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.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A3605A
SPONSOR: Seawright 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 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 5. Restores the enroll-
ment process so that the burden of screening 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.
DIFFERENCE BETWEEN ORIGINAL AND AMENDED VERSION (IF APPLICABLE):
Amended version changes language of the EPIC program to become the
Expanded Pharmaceutical insurance coverage, excludes income derived from
social security benefits and pension benefits that increased over the
previous year due solely to a cost-of-living adjustment provided by
program administrators from the definition of Income, outlines the scope
of the panel, outlines duties and responsibilities of the panel, and
outlines individuals eligible for comprehensive coverage.
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 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 participation 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 Executive 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 incor-
porates 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 enroll-
ment 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 partic-
ipating in the rebate program.
PRIOR LEGISLATIVE HISTORY:
2023-2024: A6450/Kim, Referred to Aging S3005/Cleare, Referred to
Finance(24) Referred to Aging (24) Referred to Health (23) Referred to
Aging (23) 2021-2022: A5422/Kim, Referred to Aging S4603/May, Referred
to Aging
FISCAL IMPLICATIONS FOR STATE AND LOCAL GOVERNMENTS:
To be determined.
EFFECTIVE DATE:
This act shall take effect immediately.
STATE OF NEW YORK
________________________________________________________________________
3605--A
2025-2026 Regular Sessions
IN ASSEMBLY
January 29, 2025
___________
Introduced by M. of A. SEAWRIGHT, McDONALD, REYES, DILAN, GRIFFIN, HOOKS
-- 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.
LBD00974-03-5
A. 3605--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 their
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. 3605--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-four, during the
19 year two thousand twenty-five is at least sixty years of age, during the
20 year two thousand twenty-six is at least fifty-five years of age, during
21 the year two thousand twenty-seven is at least fifty years of age,
22 during the year two thousand twenty-eight is at least forty-five years
23 of age, during the year two thousand twenty-nine is at least forty years
24 of age, during the year two thousand thirty is at least thirty-five
25 years of age, during the year two thousand thirty-one is at least thirty
26 years of age, during the year two thousand thirty-two is at least twen-
27 ty-five years of age, or during the year two thousand thirty-three is at
28 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-four, during the
36 year two thousand twenty-five is at least sixty years of age, during the
37 year two thousand twenty-six is at least fifty-five years of age, during
38 the year two thousand twenty-seven is at least fifty years of age,
39 during the year two thousand twenty-eight is at least forty-five years
40 of age, during the year two thousand twenty-nine is at least forty years
41 of age, during the year two thousand thirty is at least thirty-five
42 years of age, during the year two thousand thirty-one is at least thirty
43 years of age, during the year two thousand thirty-two is at least twen-
44 ty-five years of age, or during the year two thousand thirty-three is at
45 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-four, during the
56 year two thousand twenty-five is at least sixty years of age, during the
A. 3605--A 4
1 year two thousand twenty-six is at least fifty-five years of age, during
2 the year two thousand twenty-seven is at least fifty years of age,
3 during the year two thousand twenty-eight is at least forty-five years
4 of age, during the year two thousand twenty-nine is at least forty years
5 of age, during the year two thousand thirty is at least thirty-five
6 years of age, during the year two thousand thirty-one is at least thirty
7 years of age, during the year two thousand thirty-two is at least twen-
8 ty-five years of age, or during the year two thousand thirty-three is at
9 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-four, during the
17 year two thousand twenty-five is at least sixty years of age, during the
18 year two thousand twenty-six is at least fifty-five years of age, during
19 the year two thousand twenty-seven is at least fifty years of age,
20 during the year two thousand twenty-eight is at least forty-five years
21 of age, during the year two thousand twenty-nine is at least forty years
22 of age, during the year two thousand thirty is at least thirty-five
23 years of age, during the year two thousand thirty-one is at least thirty
24 years of age, during the year two thousand thirty-two is at least twen-
25 ty-five years of age, or during the year two thousand thirty-three is at
26 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. 3605--A 5
1 or her] such participant's need to provide any of the above required
2 information. After a reasonable effort has been made to contact the
3 participant, a participant shall be notified in writing that [he or she]
4 such participant has sixty days to provide such required information. If
5 such information is not provided within the sixty day period, the
6 participant's coverage may be terminated. A program participant who is
7 eligible to enroll in the medicare savings program shall be assisted to
8 do so, and their expanded pharmaceutical insurance coverage program
9 enrollment shall be in place throughout the medicare savings program
10 application process.
11 (f) As a condition of eligibility for benefits under this title, a
12 program participant is required to be enrolled in Medicare part D and to
13 maintain such enrollment. For unmarried participants with individual
14 annual income less than or equal to twenty-three thousand dollars and
15 married participants with joint annual income less than or equal to
16 twenty-nine thousand dollars, the [elderly] expanded pharmaceutical
17 insurance coverage program shall pay for the portion of the part D
18 monthly premium, and any late enrollment penalty that may have been
19 assessed, that is the responsibility of the participant. Such total
20 payment shall be limited to the low-income benchmark premium amount
21 established by the federal centers for medicare and medicaid services
22 and any other amount which such agency establishes under its de minimus
23 premium policy.
24 § 6. Subdivision 3 of section 250 of the elder law is amended by
25 adding a new paragraph (f) to read as follows:
26 (f) The expanded pharmaceutical insurance coverage program shall post
27 to its website the names of manufacturers that have a rebate program and
28 list the drugs that are covered by such rebate program in a manner that
29 provides enrollees with access to such information prior to the annual
30 medicare open enrollment period.
31 § 7. This act shall take effect immediately.
