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A05422 Summary:

BILL NOA05422
 
SAME ASSAME AS S04603
 
SPONSORKim
 
COSPNSR
 
MLTSPNSR
 
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 Actions:

BILL NOA05422
 
02/16/2021referred to aging
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A05422 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A5422
 
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: 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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A05422 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          5422
 
                               2021-2022 Regular Sessions
 
                   IN ASSEMBLY
 
                                    February 16, 2021
                                       ___________
 
        Introduced by M. of A. KIM -- read once and referred to the Committee on
          Aging
 
        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
     2  follows:
     3    §  240. Short title. This title shall be known and may be cited as the
     4  "program for [elderly] expanded pharmaceutical insurance coverage".
     5    § 2. Subdivisions 3 and 8 of section 241 of the elder law, subdivision
     6  8 as added by section 2 of part A of chapter 59 of the laws of 2011  and
     7  as  renumbered by section 3 of part T of chapter 56 of the laws of 2012,
     8  are amended to read as follows:
     9    3. "Income" shall mean "household gross income" as defined in the real
    10  property tax circuit breaker credit program,  pursuant  to  subparagraph
    11  (C) of paragraph one of subsection (e) of section six hundred six of the
    12  tax  law,  but  only  shall include the income of program applicants and
    13  spouses and shall exclude the income of other members of the  household,
    14  but shall not include any increase in income derived from social securi-
    15  ty  income  or pension benefits that increase over the previous year due
    16  solely to a cost of living adjustment provided by the  program  adminis-
    17  trators.
    18    8.  "Medicare  part  D  excluded drug classes" shall mean any drugs or
    19  classes of drugs, or their medical uses, which are described in  section
    20  1927(d)(2)  or  1927(d)(3)  of the federal social security act, with the
    21  exception of smoking cessation agents and medical marijuana dispensed in
    22  the state of New York.
    23    § 3. The elder law is amended by adding a new section 242-a to read as
    24  follows:
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD08041-01-1

        A. 5422                             2
 
     1    § 242-a. Expanded pharmaceutical insurance coverage panel.   1.  There
     2  is  hereby  established  within  the executive department, a panel to be
     3  known as the "expanded pharmaceutical insurance coverage panel". For the
     4  purposes of this section, the term "the panel" shall mean  the  expanded
     5  pharmaceutical insurance coverage panel.
     6    2.  The panel shall consist of the commissioners of the departments of
     7  education and health, the superintendent of the department of  financial
     8  services, and the directors of the office for the aging and the division
     9  of  the budget. Each panel member may designate an officer of his or her
    10  respective department, office, or division to represent and exercise all
    11  the powers of such panel member at any meeting of the panel  from  which
    12  such panel member may be absent.
    13    3.  The  director  of the office for the aging and the commissioner of
    14  health shall serve as co-chairs of the panel.
    15    4. The panel shall meet at such times  as  may  be  requested  by  the
    16  co-chairs, provided that the panel shall meet at least two times a year.
    17    5. The panel shall:
    18    (a)  subject to the approval of the director of the budget, promulgate
    19  program regulations pursuant to section two hundred  forty-six  of  this
    20  title;
    21    (b)  determine the annual schedule of cost-sharing responsibilities of
    22  eligible program participants pursuant to sections  two  hundred  forty-
    23  seven and two hundred forty-eight of this title;
    24    (c)  enter  into contracts pursuant to section two hundred forty-three
    25  of this title;
    26    (d) recommend and implement alternative program improvements  for  the
    27  efficient  and effective operation of the program in accordance with the
    28  provisions of this title with the advice of the  advisory  committee  as
    29  defined in subdivision seven of this section;
    30    (e)  develop  and  implement, in cooperation with area offices for the
    31  aging, an outreach program to inform  eligible  applicants  of  benefits
    32  they  may  be  entitled to pursuant to this title, and to make available
    33  information concerning the program for expanded pharmaceutical insurance
    34  coverage  and  benefits  to  which  they  may  be  entitled  through   a
    35  prescription drug coverage program funded by the federal government; and
    36    (f)  prepare  an annual report and submit such report to the governor,
    37  the temporary president of the senate, and the speaker of  the  assembly
    38  no  later  than  the  first day of January of each year. The panel shall
    39  include in such report, at a  minimum,  annual  statistical  information
    40  regarding  the  number  of  persons  enrolled  in the program by marital
    41  status and income level and age, an estimate of the per cent of eligible
    42  New York residents that are enrolled, the total number of enrollees that
    43  receive an income-related subsidy under section 1860D-14 of the  federal
    44  social  security  act,  and  the  number  that  so qualify through their
    45  enrollment in the Medicare Savings Program, the numbers of participating
    46  provider pharmacies, recipients and payments by county, a summary of the
    47  administrative cost containment initiatives completed during  the  year,
    48  projections  of program costs for the following two years, and an evalu-
    49  ation of the performance of the program contractor or contractors and of
    50  the cost effectiveness of all outreach efforts.
    51    6. The panel members shall receive no compensation for their  services
    52  as panel members.
    53    7.  There  shall  be  an  advisory committee to the panel comprised of
    54  twelve persons.  Four members shall be appointed by the governor,  three
    55  members shall be appointed by the temporary president of the senate, one
    56  member  shall  be  appointed by the minority leader of the senate, three

