Microsoft Word - CCLEP-FINAL-20080411.doc

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

CENTER FOR BENEFICIARY CHOICES

DATE April 11, 2008

To: All Prescription Drug Plan Sponsors, Medicare Advantage Organizations, Section

1876 Cost-Based Contractors and PACE Organizations

Subject: Updated Guidance on Creditable Coverage Period Determinations and the Late

Enrollment Penalty

From: Anthony Culotta, Director, Medicare Enrollment and Appeals Group

The purpose of this memorandum is to update our current guidance on creditable coverage

determinations and related late enrollment penalty issues. (See Chapter 4: Creditable Coverage

Period Determinations and the Late Enrollment Penalty and section 80.7.1 of Chapter 18: Late

Enrollment Penalty Reconsiderations in the Medicare Prescription Drug Benefit Manual, as

issued on June 12, 2007). This memo clarifies our policy in a number of areas based on our

experience implementing this guidance, and in response to questions received through our

central mailbox. These policy clarifications are effective immediately and will be incorporated

into Chapters 4 and 18 in the next update of these chapters. We have also updated several

exhibits, including the model attestation form and reconsideration request form, which are

attached to this memo.

Determining the Number of Uncovered Months

As described in the October 9, 2007 HPMS memorandum, “Announcement of Fall Software

Changes,” CMS has improved the way it processes the number of uncovered months for Part D

plans, and the way in which plans report this information on an enrollment or change transaction.

We are providing further information about the impact of those changes, including examples, in

response to plans’ requests. The most significant change for plans is that, for members with

prior Part D plan or Retiree Drug Subsidy (RDS) enrollment, the plan only needs to determine

whether the member has any period without creditable coverage (“uncovered months”) since the

date s/he disenrolled from the prior Part D or RDS plan. That is, where there is a prior

enrollment in a Part D or RDS plan, the current plan does not need to look all the way back to the

end of the member’s initial enrollment period (IEP), which is the procedure now outlined in

Section 10.2 of Chapter 4.

Instead, once the plan determines there was prior Part D/RDS plan coverage, whether through a

Beneficiary Eligibility Query (BEQ) or through the Common User Interface (Common UI), the

plan will look for any lapse of Part D or RDS enrollment of 63 or more consecutive days

between the effective date of the member’s disenrollment from the prior plan and the effective

date of the member’s enrollment in the new plan, as explained in section 10 of Chapter 4. If

there are potential uncovered months because the plan’s review of this data shows a period of 63

days or longer between the two enrollments, the plan will then follow the procedures to

determine if the full months within that period are genuinely “uncovered” (i.e., the individual did

not have other creditable coverage.) Once it is determined that there is a number of uncovered

months, the plan will submit those months as “incremental months” on a Part D enrollment

transaction (60/61/62/71) or a plan change transaction (72) if enrollment has already been

submitted. CMS will then add these months to any other uncovered months submitted by the

prior plan(s), if applicable. CMS will adjust the amount of the LEP, as appropriate, to reflect the

increase in uncovered months, and notify the plan of the change in LEP amounts. Below are two

examples to illustrate this process:

Example 1: Plan Submits Incremental Uncovered Months

Mr. Jones submits an enrollment request to Plan XYZ during the 2008 Annual

Enrollment Period, with enrollment effective on January 1, 2008. Plan XYZ learns via

the BEQ that Mr. Jones was enrolled in Plan ABC effective January 1, 2007, but

disenrolled effective July 31, 2007. Plan XYZ also sees (via the BEQ) that Mr. Jones’

IEP ended May 15, 2006, and that Plan ABC had submitted 7 uncovered months on his

behalf.

Since Mr. Jones’ enrollment in Plan XYZ will be effective on January 1, 2008, and his

last Part D plan enrollment ended on July 31, 2007, he will potentially have 5 uncovered

months between the effective date of his disenrollment from Plan ABC at the end of July,

through the end of December. In accordance with CMS guidance, Plan XYZ sends Mr.

Jones an attestation form, and learns that he did not have other creditable coverage during

this time, and therefore this period represents a total of 5 uncovered months. Plan XYZ

then submits a Plan change (code 72) transaction on behalf of Mr. Jones that sets the

creditable coverage flag to “N” and inserts “005” as the number of uncovered months,

effective with the beneficiary’s enrollment with the Plan. CMS then adds these

uncovered “incremental” months to the 7 months already submitted for Mr. Jones by Plan

ABC, for a total of 12 uncovered months, and CMS adjusts the penalty accordingly. Plan

XYZ notifies Mr. Jones of the adjustment to his LEP, as outlined in section 30.1 of

Chapter 4.

