New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL
Subchapter 2 - DEFINITIONS
Section 10:167B-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 for Senior Gold Prescription Benefits either personally or through an authorized agent.
"Authorized agent" means a person who initiates the Senior Gold Benefits application for a person who is incompetent or incapable of filing the Senior Gold Benefits application on his or 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 under the Medicare Prescription Drug Program.
"Beneficiary" means an individual who has been found eligible for Senior Gold Prescription 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 or 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 Senior Gold benefits 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 Senior Gold benefits.
"Department" means the Department of Human Services.
"Expiration date" means the date when a beneficiary's Senior Gold benefits eligibility ends.
"Legend drug" means any approved drug product which by Federal law cannot be dispensed without a prescription and bears the statement of the label: "Caution: Federal law prohibits dispensing without a prescription," or the symbol "RX."
"Medicare-approved prescription drug discount card program" means a prescription drug discount card program as to which the sponsor thereof has received Medicare approval and has entered into a contract with CMS.
"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.
"Pharmaceutical assistance" means the payments authorized by the Department to a participating pharmacy on behalf of a Senior Gold 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.
"Prescription drug(s)" means all approved legend drugs, including any interchangeable drug products contained in the latest list approved and published pursuant to N.J.A.C. 8:71 and in conformance with the provisions of the "Prescription Drug Price and Quality Stabilization Act," and insulin, insulin syringes, insulin needles and certain diabetic testing materials when prescribed.
1. The term "legend prescription drugs" includes:
i. Any drug product which by Federal law cannot be dispensed unless ordered by a licensed prescriber;
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," or the symbol "RX";
iii. Insulin, insulin syringes and insulin needles. While not legend drugs, these items are covered by this program when prescribed;
iv. Diabetic testing materials, including blood glucose regent strips which can be visually read, urine monitoring strips, tapes and tablets and bloodletting devices and lancets (electronic monitoring devices are not included); and
v. Syringes and needles for injectable medicines for the treatment of multiple sclerosis.
2. The term "prescription drugs" excludes cosmetic drugs as indicated at 10:167A-1.13 unless deemed to be medically necessary by a licensed prescriber.
"Previous year" means the calendar year preceding the year in which the person is applying or reapplying for Senior Gold benefits. For example, 2000 is the "previous year" when referring to an application which is dated between January 1, 2001 through December 31, 2001, inclusive. If a person who is required to submit a Federal, State and/or city income tax return applies for Senior Gold benefits 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 Senior Gold application.
"Program" means the Senior Gold Prescription Discount Program which was created as a result of the passage of the Senior Gold Prescription Discount Act, P.L. 2001, c. 96.
"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, Pharmaceutical Assistance to the Aged and Disabled Program, and the Senior Gold Prescription Discount 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 the prescription drug and shall include the conditions set forth in the Fiscal Year 2007 Appropriations Act, P.L. 2006, c. 45, approved July 8, 2006, 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 N.J.) for a period of 30 days immediately preceding the date of application for inclusion in the Senior Gold Program. Mere seasonal or temporary residence within the State, of whatever duration, does not constitute domicile." (See N.J.A.C. 10:69A-6.4 for residence requirements.)
"Senior Gold" means the Senior Gold Prescription Discount Program.
"Senior Gold co-pay" means the payment to the pharmacy by the eligible person that shall not be waived, discounted or rebated in whole or in part.
"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 10:167B-2.2 for provisions).
"Viatical settlement" means the sale or cashing in of a life insurance policy prior to the death of the insured, due to the fact that the insured has experienced a catastrophic, life-threatening or chronic illness or condition.