        A. 5422                             3
 
     1  members shall be appointed by the speaker of the assembly and one member
     2  shall be appointed by the minority leader of the assembly.  The  commit-
     3  tee  members shall be representatives of consumers, pharmacists, pharma-
     4  ceutical drug manufacturers and pharmaceutical wholesalers. No less than
     5  sixty  percent  of  the  committee membership shall represent consumers.
     6  Committee members shall receive no compensation for their  services  but
     7  shall  be  allowed  their  actual and necessary expenses incurred in the
     8  performance of their duties.
     9    § 4. Subdivisions 1 and 2 of section 242 of the elder law, subdivision
    10  1 as amended by section 4 of part T of chapter 56 of the laws  of  2012,
    11  and  subdivision  2  as amended by section 12 of part A of chapter 60 of
    12  the laws of 2014, are amended to read as follows:
    13    1. Persons eligible  for  comprehensive  coverage  under  section  two
    14  hundred forty-seven of this title shall include:
    15    (a)  any  unmarried  resident who is enrolled in medicare and at least
    16  sixty-five years of age in the year two thousand twenty, during the year
    17  two thousand twenty-one is at least sixty years of age, during the  year
    18  two  thousand twenty-two is at least fifty-five years of age, during the
    19  year two thousand twenty-three is at least fifty years  of  age,  during
    20  the  year  two thousand twenty-four is at least forty-five years of age,
    21  during the year two thousand twenty-five is at least forty years of age,
    22  during the year two thousand twenty-six is at least thirty-five years of
    23  age, during the year two thousand twenty-seven is at least thirty  years
    24  of  age,  during  the year two thousand twenty-eight is at least twenty-
    25  five years of age, or during the year two  thousand  twenty-nine  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  beginning  on or after January first, two thousand five, is less than or
    29  equal to twenty thousand dollars.   After the initial  determination  of
    30  eligibility,  each  eligible individual must be redetermined eligible at
    31  least every twenty-four months; and
    32    (b) any married resident who is enrolled in medicare and is  at  least
    33  sixty-five years of age in the year two thousand twenty, during the year
    34  two  thousand twenty-one is at least sixty years of age, during the year
    35  two thousand twenty-two is at least fifty-five years of age, during  the
    36  year  two  thousand  twenty-three is at least fifty years of age, during
    37  the year two thousand twenty-four is at least forty-five years  of  age,
    38  during the year two thousand twenty-five is at least forty years of age,
    39  during the year two thousand twenty-six is at least thirty-five years of
    40  age,  during the year two thousand twenty-seven is at least thirty years
    41  of age, during the year two thousand twenty-eight is  at  least  twenty-
    42  five  years  of  age,  or during the year two thousand twenty-nine is at
    43  least eighteen years of age; and whose  income  for  the  calendar  year
    44  immediately  preceding  the effective date of the annual coverage period
    45  when combined with the income in the same calendar year of such  married
    46  person's  spouse  beginning on or after January first, two thousand one,
    47  is less than or equal to twenty-six thousand dollars. After the  initial
    48  determination  of eligibility, each eligible individual must be redeter-
    49  mined eligible at least every twenty-four months.
    50    2. Persons  eligible  for  catastrophic  coverage  under  section  two
    51  hundred forty-eight of this title shall include:
    52    (a)  any  unmarried  resident who is enrolled in medicare and at least
    53  sixty-five years of age in the year two thousand twenty, during the year
    54  two thousand twenty-one is at least sixty years of age, during the  year
    55  two  thousand twenty-two is at least fifty-five years of age, during the
    56  year two thousand twenty-three is at least fifty years  of  age,  during

