PURPOSE: This rule establishes the benefits and limitations for administering the Missouri Rx Plan, Missouri’s State Pharmacy Assistance Program, to provide prescription drug assistance to Missourian’s sixty-five (65) years of age and older or disabled and receiving Social Security benefits in need of coordinating benefits with Medicare’s Prescription Drug (Part D) Program.

1. (1) Administration. The Missouri Rx Plan shall be administered by the Department of Social Services, MO HealthNet Division.

2. (2) Definitions.

   1. (A) Applicant—A person who applies to participate in the Missouri Rx Plan, either personally or through an authorized representative.
   2. (B) Application—The form completed and submitted to the Missouri Rx Plan by an applicant which is used to determine the applicant’s eligibility to participate in the Missouri Rx Plan.

   3. (C) Authorized Representative—If an applicant is incapable of submitting an application on his or her own behalf, the Missouri Rx Plan shall accept one (1) of the following persons designated by the applicant:

      1. 1. A close relative by blood or marriage,

such as a parent, spouse, son, daughter, brother, or sister;

1. 2. A representative payee designated by

the Social Security Administration; or

1. 3. A representative of a public/private

social service agency, which the applicant is a client, who has been designated by the agency to so act.

1. (D) Household Income—The combined gross income of all the related or non-related members of a household.
2. (E) Liquid Assets—Assets that can be converted to cash in a short time with little or no loss in value, including such assets as checking and savings accounts, certificates of deposit, stocks, bonds, savings bonds, mutual funds, Individual Retirement Account or similar investment, cash, and value of real estate other than the primary residence.
3. (F) Member—A person who meets the eligibility requirements of the Missouri Rx Plan and has been enrolled in the Missouri Rx Plan.
4. (G) Missouri Rx Plan—The state pharmacy assistance program administered by the Department of Social Services, MO Health- Net Division.
5. (H) Out-of-pocket costs—Means the deductible and co-pays required for prescription drug. The Missouri Rx Plan does not pay for the Medicare Part D monthly premium.

1. (3) Eligibility. To qualify for the Missouri Rx Plan the individual must be—

   1. (A) A U.S. citizen or a lawfully admitted alien;
   2. (B) A Missouri resident, a person who has, or intends to have, a fixed place of residence in Missouri, with the present intent of maintaining a permanent home in Missouri for the indefinite future; and
   3. (C) Sixty-five (65) years of age or older; or
   4. (D) Be an individual between the ages of nineteen (19) and sixty-four (64) who is disabled and receiving a Social Security Benefit; and
   5. (E) Enrolled in a Medicare Part D prescription drug plan; and
   6. (F) Is not a member of a retirement plan that is receiving a benefit under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, P.L. 108-173; and
   7. (G) Has an annual household income not to exceed one hundred eighty-five percent (185%) of the federal poverty level (FPL), subject to appropriations. The Federal Poverty Level is published annually. The revised income eligibility standard will be used to determine eligibility for the month following the month in which the standard is issued; and
   8. (H) An individual who is an inmate of a public institution is not eligible for Missouri Rx Plan.

2. (4) Application process. The application for the Missouri Rx Plan must be made in writing on the prescribed form. The request for assistance can be made by the applicant, guardian, or other individual acting for the applicant with the applicant’s knowledge and consent. The application filing date is the date the application is received by the MO HealthNet Division. The MO HealthNet will consider an application without regard to race, color, age, sex, disability, religion, national origin, or political belief as per Title VI of the Civil Rights Act of 1964. The application shall require the applicant to attest to the following information:

   1. (A) Date of birth;
   2. (B) Social Security number;
   3. (C) Medicare claim number;
   4. (D) Self-certification of Missouri residency;
   5. (E) Mailing address; 13 CSR 70-100
   6. (F) Contact information;
   7. (G) Self-certification of household income;
   8. (H) Self-certification of liquid assets;
   9. (I) Certification and attestation statement;
   10. (J) Signature of applicant or authorized representative;
   11. (K) Name of Medicare Part D Prescription Drug Plan; and
   12. (L) Additional information as may be necessary to comply with state or federal law.

3. (5) The applicant shall submit the following documentation with the application:

   1. (A) Copy of Medicare Health Insurance Card; and
   2. (B) Copy of Social Security Card.

4. (6) The MO HealthNet Division shall have the right to a review and audit of information on the application form, with a reasonable prior notice to the applicant, if selected for review.

