9 NYCRR Part 9600 - Executive Department

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Source version current through May 15, 2022

All 5 displayed sections in this Part carry the same compiled date. Status and warnings stay on each section.

9 NYCRR 9600.1 - Scope

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

These regulations govern the application and eligibility determination process under the Program for Elderly Pharmaceutical Insurance Coverage and establish the rights and responsibilities of applicants, participants and the contractor in that process.

9 NYCRR 9600.2 - Definitions

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

The following definitions shall apply to this Part:

(a)An

applicant is a person who has, directly or by a representative, expressed, in writing on the State-approved form a desire to receive coverage or to have his/her eligibility considered.

(b)An

application is the process by which a person indicates, in writing on the State- approved form, his/her desire either to receive assistance or to have his/her eligibility considered. Such action shall be considered an application even though the applicant subsequently withdraws the application or proves, upon investigation, to be ineligible.

Application may also mean the State-approved form which must be filed to complete the process.

(c)An

eligible person is one who has applied for participation in the program using the State- approved form; and who, based upon that form, has been determined to have satisfied the statutory and regulatory requirements for eligibility.

(d)Income means household gross income of the applicant and his/her spouse, pursuant to subdivision 3 of section 547-a of the State Executive Law.

(e)Resident means a person legally domiciled within the State. A person is domiciled within the State if it is his/her permanent home, as contrasted to a temporary home, or summer or winter home. Domicile is evidenced by a person's physical presence within the State on a regular and ongoing basis and by its use in official or legal documents.

(f)Authorized representative means any person duly authorized by an applicant or participant to act on his/her behalf, except a provider or physician who does not have a familial relationship to the applicant or participants. Institutions may not act as authorized representatives.

(g)Cost-sharing responsibilities include the required registration fees, premiums and copayment obligations of the participant.

(h)Program means the Program for Elderly Pharmaceutical Insurance Coverage provided for under article 19-K of the Executive Law.

(i)Annual coverage period means a consecutive 12-month period for which an eligible person has met the required registration fee, premium or deductible requirements.

(j)Fraud shall mean an intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to the person or another person and includes the acts prohibited by section 547-k of the Executive Law.

(k)Abuse shall mean participant practices that are inconsistent with sound consumer practices or that result in unnecessary costs to the program.

(l)The

executive director is the person appointed by the Governor to monitor the provision of services under the program and to perform any other functions necessary to the efficient operation of the program, or his/her duly authorized designee.

(m)Contractor means the private not-for-profit or proprietary corporation which has entered into a contract with the pharmaceutical insurance coverage panel to assist in carrying out the provisions of the program.

(n)Panel means the pharmaceutical insurance coverage panel established by the Legislature and consisting of the commissioners of the departments of Education, Health and Social Services, the Superintendent of Insurance and the directors of the State Office for the Aging and the Division of the Budget.

(o)Timely means that the notice is mailed at least 10 days before the date the action is to be effective.

(p)Adequate means that the notice is in writing and contains the details of the reasons for the action, an explanation of the person's right to a reconsideration and the circumstances under which benefits may be continued if a reconsideration is requested.

(q)Mass change in the program means changes initiated by the panel of Legislature which affect all or a significant portion of all participants.

9 NYCRR 9600.3 - Information concerning application/coverage

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

Any person shall be entitled to receive information concerning:

(a)the eligibility requirements of the program under which he/she is applying;

(b)his/her responsibility for reporting all facts material to a proper determination of eligibility;

(c)the applicant's responsibility for securing, wherever possible, records or documents to support his/her statements concerning eligibility;

(d)the kinds of verification needed;

(e)the fact that an investigation to determine eligibility may be undertaken;

(f)the cost-sharing responsibilities of the program.

9 NYCRR 9600.4 - Confidentiality

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)All applicants and participants have the right to confidentiality concerning any information provided to determine their eligibility for coverage and any information discovered in the course of an investigation of eligibility.

(b)Information received by the contractor, his agents, employees or any other person or agency concerning applicants for or participants in the program may be disclosed or used only for purposes directly related to and necessary for the proper administration of the program.

9 NYCRR 9600.5 - Statistical reports

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Dates and status

NYCRR title agency: Executive Department
Section status: Section source receipt
Source version current through: May 15, 2022

(a)The contractor shall maintain a record of every application or request for coverage and the disposition thereof.

(b)Additionally, the contractor shall maintain statistical reports as required by the executive director and provide the executive director with a periodic report of all applications denied, actions affecting coverage and reconsiderations made.

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