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SECTION 367-A
Payments; insurance
Social Services (SOS) CHAPTER 55, ARTICLE 5, TITLE 11
§ 367-a. Payments; insurance. 1. (a) Any inconsistent provision of
this chapter or other law notwithstanding, no assignment of the claim of
any supplier of medical assistance shall be valid and enforceable as
against any social services district or the department, and any payment
with respect to any medical assistance shall be made to the person,
institution, state department or agency or municipality supplying such
medical assistance at rates established by the appropriate social
services district and contained in its approved local medical plan,
except as otherwise permitted or required by applicable federal and
state provisions, including the regulations of the department; provided,
however, that for those districts for whom the department has assumed
payment responsibilities pursuant to section three hundred sixty-seven-b
of this chapter, rates shall be established by the department, except as
otherwise required by applicable provisions of federal or state law. A
social services official may apply to the department for local
variations in rates to be applicable, upon approval by the department,
to recipients for whom such district is responsible. Claims for payment
shall be made in such form and manner as the department shall determine.

(b) Where an applicant for or recipient of public assistance or
medical assistance has health insurance in force, is enrolled in a group
health insurance plan or group health plan covering care and other
medical benefits provided under this title, payment or part-payment of
the premium, co-insurance, any deductible amounts and other cost-sharing
obligations for such insurance may also be made when deemed
cost-effective pursuant to the regulations of the department.

(c) Any inconsistent provisions of this title or other law
notwithstanding and to the extent that federal financial participation
is available therefor and in accordance with the regulations of the
commissioner, payment of the premium for coverage under a group health
insurance plan or group health plan may be made under the medical
assistance program on behalf of a person not otherwise entitled to
public assistance or medical assistance if the social services official
determines that the savings in expenditures to the program as a result
of such coverage are likely to exceed the amount of the premiums paid
and such person has:

(i) income (as determined in accordance with the methodology used to
determine eligibility for benefits under the federal supplemental
security income program) in an amount less than or equal to one hundred
per cent of the federal income official poverty line (as defined and
annually revised by the federal office of management and budget)
applicable to the person's family size;

(ii) resources (as determined in accordance with the methodology used
to determine eligibility for benefits under the federal supplemental
security income program) less than or equal to twice the maximum amount
an individual is permitted to have to obtain benefits under the federal
supplemental security income program; and

(iii) coverage available under a group health insurance plan or an
employer-based group health plan provided pursuant to title XXII of the
federal public health services act, section 4980B of the federal
internal revenue code of 1986, or title VI of the employee retirement
income security act of 1974.

(d) (i) Amounts payable under this title for medical assistance for
items and services provided to eligible persons who are also
beneficiaries under part A of title XVIII of the federal social security
act and items and services provided to qualified medicare beneficiaries
under part A of title XVIII of the federal social security act shall not
be less than the amount of any deductible and co-insurance liability of
such eligible persons or for which such eligible persons or such
qualified medicare beneficiaries would be liable under federal law were
they not eligible for medical assistance or were they not qualified
medicare beneficiaries with respect to such benefits under such part A.

(ii) Amounts payable under this title for medical assistance for items
and services provided to eligible persons who are also beneficiaries
under part B of title XVIII of the federal social security act and items
and services provided to qualified medicare beneficiaries under part B
of title XVIII of the federal social security act shall not be less than
the amount of any deductible liability of such eligible persons or for
which such eligible persons or such qualified medicare beneficiaries
would be liable under federal law were they not eligible for medical
assistance or were they not qualified medicare beneficiaries with
respect to such benefits under such part B.

(iii) With respect to items and services provided to eligible persons
who are also beneficiaries under part B of title XVIII of the federal
social security act and items and services provided to qualified
medicare beneficiaries under part B of title XVIII of the federal social
security act, the amount payable for services covered under this title
shall be the amount of any co-insurance liability of such eligible
persons pursuant to federal law were they not eligible for medical
assistance or were they not qualified medicare beneficiaries with
respect to such benefits under such part B, but shall not exceed the
amount that otherwise would be made under this title if provided to an
eligible person other than a person who is also a beneficiary under part
B or is a qualified medicare beneficiary minus the amount payable under
part B; provided, however, amounts payable under this title for items
and services provided to eligible persons who are also beneficiaries
under part B or to qualified medicare beneficiaries by an ambulance
service under the authority of an operating certificate issued pursuant
to article thirty of the public health law, a psychologist licensed
under article one hundred fifty-three of the education law, or a
facility under the authority of an operating certificate issued pursuant
to article sixteen, thirty-one or thirty-two of the mental hygiene law
and with respect to outpatient hospital and clinic items and services
provided by a facility under the authority of an operating certificate
issued pursuant to article twenty-eight of the public health law, shall
not be less than the amount of any co-insurance liability of such
eligible persons or such qualified medicare beneficiaries, or for which
such eligible persons or such qualified medicare beneficiaries would be
liable under federal law were they not eligible for medical assistance
or were they not qualified medicare beneficiaries with respect to such
benefits under part B.

(iv) If a health plan participating in part C of title XVIII of the
federal social security act pays for items and services provided to
eligible persons who are also beneficiaries under part B of title XVIII
of the federal social security act or to qualified medicare
beneficiaries, the amount payable for services under this title shall be
eighty-five percent of the amount of any co-insurance liability of such
eligible persons pursuant to federal law if they were not eligible for
medical assistance or were not qualified medicare beneficiaries with
respect to such benefits under such part B; provided, however, amounts
payable under this title for items and services provided to eligible
persons who are also beneficiaries under part B or to qualified medicare
beneficiaries by an ambulance service under the authority of an
operating certificate issued pursuant to article thirty of the public
health law, or a psychologist licensed under article one hundred
fifty-three of the education law, shall not be less than the amount of
any co-insurance liability of such eligible persons or such qualified
medicare beneficiaries, or for which such eligible persons or such
qualified medicare beneficiaries would be liable under federal law were
they not eligible for medical assistance or were they not qualified
medicare beneficiaries with respect to such benefits under part B.

(e) Amounts payable under this title for medical assistance in the
form of clinic services pursuant to article twenty-eight of the public
health law, article sixteen of the mental hygiene law and independent
practitioner services for individuals with developmental disabilities
provided to eligible persons diagnosed with a developmental disability
who are also beneficiaries under part B of title XVIII of the federal
social security act, or provided to persons diagnosed with a
developmental disability who are qualified medicare beneficiaries under
part B of title XVIII of such act shall not be less than the approved
medical assistance payment level less the amount payable under part B.

(f) Amounts payable under this title for medical assistance in the
form of outpatient mental health services under article thirty-one or
outpatient chemical dependence services including opioid treatment
services under article thirty-two of the mental hygiene law provided to
eligible persons who are also beneficiaries under part B of title XVIII
of the federal social security act or provided to qualified medicare
beneficiaries under part B of title XVIII of such act shall not be less
than the approved medical assistance payment level less the amount
payable under part B.

