New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 2 - DEFINITIONS › Section 10:167-2.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings unless the context clearly indicates
				  otherwise:
"Annual income" means all income from whatever source
				  derived, actually received or anticipated.
"Anticipated income" means the amounts of income the
				  applicant can reasonably be expected to receive during the calendar
				  year.
"Applicant" means an individual who applies or reapplies for
				  PAAD, either personally or through an authorized agent.
"Authorized agent" means a person who initiates the PAAD
				  application for a person who is incompetent or incapable of filing the PAAD
				  application on his/her behalf.
"Authorized representative" means a person with legal
				  authority to act on behalf of an individual in making decisions related to the
				  individual's enrollment in, disenrollment from, and access to negotiated prices
				  in the Medicare Prescription Drug Program.
"Beneficiary" means an individual who has been found eligible
				  for PAAD benefits.
"Business income" means net income derived from a business,
				  trade, or profession or from the rental of property after deductions of the
				  ordinary and necessary expenses attributable to the business, trade,
				  profession, or to the rental of property, which are allowed under the Federal
				  Internal Revenue Code and regulations issued thereunder.
"Calendar year" means a year beginning January 1 and ending
				  on December 31. It is the base period utilized to determine annual income and
				  PAAD eligibility.
"Centers for Medicare and Medicaid Services" or "CMS" means
				  the agency of the Federal Department of Health and Human Services that is
				  responsible for the administration of the Medicare program in the United
				  States.
"Commissioner" means the Commissioner of the Department of
				  Human Services.
"Current year" means the calendar year in which a person
				  applies or reapplies for PAAD.
"Department" means the Department of Human Services.
"Division" means the Division of Aging Services within the
				  Department of Human Services.
"Electronic Data Interchange (EDI) Enrollment Form" means an
				  agreement signed by a Medicare Part B Supplier authorizing PAAD to bill
				  Medicare electronically on its behalf for claims that are eligible under both
				  PAAD and Medicare.
"Expiration date" means the date when a beneficiary's PAAD
				  eligibility ends.
Federal Food, Drug, and Cosmetic Act, at
21
				  U.S.C. §
											355
(j)(7); and those
				  drug products approved by the FDA with therapeutic equivalence ratings of "A"
				  that appear on the FDA's "Drugs@FDA" website, bearing formal internet address
http://www.accessdata.fda.gov/scripts/cder/drugsatfda/
,
				  which is incorporated herein by reference, as amended and supplemented. The
				  Orange Book can be obtained by contacting the United States Government Printing
				  Office at PO Box 979050, St. Louis, MO 63197, or at (866) 512-1800, or it is
				  available on-line at
http://www.accessdata.fda.gov/scripts/cder/ob/
.
"Food Stamp Program" means the Federal nutrition program
				  established by
				  42
				  U.S.C. §
										1786 within the U.S. Department
				  of Agriculture/Food and Nutrition Services which provides assistance with the
				  purchase of food for low income households. This program is administered by the
				  county welfare agencies under supervision by the New Jersey Department of Human
				  Services, Division of Family Development.
"Health Insurance Claim number" means the primary reference
				  number, assigned by Medicare, which usually includes the beneficiary's Social
				  Security Number and which is used when filing Medicare claims, including
				  prescription claims under Medicare Part D.
"Interchangeable drug product" means those drug products,
				  with therapeutic equivalence ratings of "A," identified in the publication of
				  the Office of Generic Drugs in the Office of Pharmaceutical Science of the
				  Center for Drug Evaluation and Research of the Food and Drug Administration
				  (FDA) of the United States Department of Health and Human Services, "Approved
				  Drug Products with Therapeutic Equivalence Evaluations," 34th Edition,
				  incorporated herein by reference, as amended and supplemented (commonly known
				  as the "Orange Book") promulgated pursuant to the
"Legend Drug" means any approved drug product which by
				  Federal law cannot be dispensed without a prescription and bears the statement
				  on the label: "Caution: Federal law prohibits dispensing without a
				  prescription".
"Lifeline Credit Program" means the utility assistance
				  program that offers a benefit in the form of a credit to the utility account
				  during the heating season to eligible New Jersey residents.
