Payment

(1) Membership Category Contribution Schedule. (a) Contribution Schedules for applicable Enrollment Fees, Co-payments, Deductibles, and Out-of-pocket spending limits shall be established by the Plan and supplied to all Applicants and may be made available to other interested parties upon request. (b) Each Member or his or her authorized representative shall be notified in writing of any applicable Enrollment Fee, Co-payments and Deductibles. (c) The Plan shall establish Enrollment Fee, Co-payment and Deductible schedules annually. Written notification regarding changes to Members' Enrollment Fee, Co-payment and Deductible rates shall be mailed by the Plan to all affected Members or their authorized representatives at least 30 calendar days before the effective date of the change. (d) The Secretary shall modify Enrollment Fee, Co-payment and Deductible schedules and income eligibility levels after making a written determination that Plan expenditures are projected to exceed the amount appropriated for the Plan or, based on not less than nine months of claims and enrollment data for the current Fiscal Year, expenditures in the subsequent Fiscal Year are clearly projected to annualize beyond the expenditures projected by Elder Affairs in the subsequent Fiscal Year. (2) Deductibles. When acquiring Covered Benefits, Members are responsible for the payment of the Deductible applicable to the Member. For Members enrolled in a Medicare Part D Plan, supplemental assistance may be provided for the Deductible required by the Medicare Part D Plan. (3) Co-payments. After a Member meets his or her applicable Deductible amount, he or she shall pay his or her Co-payment for each purchase of a Covered Benefit from a Participating Pharmacy or approved mail service facility until the Deductible is re-calculated or until the Annual Out-of-pocket Spending Limit is met. (4) Limitation on Member Out-of-pocket Expenditures (Annual Out-of-pocket Spending Limit). (a) Once a Member's Annual Out-of-pocket Spending Limit is reached, the Plan will cover the entire cost of Covered Benefits for that Member for the remainder of the Plan Year. (b) The following are excluded from any calculation to determine a Member's Annual Out-of-pocket Spending Limit: 1. Plan contributions as set forth in 651 CMR 15.06(4); 2. Enrollment Fees (if applicable); 3. Non-covered costs paid by a Member, including, but not limited to: a. expenses paid by a Member for Prescription Drugs prior to the Member's Effective Date of Coverage; b. expenses paid by a Member for Prescription Drugs not covered by the Plan and/or; c. Co-payments, Deductibles, and coinsurance paid by a Member for Prescription Drugs acquired through any plan other than a Medicare Part D Plan or Creditable Coverage Plan. For Members of a Medicare Part D Plan, Co-payments, Deductibles and co-insurance paid pursuant to the Medicare Part D Plan will be included in a calculation to determine the Member's Annual Out-of-pocket Spending Limit.