(g) Notwithstanding any provision of this section to the contrary,
amounts payable under this title for medical assistance in the form of
hospital outpatient services or diagnostic and treatment center services
pursuant to article twenty-eight of the public health law provided to
eligible persons who are also beneficiaries under part B of title XVIII
of the federal social security act or provided to qualified medicare
beneficiaries under part B of title XVIII of such act shall not exceed
the approved medical assistance payment level less the amount payable
under part B.

(h) Amounts payable under this title for medical assistance in the
form of freestanding clinic services pursuant to article twenty-eight of
the public health law provided to eligible persons participating in the
New York traumatic brain injury waiver program who are also
beneficiaries under part B of title XVIII of the federal social security
act or who are qualified medicare beneficiaries under part B of title
XVIII of such act shall not be less than the approved medical assistance
payment level less the amount payable under part B.

2. (a) Any inconsistent provision of this chapter notwithstanding,
provision for medical care and other medical benefits available under
this title may be made, in whole or in part, either under this title or
other appropriate provisions of this chapter, through insurance or other
prepaid plans, in accordance with the regulations of the department.

(b) Any inconsistent provision of this chapter or other law
notwithstanding, upon furnishing assistance under this title to any
applicant or recipient of medical assistance, the local social services
district or the department shall be subrogated, to the extent of the
expenditures by such district or department for medical care furnished,
to any rights such person may have to medical support or reimbursement
from liable third parties, including but not limited to health insurers,
self-insured plans, group health plans, service benefit plans, managed
care organizations, pharmacy benefit managers, or other parties that
are, by statute, contract, or agreement, legally responsible for payment
of a claim for a health care item or service. For purposes of this
section, the term medical support shall mean the right to support
specified as support for the purpose of medical care by a court or
administrative order. The right of subrogation does not attach to
insurance benefits paid or provided under any health insurance policy
prior to the receipt of written notice of the exercise of subrogation
rights by the carrier issuing such insurance, nor shall such right of
subrogation attach to any benefits which may be claimed by a social
services official or the department, by agreement or other established
procedure, directly from an insurance carrier. No right of subrogation
to insurance benefits available under any health insurance policy shall
be enforceable unless written notice of the exercise of such subrogation
right is received by the carrier within three years from the date
services for which benefits are provided under the policy or contract
are rendered. Liable third parties shall not deny a claim made by a
social services official or the department in conformance with this
paragraph solely on the basis of the date of submission of the claim,
the type or format of the claim form, a failure to obtain prior
authorization, or a failure to present proper documentation at the
point-of-sale that is the basis of the claim. Liable third parties shall
respond to a request for payment within sixty calendar days after
receipt of written proof of loss or claim for payment for health care
services provided to a recipient of Medicaid who is covered by the third
party and shall not charge a fee to process or adjudicate a claim. The
local social services district or the department shall also notify the
carrier when the exercise of subrogation rights has terminated because a
person is no longer receiving assistance under this title. Such carrier
shall establish mechanisms to maintain the confidentiality of all
individually identifiable information or records. Such carrier shall
limit the use of such information or record to the specific purpose for
which such disclosure is made, and shall not further disclose such
information or records.

(c) In accordance with regulations of the department and to the extent
authorized by federal law and regulation, the social services district
is authorized to retain, in addition to amounts retained as repayment
for its share of the costs of medical assistance provided, a portion of
the federal share of the amount collected as medical support or third
party benefits assigned under paragraph (f) of subdivision four of
section three hundred sixty-six of this article, when such district, or
other governmental agency pursuant to an agreement with such district,
has collected such medical support or third party benefits on behalf of
a person receiving medical assistance whose rights to medical support or
third party benefits have been assigned to the state or to the
appropriate social services official. Where more than one district has
been involved in enforcing or collecting such amounts, the federal
incentive shall be apportioned among each such district in accordance
with the regulations of the department.

3. (a) Payment of premiums for enrolling qualified disabled and
working individuals and qualified medicare beneficiaries under Part A of
title XVIII of the federal social security act and for enrolling such
beneficiaries and eligible recipients of public assistance under part B
of title XVIII of the federal social security act, together with the
costs of the applicable co-insurance and deductible amounts on behalf of
such beneficiaries, and recipients, and premiums under section 1839 of
the federal social security act for persons who would be qualified
medicare beneficiaries except that their incomes exceed one hundred
percent of the federal income poverty line applicable to the person's
family size but, in calendar years nineteen hundred ninety-three and
nineteen hundred ninety-four, is less than one hundred ten percent of
such poverty line and, in calendar year beginning in nineteen hundred
ninety-five, is less than one hundred twenty percent of such poverty
line shall be made and the cost thereof borne by the state or by the
state and social services districts, respectively, in accordance with
the regulations of the department, provided, however, that the share of
the cost to be borne by a social services district, if any, shall in no
event exceed the proportionate share borne by such district with respect
to other expenditures under this title. Moreover, if the director of the
budget approves, payment of premiums for enrolling persons who have been
determined to be eligible for medical assistance only may be made and
the cost thereof borne or shared pursuant to this subdivision.

(b) (1) For purposes of this subdivision, "qualified medicare
beneficiaries" are those persons who are entitled to hospital insurance
benefits under part A of title XVIII of the federal social security act,
whose income does not exceed one hundred percent of the official federal
poverty line applicable to the person's family size and whose resources
do not exceed twice the maximum amount of resources a person may have in
order to qualify for benefits under the federal supplemental security
income program of title XVI of the federal social security act, as
determined for purposes of such program.

(2) Notwithstanding any provision of subparagraph one of this
paragraph to the contrary, to the extent that federal financial
participation is available, a person whose resources are in excess of
the amount specified but otherwise meets the requirements of
subparagraph one of this paragraph shall be considered a "qualified
medicare beneficiary" for the purposes of this subdivision. The
commissioner is authorized to submit amendments to the state plan for
medical assistance and/or submit one or more applications for waivers of
the federal social security act, to obtain the federal approvals
necessary to implement this subparagraph.

(c) (1) For purposes of this subdivision, "qualified disabled and
working individuals" are individuals who are not otherwise eligible for
medical assistance and:

(i) who are entitled to enroll for hospital insurance benefits under
section 1818A of part A of title XVIII of the federal social security
act;

(ii) whose income does not exceed two hundred percent of the official
federal poverty line applicable to the person's family size; and

(iii) whose resources do not exceed twice the maximum amount of
resources that an individual or a couple, in the case of a married
individual, may have and obtain federal supplemental security income
benefits under title XVI of the federal social security act, as
determined for purposes of that program.

(2) For purposes of this paragraph, income and resources are
determined by the same methodology as is used for determining
eligibility under the federal supplemental security income benefits
under title XVI of the federal social security act.

