Title 9 Part 9800 NYCRR — browse free

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Compiled text through May 15, 2022Register checked through July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)

All 8 displayed sections in this Part carry the same compiled date. Status and warnings stay on each section.

9 NYCRR 9800.1 - Policy and scope

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Dates and status

Compiling agency: Executive Department
Text status: Phase2b Dequote Reversal
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: May 19, 2026

(a)The policy of the State is to assist elderly persons with low income to meet the cost of their prescription drug expenditures. In pursuit of this goal, the State will contract with only those pharmacies which can demonstrate that they are qualified to provide prescription drugs and which can provide reasonable assurance that public funds will be properly utilized. Only qualified and responsible pharmacies may be enrolled as providers under the Program for Elderly Pharmaceutical Insurance Coverage.

(b)The following definitions shall apply to this Part unless the context requires otherwise:

(1)Affiliate or affiliated person means any person having an overt, covert or conspiratorial relationship with another, such that either of them may directly or indirectly control the other or such that they are under a common control. For example: persons with an ownership or control interest in a provider; agents and managing employees of a provider; subcontractors; and wholly owned suppliers of a provider with whom the provider has significant business transactions-are considered affiliated with each other. Similarly, providers sharing a common ownership or control interest are affiliated with each other.

(2)Fraud shall mean an intentional deception or misrepresentation made with the knowledge that the deception could result in same unauthorized benefit to the person or another person, and includes the acts prohibited by section 547-k of the Executive Law.

(3)Abuse shall mean practices that are inconsistent with sound fiscal business or generally accepted pharmacy practice and result in unnecessary costs to the program.

(4)Agent means a person who has actual or apparent authority to obligate or to act for another.

(5)Pharmacy-applicant is any pharmacy which has submitted an application for enrollment.

(6)Application for enrollment or application means any document submitted by a person for the purpose of enrolling in the program.

(7)Conviction or convicted means that a plea of guilty or no contest or a verdict of guilty has been entered in a Federal, State or local court, regardless of whether an appeal from the judgment is pending or whether a certificate of relief from civil disabilities has been granted.

(8)Contractor means the State fiscal intermediary responsible for enrollment of providers and making payments under the program.

(9)Enrollment or enrolling is the process by which a pharmacy-applicant contracts to participate in the program as a provider of prescription drugs.

(10)Furnishes means the provision of prescription drugs either directly or indirectly by supervising the provision thereof.

(11)Indirect ownership interest means an ownership interest in an entity that has an ownership interest in a provider. This term includes an ownership interest in any entity that has an indirect ownership interest in a provider.

(12)Indictment means an indictment has been handed down by a grand jury, or an accusatory instrument charging a crime which would be a felony under New York State law has been filed.

(13)Managing employee means a general manager, business manager, administrator, director, or other person who exercises operational or managerial control of a provider, or who directly or indirectly conducts the day-to-day operation of a provider.

(14)Medicaid is the program of State-administered medical assistance established by title XIX of the Social Security Act.

(15)Medical assistance program

(16)Medicare is the program of hospital and medical insurance established under title XVIII of the Social Security Act.

(17)Ownership interest means possession of equity in the capital, the stock or the profits of a provider.

(18)Participation is the ability and authority to furnish prescription drugs to eligible participants and to receive payment from the program.

(19)Person includes natural persons, corporations, partnerships, associations, clinics, groups and other entities.

(20)Person with an ownership or control interest means a person who:

(i)has an ownership interest totalling five percent or more in a provider;

(ii)has an indirect ownership interest equal to five percent or more in a provider;

(iii)has a combined direct and indirect ownership interest equal to five percent or more in a provider;

(iv)owns an interest of five percent or more in any mortgage, deed of trust, note or other obligation secured by the provider if that interest equals at least five percent of the value of the property or assets of the provider;

(v)is an officer or director of a provider that is organized as a corporation; and

(vi)is a partner in a provider that is organized as a partnership.

