14 CRR-NY 635-11.1NY-CRR
STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 14. DEPARTMENT OF MENTAL HYGIENE
CHAPTER XIV. OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES
PART 635. GENERAL QUALITY CONTROL AND ADMINISTRATIVE REQUIREMENTS APPLICABLE TO PROGRAMS, SERVICES OR FACILITIES FUNDED OR CERTIFIED BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES
SUBPART 635-11. ENROLLMENT IN MEDICARE PRESCRIPTION DRUG PLANS AND FULLY INTEGRATED DUALS ADVANTAGE PLANS FOR INDIVIDUALS WITH INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (FIDA-IDD)
14 CRR-NY 635-11.1
14 CRR-NY 635-11.1
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.
14 CRR-NY 635-11.1
Current through June 30, 2021
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IMPORTANT NOTE REGARDING CONTENT CURRENCY: JULY 31, 2023, is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Admisnistrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of the NYS Rules.