        A. 5422                             4
 
     1  the  year  two thousand twenty-four is at least forty-five years of age,
     2  during the year two thousand twenty-five is at least forty years of age,
     3  during the year two thousand twenty-six is at least thirty-five years of
     4  age,  during the year two thousand twenty-seven is at least thirty years
     5  of age, during the year two thousand twenty-eight is  at  least  twenty-
     6  five  years  of  age,  or during the year two thousand twenty-nine is at
     7  least eighteen years of age; and whose  income  for  the  calendar  year
     8  immediately  preceding  the effective date of the annual coverage period
     9  beginning on or after January first, two  thousand  one,  is  more  than
    10  twenty thousand and less than or equal to seventy-five thousand dollars.
    11  After the initial determination of eligibility, each eligible individual
    12  must be redetermined eligible at least every twenty-four months; and
    13    (b)  any  married  resident  who  is enrolled in medicare and at least
    14  sixty-five years of age in the year two thousand twenty, during the year
    15  two thousand twenty-one is at least sixty years of age, during the  year
    16  two  thousand twenty-two is at least fifty-five years of age, during the
    17  year two thousand twenty-three is at least fifty years  of  age,  during
    18  the  year  two thousand twenty-four is at least forty-five years of age,
    19  during the year two thousand twenty-five is at least forty years of age,
    20  during the year two thousand twenty-six is at least thirty-five years of
    21  age, during the year two thousand twenty-seven is at least thirty  years
    22  of  age,  during  the year two thousand twenty-eight is at least twenty-
    23  five years of age, or during the year two  thousand  twenty-nine  is  at
    24  least  eighteen  years  of  age;  and whose income for the calendar year
    25  immediately preceding the effective date of the annual  coverage  period
    26  when  combined with the income in the same calendar year of such married
    27  person's spouse beginning on or after January first, two  thousand  one,
    28  is  more  than twenty-six thousand dollars and less than or equal to one
    29  hundred thousand dollars. After the initial determination  of  eligibil-
    30  ity,  each  eligible  individual  must be redetermined eligible at least
    31  every twenty-four months.
    32    § 5. Paragraphs (e) and (f) of subdivision 3 of  section  242  of  the
    33  elder  law, paragraph (e) as amended by section 3-d of part A of chapter
    34  59 of the laws of 2011, and paragraph (f) as amended  by  section  1  of
    35  part  T  of  chapter  56  of  the  laws  of 2012, are amended to read as
    36  follows:
    37    (e) As a condition of eligibility for benefits under this title, if  a
    38  program  participant's  income  indicates  that the participant could be
    39  eligible for an income-related subsidy under  section  1860D-14  of  the
    40  federal  social  security  act by either applying for such subsidy or by
    41  enrolling in a medicare savings program as a qualified medicare  benefi-
    42  ciary  (QMB),  a  specified low-income medicare beneficiary (SLMB), or a
    43  qualifying  individual  (QI),  a  program  participant  is  required  to
    44  provide,  and  to authorize the [elderly] expanded pharmaceutical insur-
    45  ance coverage  program  to  obtain,  any  information  or  documentation
    46  required  to  establish  the participant's eligibility for such subsidy,
    47  and to authorize the [elderly] expanded pharmaceutical insurance  cover-
    48  age program to apply on behalf of the participant for the subsidy or the
    49  medicare  savings  program.  [The elderly] Upon receipt of an enrollment
    50  application, or at any time after enrollment when the program has infor-
    51  mation that indicates an  enrollee  is  eligible  for  a  subsidy  under
    52  section  1860D-14  of  the  federal social security act or in a medicare
    53  savings program, the expanded pharmaceutical insurance coverage  program
    54  shall  make a reasonable effort to notify the program participant of his
    55  or her need to provide any of the above required  information.  After  a
    56  reasonable  effort  has  been made to contact the participant, a partic-

        A. 5422                             5
 
     1  ipant shall be notified in writing that he or  she  has  sixty  days  to
     2  provide  such  required information. If such information is not provided
     3  within the sixty day period, the participant's coverage  may  be  termi-
     4  nated.   A program participant who is eligible to enroll in the medicare
     5  savings program shall be assisted to do so, and their  expanded  pharma-
     6  ceutical  insurance  coverage  program  enrollment  shall  be  in  place
     7  throughout the medicare savings program application process.
     8    (f) As a condition of eligibility for benefits  under  this  title,  a
     9  program participant is required to be enrolled in Medicare part D and to
    10  maintain  such  enrollment.  For  unmarried participants with individual
    11  annual income less than or equal to twenty-three  thousand  dollars  and
    12  married  participants  with  joint  annual  income less than or equal to
    13  twenty-nine thousand  dollars,  the  [elderly]  expanded  pharmaceutical
    14  insurance  coverage  program  shall  pay  for  the portion of the part D
    15  monthly premium, and any late enrollment  penalty  that  may  have  been
    16  assessed,  that  is  the  responsibility  of the participant. Such total
    17  payment shall be limited to  the  low-income  benchmark  premium  amount
    18  established  by  the  federal centers for medicare and medicaid services
    19  and any other amount which such agency establishes under its de  minimus
    20  premium policy.
    21    §  6.  Subdivision  3  of  section  250 of the elder law is amended by
    22  adding a new paragraph (f) to read as follows:
    23    (f) The expanded pharmaceutical insurance coverage program shall  post
    24  to its website the names of manufacturers that have a rebate program and
    25  list  the drugs that are covered by such rebate program in a manner that
    26  provides enrollees with access to such information prior to  the  annual
    27  medicare open enrollment period.
    28    § 7. This act shall take effect immediately.
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