Example 2: Plan Submits No Incremental Uncovered Months

Mrs. Smith submits an enrollment request to Plan XYZ during the 2008 Annual

Enrollment Period, with enrollment effective on January 1, 2008. Plan XYZ learns via

the BEQ that Mrs. Smith is currently enrolled in Plan ABC, effective January 1, 2007 and

has “0” uncovered months reported by Plan ABC. Mrs. Smith’s enrollment in Plan XYZ

will disenroll her from Plan ABC effective December 31, 2007. Therefore, she will have

no break between these two Part D plans and there is no break in creditable coverage.

Plan XYZ would then set the creditable coverage flag to “Y” and submit “000”

uncovered months for Mrs. Smith on a Part D enrollment transaction (60/61/62). Since

there are no prior uncovered months submitted by Plan ABC, the total number of

uncovered months will be zero, and there will be no LEP.

Note: If the member is enrolling in Part D for the first time, then the plan will still have to look

back to the end of the member’s IEP, and report any uncovered months, as explained in section

10 of Chapter 4. Plans may use either the BEQ or Common UI to obtain Part D and RDS plan

history for a beneficiary; both will display correct information about prior Part D plan enrollment

and/or coverage under a plan receiving the Retiree Drug Subsidy (RDS), as well as provide

information regarding the number of uncovered months submitted by any Part D plan in which

the individual was previously enrolled.

Revised Attestation Form and New Checklist

Since our independent review entity, currently Maximus, began processing beneficiary’s requests

for a reconsideration of the LEP last fall, we have learned that the majority of the requests are

from beneficiaries who had creditable coverage during the period in question, but failed to

submit or complete the attestation form. In these cases, Maximus ultimately issues a favorable

decision for those beneficiaries who can show that they had prior creditable coverage, but not

until considerable time and resources have been expended on the part of the beneficiary, the

plan, Maximus, and CMS. We are also concerned, based on anecdotal information, that

beneficiaries do not understand the form or appreciate the importance of completing and

submitting the form timely.

Therefore, we have taken a number of steps to address this issue, first by simplifying the current

attestation form. The simplified attestation form includes a checklist designed to focus

beneficiaries’ attention on the form, and emphasizes the urgency of completing the attestation

process. (See Exhibit 1A). Second, we have added a new model notice for plans to remind

enrollees of the need to submit a timely attestation if they have prior creditable prescription drug

coverage. This model serves as a “final notice” that an LEP will be imposed if the enrollee does

not return the attestation form or call their plan with this information by the stated deadline. (See

Exhibit 1B).

These documents are provided as models and may therefore be modified, subject to CMS review

and approval. However, we urge plans to refrain from adding extraneous information to either

the form or the checklist, or from putting their own letterhead on the checklist in addition to the

CMS letterhead. We believe that emphasizing to beneficiaries that the information about prior

coverage is being collected on behalf of Medicare will dispel any notions (as shown by anecdotal

reports) that the plan is collecting this information for other purposes, or that the request is not

legitimate.

Plans must begin using these new models with enrollments received on or after June 1, 2008, but

may begin using them sooner, and are, in fact, encouraged to do so. Neither the previous model

nor previously-approved notices should be used after that date. As noted above, using the new

form immediately should be in the best interests of both plans and beneficiaries, since timely

completion of the form will reduce the burden associated with the reconsideration process on all

parties involved.

Mailing of Attestation Forms to Members

Please note that plans may not include the attestation form with an enrollment form, nor may

they include a question(s) regarding the individual’s creditable coverage on the enrollment form,

as doing so may lead the enrollee to believe that his/her enrollment in the plan is contingent upon

having prior creditable coverage. CMS has also removed questions about creditable coverage

from its model enrollment form for 2008. However, if the beneficiary, on his/her own initiative,

includes creditable coverage information and/or documentation with the enrollment form, the

plan shall take that information into account when determining whether there has been a gap in

coverage. Thus, the plan may not need to send an attestation form if the documentation shows

that there is no gap in coverage.

Plans may not send the LEP Reconsideration Notice and Reconsideration Request Forms to

members with the attestation form. Experience has shown that doing so confuses the beneficiary

and prompts reconsideration requests in situations where no LEP will be assessed. Plans are

advised to ensure that their call center staff has proper scripting, so that they can answer

questions about the attestation form.

