New York Codes, Rules and Regulations › Title 9 - EXECUTIVE DEPARTMENT › Subtitle KK - Program for Elderly Pharmaceutical Insurance Coverage › Part 9600 - General › Section 9600.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The following definitions shall apply to this Part:
(a) An applicant is a person who has,
				directly or by a representative, expressed, in writing on the State-approved
				form a desire to receive coverage or to have his/her eligibility
				considered.
(b) An application is
				the process by which a person indicates, in writing on the State- approved
				form, his/her desire either to receive assistance or to have his/her
				eligibility considered. Such action shall be considered an application even
				though the applicant subsequently withdraws the application or proves, upon
				investigation, to be ineligible. Application may also mean the State-approved
				form which must be filed to complete the process.
(c) An eligible person is one who has applied
				for participation in the program using the State- approved form; and who, based
				upon that form, has been determined to have satisfied the statutory and
				regulatory requirements for eligibility.
(d) Income means household gross income of
				the applicant and his/her spouse, pursuant to subdivision 3 of section 547-a  of
				the State Executive Law.
(e)
				Resident means a person legally domiciled within the State. A person is
				domiciled within the State if it is his/her permanent home, as contrasted to a
				temporary home, or summer or winter home. Domicile is evidenced by a person's
				physical presence within the State on a regular and ongoing basis and by its
				use in official or legal documents.
(f) Authorized representative means any
				person duly authorized by an applicant or participant to act on his/her behalf,
				except a provider or physician who does not have a familial relationship to the
				applicant or participants. Institutions may not act as authorized
				representatives.
(g) Cost-sharing
				responsibilities include the required registration fees, premiums and copayment
				obligations of the participant.
(h)
				Program means the Program for Elderly Pharmaceutical Insurance Coverage
				provided for under article 19-K of the Executive Law.
(i) Annual coverage period means a
				consecutive 12-month period for which an eligible person has met the required
				registration fee, premium or deductible requirements.
(j) Fraud shall mean an intentional deception
				or misrepresentation made with the knowledge that the deception could result in
				some unauthorized benefit to the person or another person and includes the acts
				prohibited by section 547-k  of the Executive Law.
(k) Abuse shall mean participant practices
				that are inconsistent with sound consumer practices or that result in
				unnecessary costs to the program.
(l) The executive director is the person
				appointed by the Governor to monitor the provision of services under the
				program and to perform any other functions necessary to the efficient operation
				of the program, or his/her duly authorized designee.
(m) Contractor means the private
				not-for-profit or proprietary corporation which has entered into a contract
				with the pharmaceutical insurance coverage panel to assist in carrying out the
				provisions of the program.
(n)
				Panel means the pharmaceutical insurance coverage panel established by the
				Legislature and consisting of the commissioners of the departments of
				Education, Health and Social Services, the Superintendent of Insurance and the
				directors of the State Office for the Aging and the Division of the
				Budget.
(o) Timely means that the
				notice is mailed at least 10 days before the date the action is to be
				effective.
(p) Adequate means that
				the notice is in writing and contains the details of the reasons for the
				action, an explanation of the person's right to a reconsideration and the
				circumstances under which benefits may be continued if a reconsideration is
				requested.
(q) Mass change in the
				program means changes initiated by the panel of Legislature which affect all or
				a significant portion of all participants.