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A06450 Summary:

BILL NOA06450A
 
SAME ASSAME AS S03005-A
 
SPONSORKim
 
COSPNSRDickens, Gibbs, McDonald
 
MLTSPNSRCook
 
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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A06450 Actions:

BILL NOA06450A
 
04/11/2023referred to aging
01/03/2024referred to aging
02/27/2024amend and recommit to aging
02/27/2024print number 6450a
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A06450 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A6450A
 
SPONSOR: Kim
  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 OR GENERAL IDEA OF BILL: 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 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 latter 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 5. 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. 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 infoLluation 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 enrollment or make a referral to an agency that will. * a change implemented in October 2019 that eliminated the previous benefit to include payment of any Medicare Part D late enrollment penal- ty 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 operations, the chang- es 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 2023, 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 manufactur- ers 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 participate in the rebate program. Medicare counsellors assist enrollees in understanding what their future out of pocket costs will be when choosing a Part D plan, but cannot give a full picture without knowing whether a manufacturer is excluded from EPIC. This bill will require the list of manufacturers and drugs participating in the rebate program.   PRIOR LEGISLATIVE HISTORY: New Bill   FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS: 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 SFY 2020-21.   EFFECTIVE DATE: This act shall take effect immediately
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A06450 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         6450--A
 
                               2023-2024 Regular Sessions
 
                   IN ASSEMBLY
 
                                     April 11, 2023
                                       ___________
 
        Introduced  by M. of A. KIM, DICKENS, GIBBS, McDONALD -- Multi-Sponsored
          by -- M. of A.  COOK -- read once and referred  to  the  Committee  on
          Aging  --  recommitted  to  the  Committee on Aging in accordance with
          Assembly Rule 3, sec. 2 -- committee discharged, bill amended, ordered
          reprinted as amended and recommitted to said committee

        AN ACT to amend the elder law, in relation to  improving  and  expanding
          the  pharmaceutical  insurance  coverage  program for certain medicare
          enrollees
 
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section 1. Section 240 of the elder law is amended to read as follows:
     2    §  240. Short title. This title shall be known and may be cited as the
     3  "program for [elderly] expanded pharmaceutical insurance coverage".
     4    § 2. Subdivisions 3 and 8 of section 241 of the elder law, subdivision
     5  8 as added by section 2 of part A of chapter 59 of the laws of 2011  and
     6  as  renumbered by section 3 of part T of chapter 56 of the laws of 2012,
     7  are amended to read as follows:
     8    3. "Income" shall mean "household gross income" as defined in the real
     9  property tax circuit breaker credit program,  pursuant  to  subparagraph
    10  (C) of paragraph one of subsection (e) of section six hundred six of the
    11  tax  law,  but  only  shall include the income of program applicants and
    12  spouses and shall exclude the income of other members of the  household,
    13  but shall not include any increase in income derived from social securi-
    14  ty  income  or pension benefits that increase over the previous year due
    15  solely to a cost-of-living adjustment provided by the  program  adminis-
    16  trators.
    17    8.  "Medicare  part  D  excluded drug classes" shall mean any drugs or
    18  classes of drugs, or their medical uses, which are described in  section
    19  1927(d)(2)  or  1927(d)(3)  of the federal social security act, with the
    20  exception of smoking cessation agents and medical marijuana dispensed in
    21  the state of New York.
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD01416-03-4

