In addition to the definitions in 53-6-1001, MCA, the following definitions apply to this chapter:

(1) "Assets" mean cash or other resources that a person owns and could convert to cash to be used for his or her support and maintenance.

(2) "Closed" means an individual or case that was enrolled but is no longer receiving a benefit amount or was on a waiting list but is no longer on the waiting list.

(3) "Completed application" means the applicant has provided all required information to the department.

(4) "Contract" means an agreement between the department and a PDP provider for the provision of premium payments for enrollees of the program.

(5) "Countable income" means the amount of an applicant's income that is compared to the federal poverty level (FPL) to determine the applicant's FPL percentage.

(6) "Department" means the Department of Public Health and Human Services.

(7) "Earned income" means salary, wages, and self-employment net earnings.

(8) "Eligible" means an applicant has met all the Big Sky Rx Program eligibility criteria stated in ARM 37.81.307.

(9) "Eligibility threshold" means Big Sky Rx Program income up to 200% of FPL.

(10) "Enrolled" means an eligible applicant enrolled in the program.

(11) "Extra help" means the federal program that assists with premiums, copayments, and deductibles for clients who meet the social security program's requirements. The program is sometimes referred to as Low Income Subsidy (LIS).

(12) "Family" means individuals residing together, related by blood, marriage, or adoption, and dependent on the household for at least one-half of their support.

(13) "Federal poverty level (FPL)" means the poverty income guidelines published annually in the Federal Register by the U.S. Department of Health and Human Services.

(14) "First in first served" means completed applications will be processed and eligible applicants enrolled based on the date the complete application is received by the department.

(15) "Income" or "family income" means salary, wage, self-employment net earnings, royalties, honoraria, social security benefits, veterans benefits, railroad benefits, pensions, workers compensation, alimony, net rental income, trust income, dividends, and interest.

(16) "Incomplete" means the application is missing information required by ARM 37.81.318.

(17) "Ineligible" means the individual or case does not meet the criteria for enrollment in the program.

(18) "Insurer" means an authorized insurer of the federal Medicare Part D Prescription Drug Plan (PDP).

(19) "Low income subsidy (LIS)" means the federal program that assists with premiums, copayments, and deductibles for clients who meet the social security program's requirements. The program is sometimes referred to as Extra Help.

(20) "Open" means a case or individual that is pending, currently enrolled, or eligible to receive the benefit amount but on a waiting list.

(21) "Pending" means the department is waiting to determine eligibility because the individual's application was incomplete.

(22) "Premium assistance" or "benefit amount" means the amount of money the department either pays monthly to an insurer for the provision of benefits for an enrollee or pays to an enrollee.

(23) "Prepopulated" means a computer generated document that includes information from the department's records to be verified by the applicant.

(24) "Prescription drug plan (PDP)" means the private insurance plans for federal prescription drug benefit for people with Medicare. The benefit was created by the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA), (42 USC 1302, 1395w-101 through 1395w-152, and 1395hh). It is implemented at 42 CFR, part 423.

(25) "Processing" means the application is matched against program criteria.

(26) "Program" means the Big Sky Rx Program administered by the department.

(27) "Qualified" means the applicant is a Montana resident with a family income at or below 200% of the FPL.

(28) "Renewal" means the process of verification to remain eligible for Big Sky Rx benefits.

(29) "Representative" means a person who the applicant has given permission to assist the applicant with program requirements by communicating with the program and receiving information from the department.

(30) "Residing" means living in Montana voluntarily with the intention of making a home here and not for a temporary purpose.

(31) "Temporary enrollment" means the three month enrollment allowed for those applicants that are only missing Social Security Extra Help determination.

(32) "Unearned income" means any income other than salary, wages, and earnings from self-employment.

(33) "Waiting list" means the list compiled by the department of applicants who are eligible for premium assistance but who are not enrolled in the Big Sky Rx Program because funds are not available to pay their program benefits.

