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NEW YORK ELDERLY DRUG COVERAGE PROGRAM’s ELIGIBILITY EXPANDED

Executive Summary

NEW YORK ELDERLY DRUG COVERAGE PROGRAM's ELIGIBILITY EXPANDED by a legislative compromise worked out by both chambers of the state legislative July 2. In addition, patient cost-sharing policies would be streamlined under the Elderly Pharmaceutical Insurance Coverage (EPIC) program. Both moves are aimed at boosting program participation. New York Governor Cuomo (D) has in the past few years advocated modifications to make program participation easier. Although state officials participated in the legislature's negotiations, the governor's office is reserving a position on the legislation until the final version is reviewed. Once the bill is transmitted from the legislature, the governor has 10 days to decide whether to sign it. The EPIC program presently has about 80,000 enrollees. The changes could result in the addition of 25,000 participants, the state's Health Department estimates. The program's complexity has been blamed for disappointing enrollment thus far - as little as one-quarter of what had been projected when EPIC was created three years ago. Geared to residents who do not qualify for Medicaid, the EPIC program has separate rules for low-income and moderate-income elderly. Presently, low-income persons are defined as individuals with annual incomes of less than $9,000 and married couples with incomes below $12,000. The bill would raise the permitted income levels for individuals to $10,000 for the year beginning April 1, 1991, and $12,000 for the following year. Eligibility would be expanded to married couples with incomes up to $13,000 in 1991 and $15,000 the next year. Low-income participants would pay a$10 single lifetime application fee under the bill, replacing the present 27 quarterly premium levels based on income. Eligibility criteria for moderate-income individuals would be raised from the present $15,000 to $16,000 in 1991 and $18,000 in 1992. For married couples, the levels would be set at $21,000 in 1991 and $23,000 in 1992. Coverage in the two parts of the program are the same, except that participants with moderate incomes must pay an annual deductible before EPIC reimbursement begins. The bill would replace the current 14 deductibles, ranging from $400 to $638, with a $150 deductible for all moderate-income participants. The bill also would replace the five copayment levels with two. Both low-and moderate-income participants would pay $6 for every prescription priced up to $29.99 and $15 for higher-priced prescriptions. Prescription amounts are generally limited to the greater of a 30-day supply or 100 doses. A cap on total annual out-of-pocket drug spending is based on income, and ranges from$400 to $1,035 for a single individual and $300 to $982 for a married participant.

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