(d) (1) Beginning April first, two thousand two and to the extent that
federal financial participation is available at a one hundred percent
federal Medical assistance percentage and subject to sections 1933 and
1902(a)(10)(E)(iv) of the federal social security act, medical
assistance shall be available for full payment of medicare part B
premiums for individuals (referred to as qualified individuals 1) who
are entitled to hospital insurance benefits under part A of title XVIII
of the federal social security act and whose income exceeds the income
level established by the state and is at least one hundred twenty
percent, but less than one hundred thirty-five percent, of the federal
poverty level, for a family of the size involved and who are not
otherwise eligible for medical assistance under the state plan;

(2) Premium payments for the individuals described in subparagraph one
of this paragraph will be one hundred percent federally funded up to the
amount of the federal allotment. The department shall discontinue
enrollment into the program when the part B premium payments made
pursuant to subparagraph one of this paragraph meet the yearly federal
allotment.

(3) The commissioner of health shall develop a simplified application
form, consistent with federal law, for payments pursuant to this
section. The commissioner of health, in cooperation with the office for
the aging, shall publicize the availability of such payments to medicare
beneficiaries.

(e) (1) Payment of premiums for enrolling individuals in qualified
health plans offered through a health insurance exchange established
pursuant to the federal Patient Protection and Affordable Care Act (P.L.
111-148), as amended by the federal Health Care and Education
Reconciliation Act of 2010 (P.L. 111-152), shall be available to
individuals who:

(i) immediately prior to being enrolled in the qualified health plan,
were or would have been eligible under the family health plus program as
a parent or stepparent of a child under the age of twenty-one, and whose
MAGI household income, as defined in subparagraph eight of paragraph (a)
of subdivision one of section three hundred sixty-six of this title,
exceeds one hundred thirty-three percent of the federal poverty line for
the applicable family size;

(ii) are not otherwise eligible for medical assistance under this
title; and

(iii) are enrolled in a standard health plan in the silver level, as
defined in 42 U.S.C. 18022.

(2) Payment pursuant to this paragraph shall be for premium
obligations of the individual under the qualified health plan and shall
continue only if and for so long as the individual's MAGI household
income exceeds one hundred thirty-three percent, but does not exceed one
hundred fifty percent, of the federal poverty line for the applicable
family size, or, if earlier, until the individual is eligible for
enrollment in a standard health plan pursuant to section three hundred
sixty-nine-gg of this article.

(3) The commissioner of health shall submit amendments to the state
plan for medical assistance and/or submit one or more applications for
waivers of the federal social security act as may be necessary to
receive federal financial participation in the costs of payments made
pursuant to this paragraph; provided further, however, that nothing in
this subparagraph shall be deemed to affect payments for premiums
pursuant to this paragraph if federal financial participation in the
costs of such payments is not available.

4. No social services district shall make final payments pursuant to
title XIX of the federal social security act for benefits available
under title XVIII of such act without documentation that title XVIII
claims have been filed and denied.

5. (a) When medical care, services and supplies are furnished an
eligible person on behalf of a social services district under this
title, such social services district is authorized to utilize any
appropriate organization as a fiscal intermediary to audit and make
payment for such district's share of the cost of such care, services and
supplies.

(b) To carry out the purposes of paragraph (a), the department, on
behalf of itself and any of the social services districts, may enter
into agreements with appropriate organizations to act as fiscal
intermediaries.

6. (a) Notwithstanding any inconsistent provision of law, payment for
claims for services as specified in paragraph (d) of this subdivision
furnished to eligible persons under this title, subject to paragraph (b)
of this subdivision shall be reduced in accordance with the provisions
of paragraph (c) of this subdivision by an amount not to exceed the
maximum amount authorized by federal law and regulations as a co-payment
amount, which co-payment amount the provider of such services may charge
the recipient, provided, however, no provider may deny such services to
an individual eligible for services based on the individual's inability
to pay the co-payment amount.

(b) Co-payments shall apply to all eligible persons for the services
defined in paragraph (d) of this subdivision with the exception of:

(i) individuals under twenty-one years of age;

(ii) pregnant women;

(iii) individuals who are inpatients in a medical facility who have
been required to spend all of their income for medical care, except
their personal needs allowance or residents of community based
residential facilities licensed by the office of mental health or the
office for people with developmental disabilities who have been required
to spend all of their income, except their personal needs allowance;

(iv) individuals enrolled in health maintenance organizations or other
entities which provide comprehensive health services, or other managed
care programs for services covered by such programs, except that such
persons, other than persons otherwise exempted from co-payments pursuant
to subparagraphs (i), (ii), (iii) and (v) of this paragraph, and other
than those persons enrolled in a managed long term care program, shall
be subject to co-payments as described in subparagraph (v) of paragraph
(d) of this subdivision;

(v) individuals whose family income is less than one hundred percent
of the federal poverty line, as defined in subparagraph four of
paragraph (a) of subdivision one of section three hundred sixty-six of
this title, for a family of the same size; and

(vi) any other individuals required to be excluded by federal law or
regulations.

(b-1) The commissioner is authorized to submit any request or
application to the Centers for Medicare and Medicaid Services as may be
necessary to be granted a waiver of the requirement for the department
of health to calculate its Medicaid payments to managed care
organizations to include cost sharing established under the state plan
for medical assistance for enrollees who are not exempt from cost
sharing. In the absence of such a waiver, the commissioner shall adjust
Medicaid payments to managed care organizations beginning October first,
two thousand fifteen or on the date the Centers for Medicare and
Medicaid Services commences enforcement of such requirement, whichever
is later.

* (c) (i) Co-payments charged pursuant to this subdivision for
non-institutional services shall not exceed the following table,
provided, however, that the department may establish standard
co-payments for services based upon the average or typical payment for
that service:

State's payment Maximum co-payment

for the services chargeable to recipient

$10 or less $.50

$10.01 to $25 $1.00

$25.01 to $50 $2.00

$50.01 or more $3.00

(ii) co-payments charged pursuant to this subdivision for each
discharge for inpatient care shall be twenty-five dollars.

(iii) Notwithstanding any other provision of this paragraph,
co-payments charged for each generic prescription drug dispensed shall
be one dollar and for each brand name prescription drug dispensed shall
be two dollars and fifty cents; provided, however, that the co-payments
charged for each brand name prescription drug reimbursed pursuant to
subparagraph (ii) of paragraph (a-1) of subdivision four of section
three hundred sixty-five-a of this title shall be one dollar.

(iv) When an individual is initially dispensed or prescribed a seven
or fewer days supply of an opioid pursuant to paragraph (b) of
subdivision five of section three thousand three hundred thirty-one of
the public health law, and is subsequently dispensed or prescribed an
additional supply of such opioid for the same underlying condition, the
total co-payment that may be charged to such an individual for the
initial prescription plus all subsequent prescriptions for the same
underlying condition for up to a total of thirty-days supply of such
opioid shall not exceed the amount set forth in subparagraph (iii) of
this paragraph.

