ARTICLE 8 SUBSTITUTE A

RELATING TO ELDERLY AFFAIRS PROGRAMS

SECTION 1. Section 42-66-4.2 of the General Laws in Chapter 42-66 entitled "Elderly Affairs Department” is hereby repealed .

§ 42-66-4.2  Photo identification cards. – The department shall make available to every disabled person eighteen (18) years of age or older requesting one, a photo identification card at a cost of two dollars ($2.00) for each card. The card shall contain a photo of the person, his or her address, an identification number and any other information as ordered by the director to the benefit of the disabled person. All funds collected shall be deposited as general revenues of the state.

SECTION 2. Sections 42-66.2-3, 42-66.2-5, 42-66.2-6, 42-66.2-7, and 42-66.2-9 of the General Laws in Chapter 42-66.2 entitled “Pharmaceutical Assistance to the Elderly Act” are hereby amended to read as follows:

42-66.2-3. Definitions. – As used in this chapter, unless the context requires otherwise:

   (1) "Consumer" means any full-time resident of the state who fulfills the eligibility requirements set forth in § 42-66.2-5. Residence for purposes of this chapter shall be in accordance with the definitions and evidence standards set forth in § 17-1-3.1.

   (2) "Contractor" means a third party or private vendor capable of administering a program of reimbursement for prescription drugs, and drug program eligibility administrative support as required by the director, the vendor to be determined through a competitive bid process in which the director awards a three (3) year contract for services.

   (3) "Department" means the department of elderly affairs.

   (4) "Director" means the director of the department of elderly affairs.

   (5) "Eligible drugs" means insulin, injectable drugs for multiple sclerosis, and shall mean non-injectable drugs which require a physician's prescription according to federal law and which are contained in the following American Hospital Formulary Service pharmacologic-therapeutic classifications categories that have not been determined by the federal "Drug Efficacy and Safety Implementation (DESI) Commission" to lack substantial evidence of effectiveness. Eligible drugs are limited to the following classification categories: cardiac drugs, hypotensive drugs, diuretics, anti-diabetic agents, insulin, disposable insulin syringes, vasodilators (cardiac indications only), anticoagulants, hemorreolgic agents, glaucoma drugs, drugs for the treatment of Parkinson's disease, antilipemic drugs and oral antineoplastic drugs and drugs for the treatment of asthma and other chronic respiratory diseases and prescription vitamin and mineral supplements for renal patients, and drugs approved for the treatment of Alzheimer's disease, drugs used for the treatment of depression, those drugs approved for the treatment of urinary incontinence, anti-infectives, drugs used for the treatment of arthritis, drugs approved for the treatment of osteoporosis, and neuraminidase inhibiting drugs indicated for the treatment of influenza A and B.

   (ii) "Additional drugs" means non-injectable drugs which require a physician's prescription according to federal law and which are contained in the American Hospital Formulary Service pharmacologic-therapeutic classifications categories that have not been determined by the federal "Drug Efficacy and Safety Implementation (DESI) Commission" to lack substantial evidence of effectiveness, which are not included in the definition of drugs as defined in this subdivision. However, this shall not include prescription drugs used for cosmetic purposes.

   (6) "Income" for the purposes of this chapter means the sum of federal adjusted gross income as defined in the Internal Revenue Code of the United States, 26 U.S.C. § 1 et seq., and all nontaxable income including, but not limited to, the amount of capital gains excluded from adjusted gross income, alimony, support money, nontaxable strike benefits, cash public assistance and relief (not including relief granted under this chapter), the gross amount of any pension or annuity (including Railroad Retirement Act benefits, 45 U.S.C. § 231 et seq., all payments received under the federal Social Security Act, 42 U.S.C. § 301 et seq., state unemployment insurance laws, and veterans' disability pensions), nontaxable interest received from the federal government or any of its instrumentalities, workers' compensation, and the gross amount of "loss of time" insurance. It does not include gifts from nongovernmental sources, or surplus foods or other relief in kind supplied by a public or private agency.

   (7) "Pharmaceutical manufacturer" means any entity holding legal title to or possession of a national drug code number issued by the federal food and drug administration.

