Expands the program for elderly pharmaceutical insurance coverage to the level of coverage provided prior to the 2011 budget; repealer

Summary of provisions

Section one amends Elder Law (EL) §242(3)(f) to provide, that as a condition of continued eligibility for benefits under the Elderly Phar- maceutical Insurance Coverage (EPIC) program, a participant shall enroll in Medicare Part D at the first available enrollment period. This requirement shall be waived if such would result in significant finan- cial liability to the participant. This section is also amended to provide that EPIC will pay for the portion of the Part D monthly premium that is the responsibility of the participant. This payment shall be limited to the low-income benchmark premium amount established by the federal Centers for Medicare and Medicaid Services (CMS). For partic- ipants with catastrophic coverage, EPIC 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 CMS.

Section two amends EL §241(6) to define the "annual coverage period" as the period of twelve consecutive calendar months for which an eligible program participant has met the application fee or deductible require- ments.

Sections three and four restore prior comprehensive coverage eligibility requirements.

Section five amends the eligibility requirements for catastrophic cover- age to income levels $20,000-$35,000 for unmarried individuals, and $26,000-$50,000 for married individuals.

Section six repeals EL §242(3)(c) and adds a new paragraph (c) to provide for the fact that some of an individual's prescription drug expenses are paid or reimbursable under provisions of the Medicare program shall not disqualify otherwise eligible applicants, and restores the provisions, relating the process for state reimbursement of such.

Section seven adds a new EL §242(d) to authorize EPIC to apply for tran- sition assistance under the Medicare Prescription Drug Discount Program on behalf of program participants.

Section eight amends EL §242(3)(e) to provide that such conditions of eligibility are only required for continued eligibility.

Section nine amends EL §242(3)(g) to direct EPIC to conduct an enroll- ment program.

Sections 10, 11 and 12 amend the EL to restore previous provisions relating to EPIC's ability to represent program participants in certain instances, at no cost to the participant, and to restore the EPIC panel.

Section 13 amends EL §247 to amend a reference to comprehensive coverage cost-sharing responsibilities.

Section 14 and 15 reinstate previous registration fee requirements and limits on point of sale copayments.

Section 16 restores previous co-payment provisions.

Section 17 adds a new EL §248 to restore EPIC cost-sharing responsibil- ities for catastrophic coverage and the deductible schedule for such coverage.

Section 18 makes several technical corrections and provides that EPIC shall reimburse for covered drugs which are dispensed under the program by a provider pharmacy only pursuant to the terms of a rebate agreement between the program and the manufacturer. This section also restores provisions for when EPIC shall provide reimbursement to participants qualified for both EPIC and Medicare.

Section 19 amends EL §254, which pertains to the panel's ability to adjust individual and joint income categories.

Section 20 provides that this act shall take effect on April 1, 2012, provided however, that if this act shall not become law on or before April 1, 2012, this action shall take effect immediately and shall have been deemed to have been in full force and effect on and after April 1, 2012.

Justification

EPIC is a New York State program that helps more than 280,000 income-el- igible seniors aged 65 and older to supplement their out-of-pocket Medi- care Part D drug plan costs.

The SFY 2011-12 budget made eliminated many of the components integral to the EPIC program. These changes required that, beginning July 1, 2011, EPIC deductible credits be eliminated. Beginning January 1, 2012, all members were required to enroll in Medicare Part D prior to obtain- ing EPIC coverage. Members are also, as of January 1, 2012, responsible for their Part D deductible and their Part D co-payments, until they reach the Medicare coverage gap (i.e. the donut hole). Thus, under its current manifestation, EPIC provides premium assistance to low income seniors, and only provides supplemental coverage (to lower out-of-pocket

costs) for Medicare Part D drugs and Medicare Part D excluded drugs when purchased during the coverage gap. Many seniors rely on the EPIC program, and as such many were negatively affected by the changes made to this program in last year's budget. This bill will restore EPIC deductible and co-payment assistance to its previous state.

Prior legislative history

New bill.

Fiscal implications

To be determined.

Effective date

This act shall take effect on April 1, 2012, provided however, that if this act shall not become law on or before April 1, 2012, this action shall take effect immediately and shall have been deemed to have been in full force and effect on and after April 1, 2012.