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
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.