   (8) "Pharmacy" means a pharmacy licensed by the state of Rhode Island.

(9) "Pilot program contractor" means Blue Cross and Blue Shield of Rhode Island.

42-66.2-5. Persons eligible. – (a) Persons eligible for assistance under the provisions of this chapter include any resident of the state who is at least sixty-five (65) years of age or at least fifty-five (55) years of age and receiving social security disability benefits. State and consumer co-payment shares for these persons shall be determined as follows:

   (1) For unmarried persons or married persons living separate and apart whose income for the calendar year immediately preceding the year in which assistance is sought is:

   (i) Less than fifteen thousand nine hundred and thirty-two dollars ($15,932) nineteen thousand three hundred forty-one dollars ($19,341) the state shall pay sixty percent (60%) of the cost of the prescriptions and the consumer shall pay forty percent (40%) of the cost of the prescriptions.

   (ii) More than fifteen thousand nine hundred and thirty-two dollars ($15,932) nineteen thousand three hundred forty-one dollars ($19,341) and less than twenty thousand dollars ($20,000), twenty-four thousand two hundred and eighty dollars ($24,280) the state shall pay thirty percent (30%) of the cost of the prescriptions and the consumer shall pay seventy percent (70%) of the cost of the prescriptions; and

   (iii) More than twenty thousand dollars ($20,000) twenty-four thousand two hundred and eighty dollars ($24,280) and less than thirty-five thousand dollars ($35,000) forty-two thousand four hundred and ninety-three dollars ($42,493), the state shall pay fifteen percent (15%) of the cost of prescriptions and the consumer shall pay eighty-five percent (85%) of the cost of prescriptions.

   (2) For married persons whose income for the calendar year immediately preceding the year in which assistance is sought hereunder when combined with any income of the person's spouse in the same year is:

   (i) Nineteen thousand nine hundred and sixteen dollars ($19,916) Twenty-four thousand one hundred and seventy-nine dollars ($24,179) or less, the state shall pay sixty percent (60%) of the cost of the prescriptions and the consumer shall pay forty percent (40%) of the cost of the prescriptions;

   (ii) More than nineteen thousand nine hundred and sixteen dollars ($19,916) twenty-four thousand one hundred and seventy-nine dollars ($24,179) and less than twenty-five thousand dollars ($25,000) thirty thousand three hundred and fifty-two dollars ($30,352), the state shall pay thirty percent (30%) of the cost of the prescriptions and the consumer shall pay seventy percent (70%) of the cost of prescriptions; and

   (iii) More than twenty-five thousand dollars ($25,000) thirty thousand three hundred and fifty-two dollars ($30,352) and less than forty thousand dollars ($40,000) forty-eight thousand five hundred and sixty-three dollars ($48,563), the state shall pay fifteen percent (15%) of the cost of prescriptions and the consumer shall pay eighty-five percent (85%) of the cost of prescriptions.

   (3) Eligibility may also be determined by using income data for the ninety (90) days prior to application for benefits and projecting that income on an annual basis. The income levels shall not include those sums of money expended for medical and pharmaceutical that exceed three percent (3%) of the applicant's annual income or three percent (3%) of the applicant's preceding ninety (90) day income computed on an annual basis.

   (4) For persons on social security disability benefits who are: (i) unmarried or married and living separate and apart with income for the calendar year immediately preceding the year in which assistance is sought that is less than thirty-seven thousand one hundred and sixty-seven dollars ($37,167) forty-two thousand four hundred and ninety-three dollars ($42,493); or (ii) married with income that is less than forty-two thousand four hundred seventy-six dollars ($42,476) forty-eight thousand five hundred and sixty-three dollars ($48,563) the state shall pay fifteen percent (15%) of the cost of prescriptions and the consumer shall pay eighty-five percent (85%) of the cost.

   (b) On July 1 of each year, the maximum amount of allowable income for both unmarried and married residents set forth in subsection (a) shall be increased by a percentage equal to the percentage of the cost of living adjustment provided for social security recipients.

