Relates to medicaid payment for co-payments due under Medicare Part D; authorizes the commissioner of health to create a system to incorporate co-payments billed to a recipient under Medicare Part D towards the recipient's total annual co-payments under medical assistance.
TITLE OF BILL: An act to amend the public health law and the social services law, in relation to medicaid payment for co-payments due under Medicare Part D
PURPOSE OR GENERAL IDEA OF BILL:
To aid dual-eligible Medicare Part D recipients with prescription drug co-payments.
SUMMARY OF SPECIFIC PROVISIONS:
The bill provides for Medicaid to pay the Medicare Part D co-payments for dual-eligible Medicare-Medicaid recipients, once the recipient has reached the Medicaid $200-a-year co-payment cap (counting Part D co-payments). Coverage for these co-payments would be exempt from Medicaid prior authorization. it directs the Commissioner of Health to create a system that allows pharmacists to register a dual-eligible individual's Medicare Part D co-payments in the Medicaid system, and establishes that Medicaid shall provide for payment of the Part D co-payment after $200 in co-payments have been made.
Medicaid's co-payment system has always allowed an individual to receive their medications, even if they do not have the ability to pay their co-payment. But under Medicare Part D (which they are required to participate in), these individuals are required to pay the co-payments required by their Part D plan. When they cannot afford to pay, they go without necessary medications and then receive much more costly medical care, at the expense of the Medicaid program. This law will remove a loophole from the Medicaid law, where individuals who are eligible for both Medicare and Medicaid receive an inferior level of care than those only eligible for Medicaid by extending the co-payment can to prescription drugs provided under the Part D program, a right that all other Medicaid recipients currently enjoy.
PRIOR LEGISLATIVE HISTORY:
2006: A11377 (Friedman) - passed Assembly 2007: A3598-A (Gottfried) - referred to Ways and Means 2008: A3598-A (Gottfried) - referred to Ways and Means 2009-10: A.884 - referred to Ways and Means 2011-12; A.576 - referred to Health
This bill shall take effect on the first of April next succeeding the data on which it shall have become law.
STATE OF NEW YORK ________________________________________________________________________ 6446 IN SENATE January 24, 2014 ___________Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Health AN ACT to amend the public health law and the social services law, in relation to medicaid payment for co-payments due under Medicare Part D THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subdivision 7 of section 273 of the public health law, as amended by section 7 of part C of chapter 58 of the laws of 2008, is amended to read as follows: 7. No prior authorization under the preferred drug program shall be required when a prescriber prescribes a drug on the preferred drug list, OR WHEN MEDICAL ASSISTANCE PAYMENT IS MADE, UNDER PARAGRAPH (G) OF SUBDIVISION TWO OF SECTION THREE HUNDRED SIXTY-FIVE-A OF THE SOCIAL SERVICES LAW SOLELY FOR THE CO-PAYMENT FOR PRESCRIPTIONS PROVIDED UNDER PART D OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT; provided, however, that the commissioner may identify
[such]a drug for which prior authorization is required pursuant to the provisions of the clin- ical drug review program established under section two hundred seventy- four of this article. S 2. Subparagraph (ii) of paragraph (f) of subdivision 6 of section 367-a of the social services law, as amended by section 42 of part C of chapter 58 of the laws of 2005, is amended to read as follows: (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, INCLUDING THOSE required by this subdivision [, nor]AND, FOR RECIPIENTS ELIGIBLE FOR COVERAGE UNDER PART D OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT (REFERRED TO IN THIS SECTION AS "MEDICARE PART D"), THOSE CO-PAYMENTS REQUIRED BY MEDI- CARE PART D. NOR shall reductions in payments as a result of such co-payments exceed two hundred dollars for any recipient. THE COMMIS- SIONER OF HEALTH SHALL CREATE A SYSTEM TO INCORPORATE CO-PAYMENTS BILLED TO A RECIPIENT UNDER MEDICARE PART D TOWARDS THE RECIPIENT'S TOTAL ANNU- AL CO-PAYMENTS UNDER MEDICAL ASSISTANCE. AS PART OF THIS SYSTEM, PHAR- MACISTS SHALL RECORD ALL CO-PAYMENTS DUE UNDER MEDICARE PART D FROM SUCHEXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD04596-01-3 S. 6446 2
RECIPIENTS WITH THE MEDICAL ASSISTANCE PROGRAM, THROUGH THE MEDICAL ASSISTANCE ELECTRONIC BILLING SYSTEM. THE COMMISSIONER OF HEALTH SHALL INCLUDE THE CO-PAYMENTS BILLED UNDER MEDICARE PART D ALONG WITH THE CO-PAYMENTS REQUIRED UNDER THIS SUBDIVISION IN DETERMINING WHEN THE RECIPIENT'S TOTAL ANNUAL CO-PAYMENTS HAVE REACHED TWO HUNDRED DOLLARS. S 3. Paragraph (g-1) of subdivision 2 of section 365-a of the social services law, as amended by section 23 of part H of chapter 59 of the laws of 2011, is amended to read as follows: (g-1) drugs provided on an in-patient basis, those drugs contained on the list established by regulation of the commissioner of health pursu- ant to subdivision four of this section, AND, FOR RECIPIENTS ELIGIBLE FOR COVERAGE UNDER PART D OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT (REFERRED TO IN THIS SECTION AS "MEDICARE PART D"), PAYMENT OF THE CO-PAYMENT FOR DRUGS PROVIDED BY A MEDICARE PART D PLAN, AFTER THE INDI- VIDUAL HAS REACHED THE ANNUAL CAP ON CO-PAYMENTS AS DEFINED IN SUBPARA- GRAPH (II) OF PARAGRAPH (F) OF SUBDIVISION SIX OF SECTION THREE HUNDRED SIXTY-SEVEN-A OF THIS TITLE, and those drugs which may not be dispensed without a prescription as required by section sixty-eight hundred ten of the education law and which the commissioner of health shall determine to be reimbursable based upon such factors as the availability of such drugs or alternatives at low cost if purchased by a medicaid recipient, or the essential nature of such drugs as described by such commissioner in regulations, provided, however, that such drugs, exclusive of long- term maintenance drugs, shall be dispensed in quantities no greater than a thirty day supply or one hundred doses, whichever is greater; provided further that the commissioner of health is authorized to require prior authorization for any refill of a prescription when less than seventy- five percent of the previously dispensed amount per fill should have been used were the product used as normally indicated; provided further that the commissioner of health is authorized to require prior authori- zation of prescriptions of opioid analgesics in excess of four prescriptions in a thirty-day period in accordance with section two hundred seventy-three of the public health law; medical assistance shall not include any drug provided on other than an in-patient basis for which a recipient is charged or a claim is made in the case of a prescription drug, in excess of the maximum reimbursable amounts to be established by department regulations in accordance with standards established by the secretary of the United States department of health and human services, or, in the case of a drug not requiring a prescription, in excess of the maximum reimbursable amount established by the commissioner of health pursuant to paragraph (a) of subdivision four of this section; S 4. This act shall take effect on the first of April next succeeding the date on which it shall have become a law.