Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.02 - Definitions

Current through Register 1525, July 5, 2024
Administrative Review
. The final level
				of review upon the timely request of a Member or Applicant, or his or her
				designee, of decisions made by the Plan to deny or terminate Enrollment, Plan
				determinations of a Member's Gross Annual Household Income, or decisions by the
				Plan to deny or limit Covered Benefits, including Supplemental
				Assistance.
Administrative Review Officer
. An
				employee or agent of Elder Affairs who conducts Administrative Reviews.
Applicant
. An individual who has
				completed and submitted an application that has been received by the Plan, and
				who is awaiting a determination of eligibility.
Authorized Representative
. An
				individual designated by an Applicant or Member to:
(a) make decisions regarding the Plan on behalf of the
				Applicant or Member; and
(b) receive all Plan correspondence, which may include the
				Protected Health Information of an Applicant or Member.
Brand-name Drug
. A Prescription Drug
				that receives patent protection for its name, chemical formulation and/or
				manufacturing process, and is approved by the Food and Drug Administration
				(FDA).
Business Day
. A day during which Elder
				Affairs is open to the public during regular business hours. If the last day of
				a time period set forth in
				651 CMR 15.00 falls on a day
				during which Elder Affairs is closed to the public, the next Business Day
				during which Elder Affairs is open shall be deemed to be the last day of the
				time period.
Co-insurance
. The amount of money that
				a Member pays to a Participating Pharmacy or approved mail order facility,
				based on a percentage of the cost of a Prescription Drug as determined by the
				Member's Medicare Prescription Drug Plan.
CommonHealth
. A MassHealth program
				administered by the Office of Medicaid to furnish and pay for medical benefits
				to eligible individuals pursuant to M.G.L. c. 118E, §§ 9A, 16 and
				16A.
Commonwealth
. The Commonwealth of
				Massachusetts.
Co-payment
. The applicable point of
				purchase contribution established by the Plan and paid by a Member to a
				Participating Pharmacy or approved mail service facility for each Prescription
				Drug dispensed.
Covered Benefits
. Items listed on the
				Plan Formulary. Covered Benefits include Prescription Drugs that are on the
				Plan Formulary, are dispensed by a retail pharmacy (including mail service) and
				can be self-administered. Covered benefits do not include any Prescription
				Drugs that are administered in an inpatient setting. For any Member who is
				enrolled in a Medicare Part D Plan or Creditable Coverage Plan, covered
				benefits are only those products that are covered by the Member's Part D Plan
				or Creditable Coverage Plan and benzodiazepines.
Creditable Coverage Plan
. A plan which
				provides creditable prescription drug coverage as defined by Section 104 of the
				Medicare Prescription Drug, Improvement, and Modernization Act of 2003, and
				which provides coverage for the cost of prescription drugs actuarially equal to
				or better than that provided by Medicare Part D.
Deductible
. The amount of money paid
				by a Member toward Covered Benefit costs prior to gaining access to Covered
				Benefits at the applicable Co-payment rates.
Effective Date of Coverage
. The date
				on which a Member is eligible to receive Covered Benefits.
Elder Affairs
. The Massachusetts
				Executive Office of Elder Affairs (also called the Department of Elder
				Affairs).
Enrollment
. The process during which
				the Plan accepts applications for the purpose of review, determination of
				eligibility, and approval of Applicants to receive Covered Benefits.
Enrollment Fee
. An annual fee a member
				may be required to pay to receive Covered Benefits or Supplemental Assistance
				under the Plan.
Federal Poverty Level
. The national
				poverty income guidelines applicable to Massachusetts. Said guidelines are
				issued annually in the Federal Register by the Secretary of the Department of
				Health and Human Services to account for changes in the cost of living as
				measured by the change in the average annual value of the Consumer Price
				Index.
Fiscal Year
. The annual accounting
				period employed by the Commonwealth, beginning on July
				1st and ending on June
				30th each year.
Generic Drug
. A Prescription Drug that
				is: approved by the Food and Drug Administration (FDA); bio-equivalent to a
				Brand-name Drug; produced by one or more drug companies under its generic name;
				and available on the Plan Formulary at the lowest Co-payment level.
Gross Annual Household Income
. The
				amount of total income as reported on federal income tax returns and any
				additional Social Security income as reported on form(s) SSA-1099 for the
				Applicant or Member and, if they live together in the same housing unit, the
				Applicant's or Member's Spouse. For Applicants or Members not required to file
				a federal income tax return, Gross Annual Household Income includes the total
				amount of money, earned or unearned, from any source, including, but not
				limited to, wages, salaries, rents, pensions, dividends and interest received
				by each Applicant or Member and his or her Spouse.
Household
. A single adult or married
				couple, and any other relatives who depend on that adult or couple to provide
				at least one half of their financial support, and who live together in the same
				housing unit.
Low-income Subsidy
. Financial
				assistance provided by Medicare pursuant to the MMA Subpart P to Members who
				qualify for payment of Medicare Part D premiums and other cost sharing
				associated with drug coverage, as defined in
				42 CFR 423.780
				and
				423.782.
Maintenance Drug
. A Prescription Drug
				prescribed to an individual for a chronic condition, the use of which is
				medically necessary for a period of 90 consecutive calendar days or
				longer.
MassHealth
. The medical assistance or
				benefit program administered by the Office of Medicaid pursuant to Title XIX of
				the Social Security Act (42 U.S.C. §1396), Title XXI of the Social
				Security Act (42 U.S.C. §1397), M.G.L. c. 118E, and other applicable laws
				and waivers.
Medicare Advantage Prescription Drug Plan
				(MA-PD)
. A Medicare Advantage plan that provides qualified
				prescription drug coverage.
