242 - Program eligibility.

§  242.  Program  eligibility.  1.  Persons eligible for comprehensive  coverage under section two  hundred  forty-seven  of  this  title  shall  include:    (a) any unmarried resident who is at least sixty-five years of age and  whose  income  for the calendar year immediately preceding the effective  date of the annual coverage period beginning on or after January  first,  two  thousand  five,  is  less than or equal to twenty thousand dollars.  After the initial determination of eligibility, each eligible individual  must be redetermined eligible at least every twenty-four months; and    (b) any married resident who is at least sixty-five years of  age  and  whose  income  for the calendar year immediately preceding the effective  date of the annual coverage period when combined with the income in  the  same calendar year of such married person's spouse beginning on or after  January  first,  two  thousand  one, is less than or equal to twenty-six  thousand dollars. After the initial determination of  eligibility,  each  eligible  individual  must  be  redetermined  eligible  at  least  every  twenty-four months.    2. Persons  eligible  for  catastrophic  coverage  under  section  two  hundred forty-eight of this title shall include:    (a) any unmarried resident who is at least sixty-five years of age and  whose  income  for the calendar year immediately preceding the effective  date of the annual coverage period beginning on or after January  first,  two thousand one, is more than twenty thousand and less than or equal to  thirty-five   thousand  dollars.  After  the  initial  determination  of  eligibility, each eligible individual must be redetermined  eligible  at  least every twenty-four months; and    (b)  any  married resident who is at least sixty-five years of age and  whose income for the calendar year immediately preceding  the  effective  date  of the annual coverage period when combined with the income in the  same calendar year of such married person's spouse beginning on or after  January first, two  thousand  one,  is  more  than  twenty-six  thousand  dollars  and  less  than  or  equal to fifty thousand dollars. After the  initial determination of eligibility, each eligible individual  must  be  redetermined eligible at least every twenty-four months.    3.  (a)  Eligibility  for  assistance  under  this  title shall not be  granted to any person  who  at  the  time  an  application  is  made  is  receiving  medical  assistance  under section three hundred sixty-six of  the social services law, or to any person receiving equivalent or better  coverage from any other public or private third party payment source  or  insurance plan than those benefits provided for under this title.    (b) An individual who is determined eligible for assistance under this  title  whose  prescription  costs  are  covered in part by any public or  private plan may receive reduced assistance under this  title.  In  such  cases, benefits provided through this title shall be considered payments  of last resort.    (c)  (1)  The  fact  that  some  of  an individual's prescription drug  expenses are paid or reimbursable under the provisions of  the  medicare  program  shall  not  disqualify an individual, if he or she is otherwise  eligible, from receiving assistance under this title. In such cases, the  state shall pay the portion of  the  cost  of  those  prescriptions  for  qualified  drugs  for  which  no payment or reimbursement is made by the  medicare program or any federally funded prescription drug benefit, less  the participant's co-payment required on the  amount  not  paid  by  the  medicare program.    (2)  Coverage  under  this paragraph shall be available only after the  participant has first exhausted the first two levels of appeal available  under Part D of title XVIII of the federal social security act  and  the  appeal  has  been  denied.  During the coverage determination and appealperiod, the elderly  pharmaceutical  insurance  coverage  program  shall  provide  up to a ninety day supply of the prescribed medication, or such  lesser supply as specified on the prescription, if: (i)  the  pharmacist  notifies  the prescriber that the participant's Medicare Part D plan and  the  elderly  pharmaceutical  insurance  coverage  program  have  denied  payment  for  the  prescribed medication and that if the prescriber does  not choose to change the prescription to a drug that is covered  by  the  participant's  Medicare  Part  D  plan, a Medicare Part D appeal must be  pursued; and (ii) the prescriber  notifies  the  elderly  pharmaceutical  insurance  coverage  program  of  the  prescriber's  intent  to  provide  necessary information and cooperation in the  pursuit  of  the  Medicare  Part   D  appeal.  In  instances  where  the  pharmacist  is  unable  to  immediately reach the prescriber, the elderly  pharmaceutical  insurance  coverage  program shall, upon the request of the pharmacist, authorize a  three day emergency supply of the  prescribed  medication.  The  elderly  pharmaceutical   insurance   coverage   program   shall  authorize  such  additional ninety day supplies of the  prescribed  medication,  or  such  lesser  supply  as  specified  on  the prescription, and such additional  three day emergency supplies as  required  to  ensure  coverage  of  the  prescribed medication during the pendency of the Medicare Part D appeal.    (3)  The  participant  registration  fee  charged  to eligible program  participants for comprehensive coverage pursuant to section two  hundred  forty-seven  of this title shall be waived for the portion of the annual  coverage period that the participant is also enrolled as a full  subsidy  individual  in  a  prescription drug or MA-PD plan under Part D of title  XVIII of the federal social security act.    (d)  The  elderly  pharmaceutical  insurance   coverage   program   is  authorized  to  apply  for  transitional  assistance  under the medicare  prescription drug discount program with a specific  drug  discount  card  under  title  XVIII  of  the  federal  social  security act on behalf of  applicants and eligible  program  participants  under  this  title.  The  elderly   pharmaceutical   insurance   coverage  program  shall  provide  applicants and eligible program participants with prior  written  notice  of, and the opportunity to decline, such automatic enrollment.    (e)  As  a  condition of continued eligibility for benefits under this  title, if a program participant's income indicates that the  participant  could  be  eligible for an income-related subsidy under section 1860D-14  of the federal social security act by either applying for  such  subsidy  or  by  enrolling  in a medicare savings program as a qualified medicare  beneficiary (QMB), a specified low-income medicare  beneficiary  (SLMB),  or  a  qualifying  individual (QI), a program participant is required to  provide, and to authorize the elderly pharmaceutical insurance  coverage  program   to  obtain,  any  information  or  documentation  required  to  establish  the  participant's  eligibility  for  such  subsidy,  and  to  authorize the elderly pharmaceutical insurance coverage program to apply  on  behalf  of  the  participant for the subsidy or the medicare savings  program. The elderly pharmaceutical  insurance  coverage  program  shall  make a reasonable effort to notify the program participant of his or her  need  to  provide  any  of  the  above  required  information.  After  a  reasonable  effort  has  been  made  to  contact  the   participant,   a  participant  shall  be notified in writing that he or she has sixty days  to provide  such  required  information.  If  such  information  is  not  provided  within the sixty day period, the participant's coverage may be  terminated.    (f) As a condition of continued eligibility for  benefits  under  this  title,  if  a  program  participant is eligible for Medicare part D drug  coverage under section 1860D of the federal  social  security  act,  the  participant  is  required  to  enroll  in  Medicare  part D at the firstavailable enrollment  period  and  to  maintain  such  enrollment.  This  requirement   shall  be  waived  if  such  enrollment  would  result  in  significant  additional  financial   liability   by   the   participant,  including,  but not limited to, individuals in a Medicare advantage plan  whose cost sharing would be  increased,  or  if  such  enrollment  would  result  in  the  loss of any health coverage through a union or employer  plan for the participant, the participant's spouse or  other  dependent.  The  elderly  pharmaceutical  insurance  coverage  program shall provide  premium assistance for all participants enrolled in Medicare part  D  as  follows:    (i)  for  participants  with  comprehensive coverage under section two  hundred forty-seven of this title, the elderly pharmaceutical  insurance  coverage program shall pay for the portion of the part D monthly premium  that  is  the  responsibility  of the participant. Such payment shall be  limited to the low-income benchmark premium amount  established  by  the  federal  centers for Medicare and Medicaid services and any other amount  which such agency establishes  under  its  de  minimus  premium  policy,  except  that  such payments made on behalf of participants enrolled in a  Medicare advantage plan may  exceed  the  low-income  benchmark  premium  amount if determined to be cost effective to the program.    (ii)  for  participants  with  catastrophic coverage under section two  hundred forty-eight of this title, the elderly pharmaceutical  insurance  coverage  program shall credit the participant's annual personal covered  drug expenditure amount required under this title by an amount equal  to  the  annual  low-income  benchmark  premium  amount  established  by the  centers for Medicare and Medicaid services, prorated for  the  remaining  portion  of  the participant's elderly pharmaceutical insurance coverage  program coverage period. The elderly pharmaceutical  insurance  coverage  program   shall,   at   appropriate   times,  notify  participants  with  catastrophic coverage under section  two  hundred  forty-seven  of  this  title  of their right to coordinate the annual coverage period with that  of Medicare part D, along with the possible advantages and disadvantages  of doing so.    (g)  The  elderly  pharmaceutical  insurance   coverage   program   is  authorized  and directed to conduct an enrollment program to facilitate,  in as prompt and streamlined a fashion as possible, the enrollment  into  Medicare  part  D  of  program  participants  who  are  required  by the  provisions of this section to enroll in part D. Provided, however,  that  a  participant  shall  not  be prevented from receiving his or her drugs  immediately at the pharmacy under the elderly  pharmaceutical  insurance  coverage  program  as  a  result  of  such  participant's  enrollment in  Medicare part D.    (h) In order to maximize prescription  drug  coverage  under  Medicare  part  D,  the  elderly  pharmaceutical  insurance  coverage  program  is  authorized to represent program participants under  this  title  in  the  pursuit  of  such  coverage. Such representation shall not result in any  additional financial liability on behalf of  such  program  participants  and shall include, but not be limited to, the following actions:    (i)  application  for the premium and cost-sharing subsidies on behalf  of eligible program participants;    (ii) enrollment in a prescription drug plan or MA-PD plan; the elderly  pharmaceutical  insurance  coverage  program   shall   provide   program  participants  with  prior  written  notice  of,  and  the opportunity to  decline such facilitated enrollment subject, however, to the  provisions  of paragraph (f) of this subdivision;    (iii) pursuit of appeals, grievances, or coverage determinations.