* NB Repealed March 31, 2026

(d) Co-payments shall apply to the following services, subject to such
exceptions for subcategories of these services as recognized by the
commissioner in regulations, provided in accordance with section three
hundred sixty-five-a of this article and the regulations of the
department, to the extent permitted by title XIX of the federal social
security act:

(i) in-patient care in a general hospital, as defined in subdivision
ten of section twenty-eight hundred one of the public health law;

(ii) out-patient hospital and clinic services except for mental health
services, mental retardation and developmental disability services,
alcohol and substance abuse services and methadone maintenance services;

(iii) home health services, including services provided under the long
term home health care program, provided however, home health providers
shall not require employees providing services in the home to collect
the co-payment amount;

(iv) sickroom supplies;

(v) drugs, excepting psychotropic drugs and drugs with FDA approved
indications for the treatment of tuberculosis as specified by the
department and those drugs intended for use by residents of adult care
facilities licensed by the department of health who have been required
to spend all of their income, except their personal needs allowance;

(vi) clinical laboratory services;

(vii) x-rays;

(viii) emergency room services provided for non-urgent or
non-emergency medical care, provided however, co-payments shall not be
required for emergency services or family planning services and
supplies;

(e) In the period from January first, nineteen hundred ninety-three to
March thirty-first, nineteen hundred ninety-three no recipient shall be
required to pay more than a total of fifty dollars in co-payments
required by this subdivision for drugs, nor shall reductions in payments
as a result of such co-payments exceed fifty dollars for any recipient.

(f) (i) In the year commencing April first, nineteen hundred
ninety-three and for each year thereafter, and ending in the year
concluding on March thirty-first, two thousand five, no recipient shall
be required to pay more than a total of one hundred dollars in
co-payments required by this subdivision, nor shall reductions in
payments as a result of such co-payments exceed one hundred dollars for
any recipient.

(ii) In the year commencing April first, two thousand five and for
each year thereafter, no recipient shall be required to pay more than a
total of two hundred dollars in co-payments required by this
subdivision, nor shall reductions in payments as a result of such
co-payments exceed two hundred dollars for any recipient.

(g) The commissioner shall promptly:

(i) promulgate a regulation making it an unacceptable practice under
the medical assistance program for a provider to deny services to an
individual eligible for services based on the individual's inability to
pay the co-pay amount required by this subdivision;

(ii) establish and maintain a toll-free hotline which may be used to
report a violation of the regulation promulgated pursuant to
subparagraph (i) of this paragraph; and

(iii) provide notice to all recipients summarizing their rights and
obligations under this subdivision.

7. (a) Every manufacturer or wholesaler of drugs, prescriptions or
poisons registered under the provisions of section sixty-eight hundred
eight of the education law, shall, upon request of the department for
any information pertaining to wholesale prices charged to pharmacists
for any drugs available under the medical assistance program, make the
requested information available to the department on a monthly basis, or
such other periodic basis as the department shall request.

(b) The department shall provide for financial arrangements with any
manufacturer or wholesaler of drugs, prescriptions or poisons as may be
necessary to reimburse such manufacturer or wholesaler for its actual
and necessary costs included in furnishing the requested information.

(c) Any information obtained pursuant to the provisions of this
subdivision shall not be made available for public inspection or copying
under the provisions of article six of the public officers law. The
department shall not disclose such information to any person, firm,
department or agency, except any state agency or department as may be
necessary for the administration of the medical assistance program under
the provisions of this chapter or any other law.

(d) Notwithstanding any inconsistent provision of law, if a
manufacturer (as defined under section 1927 of the federal social
security act) has entered into a rebate agreement with the department or
with the federal secretary of health and human services on behalf of the
department under section 1927 of the federal social security act, the
department shall reimburse for covered outpatient drugs which are
dispensed under the medical assistance program to all persons in receipt
of medical assistance benefits as a result of their eligibility having
been established under subparagraph one or nine of paragraph (a) of
subdivision one of section three hundred sixty-six of this title, and
which are dispensed to all persons eligible for health care services as
a result of their eligibility having been established under subdivision
two of section three hundred sixty-nine-ee of this article, only
pursuant to the terms of the rebate agreement between the department and
such manufacturer; provided, however, that any agreement between the
department and a manufacturer entered into before August first, nineteen
hundred ninety-one, shall be deemed to have been entered into on April
first, nineteen hundred ninety-one; and provided further, that if a
manufacturer has not entered into an agreement with the department
before August first, nineteen hundred ninety-one, such agreement shall
not be effective until April first, nineteen hundred ninety-two, unless
such agreement provides that rebates will be retroactively calculated as
if the agreement had been in effect on April first, nineteen hundred
ninety-one. The rebate agreement between such manufacturer and the
department shall utilize for single source drugs and innovator multiple
source drugs the identical formula used to determine the basic rebate
for federal financial participation single source drugs and innovator
multiple source drugs, pursuant to paragraph one of subdivision (c) of
section 1927 of the federal social security act, to determine the amount
of the rebate pursuant to this paragraph. The rebate agreement between
such manufacturer and the department shall utilize for non-innovator
multiple source drugs the identical formula used to determine the basic
rebate for federal financial participation non-innovator multiple source
drugs, pursuant to paragraphs three and four of subdivision (c) of
section 1927 of the federal social security act, to determine the amount
of the rebate pursuant to this paragraph. The terms and conditions of
such rebate agreement with respect to periodic payment of the rebate,
provision of information by the department, audits, manufacturer
provision of information verification of surveys, penalties,
confidentiality of information, and length of the agreement shall apply
to drugs of the manufacturer dispensed under the medical assistance
program to all persons in receipt of medical assistance benefits as a
result of their eligibility having been established under subparagraph
one or nine of paragraph (a) of subdivision one of section three hundred
sixty-six of this title, and which are dispensed to all persons eligible
for health care services as a result of their eligibility having been
established under subdivision two of section three hundred sixty-nine-ee
of this article. The department in providing utilization data to a
manufacturer (as provided for under section 1927.4(b)(1)(A) of the
federal social security act) shall provide such data by zip code, if
requested, for drugs covered under a rebate agreement.

* (e) During the period from April first, two thousand fifteen through
March thirty-first, two thousand twenty-three, the commissioner may, in
lieu of a managed care provider or pharmacy benefit manager, negotiate
directly and enter into an arrangement with a pharmaceutical
manufacturer for the provision of supplemental rebates relating to
pharmaceutical utilization by enrollees of managed care providers
pursuant to section three hundred sixty-four-j of this title and may
also negotiate directly and enter into such an agreement relating to
pharmaceutical utilization by medical assistance recipients not so
enrolled. Such rebate arrangements shall be limited to the following:
antiretrovirals approved by the FDA for the treatment of HIV/AIDS,
opioid dependence agents and opioid antagonists listed in a statewide
formulary established pursuant to subparagraph (vii) of this paragraph,
hepatitis C agents, high cost drugs as provided for in subparagraph
(viii) of this paragraph, gene therapies as provided for in subparagraph
(ix) of this paragraph, and any other class or drug designated by the
commissioner for which the pharmaceutical manufacturer has in effect a
rebate arrangement with the federal secretary of health and human
services pursuant to 42 U.S.C. § 1396r-8, and for which the state has
established standard clinical criteria. No agreement entered into
pursuant to this paragraph shall have an initial term or be extended
beyond the expiration or repeal of this paragraph.

