(a) This Subpart sets forth rules concerning:

1. (1) who can enroll beneficiaries or individuals in:

   1. (i) a Medicare Part D prescription drug plan or in a Medicare advantage plan with prescription drug coverage; or
   2. (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. (2) who can pursue grievances, complaints, exceptions and appeals in such plans;

3. (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:

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

   1. (i) filing a grievance;
   2. (ii) submitting a complaint to the quality improvement organization or to Federal or State government regulatory agencies;
   3. (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);
   4. (iv) filing and requesting appeals and dealing with, or participating in, any part of the appeals process;

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

   1. (i) filing a grievance;
   2. (ii) submitting a complaint to the quality improvement organization;
   3. (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
   4. (iv) filing and requesting appeals and dealing with any part of the appeals process;
6. (3) DDRO means an OPWDD Developmental Disabilities Regional Office.
7. (4) DDSOO means an OPWDD Developmental Disabilities State Operations Office.

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

   1. (i) a PDP; and/or
   2. (ii) a FIDA-IDD plan.
9. (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.
10. (7) Party means someone or an entity or organization.
11. (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.