(1)
Membership Category
Contribution Schedule.
(a)
Contribution Schedules for applicable Enrollment Fees, Co-payments,
Deductibles, and Out-of-pocket spending limits shall be established by the Plan
and supplied to all Applicants and may be made available to other interested
parties upon request.
(b) Each
Member or his or her authorized representative shall be notified in writing of
any applicable Enrollment Fee, Co-payments and Deductibles.
(c) The Plan shall establish Enrollment Fee,
Co-payment and Deductible schedules annually. Written notification regarding
changes to Members' Enrollment Fee, Co-payment and Deductible rates shall be
mailed by the Plan to all affected Members or their authorized representatives
at least 30 calendar days before the effective date of the change.
(d) The Secretary shall modify Enrollment
Fee, Co-payment and Deductible schedules and income eligibility levels after
making a written determination that Plan expenditures are projected to exceed
the amount appropriated for the Plan or, based on not less than nine months of
claims and enrollment data for the current Fiscal Year, expenditures in the
subsequent Fiscal Year are clearly projected to annualize beyond the
expenditures projected by Elder Affairs in the subsequent Fiscal
Year.
(2)
Deductibles. When acquiring Covered Benefits, Members
are responsible for the payment of the Deductible applicable to the Member. For
Members enrolled in a Medicare Part D Plan, supplemental assistance may be
provided for the Deductible required by the Medicare Part D Plan.
(3)
Co-payments.
After a Member meets his or her applicable Deductible amount, he or she shall
pay his or her Co-payment for each purchase of a Covered Benefit from a
Participating Pharmacy or approved mail service facility until the Deductible
is re-calculated or until the Annual Out-of-pocket Spending Limit is
met.
(4)
Limitation on
Member Out-of-pocket Expenditures (Annual Out-of-pocket Spending
Limit).
(a) Once a Member's
Annual Out-of-pocket Spending Limit is reached, the Plan will cover the entire
cost of Covered Benefits for that Member for the remainder of the Plan
Year.
(b) The following are
excluded from any calculation to determine a Member's Annual Out-of-pocket
Spending Limit:
1. Plan contributions as set
forth in
651 CMR
15.06(4);
2. Enrollment Fees (if applicable);
3. Non-covered costs paid by a Member,
including, but not limited to:
a. expenses
paid by a Member for Prescription Drugs prior to the Member's Effective Date of
Coverage;
b. expenses paid by a
Member for Prescription Drugs not covered by the Plan and/or;
c. Co-payments, Deductibles, and coinsurance
paid by a Member for Prescription Drugs acquired through any plan other than a
Medicare Part D Plan or Creditable Coverage Plan. For Members of a Medicare
Part D Plan, Co-payments, Deductibles and co-insurance paid pursuant to the
Medicare Part D Plan will be included in a calculation to determine the
Member's Annual Out-of-pocket Spending Limit.