(1) On January 1, 2006, Medicare Prescription Drug Plans (PDPs) became available to people with Medicare. This is a voluntary federal program created by the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) 42 USC 1302, 1395w-101 through 1395w-152, and 1395hh. It is referred to as "Medicare Part D" in these rules and implemented in 42 CFR part 423.

(2) An individual entitled to benefits under Medicare Part A or enrolled in Medicare Part B is eligible to enroll in a Medicare Part D PDP. An individual enrolled in a PDP is responsible for the premium and receives prescription drug coverage. There is also a federal premium subsidy called "Social Security Extra Help" for some individuals that assists in paying copayments, deductibles, and premiums.

(3) The purpose of Montana's Big Sky Rx Program is to pay a portion or all of the cost of the PDP premium for eligible Montana residents.

(4) The individual enrolled in Part D must choose and enroll in a federally approved PDP.

(5) The program does not provide assistance with selecting or enrolling in a PDP.

(1) An applicant eligible for the Big Sky Rx PDP premium assistance may receive a benefit not to exceed $38.90 per month. The benefit amount will not exceed $38.90 regardless of the cost of the premium for the PDP the individual chooses.

(a) If a portion of the applicant's PDP premium is paid through the Extra Help Program, the Big Sky Rx Program will pay the applicant's portion of the PDP premium up to $38.90 per month.

(b) Big Sky Rx does not pay for the cost of an enrollee's drugs or the cost of an enrollee's deductible, coinsurance, or copayments.

(c) All expenditures are contingent on legislative appropriation. The amount of the monthly benefit, $38.90, extends the Social Security Extra Help benefit amount to Montana residents with income up to 200% FPL. The department's total expenditure for the program will be based on appropriation and the number of enrolled applicants.

(1) An applicant must be eligible and enrolled in the program to receive premium assistance.

(2) To qualify the applicant must:

(a) be a resident of the state of Montana; and

(b) have a family income at or below 200% FPL.

(3) An applicant who meets the eligibility requirements for Social Security Extra Help as outlined in 42 CFR 423.773 (2007), which is adopted and incorporated by reference, must provide a determination from Social Security Extra Help.

(4) An individual who is receiving benefits for Medicaid is not eligible for the Big Sky Rx Program.

(5) An individual in a LIS program with full premium subsidy is not eligible.

(6) Eligibility determinations shall be effective for 12 months from the date of determination regardless of change in income or household size. This also applies to an applicant on the waiting list as provided in ARM 37.81.326.

(7) Enrollees in the program must comply with procedures specified by the PDP, the department, Extra Help, and Social Security (if applicable) to receive premium assistance.

(8) Program enrollment and eligibility will terminate at the end of the month in which any of the following events occur:

(a) the enrollee becomes Medicaid eligible;

(b) by income verification, the enrollee's income is found to exceed 200% of the FPL;

(c) the enrollee is no longer enrolled in a PDP;

(d) the enrollee did not provide an Extra Help determination, if appropriate, or reapply for Extra Help;

(e) the enrollee dies;

(f) the enrollee is incarcerated; or

(g) the enrollee fails to provide information requested by the department.

(9) Termination of the benefit amount will be effective at the end of the month and a notice of termination will be mailed to the enrollee.

(10) Big Sky Rx eligibility and benefits are not an entitlement. If funding is insufficient, the department may reduce enrollment numbers or enrollment criteria to limit the number of individuals who are eligible to participate.

(1) Family income must be at or below 200% FPL to qualify for the program. Assets are not considered. Family income is the total of the applicant's income and the spouse's income if married and living together. For purposes of determining Big Sky Rx eligibility, the income items listed in this rule are included in family income.

(2) Earned income includes gross wages, net earnings from self-employment, payment for services performed in a sheltered workshop or work activities center, royalties, and honoraria.

