S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   8226
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                May 5, 2025
                                ___________
 
 Introduced  by  M.  of A. TAPIA, DE LOS SANTOS, HEVESI, LUNSFORD, LEVEN-
   BERG, SANTABARBARA, GLICK, COLTON, CRUZ, DAVILA,  SHIMSKY,  ROSENTHAL,
   E. BROWN, RAGA -- read once and referred to the Committee on Aging
 
 AN  ACT  to  amend the elder law, in relation to program eligibility for
   health plans comparable to Medicare part D; and to  amend  the  public
   health law, in relation to assessment of prescription drug coverage by
   health plans
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. Paragraphs (f) and (h) of subdivision 3 and  subdivision  4
 of  section  242  of  the  elder  law, paragraph (f) of subdivision 3 as
 amended by section 1 of part T of chapter 56 of the laws of 2012,  para-
 graph  (h) of subdivision 3 as amended by section 3-f of part A of chap-
 ter 59 of the laws of 2011, and subdivision 4 as added by  section  12-a
 of  part  T  of  chapter  56 of the laws of 2012, are amended to read as
 follows:
   (f) As a condition of eligibility for benefits  under  this  title,  a
 program  participant  is  required to be enrolled in Medicare part D, OR
 ANY OTHER PUBLIC OR PRIVATE DRUG  PLAN  WHICH  HAS  SUCCESSFULLY  DEMON-
 STRATED TO CMS THAT THE COVERAGE MEETS OR EXCEEDS THE ACTUARIAL VALUE OF
 THE  DEFINED  STANDARD  COVERAGE  UNDER THE MEDICARE PART D PRESCRIPTION
 DRUG BENEFIT, AS DETERMINED BY CMS, 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 OR COMPARABLE PLAN 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 agen-
 cy establishes under its de minimus premium policy.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD00618-04-5
              

 A. 8226                             2
 
   (h)  The  elderly pharmaceutical insurance coverage program is author-
 ized to represent program participants under this title with respect  to
 their Medicare part D OR COMPARABLE coverage.
   4.  As  a  condition  of  eligibility  for  benefits under this title,
 participants must be enrolled in [medicare]  MEDICARE  part  D,  OR  ANY
 OTHER PUBLIC OR PRIVATE DRUG PLAN WHICH HAS SUCCESSFULLY DEMONSTRATED TO
 CMS  THAT  THE  COVERAGE  MEETS  OR  EXCEEDS  THE ACTUARIAL VALUE OF THE
 DEFINED STANDARD COVERAGE UNDER THE MEDICARE PART  D  PRESCRIPTION  DRUG
 BENEFIT, AS DETERMINED BY CMS, 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] MEDICARE part D plan OR COMPARA-
 BLE  PLAN or a drug in a [medicare] MEDICARE part D excluded drug class,
 as defined in subdivision eight of section two hundred forty-one of this
 title, provided that such drug is a covered drug, as defined in subdivi-
 sion one of 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] MEDICARE part  D  OR
 COMPARABLE plan deductibles.
   § 2.  Section 241 of the elder law is amended by adding a new subdivi-
 sion 9 to read as follows:
   9. "CMS" MEANS THE CENTERS FOR MEDICARE & MEDICAID SERVICES WITHIN THE
 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES.
   § 3. The public health law is amended by adding a new section 280-e to
 read as follows:
   § 280-E. ASSESSMENT OF PRESCRIPTION DRUG COVERAGE. 1. FOR THE PURPOSES
 OF THIS SECTION, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS:
   (A)  "INSURER" MEANS AN INSURANCE COMPANY SUBJECT TO ARTICLE FORTY-TWO
 OR A CORPORATION SUBJECT TO ARTICLE FORTY-THREE OF THE INSURANCE LAW, OR
 A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO  ARTICLE  FORTY-
 FOUR  OF  THE  PUBLIC HEALTH LAW THAT CONTRACTS OR OFFERS TO CONTRACT TO
 PROVIDE, DELIVER, ARRANGE, PAY OR REIMBURSE ANY OF THE COSTS  OF  HEALTH
 CARE SERVICES.
   (B)  "HEALTH PLAN" MEANS A POLICY, CONTRACT OR CERTIFICATE, OFFERED OR
 ISSUED BY AN INSURER TO PROVIDE, DELIVER, ARRANGE FOR, PAY FOR OR  REIM-
 BURSE  ANY  OF  THE COSTS OF HEALTH CARE SERVICES. HEALTH PLAN SHALL NOT
 INCLUDE THE FOLLOWING:
   (I) ACCIDENT INSURANCE OR DISABILITY INCOME INSURANCE, OR ANY COMBINA-
 TION THEREOF;
   (II) COVERAGE ISSUED AS A SUPPLEMENT TO LIABILITY INSURANCE;
   (III) LIABILITY INSURANCE, INCLUDING GENERAL LIABILITY  INSURANCE  AND
 AUTOMOBILE LIABILITY INSURANCE;
   (IV) WORKERS' COMPENSATION OR SIMILAR INSURANCE;
   (V) AUTOMOBILE NO-FAULT INSURANCE;
   (VI) CREDIT INSURANCE;
   (VII)  OTHER SIMILAR INSURANCE COVERAGE, AS SPECIFIED IN FEDERAL REGU-
 LATIONS, UNDER WHICH BENEFITS FOR MEDICAL CARE ARE  SECONDARY  OR  INCI-
 DENTAL TO OTHER INSURANCE BENEFITS;
   (VIII) LIMITED SCOPE DENTAL OR VISION BENEFITS, BENEFITS FOR LONG-TERM
 CARE  INSURANCE,  NURSING  HOME  INSURANCE,  HOME CARE INSURANCE, OR ANY
 COMBINATION THEREOF, OR SUCH  OTHER  SIMILAR,  LIMITED  BENEFITS  HEALTH
 INSURANCE  AS  SPECIFIED  IN  FEDERAL  REGULATIONS,  IF THE BENEFITS ARE
 PROVIDED UNDER A SEPARATE POLICY, CERTIFICATE OR CONTRACT  OF  INSURANCE
 OR ARE OTHERWISE NOT AN INTEGRAL PART OF THE PLAN;
 A. 8226                             3
 