(i) The manufacturer shall not enter into any rebate arrangements with
a managed care provider, or any of a managed care provider's agents,
including but not limited to any pharmacy benefit manager on the gene
therapy, drug, or drug classes subject to this paragraph when the state
has a rebate arrangement in place and standard clinical criteria are
imposed on the managed care provider.

(ii) The commissioner shall establish adequate rates of reimbursement
which shall take into account both the impact of the commissioner
negotiating such arrangements and any limitations imposed on the managed
care provider's ability to establish clinical criteria relating to the
utilization of such drugs. In developing the managed care provider's
reimbursement rate, the commissioner shall identify the amount of
reimbursement for such drugs as a separate and distinct component from
the reimbursement otherwise made for prescription drugs as prescribed by
this section.

(iii) The commissioner shall submit a report to the temporary
president of the senate and the speaker of the assembly annually by
December thirty-first. The report shall analyze the adequacy of rates to
managed care providers for drug expenditures related to the classes
under this paragraph.

(iv) Nothing in this paragraph shall be construed to require a
pharmaceutical manufacturer to enter into a rebate arrangement
satisfactory to the commissioner relating to pharmaceutical utilization
by enrollees of managed care providers pursuant to section three hundred
sixty-four-j of this title or relating to pharmaceutical utilization by
medical assistance recipients not so enrolled.

(v) All clinical criteria, including requirements for prior approval,
and all utilization review determinations established by the state as
described in this paragraph for the gene therapies, drugs, or drug
classes subject to this paragraph shall be developed using
evidence-based and peer-reviewed clinical review criteria in accordance
with article two-A of the public health law, as applicable.

(vi) All prior authorization and utilization review determinations
related to the coverage of any drug subject to this paragraph shall be
subject to article forty-nine of the public health law, section three
hundred sixty-four-j of this title, and article forty-nine of the
insurance law, as applicable. Nothing in this paragraph shall diminish
any rights relating to access, prior authorization, or appeal relating
to any drug class or drug afforded to a recipient under any other
provision of law.

(vii) The department shall publish a statewide formulary of opioid
dependence agents and opioid antagonists, which shall include as
"preferred drugs" all drugs in such classes, which shall include all
subclasses of a given drug that have a different pharmacological route
of administration, provided that:

(A) for all drugs that are included as of the date of the enactment of
this subparagraph on a formulary of a managed care provider, as defined
in section three hundred sixty-four-j of this title, or in the Medicaid
fee-for-service preferred drug program pursuant to section two hundred
seventy-two of the public health law, the cost to the department for
such drug is equal to or less than the lowest cost paid for the drug by
any managed care provider or by the Medicaid fee-for-service program
after the application of any rebates, as of the date that the department
implements the statewide formulary established by this subparagraph.
Where there is a generic version of the drug approved by the Food and
Drug Administration as bioequivalent to a brand name drug pursuant to 21
U.S.C. § 355(j)(8)(B), the cost to the department for the brand and
generic versions shall be equal to or less than the lower of the two
maximum costs determined pursuant to the previous sentence; and

(B) for all drugs that are not included as of the date of the
enactment of this subparagraph on a formulary of a managed care
provider, as defined in section three hundred sixty-four-j of this
title, or in the Medicaid fee-for-service preferred drug program
pursuant to section two hundred seventy-two of the public health law,
the department is able to obtain the drug at a cost that is equal to or
less than the lowest cost to the department of other comparable drugs in
the class, after the application of any rebates. Where there is a
generic version of the drug approved by the Food and Drug Administration
as bioequivalent to a brand name drug pursuant to 21 U.S.C. §
355(j)(8)(B), the cost to the department for the brand and generic
versions shall be equal to or less than the lower of the two maximum
costs determined pursuant to the previous sentence.

(viii) The commissioner may identify and refer high cost drugs, as
defined in clause (D) of this subparagraph, that are not included as of
the date of the enactment of this subparagraph on a formulary of a
managed care provider or covered by the Medicaid fee for service of
program to the drug utilization review board established by section
three hundred sixty-nine-bb of this article for a recommendation as to
whether a target supplemental Medicaid rebate should be paid by the
manufacturer of the drug to the department and the target amount of the
rebate.

(A) If the commissioner intends to refer a high cost drug to the drug
utilization review board pursuant to this subparagraph, the commissioner
shall notify the manufacturer of such drug and shall attempt to reach
agreement with the manufacturer on a rebate arrangement satisfactory to
the commissioner for the drug prior to referring the drug to the drug
utilization review board for review. Such arrangement may be based on
evidence based research, including, but not limited to, such research
operated or conducted by or for other state governments, the federal
government, the governments of other nations, and third party payers or
multi-state coalitions, provided however that the department shall
account for the effectiveness of the drug in treating the conditions for
which it is prescribed or in improving a patient's health, quality of
life, or overall health outcomes, and the likelihood that use of the
drug will reduce the need for other medical care, including
hospitalization.

(B) In the event that the commissioner and the manufacturer have
previously agreed to a rebate arrangement for a drug pursuant to this
paragraph, the drug shall not be referred to the drug utilization review
board for any further rebate agreement for the duration of the previous
rebate agreement, provided however, the commissioner may refer a drug to
the drug utilization review board if the commissioner determines there
are significant and substantiated utilization or market changes, new
evidence-based research, or statutory or federal regulatory changes that
warrant additional rebates. In such cases, the department shall notify
the manufacturer and provide evidence of the changes or research that
would warrant additional rebates, and shall attempt to reach agreement
with the manufacturer on a rebate for the drug prior to referring the
drug to the drug utilization review board for review.

(C) If the commissioner is unsuccessful in entering into a rebate
arrangement with the manufacturer of the drug satisfactory to the
department, the drug manufacturer shall in that event be required to
provide to the department, on a standard reporting form developed by the
department, the information as described in subdivision six of section
two hundred eighty of the public health law. All information disclosed
pursuant to this clause shall be considered confidential and shall not
be disclosed by the department in a form that identifies a specific
manufacturer or prices charged for drugs by such manufacturer.

