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