(21)Covered drug means a drug dispensed subject to a legally authorized prescription pursuant to section 6810 of the Education Law, and insulin, an insulin syringe or an insulin needle, as more fully defined in Part 9960 of this Title.

(22)Program means the Program for Elderly Pharmaceutical Insurance Coverage as provided for by article 19-K of the Executive Law.

(23)Provider is any person who has enrolled as a provider of prescription drugs under the program.

(24)Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 or five percent of a provider's total operating expenses.

(25)Subcontractor means any person to which a provider has contracted or delegated some of its management functions or responsibilities for providing covered drugs.

(26)Supplier means a person from whom a provider purchases goods and services used in carrying out its responsibilities under the program.

(27)Wholly owned supplier means a supplier whose total ownership interest is held by a provider or a person with an ownership or control interest in a provider.

(28)Common ownership means:

(i)ownership by a person or group of persons who have a combined direct or indirect ownership interest of 50 percent or more in two or more providers; or

(ii)two or more providers with any common ownership where common purchasing is practiced.

(29)24-hour emergency prescription services means a service in which a pharmacist is available to fill or refill a prescription at any time of the day or night, to treat the existence of any condition requiring the alleviation of severe pain or which threatens to cause disability or take life if not promptly treated.

(30)Emergency delivery service at no cost to the consumer means a participant is able to obtain free emergency delivery service, within a five-mile radius of the pharmacy, during operating hours, to treat the existence of any condition requiring the alleviation of severe pain or which threatens to cause disability or take life if not promptly treated.

(31)Maintain a patient profile means each pharmacist shall maintain a patient medication profile. Such medication profile shall include, but not be limited to, the patient's name, address, telephone number, gender, date of birth or age, known allergies and drug reactions, chronic diseases, a comprehensive list of medications and relevant devices and other information reported to the pharmacist which is appropriate for counseling an individual regarding use of prescription and over-the-counter drugs. Pharmacists shall conduct a prospective drug review before each prescription is dispensed or delivered to a patient or person acting on behalf of the patient. Such review shall include screening for potential drug therapy problems due to therapeutic duplication, drug-drug interactions, including serious interactions with over-the- counter drugs, incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse or misuse.

(32)Direct patient consultation with each prescription shall mean pharmacists providing prescription services shall offer to discuss with each patient, recipient or caregiver of such patient, (in person, when ever practicable, or by telephone, or for pharmacies engaged primarily in the mail order delivery of prescriptions, through access to a telephone service which is toll-free for long-distance calls) who presents a prescription, matters which in exercise of the pharmacist's professional judgment, the pharmacist deems significant, including the following:

(i)the name and description of the medication;

(ii)dosage form, dosage, route of administration and duration of drug therapy;

(iii)special directions and precautions for preparation, administration and use by the patient;

(iv)common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur;

(v)techniques for self-monitoring drug therapy;

(vi)proper storage;

(vii)prescription refill information; and

(viii)action to be taken in the event of a missed dose.

If the offer to counsel is accepted, the pharmacist, or registered pharmacy intern shall counsel the person presenting the prescription to the extent the pharmacist deems appropriate in the pharmacist's professional judgment. Such counseling may include subparagraphs (i)-(viii) of this paragraph. In the event a patient chooses not to supply information necessary for maintenance of a medication profile, or not to accept counseling, a pharmacist may fill a prescription as presented, without having violated this regulation, provided the refusal to provide such information or accept counseling is documented in the records of the pharmacy. Patient medication profiles shall be maintained in a retrievable form for five years following the date of the most recent entry.

9 NYCRR 9800.2 - Application for enrollment

No later Register activity identified in this check.

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Dates and status

Compiling agency: Executive Department
Text status: Source receipt
Compiled text through: May 15, 2022
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: Jun 6, 2026

(a)Information regarding application for enrollment may be obtained by writing to the provider enrollment unit of the contractor.

(b)Any person who furnishes covered drugs and who wishes to receive payments under the program must enroll as a provider of services prior to being eligible to receive such payments.