Other Information About Creditable Coverage

In addition to information from the BEQ or Common UI, Part D sponsors should rely on other

available information to determine that there is no lapse in creditable coverage of 63 or more

consecutive days. For example, a sponsor may be able to document that a new member of its

Part D plan also had creditable coverage through another product it offers, i.e., employer

coverage, individual coverage, or coverage offered by another plan benefit package (PBP). If

this information shows that there has been no lapse in coverage, the sponsor should not send an

attestation form to the member, but instead include appropriate documentation in the member’s

file and report zero uncovered months to CMS.

Attestations from Third Parties

CMS currently allows employers and unions that enroll groups of beneficiaries into Medicare

prescription drug coverage to attest to their members’ creditable coverage history with the

employer or union for purposes of reporting covered months. (See Chapter 4, section 10.2.4.)

We will now allow any employer or union group to attest to their members’ creditable coverage

history, even if they do not also group enroll their members. We continue to refrain from

specifying the form and manner of that attestation and instead defer to arrangements made

between the plan and the employer or union group. For example, documentation can include

individual attestations signed by the employer or union, or one attestation, supplemented by a list

of affected members. Plans shall accept and retain such attestations and provide the

documentation to CMS upon request.

We are also further expanding our policy to allow State Pharmaceutical Assistance Programs

(SPAPs) to attest to creditable coverage on their members’ behalf. As with employer or union

groups, plans shall accept attestation information from the SPAP that includes members’ names

and dates of creditable SPAP coverage.

Note: In the event that an employer, union, or SPAP attests to creditable coverage on behalf of

its members, but a member has also completed an attestation form, the plan shall use the

information most favorable to the beneficiary. Thus, the information provided by the employer,

union, or SPAP will supersede the beneficiary’s signed attestation only if it would eliminate or

reduce the LEP.

Telephonic Attestation

As discussed above, we are concerned that beneficiaries may not understand the attestation form

or appreciate the importance of completing the form and returning it to their plan in a timely

fashion. We understand that some plans have made follow-up telephone calls to their members

who fail to complete the form in order to encourage them to complete the form. These plans

have explained that, to the extent they are able to reach their members via phone, they could

complete the attestation process more quickly and effectively if they were able to accept the

attestation over the phone, rather than relying on the beneficiary to complete the form and return

it. Thus, we are expanding our policy to allow beneficiaries or their authorized representatives to

complete the entire attestation over the telephone. The plan sponsor is not required to record the

conversation, but must document the call and ensure that it captures all of the requisite elements

of the attestation (shown in the attached model attestation form) and amend the beneficiary’s

record. We would note that this new telephonic option is only available where the member has

failed to return or complete the form. Plans are still required to mail an attestation form to their

members. We have modified the model attestation form (Exhibits 1A/1B) to include language

for plans that offer telephonic attestation.

Currently, plans are permitted to obtain missing information via telephone, but must obtain the

beneficiary’s “wet” signature on the actual form. Consistent with our expanded policy allowing

telephonic attestation, beneficiaries can now verbally attest to the information already provided

via telephone in lieu of providing a “wet” signature on the form. As noted above, plans are not

required to record the conversation with the beneficiary, but must amend the beneficiary’s

record.

Determinations Based on Incomplete or Missing Attestation Forms

Currently, plans are strongly encouraged to follow-up with their members, either via phone or in

writing, to obtain any missing information or to obtain the actual form, if none has been returned.

If a beneficiary returns an incomplete attestation, the plan must report its determination to CMS

within 21 calendar days of receipt of the incomplete form. Effective with this guidance, CMS is

affording plans an additional 7 calendar days (for a total of 28 days) to attempt to obtain missing

information and report its determination to CMS.

Currently, beneficiaries have 30 days from the date on the form to complete and return the form

to the plan. If the beneficiary fails to return the attestation form by the stated deadline, the Part

D plan sponsor must report its determination to CMS within 7 calendar days of the stated

deadline. Consistent with the additional time afforded for incomplete attestation forms described

above, plans have an additional 7 calendar days (for a total of 14 calendar days) beyond the

deadline on the form to report their determinations to CMS.

Again, plans are strongly encouraged to follow-up with the beneficiary via phone or other

methods to obtain a completed form, or obtain the necessary information and a verbal

confirmation from the beneficiary, as described above. It is certainly in plans’ best interests to

attempt to contact the beneficiary and obtain the necessary information or the attestation itself,

since, in doing so, the plan may avoid having to expend additional resources in the future if the

beneficiary chooses to request a reconsideration. Plans should document any such follow-up

attempts in the beneficiary’s file.

