Chapter 60. Senior Prescription Drug Assistance Program

“Administrator” means the third party that contracts with the Department to administer the Program.

“Annual household income” has the meaning stated in Regulation .02B of this chapter.

“Department” means the Maryland Department of Health.

“Eligible individual” means an individual who meets the criteria set forth in Regulation .02A of this chapter:

“Enrollee” means an individual enrolled in the Senior Prescription Drug Assistance Program.

“Household member” means:

“Prescription drug plan sponsor” means a nongovernmental entity that is certified by the Centers for Medicare and Medicaid Services as meeting the requirements of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 for offering in the State:

“Program” means the Senior Prescription Drug Assistance Program established under Health-General Article, Title 15, Subtitle 10, Annotated Code of Maryland.

“Program Fund” means the Fund established under Insurance Article, §15-1004, Annotated Code of Maryland.

“Reasonable administrative expenses” means administrative expenses including, but not limited to, marketing, advertising, mailing, printing, and fully allocated costs for administration of the Program.

Support and Maintenance Furnished in-Kind.

Be a resident of Maryland;

Be a Medicare beneficiary enrolled in the Medicare Part D Voluntary Prescription Drug Benefit Program or a Medicare Advantage Plan that provides Part D coverage;

Have an annual household income, as described in §B of this regulation, at or below 300 percent of the Federal Poverty Guidelines that apply to the individual based on the number of household members of the individual;

Not be enrolled in a health benefit plan, other than a Medicare Part D prescription drug plan or a Medicare Advantage Plan, that provides prescription drug benefits at the time the individual applies for enrollment in the Program; and

Not be eligible for a full federal low-income subsidy under 42 CFR §423.772.

Annual household income to be considered in determining financial eligibility is both earned and unearned income of the applicant and spouse who reside in the same residence, projected for a 12-month period beginning with the month in which the person submits the application for enrollment in the Program.

Earned income includes:

Unearned income includes:

Unearned income does not include support and maintenance furnished in-kind.

The Administrator may not enroll additional individuals at a time when the Program's total enrollment reaches the level authorized by the Department.

The Program shall maintain a waiting list of individuals who meet the eligibility requirements for the Program but who are not served by the Program because of funding limitations.

If, after the Program reaches its maximum capacity as established by the Department, the number of individuals enrolled decreases, the Administrator may recommence enrolling eligible individuals in the Program as specified in this regulation, until the Program's enrollment again reaches the authorized maximum.

The Department may direct the Administrator to limit enrollment based on the amount of money remaining in the Program Fund.

The Administrator may, after first providing reasonable notice to the enrollee, disenroll from the Program an enrollee for any of the causes specified in §E(2) of this regulation.

An enrollee may be disenrolled from the Program if the enrollee:

The Department of Aging;

Local health departments;

Continuing care retirement communities;

Places of worship;

Civic organizations;

Community pharmacies; and

Any other entity that the Department determines is appropriate.

Assist eligible individuals in applying for coverage under the Program; and

Provide notice of the Program and its eligibility requirements to potentially eligible individuals who seek health insurance counseling services through the Department of Aging.

The Department shall develop a mail-in application for the Program.

The Administrator shall make available mail-in applications to eligible individuals.

Provide the prescription drug benefit subsidies described in Regulation .06 of this chapter;

Submit a detailed quarterly financial accounting of the Program, including the identification of all revenue and cost items to the Department;

Develop and implement a marketing plan designed to notify eligible individuals throughout the State of the existence and eligibility criteria for the Program; and

Collect and submit to the Department, data regarding the costs for program enrollees.

The terms of this chapter;

The Administrator contract governing operation of the Program that is executed between the Department and the Administrator; and

All applicable federal and State law.

Eligibility requirements;

A listing of available prescription drug plans and details of the prescription drug plans;

Termination provisions;

Appeal procedures;

Other Program guidelines; and

All other terms, conditions, and limitations of the Program.

Provide a prescription drug benefit subsidy, as determined by the Department, that may pay all or some of the deductibles, coinsurance payments, premiums, and copayments under the federal Medicare Part D Pharmaceutical Assistance Program for enrollees of the Program; and

Provide the subsidy to the maximum number of individuals eligible for enrollment in the Program, subject to the money available in the Program Fund.

The number of individuals to be enrolled in the Program;

The amount of subsidy to be provided under §A of this regulation; and

The amount of any additional subsidy provided under §B of this regulation.

Medicare Part D and any federal regulations adopted to implement Medicare Part D;

The Program;

The terms and conditions of the contract; and

Guidance from the Centers for Medicare and Medicaid Services.

Coordinate with the Program in identifying member enrollees;

Accept the premium subsidy on behalf of member enrollees;

Apply the premium subsidy to the member enrollee's total premium costs;

Separately bill member enrollees for any premium owed in excess of the premium subsidy paid by the Program;

Account for the subsidies received from the Program;

Communicate in writing with member enrollees, including notifying member enrollees of their enrollment status;

Share enrollment data and information with the Department;

Report data and enrollment information as required by the Department;

Reconcile Program and member payments with enrollment data; and

Transmit information to appropriate third-parties, including the Administrator and the Centers for Medicare and Medicaid Services.

Interest and investment income attributable to the Program Fund; and

Money deposited to the account by a nonprofit health service plan in accordance with §C of this regulation.

Shall be determined by the Department based on enrollment, expenditures, and revenue for the previous year; and

May not exceed the amounts specified in Insurance Article, §14-106(e), Annotated Code of Maryland.

Permit inspection of its papers, books, and records pertaining to its operation of the Program by the Department or its designee; and

Cooperate with any inspections and audits performed on the Administrator or the Program by the Department or its designee.