NAC439.771. Requirements for application; request for waiver of eligibility requirement regarding household income.

     1. In addition to meeting the criteria for receiving a subsidy set forth in NRS 439.745, an applicant who wishes to receive a subsidy must file a properly completed application for a subsidy with the Department during a period of open enrollment.

     2. The application must be made:

     (a) On a form prescribed by the Department; and

     (b) Under oath as required pursuant to NRS 439.755.

     3. The Department may require an applicant to provide, with the application, proof of his or her:

     (a) Disability by submitting:

          (1) A copy of a disability determination letter issued by a public agency or private organization, approved by the Department, whose programs or services are based at least in part on disability;

          (2) Any other appropriate documentation satisfactory to the Department, including, without limitation, the statement of a physician; or

          (3) Any combination of the proof required pursuant to subparagraph (1) or (2);

     (b) Income by submitting a copy of his or her income tax returns, a copy of his or her Social Security Form SSA-1099, copies of wage statements, copies of dividend statements or other appropriate documentation satisfactory to the Department of any other sources of income received by the applicant in the 12 months immediately preceding the date of the application;

     (c) Assets by submitting a copy of income tax returns, copies of savings account statements, copies of stock certificates or other appropriate documentation satisfactory to the Department; and

     (d) Continuous residency in this State for at least the 12 months immediately preceding the date of the application by submitting a copy of utility bills, rental agreements or any other appropriate documentation satisfactory to the Department.

     4. Each applicant shall provide the Department with his or her social security number.

     5. Each applicant shall provide the following information about his or her status regarding Medicare Part D:

     (a) Each applicant must declare whether he or she is eligible for and enrolled in Medicare Part D, whether in a PDP or MA-PD, and, if so, must provide the name of the plan.

     (b) Each applicant who is eligible for Medicare Part D must avail himself or herself of that benefit and apply for any applicable federal low-income subsidy before seeking additional assistance through the Disability Prescription Program.

     (c) If the applicant is not enrolled in Medicare Part D because the applicant missed the period of open enrollment, such an applicant must state the reason for missing the period of open enrollment. Depending upon the circumstances, such an applicant may be considered for temporary enrollment in the Traditional Disability Prescription Program. The applicant must then enroll in Medicare Part D and a PDP or MA-PD at the next available opportunity or the applicant will be terminated from the Disability Prescription Program.

     (d) By checking “Yes” or “No” in the appropriate place, the applicant must decide whether to grant the Disability Prescription Program the authority to act as his or her authorized representative and, as such, to enroll the applicant in an appropriate PDP or MA-PD. Such authority does not preclude the applicant from changing his or her PDP or MA-PD before implementation of Medicare Part D on January 1, 2006, or during subsequent periods of open enrollment if the applicant is not satisfied with the assignment made by the Disability Prescription Program.

     6. An application shall be deemed received by the Department on the date that the completed application is received by the Department.

     7. An application shall be deemed properly completed if the application:

     (a) Is submitted on the form prescribed by the Department and filled out completely;

     (b) Includes the documentation described in subsection 3, if such documentation is required by the Department; and

     (c) Includes the social security number of the applicant as required pursuant to subsection 4.

Ê The Department will return any incomplete application to the applicant with a designation that the application has not been processed by the Department.

     8. If an applicant or enrollee requests a waiver of the eligibility requirement regarding household income pursuant to subsection 5 of NRS 439.745 because of an illness or disability or extreme financial hardship, the applicant or enrollee must include with that request a written statement signed by a licensed physician certifying the illness or disability or other appropriate documentation that satisfies the Department that an extreme financial hardship exists. The Department will consider each request for such a waiver on a case-by-case basis.

     (Added to NAC by Dep’t of Health & Human Services by R157-05, eff. 11-17-2005)