(c)A pharmacy-applicant must hold a proper and currently valid New York State pharmacy license and registration to be eligible to furnish the care, services or supplies under the program.

(d)To apply for enrollment as a provider of covered drugs, a pharmacy-applicant must submit a complete, original, signed and sworn application in the form and manner as may be required by the contractor. The ownership and disclosure form required by the contractor is part of the application.

(e)The contractor may require the provision of information relative to the pharmacy-applicant's ability to provide high-quality services and to be financially responsible.

9 NYCRR 9800.3 - Duties of the provider

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Dates and status

Compiling agency: Executive Department
Text status: Source receipt
Compiled text through: May 15, 2022
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: Jun 6, 2026

By enrolling, the provider agrees:

(a)to prepare and to maintain contemporaneous records demonstrating its right to receive payment under the program and to keep, for a period of three years from the date care, services or supplies were furnished, all records necessary to disclose the nature and extent of services furnished and all information regarding claims for payment submitted by, or on behalf of, the provider, and to furnish such records and information, upon request, to the contractor, the panel, executive director, or agents and designees;

(b)to comply with the disclosure requirements with respect to ownership and control interests, significant business transactions and involvement with convicted persons;

(c)to accept payment from the program as payment in full for all covered drugs billed under the program, except where specifically provided in law to the contrary with respect to required copayments;

(d)not to illegally discriminate on the basis of handicap, race, color, religion, national origin, sex or age;

(e)to submit claims for payment only for covered drugs actually furnished and which were provided to eligible persons;

(f)to submit claims on officially authorized claim forms in the manner specified by the contractor in accordance with the standards and procedures for claims submission;

(g)to permit audits, by the persons and agencies denominated in subdivision (a) of this section, of all books and records or, in the discretion of the auditing agency, a sample thereof, relating to services furnished and payments received under the program;

(h)that the information provided in relation to any claim for payment shall be true, accurate and complete; and

(i)to comply with the rules, regulations of the program and official directives of the contractor and the executive director.

9 NYCRR 9800.4 - Duties of the contractor

No later Register activity identified in this check.

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Dates and status

Compiling agency: Executive Department
Text status: Source receipt
Compiled text through: May 15, 2022
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: Jun 6, 2026

(a)Upon receipt of a complete, original and signed application, an appropriate review, at the direction of the executive director, shall be conducted to verify or supplement the information contained in the application. Incomplete applications shall be returned to the pharmacy-applicant within three working days with deficiencies noted.

(b)The contractor may request further information from a pharmacy-applicant. In such a case, it shall make a clear and precise request to the pharmacy-applicant for the information and inform the pharmacy-applicant whether or not action on the application will be postponed pending receipt of the requested information. Delay occasioned by the pharmacy-applicant's failure to timely reply shall not be counted in calculating the time within which the contractor shall make its determination on the application.

(c)The contractor shall complete its review and determine whether or not to enroll the pharmacy-applicant within 30 calendar days after receipt of an application.

(d)If a pharmacy-applicant cannot be fully reviewed within the required time, the contractor may extend the time for acting on an application for up to one additional 30-day period from the date of receipt of the application. Written notice of this extension will be mailed to the pharmacy-applicant within 30 calendar days from the time the application was received.

(e)Upon completion of its consideration of an application, the contractor shall either:

(1)enroll the pharmacy-applicant as a provider; or

(2)deny the application, if it is in the best interests of the program to do so, specifying the reasons for denial.

9 NYCRR 9800.5 - Denial of an application

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Dates and status

Compiling agency: Executive Department
Text status: Source receipt
Compiled text through: May 15, 2022
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: Jun 6, 2026

(a)In determining whether to enter into a contract with a pharmacy-applicant, the following factors shall be grounds for denial of an application:

(1)any false representation or omission of any material fact in making the application;

(2)any previous or current suspension, exclusion or involuntary withdrawal from participation in the medical assistance program or the Medicaid program of any other state of the United States or from participation in any other governmental or private medical insurance program, including but not limited to Medicare, workers' compensation, physically handicapped children's program and rehabilitation services;