"Low Income Home Energy Assistance Program" means the Federal
				  program authorized by
				  42 U.S.C. §
										8621 that assists low income households that
				  pay a high proportion of household income for home energy, primarily in meeting
				  their immediate home energy needs, and which is administered in New Jersey by
				  the Department of Community Affairs.
"Low income subsidy" means the additional financial
				  assistance provided by the Medicare Part D Program to individuals approved by
				  the Federal Social Security Administration, which pays, in part or in whole,
				  Medicare Part D premiums, deductibles and coinsurance for the eligible person,
				  pursuant to 20 CFR Part 418, Subpart D, and 42 CFR Part 423, which are
				  incorporated herein by reference, as amended and supplemented.
"Low income subsidy application" means the Federal Social
				  Security application for the Medicare Part D low income subsidy entitled the
				  "Application for Help with Medicare Prescription Drug Plan Costs", form
				  SSA-1020, available on-line at
http://www.socialsecurity.gov
.
"Medicare" means medical assistance provided to certain aged
				  and disabled persons as authorized under Title XVIII (Medicare) of the Social
				  Security Act.
"Medicare authorized prescription drug plan" or "PDP" means a
				  private prescription drug plan that has been submitted to and approved by the
				  Centers for Medicare and Medicaid Services to provide prescription insurance
				  coverage for individual citizens under the Medicare Part D program.
"Medicare Part B Supplier" means a supplier of Medicare Part
				  B (Medical Insurance) services to Medicare beneficiaries including Durable
				  Medicare Equipment, Prosthesis, Orthotics, and Supplies (DMEPOS).
"Medicare Prescription Drug Program" means the program
				  established under the Medicare Prescription Drug, Improvement, and
				  Modernization Act of 2003, Pub. L. 108-173, 117 Stat.
				  2066, approved December 8, 2003.
"National Suppliers Clearinghouse (NSC)" means the entity
				  that issues Durable Medicare Equipment, Prosthesis, Orthotics, and Supplies
				  (DMEPOS) supplier authorization numbers nationwide to Medicare Part B Suppliers
				  for the Centers for Medicare and Medicaid Services (CMS). The National Supplier
				  Clearinghouse is located at P.O. Box 100142, Columbia, SC 29202-3142.
"NSC Supplier Number" means the authorization number issued
				  by the National Supplier Clearinghouse (NSC) to a Medicare Part B Supplier of
				  Durable Medicare Equipment, Prosthesis, Orthotics, and Supplies (DMEPOS) for
				  the Centers for Medicare and Medicaid Services (CMS).
"PAAD Co-pay" means a maximum amount of $ 5.00 for generic
				  drugs and $ 7.00 for brand name drugs, which must be paid by each PAAD
				  beneficiary, or by the primary payer(s) on behalf of the beneficiary, to the
				  pharmacy toward the cost for each prescription for a legend drug and/or
				  insulin, insulin syringes, and insulin needles. If the prescription is paid
				  first by payers other than PAAD and the remaining cost of the prescription is
				  less than $ 5.00 for generic drugs and $ 7.00 for brand name drugs, then that
				  remaining cost becomes the PAAD co-pay. The co-pay is not reimbursable by the
				  PAAD. The co-payment shall be paid in full by each eligible person, or by the
				  primary payer(s) on behalf of the eligible person, to the pharmacist at the
				  time of each purchase of prescription drugs, and shall not be waived,
				  discounted, or rebated in whole or in part. PAAD co-payment amounts shall be
				  determined in accordance with the Fiscal Year 2016 Appropriations Act, P.L.
				  2015, c. 63, approved June 26, 2015, as amended and supplemented by subsequent
				  State appropriations acts.
"Pharmaceutical assistance" means the payments authorized by
				  the Department to a participating pharmacy on behalf of a PAAD
				  beneficiary.
"Pharmacy" means any pharmacy located in New Jersey,
				  operating under a valid permit from the Board of Pharmacy of the State of New
				  Jersey, which has filed an application and agreement of participation, which
				  has been approved by the New Jersey Medicaid Program. The term "pharmacy" also
				  includes any volunteer prescription drug mail-order program in a Medicare Part
				  D plan provider network.