(3) Unearned income includes Social Security benefits, veterans benefits, railroad benefits, public and private pensions, annuities, workers' compensation, alimony, child support, unemployment, income from a trust, net rental income, dividends, interest, and inheritances.

(4) Income tax refunds, assistance based on need funded by a state or local government, and small amounts of income received infrequently or irregularly are not counted. The income listed in (2) and (3) may also be decreased based on the adjustments stated in 20 CFR 416 to calculate income for purposes of Social Security Supplemental Income (SSI).

(5) The result of adding (2) and (3) and making any disregards of income provided for in (4) equals countable income.

(6) Compare countable income with household size to figure FPL.

(1) The department will process applications on a first in first served basis using the date the application is received by the department.

(a) The program will not enroll or pay benefits retroactively.

(b) Benefits will only be paid to eligible and enrolled individuals as of the first month following enrollment.

(2) Applications will be processed by the department and individuals will be notified in writing of their eligibility status as:

(a) ineligible;

(b) qualified but incomplete;

(c) incomplete;

(d) eligible and enrolled; or

(e) eligible and on the waiting list for the Big Sky Rx Program.

(3) A completed application consists of:

(a) a signed Big Sky Rx application form with the following information:

(i) applicant's and spouse's (if applicable) name;

(ii) Social Security number;

(iii) Medicare number;

(iv) date of birth;

(v) gender;

(vi) home phone number;

(vii) mailing address;

(viii) family size;

(ix) family income;

(x) gross wages;

(xi) family assets;

(xii) disability or blind related work expense;

(xiii) name of applicants' PDP; and

(xiv) payment option of direct deposit or mail if applicant wishes to be paid directly.

(4) An applicant must sign the application and self-declare Montana residency and application for Big Sky Rx.

(5) An applicant must provide documentation of Medicare Part D PDP or Medicare advantage plan enrollment including documentation of Part D name, group number, and premium payment portion amount.

(6) An applicant who meets the eligibility requirements for Social Security Extra Help and is missing no other program requirement will receive a three month temporary enrollment. Within three months a temporary enrollee must provide documentation of a Social Security Extra Help determination. If no documentation is provided, the temporary enrollee will be disenrolled.

(7) An application is incomplete if it is missing any item listed in (3) through (6).

(8) Individuals not meeting the eligibility criteria in ARM 37.81.307 will be considered ineligible and mailed a program notice containing the reason for ineligibility. An individual may request an appeal, as provided in ARM 37.81.330. An individual may reapply for the program at any time.

(9) Qualified but incomplete applications will be marked "pending" until the applicant provides the PDP information and any missing application material.

(a) The applicant will be mailed a notice that the application is pending. The application will be held for 60 days from the application date. Following the 61st day, a notice will be mailed to the applicant as a reminder of the missing information.

(b) The application will remain "pended" until the information can be processed. If the information is still missing on the 91st day following the application date, the department will consider the applicant ineligible and the individual will be mailed a notice. The department will take no further action.

(10) Incomplete applications that are not otherwise qualified are considered "pending" by the department. These individuals will be mailed a notice of the missing information.

(a) A pended application will be held for 30 days waiting for missing information. If the missing information is received within the 30 days from the application date, the application will be processed.

(b) Following the 31st day the department will consider the application incomplete. The applicant becomes ineligible, and will be mailed a notice. The department will take no further action.

(11) Eligible individuals must meet all of the eligibility criteria in ARM 37.81.307. An eligible applicant will be enrolled in the program on a first in first served basis using the date the completed application is received by the department.

(12) Program enrollment starts the first day of the following month. Enrollees will be mailed an enrolled notice, including the approved premium benefit amount. The premium benefit amount will be paid to the PDP or the individual for the following month.

(13) If no premium assistance is available because of funding, eligible individuals will be placed on the department's waiting list. If funds become available, a notice will be sent and the applicant will be enrolled.

(1) Sixty days prior to the end of the 12-month eligibility period, a prepopulated notice will automatically be generated and mailed to the client. This notice is generated based on the client's eligibility enrollment determination date.

