SF0133 - Prescription drug assistance program.
2001 |
State of Wyoming |
01LSO-0370 Substitute No. 1 |
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 ten million dollars
6
($10,000,000.00) from the general fund to the department of
7
health for the fiscal year beginning July 1, 2001, to
8
implement the purposes of this act. There is appropriated
9
three hundred twenty thousand dollars ($320,000.00) from
10 the general fund to the department of family
services for
11 fiscal year beginning July 1, 2001, to
implement purposes
12 of this act. The department of family services is
13 authorized eight (8) full-time and ten (10)
part-time
14 employees.
15
16 Section 3. This act is effective
immediately upon
17 completion of all acts necessary for a bill
to become law
18 as provided by Article 4, Section 8 of the
Wyoming
19 Constitution.
20
21 (END)
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