(D) For the purposes of this subparagraph, the term "high cost drug"
shall mean a brand name drug or biologic that has a launch wholesale
acquisition cost of thirty thousand dollars or more per year or course
of treatment, or a biosimilar drug that has a launch wholesale
acquisition cost that is not at least fifteen percent lower than the
referenced brand biologic at the time the biosimilar is launched, or a
generic drug that has a wholesale acquisition cost of one hundred
dollars or more for a thirty day supply or recommended dosage approved
for labeling by the federal Food and Drug Administration, or a brand
name drug or biologic that has a wholesale acquisition cost increase of
three thousand dollars or more in any twelve-month period, or course of
treatment if less than twelve months.

(ix) For purposes of this paragraph, a "gene therapy" is a drug (A)
approved under section 505 of the Federal Food, Drug and Cosmetics Act
or licensed under subsection (a) or (k) of section 351 of the Public
Health Services Act; (B) that treats a rare disease or condition, as
defined in 21 USC § 360bb(a)(2), that is life-threatening, as defined in
42 CFR 321.18; (C) is considered a gene therapy by the federal Food and
Drug Administration for which a biologics license pursuant to 21 CFR
600-680 is held; (D) if administered in accordance with the labeling of
such drug, is expected to result in either the cure of such disease or
condition or a reduction in the symptoms of such disease or condition
that materially improves the patient's length or quality of life; and
(E) is expected to achieve the result described in clause (D) of this
subparagraph after not more than three administrations.

* NB Repealed March 31, 2026

* (f) (1) The department may require manufacturers of drugs other than
single source drugs and innovator multiple source drugs, as such terms
are defined in 42 U.S.C. § 1396r-8(k), to provide rebates to the
department for any drug that has increased more than three hundred
percent of its state maximum acquisition cost (SMAC) during the period
April 1, 2016 through March thirty-first, two thousand seventeen, or
that has increased more than seventy-five percent of its SMAC on or
after April first, two thousand seventeen, in comparison to its SMAC at
any time during the course of the preceding twelve months. The required
rebate shall be limited to the amount by which the current SMAC for the
drug exceeds the applicable percentage of the SMAC for the same drug at
any time during the course of the preceding twelve months. Such rebates
shall be in addition to any rebates payable to the department pursuant
to any other provision of federal or state law. Nothing herein shall
affect the department's obligation to reimburse for covered outpatient
drugs pursuant to paragraph (d) of this subdivision.

(2) Except as provided in subparagraph three of this paragraph, the
commissioner shall not determine any further rebates to be payable
pursuant to this paragraph once the Centers for Medicare and Medicaid
Services has adopted a final methodology for determining the amount of
additional rebates under the federal generic drug price increase rebate
program pursuant to 42 U.S.C. § 1396r-8 (c)(3), as amended by section
602 of the Bipartisan Budget Act of 2015.

(3) During state fiscal year 2016-2017, if the Centers for Medicare
and Medicaid Services has adopted a final methodology for determining
the amount of additional rebates under the federal generic drug price
increase rebate program pursuant to 42 U.S.C. § 1396r-8 (c)(3), as
amended by section 602 of the Bipartisan Budget Act of 2015, the
department may collect for a given drug the portion of the rebate
determined under this paragraph that is in excess of the rebate required
by such federal rebate program.

(4) The additional rebates authorized pursuant to this paragraph shall
apply to generic prescription drugs dispensed to enrollees of managed
care providers pursuant to section three hundred sixty-four-j of this
title and to generic prescription drugs dispensed to Medicaid recipients
who are not enrollees of such providers.

(5) Beginning in two thousand seventeen, the department shall provide
an annual report to the legislature no later than February first setting
forth:

(i) The number of drugs that exceeded the ceiling price established in
this paragraph during the preceding year in comparison to the number of
drugs that experienced at least a three hundred percent price increase
during two thousand fourteen and two thousand fifteen, or at least a
seventy-five percent price increase during two thousand fifteen and two
thousand sixteen;

(ii) The average percent amount above the ceiling price of drugs that
exceeded the ceiling price in the preceding year in comparison to the
number of drugs that experienced a price increase more than three
hundred percent during two thousand fourteen and two thousand fifteen,
or at least a seventy-five percent price increase during two thousand
fifteen and two thousand sixteen;

(iii) The number of generic drugs available to enrollees in Medicaid
fee for service or Medicaid managed care, by fiscal quarter, in the
preceding year in comparison to the drugs available, by fiscal quarter,
during two thousand fourteen, two thousand fifteen, and two thousand
sixteen; and

(iv) The total drug spend on generic drugs for the preceding year in
comparison to the total drug spend on generic drugs during two thousand
fourteen, two thousand fifteen, and two thousand sixteen.

* NB Repealed March 31, 2022

* 8. No government agency shall purchase, pay for, or make
reimbursement or grants-in-aid for any service in a residential
treatment facility for children and youth or a comprehensive psychiatric
emergency program unless at the time such service was provided, the
residential treatment facility for children and youth or comprehensive
psychiatric emergency program possessed a valid operating certificate
authorizing such service. Notwithstanding any inconsistent provision of
law, no government agency shall make payments pursuant to this title or
title nineteen of the federal social security act to a residential
treatment facility for children and youth for service to a person whose
need for care and treatment in such a facility was not certified
pursuant to section 9.51 of the mental hygiene law.

* NB Effective until July 1, 2024

* 8. No government agency shall purchase, pay for, or make
reimbursement or grants-in-aid for any service in a residential
treatment facility for children and youth unless at the time such
service was provided, the residential treatment facility for children
and youth possessed a valid operating certificate authorizing such
service. Notwithstanding any inconsistent provision of law, no
government agency shall make payments pursuant to this title or title
nineteen of the federal social security act to a residential treatment
facility for children and youth for service to a person whose need for
care and treatment in such a facility was not certified pursuant to
section 9.51 of the mental hygiene law.

* NB Effective July 1, 2024

* 9. Notwithstanding any inconsistent provision of law or regulation
to the contrary, for those drugs which may not be dispensed without a
prescription as required by section sixty-eight hundred ten of the
education law and for which payment is authorized pursuant to paragraph
(g) of subdivision two of section three hundred sixty-five-a of this
title, and for those drugs that are available without a prescription as
required by section sixty-eight hundred ten of the education law but are
reimbursed as items of medical assistance pursuant to paragraph (a) of
subdivision four of section three hundred sixty-five-a of this title,
payments under this title shall be made at the following amounts:

(a) for drugs provided by medical practitioners and claimed separately
by the practitioners, the actual cost of the drugs to the practitioners;
and

(b) for drugs dispensed by pharmacies:

(i) (A) if the drug dispensed is a generic prescription drug, the
lower of: (1) an amount equal to the national average drug acquisition
cost set by the federal centers for medicare and medicaid services for
the drug, if any, or if such amount if not available, the wholesale
acquisition cost of the drug based on the package size dispensed from,
as reported by the prescription drug pricing service used by the
department, less seventeen and one-half percent thereof; (2) the federal
upper limit, if any, established by the federal centers for medicare and
medicaid services; (3) the state maximum acquisition cost, if any,
established pursuant to paragraph (e) of this subdivision; or (4) the
dispensing pharmacy's usual and customary price charged to the general
public; (B) if the drug dispensed is available without a prescription as
required by section sixty-eight hundred ten of the education law but is
reimbursed as an item of medical assistance pursuant to paragraph (a) of
subdivision four of section three hundred sixty-five-a of this title,
the lower of (1) an amount equal to the national average drug
acquisition cost set by the federal centers for medicare and medicaid
services for the drug, if any, or if such amount is not available, the
wholesale acquisition cost of the drug based on the package size
dispensed from, as reported by the prescription drug pricing service
used by the department, (2) the federal upper limit, if any, established
by the federal centers for medicare and medicaid services; (3) the state
maximum acquisition cost if any, established pursuant to paragraph (e)
of this subdivision; or (4) the dispensing pharmacy's usual and
customary price charged to the general public;

(ii) if the drug dispensed is a brand-name prescription drug, the
lower of:

(A) an amount equal to the national average drug acquisition cost set
by the federal centers for medicare and medicaid services for the drug,
if any, or if such amount is not available, the wholesale acquisition
cost of the drug based on the package size dispensed from, as reported
by the prescription drug pricing service used by the department, less
three and three-tenths percent thereof; or (B) the dispensing pharmacy's
usual and customary price charged to the general public; and

(iii) notwithstanding subparagraphs (i) and (ii) of this paragraph and
paragraphs (d) and (e) of this subdivision, if the drug dispensed is a
drug that has been purchased from a manufacturer by a covered entity
pursuant to section 340B of the federal public health service act (42
USCA § 256b), the actual amount paid by such covered entity pursuant to
such section, plus the reasonable administrative costs, as determined by
the commissioner, incurred by the covered entity or by an authorized
contract pharmacy in connection with the purchase and dispensing of such
drug and the tracking of such transactions. For purposes of this
subparagraph, a "covered entity" is an entity that meets the
requirements of paragraph four of subsection (a) of such section, that
elects to participate in the program established by such section, and
that causes claims for payment for drugs covered by this subparagraph to
be submitted to the medical assistance program, either directly or
through an authorized contract pharmacy. No medical assistance payments
may be made to a covered entity or to an authorized contract pharmacy of
a covered entity for drugs that are eligible for purchase under the
section 340B program and are dispensed on an outpatient basis to
patients of the covered entity, other than under the provisions of this
subparagraph. Pharmacies submitting claims for reimbursement of drugs
purchased pursuant to section 340B of the public health service act
shall notify the department that the claim is eligible for purchase
under the 340B program, consistent with claiming instructions issued by
the department to identify such claims.

(c) Notwithstanding subparagraph (i) of paragraph (b) of this
subdivision, if a qualified prescriber certifies "brand medically
necessary" or "brand necessary" in his or her own handwriting directly
on the face of a prescription for a multiple source drug for which a
specific upper limit of reimbursement has been established by the
federal agency, in addition to writing "d a w" in the box provided for
such purpose on the prescription form, payment under this title for such
drug must be made under the provisions of subparagraph (ii) of such
paragraph.

(d) In addition to the amounts paid pursuant to paragraph (b) of this
subdivision, the department shall pay a professional pharmacy dispensing
fee for each such drug dispensed in the amount of ten dollars and eight
cents per prescription or written order of a practitioner; provided,
however that this professional dispensing fee will not apply to drugs
that are available without a prescription as required by section
sixty-eight hundred ten of the education law but do not meet the
definition of a covered outpatient drug pursuant to Section 1927K of the
Social Security Act.

(e) For a multiple source generic drug for which no specific upper
payment limit has been established by the federal centers for medicare
and medicaid services, the commissioner of health may establish a
maximum acquisition cost for such drug which shall be effective until
such time as a specific federal upper payment limit has been established
for such drug. The department shall use a similar methodology in
establishing such an interim price as that utilized by the centers for
medicare and Medicaid services in establishing the federal upper payment
limit. For this purpose, the department is authorized to enter into a
contract with an entity to provide technical and administrative support
to the commissioner of health.

(g) Notwithstanding any other provision of this subdivision to the
contrary, the department is authorized to implement a specialty pharmacy
program for the purpose of procuring certain specialty drugs at reduced
cost. The department is authorized to enter into contracts with one or
more contractors in order to obtain certain specialty drugs from a
limited number of sources at reduced prices. For purposes of this
paragraph, specialty drugs include, but are not limited to, chemotherapy
agents, hydration therapy agents, pain therapy agents, intravenous
administration of antibiotics or other drugs, and total parenteral
nutrition. All contracts entered into by the department to effectuate
the provisions of this section shall require the contractors to take
steps to assure that drugs provided pursuant to such contracts will be
readily accessible to consumers in a fashion that is no more restrictive
than that which was in effect prior to the implementation of the
specialty pharmacy program. This paragraph shall be effective only to
the extent that federal financial participation is available in the cost
of drugs obtained pursuant to this paragraph. The commissioner of health
is authorized to submit amendments to the state plan for medical
assistance and to submit applications for waivers under the social
security act to obtain the federal approvals necessary to implement this
paragraph. However, any pharmacy owned and operated by a not-for-profit
organization solely for the purpose of providing drugs to individuals
diagnosed with cystic fibrosis as part of a comprehensive clinical care
program approved by the national organization that accredits cystic
fibrosis care centers and maintains a national registry of cystic
fibrosis clinical data shall be exempt from the specialty pharmacy
program.

(h) The commissioner of health is authorized to establish a medication
therapy management pilot program in one or more counties or regions of
the state for the purpose of improving compliance with drug therapies
and improving clinical outcomes. Payments under such program may be made
to retail pharmacies for the provision of one-on-one medication regimen
counseling services for persons determined by the commissioner to be
eligible to receive such services. The commissioner is authorized to
establish fees for such counseling services, subject to the approval of
the director of the division of the budget. The provisions of this
paragraph shall not take effect unless all necessary approvals under
federal law and regulation have been obtained to receive federal
financial participation in the costs of services provided under this
paragraph.

* NB Effective until March 31, 2023

* 9. Notwithstanding any inconsistent provision of law or regulation
to the contrary, for those drugs which may not be dispensed without a
prescription as required by section sixty-eight hundred ten of the
education law and for which payment is authorized pursuant to paragraph
(g) of subdivision two of section three hundred sixty-five-a of this
title, payments under this title shall be made at the following amounts:

(a) for drugs provided by medical practitioners and claimed separately
by the practitioners, the actual cost of the drugs to the practitioners;
and

(b) for drugs dispensed by pharmacies:

(i) if the drug dispensed is a multiple source prescription drug for
which an upper limit has been set by the federal health care financing
administration, an amount equal to the specific upper limit set by such
federal agency for the multiple source prescription drug, and

(ii) if the drug dispensed is a multiple source prescription drug or a
brand-name prescription drug for which no specific upper limit has been
set by such federal agency, the lower of the estimated acquisition cost
of such drug to pharmacies, or the dispensing pharmacy's usual and
customary price charged to the general public. Estimated acquisition
cost means the average wholesale price of a prescription drug based upon
the package size dispensed from, as reported by the prescription drug
pricing service used by the department, less ten percent thereof, and
updated monthly by the department.