        A. 6450--A                          2
 
     1    § 3. The elder law is amended by adding a new section 242-a to read as
     2  follows:
     3    §  242-a.  Expanded pharmaceutical insurance coverage panel.  1. There
     4  is hereby established within the executive department,  a  panel  to  be
     5  known as the "expanded pharmaceutical insurance coverage panel". For the
     6  purposes  of  this section, the term "the panel" shall mean the expanded
     7  pharmaceutical insurance coverage panel.
     8    2. The panel shall consist of the commissioners of the departments  of
     9  education  and health, the superintendent of the department of financial
    10  services, and the directors of the office for the aging and the division
    11  of the budget. Each panel member may designate an officer of his or  her
    12  respective department, office, or division to represent and exercise all
    13  the  powers  of such panel member at any meeting of the panel from which
    14  such panel member may be absent.
    15    3. The director of the office for the aging and  the  commissioner  of
    16  health shall serve as co-chairs of the panel.
    17    4.  The  panel  shall  meet  at  such times as may be requested by the
    18  co-chairs, provided that the panel shall meet at least two times a year.
    19    5. The panel shall:
    20    (a) subject to the approval of the director of the budget,  promulgate
    21  program  regulations  pursuant  to section two hundred forty-six of this
    22  title;
    23    (b) determine the annual schedule of cost-sharing responsibilities  of
    24  eligible  program  participants  pursuant to sections two hundred forty-
    25  seven and two hundred forty-eight of this title;
    26    (c) enter into contracts pursuant to section two  hundred  forty-three
    27  of this title;
    28    (d)  recommend  and implement alternative program improvements for the
    29  efficient and effective operation of the program in accordance with  the
    30  provisions  of  this  title with the advice of the advisory committee as
    31  defined in subdivision seven of this section;
    32    (e) develop and implement, in cooperation with area  offices  for  the
    33  aging,  an  outreach  program  to inform eligible applicants of benefits
    34  they may be entitled to pursuant to this title, and  to  make  available
    35  information concerning the program for expanded pharmaceutical insurance
    36  coverage   and  benefits  to  which  they  may  be  entitled  through  a
    37  prescription drug coverage program funded by the federal government; and
    38    (f) prepare an annual report and submit such report to  the  governor,
    39  the  temporary  president of the senate, and the speaker of the assembly
    40  no later than the first day of January of each  year.  The  panel  shall
    41  include  in  such  report,  at a minimum, annual statistical information
    42  regarding the number of persons  enrolled  in  the  program  by  marital
    43  status and income level and age, an estimate of the per cent of eligible
    44  New York residents that are enrolled, the total number of enrollees that
    45  receive  an income-related subsidy under section 1860D-14 of the federal
    46  social security act, and  the  number  that  so  qualify  through  their
    47  enrollment in the medicare savings program, the numbers of participating
    48  provider pharmacies, recipients and payments by county, a summary of the
    49  administrative  cost  containment initiatives completed during the year,
    50  projections of program costs for the following two years, and an  evalu-
    51  ation of the performance of the program contractor or contractors and of
    52  the cost effectiveness of all outreach efforts.
    53    6.  The panel members shall receive no compensation for their services
    54  as panel members.
    55    7. There shall be an advisory committee  to  the  panel  comprised  of
    56  twelve  persons.  Four members shall be appointed by the governor, three

