Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.1 - General Provisions › Rule 37.81.104 - DEFINITIONS

Current through Register Vol. 13, July 5, 2024
In addition to the definitions in
				  53-6-1001,
				  MCA, the following definitions apply to this chapter:
(1) "Assets" mean cash or other resources
				that a person owns and could convert to cash to be used for his or her support
				and maintenance.
(2) "Closed"
				means an individual or case that was enrolled but is no longer receiving a
				benefit amount or was on a waiting list but is no longer on the waiting list.
(3) "Completed application" means
				the applicant has provided all required information to the department.
(4) "Contract" means an agreement
				between the department and a PDP provider for the provision of premium payments
				for enrollees of the program.
(5)
				"Countable income" means the amount of an applicant's income that is compared
				to the federal poverty level (FPL) to determine the applicant's FPL percentage.
(6) "Department" means the
				Department of Public Health and Human Services.
(7) "Earned income" means salary, wages, and
				self-employment net earnings.
(8)
				"Eligible" means an applicant has met all the Big Sky Rx Program eligibility
				criteria stated in ARM
				37.81.307.
(9) "Eligibility threshold" means Big Sky Rx
				Program income up to 200% of FPL.
(10) "Enrolled" means an eligible applicant
				enrolled in the program.
(11)
				"Extra help" means the federal program that assists with premiums, copayments,
				and deductibles for clients who meet the social security program's
				requirements. The program is sometimes referred to as Low Income Subsidy (LIS).
(12) "Family" means individuals
				residing together, related by blood, marriage, or adoption, and dependent on
				the household for at least one-half of their support.
(13) "Federal poverty level (FPL)" means the
				poverty income guidelines published annually in the Federal Register by the
				U.S. Department of Health and Human Services.
(14) "First in first served" means completed
				applications will be processed and eligible applicants enrolled based on the
				date the complete application is received by the department.
(15) "Income" or "family income" means
				salary, wage, self-employment net earnings, royalties, honoraria, social
				security benefits, veterans benefits, railroad benefits, pensions, workers
				compensation, alimony, net rental income, trust income, dividends, and
				interest.
(16) "Incomplete" means
				the application is missing information required by ARM
				37.81.318.
(17) "Ineligible" means the individual or
				case does not meet the criteria for enrollment in the program.
(18) "Insurer" means an authorized insurer of
				the federal Medicare Part D Prescription Drug Plan (PDP).
(19) "Low income subsidy (LIS)" means the
				federal program that assists with premiums, copayments, and deductibles for
				clients who meet the social security program's requirements. The program is
				sometimes referred to as Extra Help.
(20) "Open" means a case or individual that
				is pending, currently enrolled, or eligible to receive the benefit amount but
				on a waiting list.
(21) "Pending"
				means the department is waiting to determine eligibility because the
				individual's application was incomplete.
(22) "Premium assistance" or "benefit amount"
				means the amount of money the department either pays monthly to an insurer for
				the provision of benefits for an enrollee or pays to an enrollee.
(23) "Prepopulated" means a computer
				generated document that includes information from the department's records to
				be verified by the applicant.
(24)
				"Prescription drug plan (PDP)" means the private insurance plans for federal
				prescription drug benefit for people with Medicare. The benefit was created by
				the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA),
				(
				42
				USC 1302,
				1395w-101
				through
				1395w-152,
				and 1395hh ). It is
				implemented at 42 CFR, part 423.
(25) "Processing" means the application is
				matched against program criteria.
(26) "Program" means the Big Sky Rx Program
				administered by the department.
(27) "Qualified" means the applicant is a
				Montana resident with a family income at or below 200% of the FPL.
(28) "Renewal" means the process of
				verification to remain eligible for Big Sky Rx benefits.
(29) "Representative" means a person who the
				applicant has given permission to assist the applicant with program
				requirements by communicating with the program and receiving information from
				the department.
(30) "Residing"
				means living in Montana voluntarily with the intention of making a home here
				and not for a temporary purpose.
(31) "Temporary enrollment" means the three
				month enrollment allowed for those applicants that are only missing Social
				Security Extra Help determination.
(32) "Unearned income" means any income other
				than salary, wages, and earnings from self-employment.
(33) "Waiting list" means the list compiled
				by the department of applicants who are eligible for premium assistance but who
				are not enrolled in the Big Sky Rx Program because funds are not available to
				pay their program benefits.
AUTH:
					 53-2-201,
					 53-6-1004,
					 MCA; IMP:
					 53-2-201,
					 53-6-1001,
					 53-6-1004,
					 53-6-1005,
					 MCA