   (c) No person whose prescription drug expenses are paid or reimbursable, either in whole or in part, by any other plan of assistance or insurance is eligible for assistance under this section, until the person's prescription drug coverage for a specific covered prescription medication is exhausted or the specific prescription medication is not covered by the plan during a benefit year, and as provided in subsection (d).

   (d) The fact that some of a person's prescription drug expenses are paid or reimbursable under the provisions of the federal Medicare program shall not disqualify that person, if he or she is otherwise eligible, to receive assistance under this chapter. In those cases, the state shall pay the eligible percentage of the cost of those prescriptions for qualified drugs for which no payment or reimbursement is made by the federal government.

   (e) Eligibility for receipt of any other benefit under any other provisions of the Rhode Island general laws as a result of eligibility for the pharmaceutical assistance program authorized under this section shall be limited to those persons whose income qualify them for a sixty percent (60%) state co-payment share of the cost of prescriptions.

   (f) For all additional drugs, the consumer shall pay one hundred percent (100%) of the cost of prescriptions as set forth in § 42-66.2-4.

(g) As of July 1, 2004, all new enrollees in the program whose income qualifies them for Transitional Assistance (135% of poverty) under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Section 1860D-31 [42 U.S.C. § 1395w 141], shall apply annually, for a Medicare prescription drug discount card, to be used in conjunction with benefits offered under this chapter, in order to continue to receive benefits under this chapter. Enrollees who joined the program prior to July 1, 2004 and who qualify for Transitional Assistance (135% of poverty) under the Medicare Prescription and Drug Improvement, and Modernization Act of 2003, Section 1860D-31 [42 U.S.C. § 1395w 141], shall, by September 30, 2004 and continuously thereafter until such time as Medicare Part D becomes effective, make application for a Medicare prescription drug discount card to be used in conjunction with benefits offered under this chapter, in order to continue receiving benefits under this chapter.

(h)(g) To promote coordination of benefits between the pharmaceutical assistance program created under this chapter and the Medicare Part D prescription drug program created in the federal Medicare Prescription Drug, Improvement and Modernization Act of 2003, RIPAE enrollees whose income is at or below 150% of the federal poverty limit and whose resources are below the resource eligibility limits determined by the Centers for Medicare and Medicaid Services for low income assistance benefit under Medicare Part D must apply for and enroll in the Medicare Part D prescription drug program.

The Rhode Island Pharmaceutical Assistance to the Elderly Program (RIPAE) is authorized to apply for transitional assistance with a specific drug card under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Section 1860D-31 [42 U.S.C. § 1395w 141] on behalf of applicants and eligible members under this article. RIPAE shall provide applicants and eligible members with prior written notice of, and the opportunity to decline, such automatic enrollment.

42-66.2-6.  Responsibilities of department of elderly affairs. – (a) Determination of eligibility. The department shall adopt regulations relating to the determination of eligibility of prospective consumers and the determination and elimination of program abuse. The department has the power to declare ineligible any consumer who abuses or misuses the established prescription plan. The department has the power to investigate cases of suspected provider or consumer fraud.

(b) Rebates for expenses prohibited. (1)  A system of rebates or reimbursements to the consumer for pharmaceutical expenses shall be prohibited.

   (2) Subdivision (1) shall not be interpreted to exclude other consumers not participating in the pharmaceutical assistance to the elderly program from receiving financial offers or redeemable coupons that are available to only those who have paid for the service or product through direct cash payment, insurance premiums, or cost sharing with an employer.

(c) Program criteria. The program includes the following criteria:

   (1) Collection of the co-payment by pharmacies is mandatory;

   (2) Senior citizens participating in the program are not required to maintain records of each transaction but shall sign a receipt for eligible and additional drugs;

   (3) A system of rebates or reimbursements to the consumer for pharmaceutical expenses is prohibited;

   (ii) This subdivision shall not be interpreted to exclude other consumers from receiving financial offers or redeemable coupons that are available to only those who have paid for the service or product through direct cash payment, insurance premiums, or cost sharing with an employer.

