Did you get a notice about a Medicare Part D late enrollment penalty, but you had creditable coverage? Medicare often assesses a Part D penalty in error when people miss an attestation or fail to submit proof of prior creditable coverage. In this guide, we’ll walk you through how to appeal your Part D penalty, which form to use, where to send it, and what to include.
What Is the Medicare Part D Late Enrollment Penalty?
When you become eligible for Medicare, you must enroll in a Part D prescription drug plan to avoid a penalty.If you do not enroll in a plan and go 63 consecutive days or more without creditable coverage, Medicare may assess a late enrollment penalty. This is the case even if you only enroll in Part A. The Part D late enrollment penalty adds a permanent monthly fee to your prescription drug plan premium once you enroll in a plan.
However, if you continued working after becoming eligible for Medicare and maintained creditable group insurance coverage, you would qualify for an exemption from this penalty. You need to verify your prior coverage when leaving creditable coverage and enrolling in a plan. This usually happens when you enroll in a new Part D plan. The insurance company will send you a letter requesting you verify prior coverage. The letter will have a deadline for when to respond. If you miss this deadline or someone processes it incorrectly, Medicare will charge you a Part D penalty. See below for information on how to appeal. Learn How to Avoid the Part D Late Enrollment Penalty.
Can I Appeal My Penalty?
Absolutely! If Medicare charged you a penalty incorrectly, you can request a reconsideration of the penalty determination. This can happen if you had creditable drug coverage—such as employer coverage, VA coverage, or union coverage—but you did not verify your prior coverage or someone processed it incorrectly.
Once Medicare assesses a Part D penalty, the insurance company no longer has the authority to reverse it. You must go through a third party that reviews these disputes for Medicare.
How Do I Appeal My Part D Penalty?
To appeal your Medicare Part D late enrollment penalty, you must complete the process with C2C Innovative Solutions. Medicare contracts C2C Innovative Solutions, an independent review entity, to handle Part D penalty reconsiderations. Medicare does not process Part D appeals.
Steps to submit your Medicare Part D penalty appeal:
- Download “Part D Late Enrollment Penalty (LEP) Reconsideration Request Form”. You can download this form from the CMS site HERE.
- Complete all required fields then sign and date the form.
- Gather all required verification documents as stated on the form. (i.e. verification from former employer or VA showing prior coverage). You may need to contact your prior employer for this documentation.
- Submit yourReconsideration Form and Verification Documentation at the same time in a single submission to C2C Innovative Solutions via fax, mail, or their provided web portal. Page 2 of the reconsideration form lists the information for each of these submission methods. DO NOT SUBMIT THIS FORM TO MEDICARE!
- Do not submit your appeal form more than once! For example, if you submit through the C2C Appeals Portal, then DO NOT fax the same submission.
What happens after I submit the my appeal?
After you submit your appeal, C2C will review your documentation, determine whether it meets prior coverage requirements, and compare your coverage timeline to the dates Medicare assessed the penalty. Once completed they will issue a decision. They can approve or deny the decision based on the information you provide, so be sure to send all needed documentation. They will send you a determination letter once they process your appeal, and they will notify your plan of the decision. C2C Innovative Solutions has up to 90 days to process your Part D Late Enrollment Penalty appeal.
If C2C approves your appeal, Medicare will remove your Part D penalty. Medicare will make the correction retroactive and refund any months it charged you a penalty that you did not owe. If they deny your appeal, you must continue to pay the penalty. The reconsideration decision is generally final and not subject to further appeal. However, if you believe there was an error in the decision or you have new information that might change the decision that you did not have before, you may request to reopen your case. This is why it is important to make sure you submit complete information, dates of coverage, and accurate documentation with your reconsideration request!
Frequently Asked Questions About Part D Penalty Appeals
How long does the reconsideration process take?
C2C usually issues a decision within several weeks of receiving your appeal, but it has up to 90 days to make a final determination.
Will I have to pay the penalty while it’s under review?
Yes. You must continue paying your plan premium, including the penalty amount, while your appeal is pending.
What if I want to reopen my Part D redetermination case to send more information?
You can reopen your case if you believe there was an error or you have new information. You have 180 days from the receipt of your initial decision to reopen your case.
My plan is still charging me a Part D penalty after my appeal was processed and approved. What should I do?
If more than 90 days have passed since the date on your LEP reconsideration letter and Medicare still charges you a late enrollment penalty, call 1-800-MEDICARE.
My Part D Penalty was reversed, will I get reimbursed for the months I already paid?
If you win the appeal, Medicare will refund any penalty payments it charged for months when it assessed the penalty incorrectly.
