247. Cost-sharing responsibilities of eligible program participants for comprehensive coverage.
1. Registration fee. Eligible individuals meeting the registration fee requirements of this section may purchase prescribed covered drugs for an amount specified by subdivision three of this section, subject to the limits on point of sale co-payments specified by subdivision four of this section.
2. Registration fee schedule. Eligible individuals electing to meet the requirements of this subdivision shall pay a quarterly registration fee in a manner and form determined by the executive director; at the option of the participant, the registration fee may be paid annually in a lump sum upon the beginning of the annual coverage period. No eligible individual electing to meet the requirements of this subdivision shall have his participation in the program lapse by virtue of non-payment of the applicable registration fee unless the contractor has provided notification of the amount and due date thereof, and more than thirty days have elapsed since the due date of the individual's registration fee. The registration fee to be charged to eligible program participants for comprehensive coverage under this option shall be in accordance with the following schedule:
(a) Quarterly registration fees for unmarried individual program participants: individual income of $5,000 or less $2.00 individual income of $5,001 to $6,000 $2.00 individual income of $6,001 to $7,000 $4.00 individual income of $7,001 to $8,000 $5.50 individual income of $8,001 to $9,000 $7.00 individual income of $9,001 to $10,000 $9.00 individual income of $10,001 to $11,000 $10.00 individual income of $11,001 to $12,000 $11.50 individual income of $12,001 to $13,000 $13.50 individual income of $13,001 to $14,000 $15.00 individual income of $14,001 to $15,000 $20.00 individual income of $15,001 to $16,000 $27.50 individual income of $16,001 to $17,000 $35.00 individual income of $17,001 to $18,000 $42.50 individual income of $18,001 to $19,000 $50.00 individual income of $19,001 to $20,000 $57.50
(b) Quarterly registration fees for each married individual program participant: joint income of $5,000 or less $2.00 joint income of $5,001 to $6,000 $2.00 joint income of $6,001 to $7,000 $3.00 joint income of $7,001 to $8,000 $4.00 joint income of $8,001 to $9,000 $5.00 joint income of $9,001 to $10,000 $6.00 joint income of $10,001 to $11,000 $7.00 joint income of $11,001 to $12,000 $8.00 joint income of $12,001 to $13,000 $9.00 joint income of $13,001 to $14,000 $10.00 joint income of $14,001 to $15,000 $10.00 joint income of $15,001 to $16,000 $21.00 joint income of $16,001 to $17,000 $26.50 joint income of $17,001 to $18,000 $31.50 joint income of $18,001 to $19,000 $37.50 joint income of $19,001 to $20,000 $43.00 joint income of $20,001 to $21,000 $48.50 joint income of $21,001 to $22,000 $54.00 joint income of $22,001 to $23,000 $59.50 joint income of $23,001 to $24,000 $65.00 joint income of $24,001 to $25,000 $68.75 joint income of $25,001 to $26,000 $75.00
(c) In the event that the state expenditures per participant meeting the registration fee requirements of this subdivision, exclusive of expenditures for program administration, in the program year commencing October first, nineteen hundred eighty-eight, and in each program year thereafter, exceed such expenditures in the previous program year by a minimum of ten percent, the annual registration fees set forth in this subdivision may, unless otherwise provided by law, be increased, pro-rata, for the subsequent program year, provided that such increase shall not exceed seven and one-half percent of the prior year registration fees as may have been adjusted in accordance with this paragraph.
(d) In the event that the state expenditures per such participant, incurred pursuant to this subdivision, exclusive of expenditures for program administration, in the program year commencing October first, nineteen hundred eighty-eight, and in each program year thereafter, are less than such expenditures in the previous program year by a minimum of ten percent, the annual registration fees set forth in this subdivision may, unless otherwise provided by law, be decreased, pro-rata, for the subsequent program year, provided that such decrease shall not exceed seven and one-half percent of the prior year registration fees as may have been adjusted in accordance with this paragraph.
(e) The determination to adjust annual registration fees set forth in this subdivision shall follow a review of such factors as the relative financial capacity of the state and such eligible program participants to support such adjustments and changes in the consumer price index. The frequency of such adjustments shall not exceed once in any program year and such adjustments shall not become effective for individual program participants prior to the first day of the next annual coverage period for each participant.
3. Point of sale co-payment. (a) Upon satisfaction of the registration fee pursuant to this section an eligible program participant must pay a point of sale co-payment as set forth in paragraph (b) of this subdivision at the time of each purchase of a covered drug prescribed for such individual. Such co-payment shall not be waived or reduced in whole or in part subject to the limits provided by subdivision four of this section.