        A. 6450--A                          3
 
     1  members shall be appointed by the temporary president of the senate, one
     2  member shall be appointed by the minority leader of  the  senate,  three
     3  members shall be appointed by the speaker of the assembly and one member
     4  shall  be appointed by the minority leader of the assembly.  The commit-
     5  tee members shall be representatives of consumers, pharmacists,  pharma-
     6  ceutical drug manufacturers and pharmaceutical wholesalers. No less than
     7  sixty  percent  of  the  committee membership shall represent consumers.
     8  Committee members shall receive no compensation for their  services  but
     9  shall  be  allowed  their  actual and necessary expenses incurred in the
    10  performance of their duties.
    11    § 4. Subdivisions 1 and 2 of section 242 of the elder law, subdivision
    12  1 as amended by section 4 of part T of chapter 56 of the laws  of  2012,
    13  and  subdivision  2  as amended by section 12 of part A of chapter 60 of
    14  the laws of 2014, are amended to read as follows:
    15    1. Persons eligible  for  comprehensive  coverage  under  section  two
    16  hundred forty-seven of this title shall include:
    17    (a)  any  unmarried  resident who is enrolled in medicare and at least
    18  sixty-five years of age in the year two  thousand  twenty-three,  during
    19  the year two thousand twenty-four is at least sixty years of age, during
    20  the  year  two thousand twenty-five is at least fifty-five years of age,
    21  during the year two thousand twenty-six is at least fifty years of  age,
    22  during  the  year two thousand twenty-seven is at least forty-five years
    23  of age, during the year two thousand  twenty-eight  is  at  least  forty
    24  years of age, during the year two thousand twenty-nine is at least thir-
    25  ty-five  years  of  age, during the year two thousand thirty is at least
    26  thirty years of age, during the year two thousand thirty-one is at least
    27  twenty-five years of age, or during the year two thousand thirty-two  is
    28  at  least  eighteen years of age; and whose income for the calendar year
    29  immediately preceding the effective date of the annual  coverage  period
    30  beginning  on or after January first, two thousand five, is less than or
    31  equal to twenty thousand dollars.   After the initial  determination  of
    32  eligibility,  each  eligible individual must be redetermined eligible at
    33  least every twenty-four months; and
    34    (b) any married resident who is enrolled in medicare and is  at  least
    35  sixty-five  years  of  age in the year two thousand twenty-three, during
    36  the year two thousand twenty-four is at least sixty years of age, during
    37  the year two thousand twenty-five is at least fifty-five years  of  age,
    38  during  the year two thousand twenty-six is at least fifty years of age,
    39  during the year two thousand twenty-seven is at least  forty-five  years
    40  of  age,  during  the  year  two thousand twenty-eight is at least forty
    41  years of age, during the year two thousand twenty-nine is at least thir-
    42  ty-five years of age, during the year two thousand thirty  is  at  least
    43  thirty years of age, during the year two thousand thirty-one is at least
    44  twenty-five  years of age, or during the year two thousand thirty-two is
    45  at least eighteen years of age; and whose income for the  calendar  year
    46  immediately  preceding  the effective date of the annual coverage period
    47  when combined with the income in the same calendar year of such  married
    48  person's  spouse  beginning on or after January first, two thousand one,
    49  is less than or equal to twenty-six thousand dollars. After the  initial
    50  determination  of eligibility, each eligible individual must be redeter-
    51  mined eligible at least every twenty-four months.
    52    2. Persons  eligible  for  catastrophic  coverage  under  section  two
    53  hundred forty-eight of this title shall include:
    54    (a)  any  unmarried  resident who is enrolled in medicare and at least
    55  sixty-five years of age in the year two  thousand  twenty-three,  during
    56  the year two thousand twenty-four is at least sixty years of age, during