(2) The client must review the information on the notice to ensure the information is accurate including, but not limited to, information about income, assets, dependent family members, and contact information.

(a) If the notice has incorrect information, the client must write the correct information on the notice and return the corrected notice to the department before the eligibility period ends.

(b) If the client has verified the information on the notice is correct, the client does not need to return it or take any other action.

(3) The department will process the enrollee's returned notice with corrected information as a renewal application in accordance with ARM 37.81.318.

(2) If no available program slot exists, the eligible individuals will not be enrolled and will be maintained on a waiting list until a slot becomes available.

(3) When slots are available, individuals will be notified in writing prior to the month of enrollment.

(4) The 12-month eligibility stated in ARM 37.81.307 applies.

(1) All decisions of the department related to the administration of the Big Sky Pharmacy Rx program are reviewable using the procedures stated at ARM 37.5.101, 37.5.304, 37.5.307, 37.5.313, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, and 37.5.334.

(2) An applicant contesting a denial, or an enrollee or guardian contesting a benefit or enrollment denial, benefit reduction, disenrollment, closure, or termination of Big Sky Rx may request a fair hearing.

(3) If a written request for hearing is not received by the department within 90 days of the mailing date of a notice of adverse action, the hearing officer may deny a hearing as provided in ARM 37.5.313.

(1) A random sample of enrolled individuals will be required to participate in an eligibility verification review and provide documentation to verify the income as stated on the application.

(2) An individual will have 30 days from the date of the written request by the department to submit the required income documentation. The client will remain enrolled during the verification process.

(a) If the required documentation is not received by the department after 30 days, the enrolled individual will be disenrolled from the program the following month.

(b) An individual who provides income verification documentation after 30 will have the application reprocessed as if it is a new application.

(3) If verified income is over 200% FPL, the applicant will be disenrolled effective the last day of the month in which the determination was made and the client was notified.

(4) For purposes of this rule, necessary income documentation may include one or more of the following:

(a) state or federal income tax returns;

(b) pay stubs or other pay statements;

(c) employee's W-2 forms;

(d) self employment records documenting income and expenses;

(e) check copies;

(f) correspondence from an employer specifying a benefit;

(g) records of any government payor; or

(h) other appropriate, persuasive documentation may be accepted at the discretion of the department.

(1) Monthly premium payments will be made:

(a) to an insurer that has contracted with the department;

(b) directly to clients if:

(i) their monthly premium is deducted from their Social Security check;

(ii) they enroll in a PDP provided by an insurer that does not contract with the department; or

(iii) the client chooses to be paid directly.

(2) Direct monthly premium payments to enrollees will be made:

(a) through direct deposit; or

(b) by check only in the following circumstances:

(i) if there is no bank account; or

(ii) the enrollee has a permanent exemption with Social Security and still receiving Social Security benefits by check or by Direct Express debit card.

(1) An insurer receiving direct payment of all or part of a PDP premium from the state on behalf of an enrollee must enter into a Memorandum of Understanding (MOU) or Business Associates Agreement (BAA) with the department.

(1) The rules in this chapter implement the Prescription Drug Consumer Information and Technical Assistance Program established in 53-6-1006, MCA. This program is referred to in these rules as the Montana PharmAssist Program.

In addition to the definitions in 53-6-1001, MCA, the following definitions apply to this chapter:

(1) "Application" means the form developed by the department to provide the program with client specific information.

(2) "Authorized client" means an applicant has met all the Montana PharmAssist authorization criteria stated in ARM 37.81.1009.

(3) "Chronic disease" means a condition or disease of long duration and generally slow progression that requires long term drug treatment such as cardiovascular disease, chronic respiratory disease, diabetes mellitus, arthritis, epilepsy, cancer, osteoporosis, depression, anxiety, bipolar disorder, or schizophrenia.

(4) "Client inventory form" means a form developed by the department to include pertinent client and health information.

