Part D Late Enrollment Penalty Appeals

For those of you who have just joined a drug plan, or for those of you who have switched drug plans, you may need some guidance on how to deal with a few issues that may come up. And remember, this advice is good if your Medicare drug plan is a stand-alone prescription drug plan (sometimes “PDP” is used to describe these), or whether your drug plan is part of your Medicare Advantage Plan (sometimes these drug plans are called an MA-PD”).

For one thing, you may get a notice that you are subject to a “late enrollment penalty.” (Medicare has a tendency to abbreviate everything; sometimes these are called “LEPs.”) That is, you may be told that, because you did not sign up for Part D at your first or earliest opportunity, you may owe a penalty which is added to your monthly Part D premium. But you may believe that this is incorrect. For example, you may have had “creditable” drug coverage with another insurance plan and you have now signed up for Part D as that plan ended or you want to augment its coverage. Or perhaps you were not properly notified that your drug coverage was not creditable. (By “creditable,” we mean drug coverage that is as good as Medicare’s; if you have drug coverage, your insurance plan is supposed to tell you every year whether or not it is “creditable.” If you have creditable coverage and then sign up for Part D, you are not supposed to be penalized for any month you had creditable coverage.) Or perhaps you have qualified for “extra help,” that is, the low income subsidy, in which case you do not owe any penalty.

You can appeal your late enrollment penalty if you believe it is incorrect. You do this by asking for a reconsideration of the decision. While you are not required to use it, a “Part D Late Enrollment Penalty Reconsideration Request Form” is very helpful to filing your request. You are supposed to get on with the notice of you late enrollment penalty, but if you didn’t, you can go to the Centers for Medicare & Medicaid Services website www.cms.hhs,gov and click on “Medicare,” then on “Prescription Drug Grievances and Appeals,” then on “Forms.” Go to the very bottom of that page; the form is “Appendix 15.” Follow the instructions it gives and send your appeal to Maximus – a company that Medicare has hired to make appeals at the address below, NOT the addresses on the form. Be sure to write your Medicare number on everything that you send, and make copies of everything. That company can be reached by calling toll free 1-877-456-5302 to discuss your late enrollment penalty appeal.

Maximus Federal Services
Medicare Part D QIC
P.O. Box 991
Victor NY 14564-0991

Tomorrow I'll blog about getting your new drug plan to pay for medicines it doesn't cover, etc.