Note: While plans are not required to retain copies of the attestation form mailed to the

beneficiary, the plan must be able to document the information included in the attestation form

(i.e., the dates of non-coverage and the IEP end date) and the date that the form was mailed to the

member in the event that there is a reconsideration of any LEP imposed. We encourage plans to

retain copies of the attestation form, where possible, to help expedite the reconsideration process

because this form contains member-specific information that would be valuable in the case of a

reconsideration. Plans are already required to retain copies of the returned attestation form,

along with any other information collected concerning a creditable coverage period

determination, as explained in Chapter 4, section 10.4.

Determinations Pending Retroactive Enrollment

If the plan or member has requested a valid retroactive enrollment that would impact (positively

or negatively) the number of uncovered months for that member, the plan shall wait until the

retroactive enrollment request has been accepted and processed prior to submitting any

uncovered months on behalf of that member, even if doing so delays the plan’s reporting of that

information past the timeframes described in this memorandum. The plan will not be considered

out of compliance with these procedures under these circumstances.

Corrections to Reports of Creditable Coverage Period Determinations

In the event a plan discovers it has erroneously calculated the number of uncovered months, or

erred in transmitting that information to CMS (e.g., a typographical error in the transaction), the

plan shall take steps to correct the error by submitting a change transaction (code 72) with the

correct information. The transaction must have the same effective date as the erroneous

transaction. In limited circumstances, there may be a change to the number of uncovered months

because of a corresponding change in a member’s enrollment effective date. The plan shall also

submit a change transaction with the appropriate effective date and the correct number of

uncovered months in this case.

The plan must then advise the member of the adjustment within ten (10) calendar days of

receiving confirmation from CMS that the transaction was accepted. The plan may use the

model notice entitled, Exhibit 6: Model Notice Informing Beneficiary of LEP Adjustment Due to

Plan Error, for this purpose or create its own form using the requisite elements shown in the

model, subject to CMS’ marketing review procedures.

If such a change results in the imposition of or increase in the LEP, the plan must include the

LEP Reconsideration Notice and Reconsideration Request Form with notice of the LEP. If, on

the other hand, such a change results in the elimination or reduction of the LEP, the beneficiary

is afforded no new reconsideration rights, and the plan need not include the forms.

If the member has already requested a review of the LEP before the plan submits a transaction

with the corrected number of uncovered months, and CMS’ independent review entity

(Maximus) has notified the plan of a pending reconsideration request (i.e., the independent

review entity has requested the case file from the plan), the plan must contact Maximus to alert

them to the change and provide documentation of the change. Plans should use the fax number

noted on the LEP Reconsideration Case File Request Form to communicate this information to

Maximus (484-688-5601 for PDP plans and 585-425-5301 for MA-PD plans). If the correction

results in removal of the LEP (zero [“0”] uncovered months), Maximus will then dismiss the

case because there are no longer uncovered months in dispute. If, however, the correction

adjusts but does not eliminate the LEP, Maximus will then proceed with its review of the LEP

based on the new information.

Effective with this guidance, plans must submit corrections when they receive a late attestation

form that indicates that the member had creditable coverage for the period in question, if the plan

has already reported uncovered months to CMS. (Currently, plans have the discretion to not

report this information to CMS.) Again, plans should use a change transaction (code 72) to do

so. We have eliminated the model notice entitled, Exhibit 9: Model Notice – Creditable

Coverage Information Received After Deadline Date since this is no longer needed.

Creditable Coverage Period Determinations for Disenrolled Members

When a beneficiary submits a valid cancellation request to the plan prior to his/her enrollment

effective date (see the CMS Eligibility, Enrollment, and Disenrollment Guidance appropriate to

your plan type for information on valid cancellation requests), the plan should not proceed with a

creditable coverage period determination in accordance with section 10 of Chapter 4. However,

if the member’s coverage is already effective, and the beneficiary later disenrolls from the plan

before the plan has had an opportunity to assess the LEP, the plan shall continue with a

creditable coverage period determination in accordance with CMS guidance, and report the

number of uncovered months to CMS. The reason it is important that plans proceed with their

determination is that subsequent plans will not look back beyond the end of the beneficiary’s

enrollment in the previous plan when determining the number of uncovered months.

LEP Reconsideration Process

Plans are reminded to include the LEP Reconsideration Notice and Reconsideration Request

Form when notifying their members of the imposition of or increase in the LEP where the

increase is due to reporting additional uncovered months. Please see the “New and Revised

Appendices and Exhibits” section below for revisions to the Reconsideration Notice and

Reconsideration Request form. Plans must begin including the notice and form on or after June

1, 2008, but are encouraged to do so sooner if practical.

