SF0133 - Prescription drug assistance program.
2001 |
State of Wyoming |
01LSO-0370.E1 ENGROSSED |
SENATE FILE NO. SF0133
Prescription drug assistance program.
Sponsored by: Senator(s) Scott, Boggs, Massie and Roberts
and Representative(s) Gay, Iekel, Parady and
Paseneaux
A BILL
for
1 AN ACT relating to
Wyoming Medical Assistance and Services
2
Act; creating the prescription drug program under the
3
Wyoming Medical Assistance and Services Act; specifying
4
eligibility criteria; specifying which drugs qualify for
5
payment under the program; establishing procedures;
6
limiting benefits as specified; providing an appropriation;
7
authorizing posititions; and providing for an effective
8
date.
9
10 Be It Enacted by the Legislature of the State of Wyoming:
11
12 Section 1. W.S. 42-4-117 is created to read:
13
14 42-4-117. Prescription
drug assistance program
15 created; eligibility criteria; benefits provided; coverage
16 of medications.
Page 1
1
2 (a) There is
created a prescription drug assistance
3
program to assist residents of the state. The program shall
4
be a state funded program to provide prescription drug
5
assistance, effective July 1, 2001, in addition to the
6
services provided under the Wyoming Medical Assistance and
7
Services Act. Effective July 1, 2001, the prescription drug
8
assistance program shall replace the minimum medical
9
program. Eligibility for assistance under the program
10 created by this section shall not
constitute an entitlement
11 and services shall be provided under
this section only to
12 the extent funds are available.
13
14 (b) Residents
of the state may apply for the
15 prescription drug assistance program
in the manner provided
16 in W.S. 42-4-106. Upon a
determination of eligibility, the
17 applicant remains eligible for
assistance under the
18 prescription drug assistance program
as provided in this
19 section. If a recipient ceases to be
a resident of the
20 state, his eligibility under the program
shall terminate.
21 The department shall by rule and
regulation establish
22 income eligibility guidelines on a
sliding scale no later
23 than July 1 of each year based on
the federal poverty
24 levels in effect on January 1 of
such calendar year. The
Page 2
1 rules
shall take into consideration family size up to four
2
(4) individuals. Eligibility for families consisting of
3
more than four (4) individuals shall be determined on the
4
basis of the income of a family of four (4) individuals.
5
Persons eligible for prescription drug assistance under
6
other state or federal programs, except the state high risk
7
health insurance pool, shall be ineligible for assistance
8
under the prescription drug assistance program. Four (4)
9
categories of eligibility shall be established as follows:
10
11 (i) One hundred
percent (100%) of the federal
12 poverty level or less;
13
14 (ii) Greater
than one hundred percent (100%) but
15 not more than one hundred fifty
percent (150%) of the
16 federal poverty level;
17
18 (iii) Greater
than one hundred fifty percent
19 (150%) but not more than two hundred
percent (200%) of the
20 federal poverty level;
21
22 (iv) Greater
than two hundred percent (200%) but
23 not more than two hundred fifty
percent (250%) of the
24 federal poverty level.
Page 3
1
2 (c) Except as
provided by this subsection, an
3
eligibility determination made under subsection (b) of this
4
section shall be valid for one (1) year. A recipient whose
5
monthly income changes by more than one-third (1/3), shall
6
report the change in income to the department. Such
7
recipient is entitled to a redetermination if his income
8
has declined and may, at the option of the department, be
9
subject to a redetermination if his income has increased.