        A. 6450--A                          4
 
     1  the  year  two thousand twenty-five is at least fifty-five years of age,
     2  during the year two thousand twenty-six is at least fifty years of  age,
     3  during  the  year two thousand twenty-seven is at least forty-five years
     4  of  age,  during  the  year  two thousand twenty-eight is at least forty
     5  years of age, during the year two thousand twenty-nine is at least thir-
     6  ty-five years of age, during the year two thousand thirty  is  at  least
     7  thirty years of age, during the year two thousand thirty-one is at least
     8  twenty-five  years of age, or during the year two thousand thirty-two is
     9  at least eighteen years of age; and whose income for the  calendar  year
    10  immediately  preceding  the effective date of the annual coverage period
    11  beginning on or after January first, two  thousand  one,  is  more  than
    12  twenty thousand and less than or equal to seventy-five thousand dollars.
    13  After the initial determination of eligibility, each eligible individual
    14  must be redetermined eligible at least every twenty-four months; and
    15    (b)  any  married  resident  who  is enrolled in medicare and at least
    16  sixty-five years of age in the year two  thousand  twenty-three,  during
    17  the year two thousand twenty-four is at least sixty years of age, during
    18  the  year  two thousand twenty-five is at least fifty-five years of age,
    19  during the year two thousand twenty-six is at least fifty years of  age,
    20  during  the  year two thousand twenty-seven is at least forty-five years
    21  of age, during the year two thousand  twenty-eight  is  at  least  forty
    22  years of age, during the year two thousand twenty-nine is at least thir-
    23  ty-five  years  of  age, during the year two thousand thirty is at least
    24  thirty years of age, during the year two thousand thirty-one is at least
    25  twenty-five years of age, or during the year two thousand thirty-two  is
    26  at  least  eighteen years of age; and whose income for the calendar year
    27  immediately preceding the effective date of the annual  coverage  period
    28  when  combined with the income in the same calendar year of such married
    29  person's spouse beginning on or after January first, two  thousand  one,
    30  is  more  than twenty-six thousand dollars and less than or equal to one
    31  hundred thousand dollars. After the initial determination  of  eligibil-
    32  ity,  each  eligible  individual  must be redetermined eligible at least
    33  every twenty-four months.
    34    § 5. Paragraphs (e) and (f) of subdivision 3 of  section  242  of  the
    35  elder  law, paragraph (e) as amended by section 3-d of part A of chapter
    36  59 of the laws of 2011, and paragraph (f) as amended  by  section  1  of
    37  part  T  of  chapter  56  of  the  laws  of 2012, are amended to read as
    38  follows:
    39    (e) As a condition of eligibility for benefits under this title, if  a
    40  program  participant's  income  indicates  that the participant could be
    41  eligible for an income-related subsidy under  section  1860D-14  of  the
    42  federal  social  security  act by either applying for such subsidy or by
    43  enrolling in a medicare savings program as a qualified medicare  benefi-
    44  ciary  (QMB),  a  specified low-income medicare beneficiary (SLMB), or a
    45  qualifying  individual  (QI),  a  program  participant  is  required  to
    46  provide,  and  to authorize the [elderly] expanded pharmaceutical insur-
    47  ance coverage  program  to  obtain,  any  information  or  documentation
    48  required  to  establish  the participant's eligibility for such subsidy,
    49  and to authorize the [elderly] expanded pharmaceutical insurance  cover-
    50  age program to apply on behalf of the participant for the subsidy or the
    51  medicare  savings  program.  [The elderly] Upon receipt of an enrollment
    52  application, or at any time after enrollment when the program has infor-
    53  mation that indicates an  enrollee  is  eligible  for  a  subsidy  under
    54  section  1860D-14  of  the  federal social security act or in a medicare
    55  savings program, the expanded pharmaceutical insurance coverage  program
    56  shall  make a reasonable effort to notify the program participant of his

        A. 6450--A                          5

     1  or her need to provide any of the above required  information.  After  a
     2  reasonable  effort  has  been made to contact the participant, a partic-
     3  ipant shall be notified in writing that he or  she  has  sixty  days  to
     4  provide  such  required information. If such information is not provided
     5  within the sixty day period, the participant's coverage  may  be  termi-
     6  nated.   A program participant who is eligible to enroll in the medicare
     7  savings program shall be assisted to do so, and their  expanded  pharma-
     8  ceutical  insurance  coverage  program  enrollment  shall  be  in  place
     9  throughout the medicare savings program application process.
    10    (f) As a condition of eligibility for benefits  under  this  title,  a
    11  program participant is required to be enrolled in Medicare part D and to
    12  maintain  such  enrollment.  For  unmarried participants with individual
    13  annual income less than or equal to twenty-three  thousand  dollars  and
    14  married  participants  with  joint  annual  income less than or equal to
    15  twenty-nine thousand  dollars,  the  [elderly]  expanded  pharmaceutical
    16  insurance  coverage  program  shall  pay  for  the portion of the part D
    17  monthly premium, and any late enrollment  penalty  that  may  have  been
    18  assessed,  that  is  the  responsibility  of the participant. Such total
    19  payment shall be limited to  the  low-income  benchmark  premium  amount
    20  established  by  the  federal centers for medicare and medicaid services
    21  and any other amount which such agency establishes under its de  minimus
    22  premium policy.
    23    §  6.  Subdivision  3  of  section  250 of the elder law is amended by
    24  adding a new paragraph (f) to read as follows:
    25    (f) The expanded pharmaceutical insurance coverage program shall  post
    26  to its website the names of manufacturers that have a rebate program and
    27  list  the drugs that are covered by such rebate program in a manner that
    28  provides enrollees with access to such information prior to  the  annual
    29  medicare open enrollment period.
    30    § 7. This act shall take effect immediately.
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