In addition, plans must now retain copies of the LEP notice sent to their members. We have

learned from Maximus that the information included in the LEP notice about the end of the

member’s IEP and the dates of the potential gap in creditable coverage is important in the event

that the beneficiary requests a reconsideration, and some plans that do not retain a copy of the

notice have not been able to provide that information to Maximus when requested. If the plan

retains a copy of the LEP notice in the member’s file, then that information will be readily and

easily available should the beneficiary request review of the LEP. We will revise existing

guidance at section 10.4 of Chapter 4 and section 80.7.1 of Chapter 18 accordingly.

Based on our experience reviewing LEP reconsideration cases to date, we are making several

revisions to our LEP reconsideration policy. We are revising existing guidance concerning the

reasons a beneficiary may request an LEP reconsideration (section 80.7.1.4 of Chapter 18). The

LEP Reconsideration Request Form will no longer include a reference to review of an LEP for

“special circumstances.” Instead, in order to provide clearer guidance on when an LEP may be

reviewed, the LEP Reconsideration Request Form has been revised to include the following

specific reasons for requesting a reconsideration:

1. The individual had prior creditable prescription drug coverage (that the enrollee believes

may have not been considered).

2. The individual had prior prescription drug coverage but didn’t get a notice that clearly

explained if the drug coverage was as good as Medicare’s (creditable).

3. The individual believes the LEP is wrong because he or she was not eligible to enroll in a

Medicare drug plan during the period stated by the Medicare drug plan.

4. The individual believes the LEP is wrong because he or she was unable to enroll in a

Medicare drug plan due to a serious medical emergency during the period the individual

was eligible to enroll in a drug plan.

5. The individual has/had extra help from Medicare to pay for prescription drug coverage.

6. The individual lived in an area affected by Hurricane Katrina at the time of the hurricane

(August 2005), and he or she joined a Part D plan before December 31, 2006.

Also, we are revising existing guidance concerning the LEP reconsideration decision-making

timeframe (section 80.7.1.5 of Chapter 18). Under this revised guidance, the IRE generally will

notify the enrollee of the final LEP reconsideration decision within 90 calendar days of receiving

an enrollee’s reconsideration request. As noted in current guidance, the IRE may take an

additional 14 days if the enrollee requests an extension or if the IRE finds good cause to extend

the timeframe – e.g., if the IRE finds a need for additional information and considers the delay to

be in the interest of the enrollee (see section 80.7.1.5 for further details).

In all LEP reconsideration cases, the IRE will continue to strive to notify enrollees of the

decision as quickly as possible. However, because of the large volume of requests being filed by

enrollees and the additional time required to obtain information related to prior prescription drug

coverage (for example, evidence of coverage from an employer sponsored plan), it may take

longer than the 30-day timeframe set out in current guidance for the case to be resolved. Unlike

Part D prescription drug benefit appeals, there is no prescribed statutory or regulatory timeframe

for issuing decisions related to an LEP. Thus, until further notice, we are extending the general

LEP reconsideration processing timeframe to 90 days, in order to establish reasonable

expectations for when these cases are likely to be processed.

Reconsideration decisions may uphold, increase, decrease or eliminate the current number of

uncovered months. When CMS’ independent review entity notifies the plan of a decision that

results in any adjustment to or removal of the LEP, the plan must take the following steps:

• If the LEP is to be removed completely, the plan must submit a Plan Change transaction

(code 72) with the creditable coverage flag “Y” and the number of uncovered months =

“0.” The effective date on the transaction is equal to the effective date of enrollment in

the plan that submitted the number of uncovered months that needs to be removed.

•

If the LEP is adjusted to a number other than “0” due to a change in the number of

uncovered months, the plan must submit a Plan Change transaction (code 72) with the

creditable coverage flag “N” and the new adjusted number of uncovered months. The

effective date on the transaction is equal to the effective date of enrollment in the plan

that submitted the number of uncovered months that needs to be changed.

Any period of time determined to be a period of uncovered months for the purposes of the Part D

LEP always occurs outside a Part D plan enrollment period. Thus, the effective date of the

“number of uncovered months” data is always equal to a Part D plan enrollment effective date,

with two exceptions. Those exceptions are when an individual becomes LIS eligible (see section

“Removal of the LEP Due to LIS Eligibility”); and when an individual has a second Part D IEP

(see section “Reporting Adjustments to the LEP Based on Subsequent Part D IEPs”).

