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A05422 Summary:

Amd §§240, 241, 242 & 250, add §242-a, Eld L
Relates to improving and expanding the pharmaceutical insurance coverage program for certain medicare enrollees; creates the expanded pharmaceutical insurance coverage panel, to be responsible for expanding pharmaceutical insurance coverage.
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A05422 Memo:

submitted in accordance with Assembly Rule III, Sec 1(f)
  TITLE OF BILL: An act to amend the elder law, in relation to improving and expanding the pharmaceutical insurance coverage program for certain medicare enrollees   PURPOSE: The Elderly Pharmaceutical Insurance Coverage program has changed dramatically since it was created. This bill will restore oversight and transparency to the function of the program and expand it to phase in coverage for persons younger than age 65 who are enrolled in Medicare Part D. The bill also changes the name of the program to be known as the Expanded Pharmaceutical Insurance Coverage program.   SUMMARY OF SPECIFIC PROVISIONS: Section 1. Changes the name from the Elderly Pharmaceutical Insurance Coverage program to the Expanded Pharmaceutical Insurance Coverage program. Section 2. Prohibits income derived from any increase in the calculation of a cost of living benefit in social security income or pension bene- fits from being used to determine enrollee eligibility for the program or for benefits defined based on income, and provides that EPIC shall include medical marijuana as a covered drug. Section 3. Restores the EPIC panel and the advisory committee, 60% of the later being composed of consumers, and requires an annual report. Section 4. Re-defines the age of eligibility to phase-in persons under the age of 65 who are enrolled in Medicare Part D. Section S. Restores the enrollment process so that the burden of screen- ing for potential eligibility for the federal Low Income Subsidy (also known as Extra Help) rests with the EPIC program and not the enrollee, ensures that EPIC applicants are enrolled in the program and eligible for its benefits while additional information is collected to qualify them for LIS if applicable, and restores the EPIC program responsibility for offsetting any Part D late enrollment penalty costs within limits. Section 6. Requires the EPIC program to post the manufacturers and drugs that are covered under an agreed to rebate program.   JUSTIFICATION: THE EPIC program has made numerous changes administratively that have negatively impacted enrollees without a public process to review proposed changes. These changes include: *a change in the application starting in 2020, that requires enrollees to determine if they must disclose asset, not otherwise a program requirement, if they fall into the income category that would allow them to apply for the federal Low Income Subsidy (LIS.) In prior years, an EPIC applicant was enrolled in without an asset test and if the EPIC staff found that the self-reported income could qualify for LIS (150% FPL,) the enrollee would be contacted for additional information on assets so that an application to LIS was completed on behalf of the enrollee. Additionally, while the current statute includes a role for EPIC staff to assist enrollees who are eligible for the Medicare Savings Program (MSP, 135% FPL,) which without an asset test, will also qualify an enrollee for LIS, the EPIC program does not assist with MSP enroll- ment or make a referral to an agency that will. *a change implemented in October 2019 that eliminated the previous bene- fit to include payment of any Medicare Part D late enrollment penalty for certain enrollees. *a change in January 2020 that eliminates past records of EPIC partic- ipation for any enrollee that failed to pay their quarterly dues on time. Their EPIC number and all income information on their records is now eradicated, and upon late payment of the dues an enrollee must reap- ply for the program as if they were never a member. In addition to making corrections to restore and improve program oper- ations, the changes noted above are addressed in this bill. Further, in order to improve transparency and accountability, the EPIC panel and advisory committee are re-convened, along with a requirement for an annual report to the Legislature. During SFY 2019-20, the Executive enacted a reduction in funding for the EPIC program, derived from savings due to provisions in the Affordable Care Act that covered more of the costs of Medicare Part D drugs in the coverage gap, also known as the "donut hole." In SFY 2020-21, the Execu- tive has proposed a further reduction attributed to continuing savings due to the federal expansion of donut hole coverage. Rather than concur with the savings proposed, the Legislature finds that it is time to expand the EPIC program to offer benefits to residents with Medicare Part D who are under age 65. The bill does that incrementally, starting by lowering the age to 60 in 2021, and continuing to bring the age limit down in five year brackets in successive years. The legislation also addresses the need to have the EPIC program provide assistance with out of pocket costs for medical marijuana, which is not covered by Medicare. The legislation also incorporates provisions of another bill that exempts from income to be considered by the EPIC program that which is derived from a cost of living adjustment to social security or pension payments. The EPIC program requires drug manufacturers to participate in the state's rebate program in order for their drug to be covered. While this public policy has been well established, EPIC enrollees are unaware about whether they will have coverage until they get a refusal at their pharmacy. This information would be particularly important to have during open enrollment when an enrollee is choosing Medicare Part D coverage. The tools to compare plans indicate how much out or pocket costs will be, and the EPIC guideline provides coverage for drugs covered by a Part D plan, unless the drug manufacturer does not partic- ipate in the rebate program. Medicare counsellors assist enrollees in understanding what their future out of pocket costs will be when choos- ing a Part D plan, but cannot give a full picture without knowing wheth- er a manufacturer is excluded from EPIC. This bill will require the list of manufacturers and drugs participating in the rebate program.   FISCAL IMPLICATIONS: To be determined, but has been made difficult without publicly available annual reports on the program. In part, costs associated with program expansion to a lower age limit will be offset by rejecting the proposed program savings of $16.5m proposed for SFY2020-21.   EFFECTIVE DATE: This act shall take effect immediately, with the provisions in sections 2 and 4 taking effect on January 1, 2021.
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