N.Y. Comp. Codes R. & Regs. tit. 14 § 635-11.1

Current through Register Vol. 46, No. 25, June 18, 2024

Section 635-11.1 - Applicability and definitions

(a) This Subpart sets forth rules concerning:

(1) who can enroll beneficiaries or individuals in:

(i) a Medicare Part D prescription drug plan or in a Medicare advantage plan with prescription drug coverage; or

(ii) a Fully Integrated Duals Advantage Plan for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) which is authorized to enroll individuals with intellectual and/or developmental disabilities pursuant to section 364-j(27)(c) of the Social Services Law; and

(2) who can pursue grievances, complaints, exceptions and appeals in such plans;

(3) these rules only apply to beneficiaries who receive services which are operated, certified, authorized or funded by OPWDD.

(b) Definitions.

As used in this Subpart:

(1)Act in the FIDA-IDD plan review process means doing any of the following within a FIDA-IDD plan:

(i) filing a grievance;

(ii) submitting a complaint to the quality improvement organization or to Federal or State government regulatory agencies;

(iii) requesting and obtaining a coverage determination (including, but not limited to, a request for prior authorization, a formulary exception and a request for expedited procedures);

(iv) filing and requesting appeals and dealing with, or participating in, any part of the appeals process;

(2)Act in the Part D review process means doing any of the following within the Part D Program:

(i) filing a grievance;

(ii) submitting a complaint to the quality improvement organization;

(iii) requesting and obtaining a coverage determination (including, but not limited to, a request for prior authorization, an exception to a tiered cost sharing structure, a formulary exception and a request for expedited procedures); and

(iv) filing and requesting appeals and dealing with any part of the appeals process;

(3)DDRO means an OPWDD Developmental Disabilities Regional Office.

(4)DDSOO means an OPWDD Developmental Disabilities State Operations Office.

(5)Enroll and enrollment means enrollment in, and disenrollment from:

(i) a PDP; and/or

(ii) a FIDA-IDD plan.

(6)FIDA-IDD or FIDA-IDD plan means a Fully Integrated Duals Advantage Plan for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) authorized to enroll individuals with intellectual and/or developmental disabilities under section 364-j(27)(c) of the Social Services Law.

(7)Party means someone or an entity or organization.

(8)PDP means a prescription drug plan offered under the Medicare Part D Program or a Medicare advantage plan that provides prescription drug coverage offered under the Medicare Part D Program.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 635-11.1

Amended New York State Register October 28, 2015/Volume XXXVII, Issue 43, eff.11/1/2015

Amended New York State Register April 20, 2016/Volume XXXVIII, Issue 16, eff.4/20/2016

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016

Amended New York State Register August 22, 2018/Volume XL, Issue 34, eff.8/22/2018

Amended New York State Register June 26, 2019/Volume XLI, Issue 26, eff. 6/26/2019