Plans must notify the beneficiary of any adjustment to the beneficiary’s LEP as the result of a

reconsideration by CMS’ independent review entity. Plans may use the Exhibit 7: Model

Notice—Confirm Adjustment of Premium Based on Reconsideration of Late Enrollment Penalty

or create their own form using the requisite elements shown in the model, subject to CMS’

marketing review procedures. The plan must then issue a refund to the member or credit the

beneficiary’s future premium bills to reflect the adjustment. Beneficiaries in premium withhold

status will see a refund in a future Social Security check, once the change transaction has been

submitted by the plan, processed by CMS, and sent to the Social Security Administration.

Please note that, in limited circumstances, a plan may have to remove or adjust an LEP imposed

on a member who has since disenrolled from the plan. The plan will still need to take the actions

describe above, and ensure that the code 72 (Plan Change) transaction has the same effective

date as the initial transaction that imposed the penalty.

Creditable Coverage Period Determinations for Low-Income Subsidy (LIS) Eligibles

As described in our September 27, 2007 memorandum, “Elimination of 2008 Late Enrollment

Penalty for Low-Income Subsidy Eligible Beneficiaries,” Medicare beneficiaries who qualify for

LIS may enroll in a Medicare prescription drug plan through December 31, 2008, with no

penalty. As long as these individuals remain continuously enrolled in Medicare Part D, they will

not incur an LEP, and any uncovered months in 2006, 2007, and 2008 will not be a factor in

determining any LEP, should they incur a break in coverage in the future. Thus, plans should not

report uncovered months for any new enrollee who is LIS eligible at the time s/he makes the

enrollment request or at the time that the enrollment becomes effective. Consider the following

example:

Mrs. Jones was LIS eligible through December 31, 2007 and submitted an enrollment

request during the Annual Election Period, which began November 15, 2007. She is not

subject to the LEP, even though she lost LIS effective January 1, 2008, when the

enrollment was effective.

Beneficiaries who are dually eligible, i.e., eligible for Medicare and Puerto Rico’s Medicaid

plan, known as Reforma, are exempt from the LEP in the same manner as those who are LIS

eligible in the States.

Note: The guidance provided in both the above-referenced memo and this memo supersedes

existing guidance at Section 10.2.3 of Chapter 4.

Cessation of the LEP Due to LIS Eligibility

If a beneficiary who is currently paying an LEP becomes LIS eligible, the penalty is removed

effective with the start of LIS eligibility. (Please note that the beneficiary is responsible for any

unpaid LEP amount owed prior to the LIS eligibility effective date). Plans are responsible for

reviewing the appropriate CMS reports that include updated information about members’ LIS

status and must submit a change transaction to CMS that resets the LEP amount to zero. To

accomplish this, plans will submit a Plan Change transaction (code 72) with the creditable

coverage flag set to “R” and the number of uncovered months equal to zero (“0”) with the

effective date equal to the effective date of the individual’s LIS eligibility. Plans must notify the

LIS eligible member of the removal of the LEP and shall use either Exhibit 5: Model Letter

Informing Beneficiary of the Removal of the LEP Due to LIS Eligibility) or create their own form

using the requisite elements shown in the model, subject to CMS’ marketing review procedures.

Plans must send this notice within 14 days of receiving information about the member’s LIS

status from CMS, and, for members in direct bill status, either issue a refund of any LEP paid

since the member became LIS eligible or apply the amount to be refunded to a future premium

bill. Those in premium withhold status will receive a refund in their Social Security check.

Consider the following example:

Mrs. Robinson enrolled in Part D for the first time effective January 1, 2007. Since her

IEP ended on May 15, 2006, and because she had no other creditable coverage prior to

enrolling in Part D, she had 7 uncovered months, and has therefore been charged an LEP.

She became LIS eligible effective July 1, 2007, and her plan was notified of this change

in the CMS plan reports released at the end of July. The plan submits an Plan Change

transaction code (code 72) with the creditable coverage flag value set to “R” and the

number of uncovered months value set to “0” effective as of July 1, 2007 resetting her

LEP to zero, and notifies her accordingly. Her uncovered months in 2006 will not be

counted in the future if she later incurs a break in coverage. (Note: To “reset” means to

end an existing period of time subject to an LEP and begin a new period.)

In the event that the beneficiary loses LIS eligibility after enrolling in a Part D plan, there is no

imposition of an LEP, even if there are prior uncovered months. In the above example, if Mrs.

Robinson had subsequently lost her LIS eligibility at some point in 2008, she would not incur an

LEP as long as she incurs no future break in creditable coverage. If she ever does incur a break

in coverage, none of the months prior to her January 1, 2007 enrollment would count as

uncovered months.

