New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIV - Office for People With Developmental Disabilities › Part 635 - General Quality Control and Administrative Requirements Applicable to Programs, services or Facilities Funded or Certified by the Office for People With Developmental Disabilities › Subpart 635-11 - Enrollment in Medicare Prescription Drug Plans and Fully Integrated Duals Advantage Plans for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) › Section 635-11.2 - PDP enrollment and reviews for persons residing in a residential facility operated or certified by OPWDD or a family care home

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If a person has
				  the ability to choose a PDP, the person may enroll himself or herself in a PDP
				  or appoint another party to enroll him or her. If a person has the ability to
				  act in the Part D review process, the person may act in the Part D review
				  process for himself or herself or appoint another party to act in the Part D
				  review process for him or her.
(b)
				  If a person lacks the ability to choose a PDP, but has a guardian lawfully
				  empowered to enroll him or her in a PDP, the guardian may enroll the person in
				  a PDP or appoint another party to enroll the person. If a person lacks the
				  ability to act in the Part D review process, but has a guardian lawfully
				  empowered to act in the Part D review process for that person, the guardian may
				  act in the Part D review process or may appoint another party to act in the
				  Part D review process for the person.
(c) If a person is a minor and does not have
				  a guardian lawfully empowered to enroll him or her in a PDP or to act in the
				  Part D review process, a parent may enroll him or her or act in the Part D
				  review process for the person, or may appoint another party to enroll or act in
				  the Part D review process for him or her.
(d) In all other situations, the Chief
				  Executive Officer (CEO) (see section
				  635-99.1  of
				  this Part) of the agency operating the person's residential facility or
				  sponsoring the family care home, or a designee of the CEO, may enroll the
				  person or act in the Part D review process. The CEO or designee may also enroll
				  the person or act in the Part D review process when any party specified in
				  subdivisions (a)-(c) of this section who would otherwise enroll or act in the
				  Part D review process is unwilling or unavailable. For the purposes of this
				  subdivision only, if the person's residential facility is operated by OPWDD,
				  the CEO of the agency is the director of the DDSOO that operates the
				  residential facility.
(1) If a CEO or
				  designee enrolls a person, he or she shall give written notice of such
				  enrollment to the person's correspondent or advocate, and the person's Medicaid
				  service coordinator, or other person identified as that person's care
				  coordinator.
(2) Process to request
				  a different PDP.
(i) A correspondent or
				  advocate may request that the person be enrolled in a different PDP. Such
				  request must be in writing.
(ii)
				  The agency or sponsoring agency shall consider the request and, if it agrees
				  with the request, the CEO or designee shall enroll the person in the PDP
				  requested and notify the advocate or correspondent of the enrollment.
(iii) If the agency or sponsoring agency does
				  not agree with the request, the agency or sponsoring agency shall notify the
				  correspondent or advocate in writing of the disagreement. The notice shall also
				  inform the advocate or correspondent that he or she may appeal in writing to
				  the DDRO director for the region within which the person's residential facility
				  is located if the residential facility is not operated by OPWDD. If the
				  person's residential facility is operated by OPWDD, then the notice shall
				  inform the advocate or correspondent that he or she may appeal in writing to
				  the director of the DDSOO that operates that residential facility.
(iv) If the advocate or correspondent appeals
				  in writing to the DDRO or DDSOO director, the director shall review the request
				  and relevant information and shall decide whether to enroll the person in a
				  different PDP. Such decision shall be in writing and shall be sent to the
				  correspondent or advocate and agency or sponsoring agency.
(v) While a request is being considered, the
				  person shall remain enrolled in the PDP selected by the CEO or designee, or in
				  a PDP in which the person is subsequently enrolled by the CEO or
				  designee.
(3)
				  Notwithstanding any other provision of this Title, if the person enrolls in a
				  PDP (or a parent, guardian or appointee enrolls him or her) and the CEO or
				  designee notifies the person, guardian, parent or appointee of the agency or
				  sponsoring agency of the objection to the selection of the PDP, the agency or
				  sponsoring agency is not fiscally responsible for any excess costs that may be
				  incurred, as a result of the selection of the PDP, compared to the costs of the
				  PDP that would have been selected by the CEO or designee. The agency or
				  sponsoring agency's written notification of the objection must inform the
				  person, guardian, parent or appointee that the excess costs are not the
				  responsibility of the agency or sponsoring agency and that the person,
				  guardian, parent or appointee (whoever completed the enrollment) is responsible
				  for the additional costs. Receipt of the written notification must be
				  documented.