Section 242. Program eligibility

1.  Persons eligible for comprehensive
  coverage under 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  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
  thirty-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 fifty 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 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  fact that some of an individual's prescription drug expenses
  are paid or reimbursable under the provisions of  the  medicare  program
  shall  not disqualify an individual, if he or she is otherwise eligible,
  from receiving assistance under this title. In  such  cases,  the  state
  shall  pay  the portion of the cost of those prescriptions for qualified
  drugs for which no payment or reimbursement  is  made  by  the  medicare
  program  or  any  federally  funded  prescription drug benefit, less the
  participant's co-payment required on the amount not paid by the medicare
  program. In  addition,  the  participant  registration  fee  charged  to
  eligible  program  participants  for  comprehensive coverage pursuant to
  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  transitional  assistance  beneficiary  in  the  medicare

  prescription  drug  discount  card program, authorized pursuant to title
  XVIII of the federal social security act, provided that: (i) any sponsor
  of such drug discount card program has signed an agreement  to  complete
  coordination  of  benefit  functions with EPIC, and has been endorsed by
  the EPIC panel; or (ii) any exclusive sponsor of such drug discount card
  program authorized  pursuant  to  title  XVIII  of  the  federal  social
  security  act  that limits the participants to the medicare prescription
  drug discount card program sponsored by such  exclusive  sponsor,  shall
  coordinate  benefits  available  under  such  discount card program with
  EPIC. The participant  registration  fee  charged  to  eligible  program
  participants  for comprehensive coverage pursuant to 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.
    (d)   The   elderly   pharmaceutical  insurance  coverage  program  is
  authorized to apply  for  transitional  assistance  under  the  medicare
  prescription  drug  discount  program with a specific drug discount card
  under title XVIII of the  federal  social  security  act  on  behalf  of
  applicants  and  eligible  program  participants  under  this title. The
  elderly  pharmaceutical  insurance  coverage   program   shall   provide
  applicants  and  eligible program participants with prior written notice
  of, and the opportunity to decline, such automatic enrollment.
    (e) As a condition of continued 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 continued eligibility for benefits under this
  title, if a program participant is eligible for  Medicare  part  D  drug
  coverage  under  section  1860D  of the federal social security act, the
  participant is required to enroll  in  Medicare  part  D  at  the  first
  available  enrollment  period  and  to  maintain  such  enrollment. This
  requirement  shall  be  waived  if  such  enrollment  would  result   in
  significant   additional   financial   liability   by  the  participant,
  including, but not limited to, individuals in a Medicare advantage  plan
  whose  cost  sharing  would  be  increased,  or if such enrollment would
  result in the loss of any health coverage through a  union  or  employer
  plan  for  the participant, the participant's spouse or other dependent.
  The elderly pharmaceutical  insurance  coverage  program  shall  provide
  premium  assistance  for all participants enrolled in Medicare part D as
  follows:

    (i) for participants with comprehensive  coverage  under  section  two
  hundred  forty-seven of this title, 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,
  except that such payments made on behalf of participants enrolled  in  a
  Medicare  advantage  plan  may  exceed  the low-income benchmark premium
  amount if determined to be cost effective to the program.
    (ii) for participants with catastrophic  coverage  under  section  two
  hundred  forty-eight of this title, the elderly pharmaceutical insurance
  coverage program shall credit the participant's annual personal  covered
  drug  expenditure amount required under this title by an amount equal to
  the annual  low-income  benchmark  premium  amount  established  by  the
  centers  for  Medicare and Medicaid services, prorated for the remaining
  portion of the participant's elderly pharmaceutical  insurance  coverage
  program  coverage  period. The elderly pharmaceutical insurance coverage
  program  shall,  at  appropriate   times,   notify   participants   with
  catastrophic  coverage  under  section  two  hundred forty-seven of this
  title of their right to coordinate the annual coverage period with  that
  of Medicare part D, along with the possible advantages and disadvantages
  of doing so.
    (g)   The   elderly   pharmaceutical  insurance  coverage  program  is
  authorized and directed to conduct an enrollment program to  facilitate,
  in  as prompt and streamlined a fashion as possible, the enrollment into
  Medicare part  D  of  program  participants  who  are  required  by  the
  provisions  of this section to enroll in part D. Provided, however, that
  a participant shall not be prevented from receiving  his  or  her  drugs
  immediately  at  the pharmacy under the elderly pharmaceutical insurance
  coverage program  as  a  result  of  such  participant's  enrollment  in
  Medicare part D.
    (h)  In  order  to  maximize prescription drug coverage under Medicare
  part  D,  the  elderly  pharmaceutical  insurance  coverage  program  is
  authorized  to  represent  program  participants under this title in the
  pursuit of such coverage. Such representation shall not  result  in  any
  additional  financial  liability  on behalf of such program participants
  and shall include, but not be limited to, the following actions:
    (i) application for the premium and cost-sharing subsidies  on  behalf
  of eligible program participants;
    (ii) enrollment in a prescription drug plan or MA-PD plan; the elderly
  pharmaceutical   insurance   coverage   program  shall  provide  program
  participants with prior  written  notice  of,  and  the  opportunity  to
  decline  such facilitated enrollment subject, however, to the provisions
  of paragraph (f) of this subdivision;
    (iii) pursuit of appeals, grievances, or coverage determinations.