   1. (A) The Missouri Rx Plan may require documentation to verify Missouri residency. Documentation of Missouri residency may include one (1) of the following:

      1. 1. Valid driver’s license;
      2. 2. Valid Missouri state identification

card;

1. 3. Voter registration card; or
2. 4. Utility bill with address.

3. (B) The Missouri Rx Plan may require documentation to verify income. Documentation of income may include one (1) of the following:

   1. 1. Social Security benefits—as paid after

deduction of Medicare premium;

1. 2. Pension—as paid;
2. 3. Veterans Administration Pension—as

paid;

1. 4. U.S. Railroad Retirement Benefits—

as paid;

1. 5. Wages—net amount after deductions

for taxes and Federal Insurance Contributions Act (FICA);

1. 6. Interest/Dividends—gross amount;
2. 7. Capital Gains—gross amount from

capital gains on stocks, mutual funds, and bonds;

1. 8. Credit Life or Credit Disability Insur-

ance Payments—as paid;

1. 9. Alimony—as paid;
2. 10. Rental income from an entire

dwelling—gross rent paid minus standard deduction of twenty percent (20%) for expenses;

1. 11. Roomer/Boarder Income—gross

room/board paid minus standard deduction of ten percent (10%) for expenses;

1. 12. Self Employment—countable income

as reported to Internal Revenue Service (IRS);

1. 13. Unemployment Compensation—as

paid; or

1. 14. Additional information, as may be

necessary to verify income.

1. (7) Program eligibility will be denied or terminated if the applicant refuses to cooperate with the request for verification information. If all verification information requested is not received by the due date, an eligibility determination cannot be made. This will result in denial of the application. Verification that is provided or received may reveal a new eligibility issue not previously realized that requires additional verification. If the additional verification requested is not received by the due date given, the application will be denied or the individual terminated from the Missouri Rx Plan.
2. (8) The applicant shall assist the Missouri Rx Plan in securing corroboration of the applicant’s information on the application form and required documentation when necessary. Program eligibility will be denied or terminated if the applicant refuses to cooperate with the request.
3. (9) Individuals who are enrolled in Medicare and Medicaid (dual eligibles) are deemed to have enrolled in the Missouri Rx Plan.
4. (10) Effective Date of Coverage. Coverage begins on the date the applicant is determined eligible for the Missouri Rx Plan. There is no retroactive coverage. Eligible individuals will receive an identification card from the Missouri Rx Plan.

5. (11) Benefit Limits.

   1. (A) The Missouri Rx Plan shall pay fifty percent (50%) of the member’s out-of-pocket costs for prescription drugs covered by the Medicare Prescription Drug Program and by the members Medicare Part D Plan formulary.
   2. (B) The Missouri Rx Plan shall have the authority to change the benefit limits at any time to achieve program cost control.

6. (12) Member’s Responsibilities.

   1. (A) The member shall notify the Missouri Rx Plan within ten (10) days of any change in circumstances when the member no longer meets the eligibility requirements set forth in sections 208.780 to 208.798, RSMo and regulations.
   2. (B) The authorized representative or other responsible person shall notify the Missouri Rx Plan of the death of a member within sixty (60) days of the member’s death.
7. (13) Annual review. Missouri Rx Plan members do not need to reapply every year. Once a member is enrolled, the member does not need to reapply. Missouri Rx Plan members receive a notice to update their information from the Missouri Rx Plan. Failure to return the requested information will result in termination of eligibility. A redetermination is completed when all eligibility factors are examined and a decision regarding continued eligibility is reached.

8. (14) Termination from the Program.

   1. (A) A member shall be terminated from the Missouri Rx Plan if he or she no longer meets the eligibility requirements under sections 208.780 to 208.798, RSMo or this regulation.
9. (15) Confidentiality. The Missouri Rx Plan will provide safeguards that restrict the use or disclosure of information about applicants and members to purposes directly connected with the administration of the Missouri Rx Plan. Purposes directly related to administration of the Missouri Rx Plan include establishing eligibility, providing services for members, auditing the Missouri Rx Plan, and conducting or assisting an investigation, prosecution, or civil or criminal proceeding related to the administration of the program.

AUTHORITY: sections 208.201, 208.780 to 208.798, RSMo Supp. 2014.* Original rule filed Aug. 15, 2014, effective Feb. 28, 2015. *Original authority: 208.201, RSMo 1987, amended 2007; 208.780, RSMo 2005, amended 2014; and 208.798, RSMo 2005, amended 2011, 2014.