other  law
notwithstanding,  no  health  insurer,  self-insured  plan, managed care
organization, pharmacy benefit manager,  or  other  party  that  is,  by
statute,  contract,  or  agreement, legally responsible for payment of a
claim for a health care item or service, employer  or  organization  who
has  a  plan,  including  an  employee retirement income security act or
service benefit plan, providing care  and  other  medical  benefits  for
persons,  whether by insurance or otherwise, shall exclude a person from
eligibility, coverage or entitlement to medical benefits  by  reason  of
the  eligibility of such person for medical assistance under this title,
or by reason of the fact that such person would, except for  such  plan,
be eligible for benefits under this title.
(b)   Any   inconsistent   provisions  of  this  title  or  other  law
notwithstanding, no insurer may impose requirements on the department or
a social services district which has been  assigned  the  rights  of  an
individual  who  is eligible for medical assistance under this title and
who is covered for health benefits from the insurer, that are  different
from  requirements  applicable  to  an  agent  or  assignee of any other
individual so covered.
(c)  Any  inconsistent  provisions  of  this  title   or   other   law
notwithstanding,   the  department  may,  to  the  extent  necessary  to
reimburse  the  department  and  the  social  services   districts   for
expenditures  under  this title, certify to the commissioner of taxation
and finance pursuant to section one hundred seventy-one-f of the tax law
amounts to be withheld from tax refunds otherwise due to any  individual
who is required by court order to provide medical support in the form of
health  insurance  benefits  for  a  child  who  is eligible for medical
assistance under  this  title  and  who  has  received  payment  from  a
third-party  for  the  cost  of such services for such child but has not
used such payments to reimburse either the other parent or  guardian  of
such  child  or  the provider of such services or the appropriate social
services district; provided however, that  any  claims  for  current  or
past-due  child support shall take priority over any such claims for the
costs of such services and care. Such amounts shall be withheld pursuant
to section one hundred seventy-one-f  of  the  tax  law,  and  shall  be
credited  to  unreimbursed medical assistance incurred on behalf of such
child.  The  department  shall  by   regulation   establish   procedures
consistent  with  paragraphs  (a) and (b) of subdivision four of section
one hundred seventy-one-c of the tax law by which any individual who  is
the subject of a certification may contest such certification.
12. Prior to receiving medical assistance under subparagraphs five and
six  of  paragraph  (c)  of  subdivision  one  of  section three hundred
sixty-six of this title, a person whose net available income is at least

one hundred fifty percent of  the  applicable  federal  income  official
poverty  line, as defined and updated by the United States department of
health and human services, must pay a  monthly  premium,  in  accordance
with  a  procedure  to be established by the commissioner. The amount of
such premium shall be twenty-five  dollars  for  an  individual  who  is
otherwise  eligible for medical assistance under such subparagraphs, and
fifty dollars for a couple, both of  whom  are  otherwise  eligible  for
medical  assistance  under  such  subparagraphs.  No  premium  shall  be
required from a person whose net  available  income  is  less  than  one
hundred  fifty percent of the applicable federal income official poverty
line, as defined and updated by the United States department  of  health
and human services.