Enrollees in the Program of All-Inclusive Care For the Elderly (PACE)

As stated in the introduction to Chapter 4 of the Prescription Drug Manual, PACE organizations

offering prescription drug plans also are responsible for determining at the time of enrollment

whether a beneficiary was previously enrolled in Part D or had other creditable coverage prior to

enrolling in their plan, and are required to report any lapses in coverage of 63 days or more to

CMS. However, PACE enrollees who are dual-eligible members are not subject to the LEP, as

long as they remain enrolled in Part D. (Please see our memorandum of September 27, 2007,

described above.) Therefore, PACE organizations do not need to collect information concerning

uncovered months from these individuals or send these individuals an attestation forms. Rather,

the organization is required to complete the creditable coverage period determination only for its

Medicare-only members. In the event that, while the plan is conducting such a determination,

the member also becomes eligible for Medicaid, then the organization would suspend its

determination. If the organization has already submitted uncovered months to CMS, the

organization would then submit a change transaction with the creditable coverage flag set to “R”

to reset the amount to zero, as described above for new LIS eligibles.

Reporting Adjustments to the LEP Based on Subsequent Part D IEPs

As stated in current guidance (Section 10.1.1 of Chapter 4), an individual who becomes eligible

for Medicare prior to turning age 65 (e.g., due to disability) will have a new IEP upon becoming

entitled to Medicare due to age (i.e., turning 65). Plans should already have in place a process

for identifying members who are attaining age 65, or who have recently attained age 65. They

will also need to take the following actions described below, depending on the specific situation.

• For individuals who are currently enrolled in a Medicare prescription drug plan at the start of

their second Part D IEP, the LEP ends on the day before the second IEP begins, which is

three months prior to the month the individual attains age 65. So, for example, if a

beneficiary turns 65 on July 25, 2008, his/her LEP would end effective March 31, 2008.

Any uncovered periods prior to that date are no longer counted for purposes of the LEP. The

plan must reset the number of uncovered months to zero (“0”) by submitting a plan change

transaction (code 72) with the creditable coverage flag set to “R” and the number of

uncovered months equal to “0”. The effective date of the transaction is equal to the first of

the month of the new Part D IEP. So, in the example described above, the effective date of

the change transaction would be April 1, 2008.

• For individuals who are not enrolled in a Medicare drug plan at the time of the second IEP,

and who are still within that second IEP, the plan must reset the number of uncovered months

to zero (“0”) as part of the initial enrollment transaction, rather than a change transaction. As

described above, the creditable coverage flag is set to “R” and the number of uncovered

months equal to “0”.

• For individuals who did not enroll in a Medicare prescription drug plan by the end of their

subsequent IEP, the plan will have to take actions to “reset” or remove the first LEP and

provide any uncovered months incurred after the subsequent IEP so that a second LEP can be

imposed. The plan must reset the first LEP by submitting a change transaction as described

above, with the effective date equal to the end date of the previous Part D plan enrollment.

Then, the plan shall submit a change transaction with the creditable coverage flag set to “N”

and the number of uncovered months. The effective date of the transaction is equal to the

current enrollment effective date.

Plans must notify the member of the removal of the LEP and may Exhibit 4: Model Notice--

Removal of Late Enrollment Penalty Due to Subsequent IEP to inform beneficiaries of the

removal of the LEP or create their own form using the requisite elements shown in the model,

subject to CMS’ marketing review procedures.

Billing the Late Enrollment Penalty

Once plans receive information from CMS about the amount of the beneficiary’s LEP, they are

expected to bill and recoup any LEP amount owed since the beneficiary’s enrollment effective

date but no earlier than January 1, 2007. For those in direct bill status, the plan may retroactively

bill the member for a lump sum amount. Plans may use Exhibit 2: Model Notice—Beneficiary

Notice of Late Enrollment Penalty to reflect this possible billing option, or create their own form

using the requisite elements shown in the model, subject to CMS’ marketing review procedures.

For those beneficiaries whose premium is withheld from their Social Security check, plans do

not need to bill these beneficiaries for either prospective or retroactive amounts. (See Section

40.3 of Chapter 4.)

Annual Changes in LEP Amounts

At the start of each calendar year, the LEP amount will change based on the national base

beneficiary premium. While there is no Transaction Reply Code (TRC) associated with this

change, plans will see the adjustment in the December LIS/LEP Report (for members in direct

bill status) for January 1

plan payment and the January Monthly Premium Withhold Report (for

those in premium withhold status) for February 1

plan payment. These reports will be released

in accordance with the reports schedule contained in the Plan Communications User Guide.