(5) "Credentialed pharmacist" means a Montana licensed pharmacist in good standing who has completed the required initial training for the PharmAssist Program and has a current personal service contract with the department.

(6) "Department" means the Department of Public Health and Human Services.

(7) "Eligible client" means an applicant has met all the Montana PharmAssist eligibility criteria stated in ARM 37.81.1009.

(8) "First in first served" means completed applications will be processed and eligible applicants will be referred to a pharmacist for services based upon the date received.

(9) "Personal service contract" means the contract between the department and the credentialed pharmacist.

(10) "PharmAssist patient packet" means an application, a signed Acknowledgement of Receipt of Notice of Privacy Practices, and a Client Inventory Form.

(11) "Qualified" means an applicant has met all the Montana PharmAssist qualification criteria stated in ARM 37.81.1009.

(12) "Residing" means living in Montana voluntarily with the intention of making a home in the state and not for a temporary purpose.

(1) Beginning July 15, 2007, Montana residents may request applications for referral to a credentialed pharmacist for review of their medication regimens to address medication cost and the proper and prudent use of their medications. Clients who have applied and whose personal circumstances warrant a referral will be referred to a pharmacist for a drug regimen review and face-to-face interactions to identify therapeutic duplications and possible cost saving alternatives. The pharmacist will schedule and perform a face-to-face consultation and provide recommendations for the client to discuss with their prescriber. Upon completion, the client, their prescribers, and department representatives will receive a letter prepared by the pharmacist outlining the face-to-face discussion. The letter will include the pharmacist's recommendations for the possible alternatives available for the client. Clients are encouraged to discuss the pharmacist's recommendations with their prescribers prior to making any changes.

(1) If eligible for Montana PharmAssist, a client may receive up to $200 of pharmacist services per 12 month period as outlined in the pharmacist's Personal Service Contract. Services will include an initial face-to-face consultation and may include follow-up services if warranted and approved by the department or its designee. All expenditures are contingent on available appropriations.

(1) An applicant must be qualified, eligible, and authorized to receive pharmacist services.

(2) To qualify, an applicant must have a chronic disease and either:

(a) take four or more medications; or

(b) have a condition or health issue determined by the screening pharmacist that provides an opportunity for benefit.

(3) To be eligible, an applicant must be residing in the state of Montana.

(4) To be authorized, an applicant must submit a completed PharmAssist Patient Packet, to include:

(a) an application;

(b) a signed Acknowledgement of Receipt of Notice of Privacy Practices; and

(c) a Client Inventory Form.

(1) The department or its designee will process PharmAssist Patient Packets on a first in first served basis using the date the complete package is received.

(2) Authorized clients will be referred to a pharmacist for services.

(3) Applicants failing to meet criteria defined in ARM 37.81.1009 will be notified in writing.

(1) The department will process PharmAssist Patient Packets and notify eligible individuals in writing if no available program slot exists, either due to lack of appropriations or credentialed pharmacists in their region.

(2) Eligible individuals will have their names maintained on a waiting list until program slots become available.

(3) When program slots become available, clients will be referred to a credentialed pharmacist for services on a first in first served basis.

(1) To participate in the PharmAssist Program a pharmacist must be licensed by the state of Montana and complete initial training, which consists of a self-guided educational packet prepared by the department.

(1) All decisions of the department related to the administration of the Montana PharmAssist are reviewable using the procedures in ARM 37.5.101, 37.5.304, 37.5.307, 37.5.313, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, and 37.5.334.

(2) An aggrieved applicant may request a fair hearing in writing within 90 days. The request must be mailed to the Department of Public Health and Human Services, Quality Assurance Division, Office of Fair Hearings, P.O. Box 202953, Helena, MT 59620-2953.

(3) If a written request for hearing is received by the department more than 90 days after the mailing date of a notice of denial, the hearing officer must deny a hearing as provided in ARM 37.5.313.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.