   (IX) COVERAGE ONLY FOR A SPECIFIED DISEASE OR ILLNESS, HOSPITAL INDEM-
 NITY, OR OTHER FIXED INDEMNITY COVERAGE;
   (X)  MEDICARE  SUPPLEMENTAL INSURANCE AS DEFINED IN SECTION 1882(G)(1)
 OF THE FEDERAL SOCIAL SECURITY ACT, COVERAGE SUPPLEMENTAL TO THE  COVER-
 AGE  PROVIDED UNDER CHAPTER 55 OF TITLE 10 OF THE UNITED STATES CODE, OR
 SIMILAR SUPPLEMENTAL COVERAGE PROVIDED UNDER A GROUP HEALTH PLAN  IF  IT
 IS  OFFERED  AS A SEPARATE POLICY, CERTIFICATE OR CONTRACT OF INSURANCE;
 OR
   (XI) THE NEW YORK STATE MEDICAL INDEMNITY FUND ESTABLISHED PURSUANT TO
 TITLE FOUR OF ARTICLE TWENTY-NINE-D OF THE PUBLIC HEALTH LAW.
   (C) "EPIC PROGRAM" MEANS THE ELDERLY PHARMACEUTICAL INSURANCE COVERAGE
 PROGRAM ESTABLISHED PURSUANT TO TITLE THREE OF ARTICLE TWO OF THE  ELDER
 LAW.
   (D)  "MEDICARE  PART  D  STANDARD" MEANS THE DEFINED STANDARD COVERAGE
 UNDER THE MEDICARE PART D PRESCRIPTION DRUG BENEFIT.
   2. (A) INSURERS OPERATING IN THE STATE MAY SUBMIT THEIR  HEALTH  PLANS
 TO  THE DEPARTMENT FOR ASSESSMENT TO DETERMINE WHETHER PRESCRIPTION DRUG
 COVERAGE OFFERED UNDER ANY SUCH HEALTH PLANS MEET OR EXCEED THE ACTUARI-
 AL VALUE OF THE MEDICARE PART D STANDARD.
   (B) UPON RECEIVING A HEALTH PLAN SUBMISSION FROM AN  INSURER  PURSUANT
 TO  PARAGRAPH  (A)  OF  THIS SUBDIVISION, THE DEPARTMENT SHALL CONDUCT A
 COMPREHENSIVE  ACTUARIAL   ANALYSIS   COMPARING   SUCH   HEALTH   PLAN'S
 PRESCRIPTION DRUG COVERAGE AGAINST THE MEDICARE PART D STANDARD.
   (C)  UPON  CONCLUSION  OF AN ANALYSIS CONDUCTED UNDER PARAGRAPH (B) OF
 THIS SUBDIVISION, THE DEPARTMENT SHALL NOTIFY THE INSURER OF THE OUTCOME
 OF SUCH ANALYSIS.
   3. (A) INDIVIDUALS ENROLLED IN A HEALTH  PLAN  INCLUDING  PRESCRIPTION
 DRUG COVERAGE THAT IS NOT ALREADY LISTED ON THE ONLINE LIST PUBLISHED BY
 THE DEPARTMENT PURSUANT TO SUBDIVISION FOUR OF THIS SECTION MAY SUBMIT A
 REQUEST  TO  THE  DEPARTMENT  TO  HAVE  SUCH HEALTH PLAN ASSESSED BY THE
 DEPARTMENT TO DETERMINE WHETHER PRESCRIPTION DRUG  COVERAGE  UNDER  SUCH
 HEALTH  PLAN MEETS OR EXCEEDS THE ACTUARIAL VALUE OF THE MEDICARE PART D
 STANDARD. THE DEPARTMENT SHALL DEVELOP A PROCESS BY WHICH SUCH  REQUESTS
 MAY  BE  SUBMITTED,  AND  DETAIL ANY NECESSARY INFORMATION THAT SHALL BE