(b) The point of sale co-payment amounts which are to be charged eligible program participants shall be in accordance with the following schedule: For each prescription of covered drugs costing $15.00 or less.....$3.00 For each prescription of covered drugs costing $15.01 to $35.00...$7.00 For each prescription of covered drugs costing $35.01 to $55.00..$15.00 For each prescription of covered drugs costing $55.01 or more....$20.00
(c) For the purposes of the foregoing schedule of point of sale co-payments, "costing" shall mean the amount of reimbursement which shall be paid by the state to a participating provider pharmacy in accordance with section two hundred fifty of this title plus the point of sale co-payment, calculated as of the date of sale.
4. Limits on point of sale co-payments. During each annual coverage period no point of sale co-payment as set forth in subdivision three of this section shall be required to be made for the remainder of such period by any eligible program participant who has already incurred co-payments in excess of the limits set forth in the following schedule:
(a) Limits on co-payments by unmarried individual eligible program participants: individual income of $5,000 or less no more than $340 individual income of $5,001 to $6,000 no more than $408 individual income of $6,001 to $7,000 no more than $476 individual income of $7,001 to $8,000 no more than $544 individual income of $8,001 to $9,000 no more than $612 individual income of $9,001 to $10,000 no more than $700 individual income of $10,001 to $11,000 no more than $720 individual income of $11,001 to $12,000 no more than $827 individual income of $12,001 to $13,000 no more than $896 individual income of $13,001 to $14,000 no more than $964 individual income of $14,001 to $15,000 no more than $1,016 individual income of $15,001 to $16,000 no more than $1,034 individual income of $16,001 to $17,000 no more than $1,052 individual income of $17,001 to $18,000 no more than $1,070 individual income of $18,001 to $19,000 no more than $1,088 individual income of $19,001 to $20,000 no more than $1,160
(b) Limits on co-payments by each married individual eligible program participant: joint income of $5,000 or less no more than $291 joint income of $5,001 to $6,000 no more than $342 joint income of $6,001 to $7,000 no more than $399 joint income of $7,001 to $8,000 no more than $456 joint income of $8,001 to $9,000 no more than $513 joint income of $9,001 to $10,000 no more than $570 joint income of $10,001 to $11,000 no more than $622 joint income of $11,001 to $12,000 no more than $641 joint income of $12,001 to $13,000 no more than $660 joint income of $13,001 to $14,000 no more than $684 joint income of $14,001 to $15,000 no more than $710 joint income of $15,001 to $16,000 no more than $826 joint income of $16,001 to $17,000 no more than $877 joint income of $17,001 to $18,000 no more than $928 joint income of $18,001 to $19,000 no more than $980 joint income of $19,001 to $20,000 no more than $990 joint income of $20,001 to $21,000 no more than $1,008 joint income of $21,001 to $22,000 no more than $1,026 joint income of $22,001 to $23,000 no more than $1,044 joint income of $23,001 to $24,000 no more than $1,062 joint income of $24,001 to $25,000 no more than $1,080 joint income of $25,001 to $26,000 no more than $1,150
(c) Effective October first, nineteen hundred eighty-eight, the limits on point of sale co-payments as set forth in this subdivision may be adjusted by the panel on the anniversary date of each program participant's annual coverage period, and such adjustment shall be in effect for the duration of that annual coverage period. Any such annual adjustment shall be made using a percentage adjustment factor which shall not exceed one-half of the difference between the year-to-year percentage increase in the consumer price index for all urban consumers, as published by the United States Department of Labor, and, if larger, the year-to-year percentage increase in the aggregate average cost of covered drugs purchased under this title, which year-to-year percentage increase in such cost shall be determined by comparison of such cost in the same month of each of the appropriate successive years; provided, however, that for any such adjustment based wholly on experience in the program year commencing October first, nineteen hundred eighty-seven, the year-to-year percentage increase in such cost shall be determined by comparison of such cost in each of two months no less than five months apart and within such program year, which comparison shall be annualized. Such percentage adjustment factor shall be the same as that used to determine any similar annual adjustment for the same annual coverage periods pursuant to the provisions of subdivision four of section two hundred forty-eight of this title.
(d) Such annual adjustments shall be calculated by multiplying the percentage adjustment factor by (1) ten percent and applying the resulting percentage to the upper income limitation of each income level for unmarried individuals contained in this subdivision, and by (2) seven and one-half percent and applying the resulting percentage to the upper income limitation of each income level for married individuals contained in this subdivision; each result of such calculations, minus any applicable registration fee increases made pursuant to subdivision two of this section and plus the result of applying the percentage adjustment factor to the sum of any such annual adjustments applicable thereto for any prior annual coverage period, shall be the amount by which the limit on co-payments for each such income level may be adjusted, and such amount shall be in addition to any such amount or amounts applicable to prior annual coverage periods.
(e) The determination to adjust the limits on point of sale co-payments set forth in this subdivision shall follow a review of such factors as the relative financial capacity of the state and such eligible program participants to support such adjustments.
Last modified: February 3, 2019