10
11 (d) Upon a
determination of income eligibility, an
12 eligible family shall pay an initial
enrollment fee of
13 twenty dollars ($20.00) per
recipient and a continuing
14 enrollment fee of twenty dollars
($20.00) per recipient
15 annually thereafter as long as the
recipient remains
16 eligible for services under this
section. The fee shall be
17 collected by the department of
family services and shall be
18 deposited in the general fund. In
addition, for the first
19 three (3) full calendar months of
eligibility each
20 recipient shall be required to pay a
deductible of one
21 thousand dollars ($1,000.00) before
receiving any benefits
22 under the program. No person shall
be subject to this
23 initial high deductible requirement
more than one (1) time
24 unless he has not participated in
the prescription drug
Page 4
1 assistance
program for five (5) years or more. Person
2
qualifying pursuant to paragraph (b)(i) of this section
3
shall not pay the initial enrollment fee or continuing
4
enrollment fees or the deductible. After the first three
5
(3) months of eligibility, the following recipients shall
6
be subject to the following monthly deductibles and
7
copayment for prescription drugs, with the program paying
8
the balance:
9
10 (i) For a
person found eligible under paragraph
11 (b)(i) of this section, the
recipient shall not be required
12 to pay a deductible, but shall be
required to pay a
13 copayment per prescription of ten
dollars ($10.00) for
14 generic drugs and twenty-five
dollars ($25.00) for brand
15 name drugs;
16
17 (ii) For a
recipient found eligible under
18 paragraph (b)(ii) of this section,
the recipient shall be
19 required to pay a deductible of one
hundred dollars
20 ($100.00) each month, and a copayment
per prescription of
21 ten dollars ($10.00) for generic
drugs and twenty-five
22 dollars ($25.00) for brand name
drugs;
23
Page 5
1 (iii) For a
recipient found eligible under
2
paragraph (b)(iii) of this section, the recipient shall be
3
required to pay a deductible of three hundred dollars
4
($300.00) each month, and a copayment per prescription of
5
ten dollars ($10.00) for generic drugs and twenty-five
6
dollars ($25.00) for brand name drugs;
7
8 (iv) For a
recipient found eligible under
9
paragraph (b)(iv) of this section, the recipient shall be
10 required to pay a deductible of six
hundred dollars
11 ($600.00) each month, and a
copayment per prescription of
12 ten dollars ($10.00) for generic
drugs and twenty-five
13 dollars ($25.00) for brand name
drugs.
14
15 (e) The
department shall project costs of the program
16 created by this section at least
quarterly and compare
17 those projected costs against the
funds appropriated for
18 the program. If the funds available
to the program are
19 insufficient to meet the projected
costs of the program,
20 the department shall take action to
prevent the program
21 from incurring costs beyond
available funds, including
22 taking any of the following actions:
23
Page 6
1 (i) Imposing a
moratorium on new enrollments in
2
the program;
3
4 (ii) Reducing
the gross family income
5
eligibility levels specified in subsection (b) of this
6
section;
7
8 (iii) Increasing
the deductibles specified in
9
subsection (c) of this section;
10
11 (iv) Imposing
higher prescription drug
12 copayments;
13
14 (v) Eliminate
individual drugs from eligibility
15 if the cost of the drug is not
justified by its benefit;
16
17 (vi) Carry
claims for payment into the next
18 biennium if the amount of claims are
less than one
19 twenty-fourth (1/24) of the
appropriation that has been
20 enacted for the next biennium.
21
22 (f) Only
prescription drugs that are medically
23 necessary and cost effective are
reimbursable under the
24 program created by this section. In
determining which drugs
Page 7
1 are reimbursable the
department shall consult with the drug
2
utilization review board for Wyoming established pursuant
3
to Title XIX of the federal Social Security Act.
4
5 Section
2. There is appropriated three million two
6
hundred thousand dollars ($3,200,000.00) from the general
7
fund to the department of health for the fiscal year
8
beginning July 1, 2001, to implement the purposes of this
9
act. The department of health is authorized one (1) full-
10 time employee. There is appropriated
three hundred twenty
11 thousand dollars ($320,000.00) from
the general fund to the
12 department of family services for
fiscal year beginning
13 July 1, 2001, to implement purposes
of this act. The
14 department of family services is
authorized four (4) full-
15 time and five (5) part-time
employees.
16
17 Section 3. This act is
effective immediately upon
18 completion of all acts necessary for
a bill to become law
19 as provided by Article 4, Section 8
of the Wyoming
20 Constitution.
21
22 (END)
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