(3)the receipt of, but not having made restitution for, a Medicaid or Medicare overpayment, as determined to have been made pursuant to a final decision or determination of an agency having the powers to conduct the proceeding and after an adjudicatory proceeding in which no appeal is pending or after resolution of the proceeding by stipulation or agreement; however, if a pharmacy-applicant has entered into a plan of restitution of such overpayment, an application may not be denied based solely on this factor unless the pharmacy-applicant has defaulted in repayment;

(4)any false representation or omission of a material fact in making application in any state of the United States for any license, permit, certificate or registration related to a profession or business;

(5)any previous failure to correct deficiencies in the operation of a business or enterprise after having received written notice of the deficiencies from a State or Federal licensing or auditing agency;

(6)any failure to supply further information concerning the application after receiving a written request for such further information;

(7)the submission of an application which conceals an ownership or control interest of any person who would otherwise be ineligible to participate;

(8)an outstanding indictment for, or prior conviction of, any crime relating to the furnishing of, or billing for, medical care, services or supplies, or which is considered an offense involving theft or fraud or an offense against public administration or against public health and morals;

(9)a prior finding by a licensing, certifying or professional standards board or agency of the violation of the standards or conditions relating to licensing or certification or as to the quality of services provided;

(10)the pharmacy-applicant's prior pattern or practices in furnishing medical care, services or supplies under any private or publicly funded program or policy of insurance; and

(11)any other factor having a direct bearing on the pharmacy-applicant's ability to provide high-quality pharmaceutical services to participants in the program, or to be fiscally responsible under the program, including actions by persons affiliated with the pharmacy-applicant.

(b)If any application is denied, the pharmacy-applicant shall be given a written notice of the denial, stating the reason or reasons for the denial, within three days of the determination to deny the application. The written notice of denial will be effective upon the date it is mailed to the pharmacy-applicant.

(c)The pharmacy-applicant may request a reconsideration of a denial by submitting a written request for a reconsideration to the executive director within 30 days of the date of the denial. The request shall include all arguments and documentation which the pharmacy-applicant wishes to be considered in its behalf. A written determination of acceptance or denial of the application shall be issued by the executive director within 60 days of receipt of the request for reconsideration, stating the basis for the determination and the reasons for affirming or reversing the initial determination.

(d)If an application has been denied, the pharmacy-applicant may reapply only upon correction of the factors leading to its denial, or after one year if the factors relate to prior conduct of the pharmacy-applicant or an affiliated person.

(e)Denial of an application shall preclude the pharmacy-applicant from submitting claims for payment under the program either directly, or indirectly through any other person. Any claims submitted by such pharmacy-applicant or such other person and paid by the contractor shall constitute overpayments.

9 NYCRR 9800.6 - Acceptance of an application

No later Register activity identified in this check.

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Dates and status

Compiling agency: Executive Department
Text status: Source receipt
Compiled text through: May 15, 2022
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: Jun 6, 2026

(a)Upon acceptance of an application, the contractor shall issue to the provider a provider agreement, identification number and instructions on participation in the program and filing of claims for payment. Upon receipt of a complete, signed provider agreement, the contractor shall enroll the provider within 15 working days.

(b)Enrollment, including the use of the identifying number, is not assignable or transferable but is strictly limited to the provider to which it was issued, unless authorized in writing by the contractor prior to the assignment or transfer.

(c)A provider's participation may begin only on or after the date specified in the notification of acceptance. A provider may participate in the program for the period specified in the notice of acceptance, unless participation has been otherwise terminated or suspended.

(d)A provider may submit claims only for services provided by the provider or another person under his supervision and in compliance with this Subtitle.

9 NYCRR 9800.7 - Continued enrollment/termination

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Dates and status

Compiling agency: Executive Department
Text status: Source receipt
Compiled text through: May 15, 2022
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: Jun 6, 2026

(a)A provider's participation in the program may be terminated by the provider upon 30 days' written notice to the contractor without cause.

