N.Y.
Elder Law Section 242
Program eligibility
1.
Persons eligible for comprehensive coverage under § 247 (Cost-sharing responsibilities of eligible program participants for comprehensive coverage)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 § 248 (Cost-sharing responsibilities of eligible program participants for catastrophic coverage)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 seventy-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 one hundred 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 Social Services Law § 366 (Eligibility)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)
The participant registration fee charged to eligible program participants for comprehensive coverage pursuant to § 247 (Cost-sharing responsibilities of eligible program participants for comprehensive coverage)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.(e)
As a condition of 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 eligibility for benefits under this title, a program participant is required to be enrolled in Medicare part D and to maintain such enrollment. For unmarried participants with individual annual income less than or equal to twenty-three thousand dollars and married participants with joint annual income less than or equal to twenty-nine thousand dollars, 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.(h)
The elderly pharmaceutical insurance coverage program is authorized to represent program participants under this title with respect to their Medicare part D coverage.(i)
An individual who is determined to be eligible for assistance under this article shall not become ineligible based upon income solely because of an increase in either a public or private pension or an increase in social security benefits as provided under federal law where such increase does not exceed the consumer price index (all items United States city average) for such year. This provision shall be limited to one subsequent calendar year.4.
As a condition of eligibility for benefits under this title, participants must be enrolled in medicare part D and maintain such enrollment. For persons who meet the eligibility requirements to participate in the elderly pharmaceutical insurance coverage program, the program will pay for a drug covered by the person’s medicare part D plan or a drug in a medicare part D excluded drug class, as defined in subdivision eight of § 241 (Definitions)section two hundred forty-one of this title, provided that such drug is a covered drug, as defined in subdivision one of § 241 (Definitions)section two hundred forty-one of this title, and that the participant complies with the point of sale co-payment requirements set forth in sections two hundred forty-seven and two hundred forty-eight of this title. No payment shall be made for medicare part D plan deductibles.
Source:
Section 242 — Program eligibility, https://www.nysenate.gov/legislation/laws/ELD/242 (updated Apr. 7, 2023; accessed Dec. 21, 2024).