Medicare Part D
. The Medicare
				prescription drug program available to Medicare beneficiaries beginning January
				1, 2006.
Medicare Part D Covered Drug
.
				Prescription drugs, biological products, insulin and medical supplies
				associated with the injection of insulin, and vaccines licensed under section
				351 of the Public Health Service Act that meet the definition of a covered part
				D drug as set forth in the MMA.
Medicare Part D Plan
. A
				Medicare-approved Prescription Drug Plan, a Medicare Advantage Prescription
				Drug Plan, and, where the context requires, a Creditable Coverage Plan.
Medicare Part D Plan Formulary
. A list
				of Prescription Drugs covered by an individual Medicare Part D Plan, and the
				applicable co-payment levels.
Medicare Prescription Drug, Improvement, and
				Modernization Act of 2003 (MMA)
. The federal law enacted to
				provide a prescription drug benefit to Medicare-eligible citizens.
Medicare Prescription Drug Plan (PDP)
.
				A prescription drug plan that provides prescription drug coverage through a PDP
				sponsor that is under contract with CMS, and offered under a policy, contract,
				or plan that has been approved under 42 CFR § 423.272.
Member
. An Applicant who is determined
				eligible to receive Covered Benefits or Supplemental Assistance under the
				Plan.
Membership Categories
. Categories
				established by the Plan, based on Members' Medicare Part D coverage, coverage
				under a Creditable Coverage Plan, Gross Annual Household Income, and
				eligibility for the Medicare Low-income Subsidy. Specific benefit levels will
				apply to members in each category, including Enrollment Fees, Co-payments,
				Deductibles, Supplemental Assistance, and Annual Out-of-pocket Spending
				Limits.
Non-preferred Drug (Level 3 Drug)
. A
				Brand Name Drug available on the Plan Formulary at the highest Co-payment
				level. For Members who are eligible for Medicare Part D, each Medicare Part D
				Plan will establish its own co-payment levels.
Out-of-pocket Expenditures
. The total
				amount paid by a member to satisfy his or her applicable Plan Co-payments and
				Deductibles, not including Premiums. For members of a Medicare Part D Plan,
				out-of-pocket expenditures include the total amount paid by a Member to satisfy
				his or her Medicare Part D Co-payments, Co-insurance, and Deductibles pursuant
				to the Medicare Part D Plan, but do not include Premiums.
Out-of-pocket Spending Limit
. A cap on
				the amount that a Member must pay to satisfy his or her own applicable Plan
				Co-payments, Co-insurance, and Deductibles. The Plan shall establish this limit
				on an annual basis.
Participating Pharmacy
. Any registered
				pharmacy that has agreed to comply with the requirements, reimbursement methods
				and rates established by the Plan.
Plan Formulary
. A list of Prescription
				Drugs, including insulin and disposable insulin syringes with needles issued by
				Prescription, covered by the Plan. For Members enrolled in a Medicare Part D
				Plan, each Medicare Part D Plan will have its own list of Prescription Drugs,
				biological products, insulin, and medical supplies covered by that Medicare
				Part D Plan, define whether they are classified as generic or brand name
				drugs.
Plan Year
. The annual period of Plan
				operations beginning on July 1st and ending on June
				30th each year. As of January 1, 2006, the Plan Year
				will be the annual period of Plan operations beginning on January
				1st and ending on December
				31st. To enable this change, the period July 1, 2005
				through December 31, 2005 will be considered a separate Plan Year.
Preferred Drug (Level 2 Drug)
. A Brand
				Name Drug available on the Plan Formulary at a copayment level between a
				Generic Drug and a Non-preferred Drug. Each Medicare Part D Plan will establish
				its own co-payment levels.
Prescription
. An order for a drug,
				either written, given orally or otherwise transmitted to a registered pharmacy
				by a licensed practitioner with prescriptive privileges granted by an
				appropriate licensing authority, or his or her expressly authorized
				agent.
Prescription Advantage (the Plan)
. The
				catastrophic Prescription Drug program created by St. 2000, c. 159, § 46,
				which is administered by Elder Affairs and carried out by entities under
				agreement with Elder Affairs.
Prescription Drug
. Any and all
				outpatient drugs approved by the Food and Drug Administration (FDA) which,
				under federal law, are required, prior to being dispensed or delivered, to be
				labeled with the statement "Caution, Federal law prohibits dispensing without
				prescription" or a drug which is required by any applicable federal or state
				law or regulation to be dispensed only by Prescription.
Prior Authorization
. The process by
				which the Plan requires additional information to determine if certain
				Prescription Drugs are Covered Benefits. For Members enrolled in a Medicare
				Part D Plan, the Member's Medicare Part D Plan will define any Prior
				Authorization process.
Reconsideration
. The process by which
				a designated Plan representative evaluates decisions made by the Plan upon the
				timely request of an Applicant or Member or their designee.
Resident
. A person who lives in the
				Commonwealth with the intent to remain permanently or for an indefinite period
				of time and, whenever absent, intends to return to the Commonwealth.
Review
. The appeal process of the
				Plan, as set forth in
				651 CMR 15.15, that
				consists of Reconsideration and Administrative Review.
Secretary
. The Secretary of the
				Executive Office of Elder Affairs
Supplemental Assistance
. Financial
				assistance provided by Prescription Advantage for premiums, Deductibles,
				payments, co-payments and co-insurance required by a Member's Medicare Part D
				Plan; or for Deductibles, payments, co-payments and co-insurance required by a
				Member's Creditable Coverage Plan.
Therapeutically Equivalent Prescription
				Drug
. A Prescription Drug that is of the same pharmacological or
				therapeutic class as another Prescription Drug and can be expected to have a
				similar therapeutic effect when administered in therapeutically equivalent
				dosages.