   (4) Prescription benefits for any single prescription may be dispensed in the amounts authorized by the physician, and agreed to by the consumer, up to a maximum of a one hundred (100) day supply or two hundred (200) doses, whichever is less and/or a one hundred (100) day supply or one quart of liquid, whichever is less; provided, however, that disposable insulin syringes are dispersed in a quantity of one hundred (100);

   (5) Experimental drugs are excluded from the program;

   (6) A system of mail order delivery for prescriptions is allowed under this program; and

   (7) Eligible and additional drugs must be dispensed within one year of the original prescription order.

   (d) The director shall issue an eligibility card containing a program ID number and the time period for which the card is valid.

   (e) The director shall institute and conduct an educational outreach program and shall provide a mechanism, within the department, to handle all public inquiries concerning the program.

   (f) The director shall establish a process, in accordance with the Administrative Procedures Act, chapter 35 of this title, to provide an appeals hearing on the determination of eligibility.

   (g) The director shall forward to the contractor a list of all eligible consumers.

   (h) Expenditures for multiple sclerosis drugs shall not exceed thirty thousand dollars ($30,000).

(i) Generic drug substitution is mandatory when there is an available generic drug equivalent.

42-66.2-7. Contract. – (a) The director is authorized and shall enter into a contract with the contractor for the effective administrative support of this program.

   (b) The pilot program contractor shall, under terms agreed to by the director, continue administrative support of the program until a competitive bid process can be implemented and a three (3) year contract awarded. The director shall initiate the competitive bid process by the issuance and advertisement of specifications and request for proposals, on or before January 1, 1988. The contract resulting from the competitive bid process shall be awarded to become effective for a three (3) year period commencing no later than July 1, 1988. A competitive bid and contract award shall occur every three (3) years thereafter. in accordance with the state Medicaid authority’s competitive bid process and cycle.

42-66.2-9.  Annual report. – (a) The director shall submit an annual report to the governor, the budget officer, the chairperson of the house finance committee, the chairperson of the senate finance committee, and the chairperson of the board of pharmacy as established by § 5-19.1-4. The report shall contain the number of consumers eligible for the program, the number of consumers utilizing the program, an outline of and a report on the educational outreach program, the number of appeals, an outline of problems encountered in the administration of the program and suggested solutions to the problems, and any recommendations to enhance the program.

   (b) The contractor shall submit an annual report to the governor, the budget officer, the chairperson of the house finance committee, the chairperson of the senate finance committee, and the board of pharmacy as established by § 5-19.1-4. The report shall contain financial and utilization statistics as to drug use by therapeutic category, actuarial projections, an outline of problems encountered in the administration of the program, and suggested solutions to the problems and any recommendations to enhance the program.

(c) The first report pursuant to this section shall be submitted on or before January 15, 1986.

SECTION 3. Section 42-66.2-11 of the General Laws in Chapter 42-66.2 entitled “Pharmaceutical Assistance to the Elderly Act” is hereby repealed.

§ 42-66.2-11  Special Legislative Commission to Reconcile the Provisions of the Pharmaceutical Assistance Program with the Medicare Prescription Drug and Modernization Act of 2003. – Due to the passage of the federal Medicare Prescription Drug and Modernization Act of 2003, some consumers of the Rhode Island Pharmaceutical Assistance for the Elderly Program will be eligible for federal Medicare coverage for some of their medication needs. It is the intent of the general assembly to study the provisions of the new federal act for Medicare prescription coverage and make recommendations for adjustments to the Rhode Island Pharmaceutical Assistance for the Elderly Program as necessary to ensure the maximum possible coverage and benefit to eligible consumers. The Special Legislative Commission to Reconcile the Provisions of the Pharmaceutical Assistance Program with the Medicare Prescription Drug and Modernization Act of 2003 shall be composed of ten (10) members, one of whom shall be the director of the department of human services, one of whom shall be the director of the department of elderly affairs, four (4) of whom shall be appointed from the house of representatives by the speaker of the house, with one of said appointees belonging to the minority leader, and four (4) of whom shall be appointed from the senate by the president of the senate, with one of said appointees belonging to the minority leader. The commission shall choose from among its member's co-chairpersons representing both chambers. State agencies shall make available any information deemed necessary by the commission to complete its task. The commission shall make its recommendations to the house and senate committees on finance on or before February 15, 2005.

SECTION 4. This article shall take effect as of July 1, 2008.