 SUBMITTED WITH SUCH REQUESTS ON ITS WEBSITE.
   (B) UPON RECEIPT OF A REQUEST UNDER PARAGRAPH (A) OF THIS SUBDIVISION,
 THE DEPARTMENT SHALL CONDUCT A COMPREHENSIVE ACTUARIAL ANALYSIS  COMPAR-
 ING  THE  HEALTH  PLAN'S PRESCRIPTION DRUG COVERAGE AGAINST THE MEDICARE
 PART D STANDARD.
   (C) UPON CONCLUSION OF AN ANALYSIS CONDUCTED UNDER  PARAGRAPH  (B)  OF
 THIS SUBDIVISION, THE DEPARTMENT SHALL NOTIFY THE INDIVIDUAL WHO SUBMIT-
 TED  THE  REQUEST  FOR SUCH ANALYSIS OF THE OUTCOME OF SUCH ANALYSIS, IN
 ADDITION TO ANY IMPLICATIONS OF SUCH  CONCLUSION  ON  SUCH  INDIVIDUAL'S
 ELIGIBILITY FOR THE EPIC PROGRAM.
   4.  (A)  THE  DEPARTMENT  SHALL MAINTAIN AND PUBLISH AN ONLINE LIST OF
 AVAILABLE HEALTH PLANS THAT QUALIFY AS MEETING OR EXCEEDING THE MEDICARE
 PART D STANDARD, AS DETERMINED UNDER SUBDIVISION TWO OR  THREE  OF  THIS
 SECTION.
   (B)  THE  DEPARTMENT SHALL ESTABLISH A SYSTEM FOR CONTINUED MONITORING
 OF HEALTH PLANS EVALUATED UNDER THIS SECTION AND LISTED UNDER  PARAGRAPH
 (A) OF THIS SUBDIVISION, TO ENSURE THAT PRESCRIPTION DRUG COVERAGE UNDER
 SUCH  PLANS REMAIN MEETING OR EXCEEDING THE ACTUARIAL VALUE OF THE MEDI-
 CARE PART D STANDARD. THE DEPARTMENT SHALL REEVALUATE  ANY  HEALTH  PLAN
 THAT  UNDERGOES  CHANGES  IN  ITS  PRESCRIPTION DRUG COVERAGE, AND SHALL
 UPDATE THE LIST UNDER PARAGRAPH (A) OF THIS SUBDIVISION ACCORDINGLY.
 A. 8226                             4
 
   § 4. The department of health, in consultation with the department  of
 financial  services,  shall  notify  all insurers providing coverage for
 prescription drugs that are operating in this state of the provisions of
 this act. Such notification shall include  detailed  guidelines  on  the
 criteria  for  the  elderly  pharmaceutical  insurance  coverage program
 (EPIC) established pursuant to title three of article two of  the  elder
 law.
   §  5. This act shall take effect on the first of April next succeeding
 the date on which it shall have become a law. Effective immediately, the
 addition, amendment and/or repeal of any rule  or  regulation  necessary
 for  the implementation of this act on its effective date are authorized
 to be made, including by emergency, and  completed  on  or  before  such
 effective date.