(b)A provider's participation in the program may be terminated, suspended or restricted for a reasonable period of time if the provider has abused the program, and shall be terminated if the provider has engaged in fraud.

(c)A provider's participation shall be terminated or suspended as of the date of the provider's suspension or termination from Medicare or the medical assistance program.

(d)A provider's participation shall be terminated or suspended as of the date of any termination, revocation or suspension of its registration.

(e)A provider must maintain an up-to-date “Disclosure of Ownership and Control Interest Statement” on file with the contractor, amending it at least biennially or sooner when necessary to assure that the information contained in the statement is true, accurate and complete. Failure to maintain an up-to-date disclosure form on file, or to submit one within 35 days of a request by the contractor, will result in the termination of the provider's participation.

(f)A provider's participation may be terminated and a new application for enrollment required where the ownership or control of the provider has substantially changed since acceptance of its enrollment application, whether by the sale or exchange of the capital stock in a provider organized as a corporation, the addition or elimination of one or more partners in a provider organized as a partnership, or the sale of the business or assets of any provider entity.

(g)A provider's participation will be terminated where the provider furnished incorrect, inaccurate or incomplete information in connection with an application and where provision of correct, accurate and complete information would have resulted in the denial of the application based upon one or more of the factors set forth in section 9800.5(a) of this Part.

(h)Where a provider's participation is to be terminated, suspended or restricted, it is entitled to notice and an opportunity to be heard in accordance with the provisions of sections 9850.7 through 9850.13 of this Title. The provider must be given written notice of the action at least 15 days prior to its effective date, stating: the reasons for the action, the effective date, the effect of the action upon the provider's participation in the program, the earliest date on which participation may be reinstated, and the requirements for requesting a hearing.

9 NYCRR 9800.8 - Audit and claim review

No later Register activity identified in this check.

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Dates and status

Compiling agency: Executive Department
Text status: Source receipt
Compiled text through: May 15, 2022
Register checked through: July 29, 2026/Vol. XLVIII, Issue 30 (2026-07-29)
Activity status: No later Register activity identified in this check.
Source snapshot: Jun 6, 2026

(a)Providers shall be subject to audit by the panel, the executive director, their agents or the contractor. With respect to such audits the provider may be required:

(1)to reimburse the contractor for overpayments discovered by audits; and

(2)to pay restitution for any direct or indirect monetary damage to the program resulting from their improperly or inappropriately furnishing covered drugs.

(b)The panel, the executive director, their agents or the contractor may conduct or have conducted audits and claims reviews which may be limited to reviews of costs of operation or validity of claims submitted, and adherence to accepted pharmacy practices and established contractor policy and procedures, conduct therapeutic drug monitoring reviews applying accepted pharmaceutical practice standards or conduct investigations as to the provider's conduct relative to fraud or abuse.

(c)The contractor upon prepayment review, or therapeutic drug monitoring review, may deny claims, adjust claims to eliminate noncompensable items or to reflect established rates or fees, pend claims for review, or approve the claim for payment, subject to post-payment audit and verification.

(1)For claims denied as a result of therapeutic drug monitoring reviews, as a condition for payment, the provider must submit information indicating that the pharmacist has either reviewed the questioned prescription(s), consulted with the participant or interacted with the prescribing physician. Information submitted must describe any actions taken as a result of such review, consultation or interaction to deter or prevent the incorrect or unnecessary consumption of a therapeutic agent.

(2)For claims denied as a result of suspected excessive quantities, providers must submit, as a condition for payment, additional dispensing information, such as the dose prescribed, which justifies the quantities billed.

(d)Where the contractor's analysis of claims or initial onsite audit findings indicate that a provider has claimed or is claiming for covered drugs which may be inconsistent with regulations governing the program or with established standards for quality, or which are otherwise inappropriate, payment of all claims submitted and of all future claims may be delayed or suspended, upon the written approval of the executive director, pending completion of an investigation upon approval of the executive director. A notice of the withholding of payment shall be sent to the provider contemporaneous with withholding of payments.

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