(c) Notwithstanding subparagraph (i) of paragraph (b) of this
subdivision, if a qualified prescriber certifies "brand medically
necessary" or "brand necessary" in his or her own handwriting directly
on the face of a prescription for a multiple source drug for which a
specific upper limit of reimbursement has been established by the
federal agency, in addition to writing "d a w" in the box provided for
such purpose on the prescription form, payment under this title for such
drug must be made under the provisions of subparagraph (ii) of such
paragraph.

(d) In addition to the amounts paid pursuant to paragraph (b) of this
subdivision to pharmacies for those drugs which may not be dispensed
without a prescription, as required by section sixty-eight hundred ten
of the education law and for which payment is authorized pursuant to
paragraph (g) of subdivision two of section three hundred sixty-five-a
of this title, the department shall pay a pharmacy dispensing fee for
each such prescription drug dispensed, which dispensing fee shall not be
less than the following amounts:

(i) for prescription drugs categorized as generic by the prescription
drug pricing service used by the department, five dollars and fifty
cents per prescription; and

(ii) for prescription drugs categorized as brand-name prescription
drug by the prescription drug pricing service used by the department,
four dollars and fifty cents per prescription.

* NB Effective March 31, 2023

10. Any provider except for those providers certified under article
twenty-eight of the public health law, of ordered services or supplies
under the medical assistance program may be required to provide
financial security to assure that funds are available to repay any
overpayments made to the provider under this title and to assure the
financial security of the medical assistance program. For the purposes
of this subdivision, "ordered services or supplies" shall mean those
services or supplies described in paragraphs (g), (i) and (j) of
subdivision two of section three hundred sixty-five-a of this title.

(a) Any financial security required by this subdivision must meet the
requirements of this paragraph. Financial security may be provided
through a bond with a corporate surety, from a company authorized to do
business in this state, or an irrevocable letter of credit or
certificate of deposit from a New York state or federally chartered
bank, trust company, savings bank or savings and loan association
qualified to do business in New York state and insured by the federal
deposit insurance corporation.

(b) The bond, letter of credit or certificate of deposit shall be
payable in favor of the people of the state of New York for the purpose
of indemnifying the medical assistance program against any overpayments
made to the provider.

(c) The bond, letter of credit or certificate of deposit filed and
maintained pursuant to this section shall not be cancelled, revoked or
terminated except after notice to, and with the consent of, the
department at least forty-five days in advance of such cancellation,
revocation or termination.

(d) The department may bring and maintain an action against the
provider and the surety or bank, trust company, savings bank or savings
and loan association for any claimed overpayments made to the provider.

(e) Financial security shall not be required for providers which do
not submit claims for payment under the medical assistance program
exceeding five hundred thousand dollars per annum or forty-two thousand
dollars per month.

(f) Financial security shall be in an amount equal to the provider's
estimated claims for payment for a one year period and may be adjusted
bi-annually in accordance with the dollar amount of claims actually
submitted. If the commissioner is satisfied from an investigation of the
financial condition of a provider that the provider is solvent and
possessed of sufficient assets to provide reasonable assurance of
recovery of any overpayments, the commissioner may modify the amount of
financial security to be provided by such provider.

(g) Financial security must be submitted by a provider upon initial
application for enrollment as a provider of medical assistance and with
each subsequent enrollment. A change in ownership of a provider shall
not release, cancel or terminate liability under this section under any
bond, letter of credit or certificate of deposit filed for a provider
while such bond, letter of credit or certificate of deposit is in effect
unless the transferee, purchaser, successor or assignee of such provider
obtains a bond, letter of credit or certificate of deposit under this
section for the benefit of such new owner. All providers enrolled in the
medical assistance program on the effective date of this subdivision
will be required to submit financial security within ninety days of
notice of such requirements by the department.

(h) The department may make the submission of the financial security
required by this subdivision a condition of participation in the medical
assistance program.

11. (a) Any inconsistent provisions of this title or other law
notwithstanding, no health insurer, self-insured plan, managed care
organization, pharmacy benefit manager, or other party that is, by
statute, contract, or agreement, legally responsible for payment of a
claim for a health care item or service, employer or organization who
has a plan, including an employee retirement income security act or
service benefit plan, providing care and other medical benefits for
persons, whether by insurance or otherwise, shall exclude a person from
eligibility, coverage or entitlement to medical benefits by reason of
the eligibility of such person for medical assistance under this title,
or by reason of the fact that such person would, except for such plan,
be eligible for benefits under this title.

(b) Any inconsistent provisions of this title or other law
notwithstanding, no insurer may impose requirements on the department or
a social services district which has been assigned the rights of an
individual who is eligible for medical assistance under this title and
who is covered for health benefits from the insurer, that are different
from requirements applicable to an agent or assignee of any other
individual so covered.

(c) Any inconsistent provisions of this title or other law
notwithstanding, the department may, to the extent necessary to
reimburse the department and the social services districts for
expenditures under this title, certify to the commissioner of taxation
and finance pursuant to section one hundred seventy-one-f of the tax law
amounts to be withheld from tax refunds otherwise due to any individual
who is required by court order to provide medical support in the form of
health insurance benefits for a child who is eligible for medical
assistance under this title and who has received payment from a
third-party for the cost of such services for such child but has not
used such payments to reimburse either the other parent or guardian of
such child or the provider of such services or the appropriate social
services district; provided however, that any claims for current or
past-due child support shall take priority over any such claims for the
costs of such services and care. Such amounts shall be withheld pursuant
to section one hundred seventy-one-f of the tax law, and shall be
credited to unreimbursed medical assistance incurred on behalf of such
child. The department shall by regulation establish procedures
consistent with paragraphs (a) and (b) of subdivision four of section
one hundred seventy-one-c of the tax law by which any individual who is
the subject of a certification may contest such certification.

12. Prior to receiving medical assistance under subparagraphs five and
six of paragraph (c) of subdivision one of section three hundred
sixty-six of this title, a person whose net available income is at least
one hundred fifty percent of the applicable federal income official
poverty line, as defined and updated by the United States department of
health and human services, must pay a monthly premium, in accordance
with a procedure to be established by the commissioner. The amount of
such premium shall be twenty-five dollars for an individual who is
otherwise eligible for medical assistance under such subparagraphs, and
fifty dollars for a couple, both of whom are otherwise eligible for
medical assistance under such subparagraphs. No premium shall be
required from a person whose net available income is less than one
hundred fifty percent of the applicable federal income official poverty
line, as defined and updated by the United States department of health
and human services.