"Prescription drugs" means all approved legend drugs,
				  including any interchangeable drug products and in conformance with the
				  provisions of the "Prescription Drug Price and Quality Stabilization Act," and
				  insulin, insulin syringes, and insulin needles when prescribed.
1. The term "prescription drugs" includes:
i. Any drug product which by Federal law cannot be dispensed
				  unless ordered by a physician, dentist or podiatrist;
ii. Every product considered to be a legend prescription drug
				  which is required by the Federal Food, Drug and Cosmetic Act to have the
				  following statement on the manufacturer's original packaging label: "Caution:
				  Federal law prohibits dispensing without a prescription";
iii. Insulin, insulin syringes and insulin needles. While not
				  legend drugs, these items are covered by this program when prescribed;
				  and
iv. Syringes and needles for injectable medicines for the
				  treatment of multiple sclerosis.
2. The term "prescription drugs" excludes cosmetics drugs as
				  indicated at
				  10:167A-1.15 unless medically
				  necessary.
"Previous year" means the calendar year preceding the year in
				  which the person is applying or reapplying for PAAD. For example, 1995 is the
				  "previous year" when referring to an application which is dated between January
				  1, 1996 through December 31, 1996, inclusive.
1. If a person, who is required to submit a Federal, State
				  and/or City Income Tax return, applies for PAAD at the beginning of a calendar
				  year but has not yet filed an income tax return for the previous year, the last
				  year for which the person filed a tax return is considered to be the "previous
				  year" when completing the PAAD application.
"Provider" means any individual, partnership, association,
				  corporation, institution, or any other public or private entity, agency, or
				  business concern, meeting applicable requirements and standards for
				  participation in the New Jersey Medicaid Program, and the Pharmaceutical
				  Assistance to the Aged and Disabled Program, and where applicable, holding a
				  current valid license, and lawfully providing medical care, services, goods and
				  supplies authorized under
				  30:4D-1 et seq. and amendments
				  thereto.
"Reasonable cost" means the maximum allowable cost of
				  prescription drugs plus a dispensing fee, which meets the conditions set forth
				  in the Fiscal Year 2009 Appropriations Act, P.L. 2008, c. 35, approved June 30,
				  2008, as amended and supplemented by subsequent State appropriations acts
				  containing methodologies or requirements for the calculation of reasonable
				  costs under the Program.
"Resident" means "one legally domiciled within the State (of
				  New Jersey) for a period of 30 days immediately preceding the date of
				  application for inclusion in the PAAD Program. Mere seasonal or temporary
				  residence within the State, of whatever duration, does not constitute
				  domicile." (See
10:167-6.4
for residence requirements.)
"Special needs trust" means a trust containing the assets of
				  a disabled individual that is established for the sole benefit of the
				  individual by a parent, grandparent, legal guardian or court prior to the time
				  the individual reaches the age of 65. (See
				  10:167-2.2 for provisions.)
"Supplemental Nutrition Assistance Program" (SNAP) means the
				  Federal nutrition program established by
42
				  U.S.C. §
											1786
within the U.S.
				  Department of Agriculture/Food and Nutrition Services, which provides
				  assistance with the purchase of food for low income households. This program is
				  administered by the county welfare agencies under supervision by the New Jersey
				  Department of Human Services, Division of Family Development.
"Tenants Lifeline Assistance Program" means a utility
				  assistance program that offers a benefit in the form of a check issued to
				  tenants whose utilities are included in their rent and do not have a separate
				  utility bill.
"Universal Service Fund" means the program established by
				  48:3-60 in the Board of Public
				  Utilities and administered by the New Jersey Department of Community Affairs
				  that helps ensure that income eligible New Jersey utility customers pay no more
				  than six percent of their annual income for their natural gas and electric
				  service combined. Households with income equal to or less than 175 percent of
				  the Federal Poverty Level are income eligible.
"Viatical settlement" means the sale or cashing in of a life
				  insurance policy prior to death of the insured, due to the fact that the
				  insured has experienced a catastrophic, life-threatening or chronic illness or
				  condition.