Plans will need to adjust their bills accordingly to reflect the new amount. Plans may include

notification of this new amount in their premium bill, or via a separate notice. CMS has

provided a new model for this purpose, Exhibit 9: Model Notice—Yearly Change to LEP

Amount. Please note that the reconsideration process is not available for adjustments to the LEP

based on a change to the new national base beneficiary premium. Therefore, plans shall not

include an LEP Reconsideration Notice or Reconsideration Request Form with notice of the

adjusted LEP.

LEP for New Members

With respect to those members who currently owe an LEP and change plans, the new plan will

be able to see in the BEQ response file or the Common UI the total number of uncovered months

associated with the beneficiary’s previous enrollment. The plan will know that the beneficiary

owes a LEP and must remind the member in the enrollment confirmation notice that the

premium owed includes this LEP amount. CMS has provided the following model language,

which can be inserted into the model enrollment confirmation notices included in the appropriate

CMS Guidance for your plan type:

Your premium continues to reflect a late enrollment penalty amount that was based on

information sent by your previous plan. Your plan should have told you about this

penalty. If you have questions about the late enrollment penalty, call <Plan Name> at

<toll-free number> <days and hours of operation>. TTY users should call <toll-free TTY

number>. You can also get information by visiting www.medicare.gov on the web or by

calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Thank you.

Provided the new plan is not reporting additional uncovered months, this notification does not

constitute an imposition of a new LEP or an increase in the previous LEP and therefore does not

trigger the right to request a review of the LEP. Thus, plans shall not include an LEP

Reconsideration Notice or Reconsideration Request Form with the enrollment confirmation

notice (as modified above) for new members who previously owed and continue to owe an LEP.

Plans are not required to provide additional information about an existing LEP but, if they

choose to do so, they may use Exhibit 3: Model Notice—Beneficiary Notice of Existing Late

Enrollment Penalty.

Reports from CMS

We are revising information provided at section 40.2 of Chapter 4 about CMS reports that

contain beneficiary-specific information about the LEP, as shown below:

PCUG

Appendix*

Name of Data File/Report Availability

E91

Weekly Transaction Reply Report (only includes beneficiaries

for whom a transaction was submitted during the prior week)

Weekly

E91

Monthly Transaction Reply Report (only includes beneficiaries

for whom a transaction was submitted during the prior month)

Monthly

E105

Low-Income Subsidy/Late Enrollment Penalty (LIS/LEP) Data

File (direct bill beneficiaries only)

Monthly

E59

Monthly Premium Withholding Report Data File (beneficiaries

in premium withhold status only)

Monthly

*Please refer to the current CMS Plan Communications User Guide (Version 3.0).

Please note: As stated in section 30.1 of Chapter 4, plans are required to notify members of the

imposition of, or adjustment to, an LEP in writing within 10 calendar days of receiving notice of

the LEP from CMS. Notice from CMS constitutes the first report from CMS that contains this

information. The monthly and weekly TRRs will only contain information for a member if a

transaction was submitted for that member the previous week or month. Thus, if information is

not available in either of those reports, but instead through the LIS/LEP report (for members in

direct bill status) or the Monthly Premium Withhold Report (for those in premium withhold

status), the plan would have 10 days from the receipt of either of these reports, as appropriate, to

send the notice of the LEP.

New and Revised Appendices and Exhibits

The following exhibits have been added or revised, as described further below, and are attached

to this memorandum. Marketing codes are inserted below so that plans can use these notices as

“file and use.”

NOTE: Marketing codes for LEP exhibits listed in Chapter 4 can be found in HPMS. (HPMS

code #8002 is no longer in use).

Chapter 4

Please note that the Exhibit numbers have changed from what exists in Chapter 4.

Appendix 1: Special Opportunity to Enroll in 2006, 2007, and 2008

This Appendix has been updated to reflect the extension of the demonstration for low-income

subsidy eligible beneficiaries through December 31, 2008.

NEW Appendix 2: Summary of MARx Transactions to Add, Change, or Remove the Number

of Uncovered Months for an Enrolled Beneficiary

Exhibit 1A: Model Notice for Beneficiary Attestation of Creditable Prescription Drug Coverage

[HPMS code: 8001]

The following changes were made to the Attestation Form:

• Updated dates to include new contract year, 2008.

• Clarified that the term “PACE organization” refers to the Program of All-Inclusive Care

for the Elderly.

• Optional language has been inserted so that plans can customize references to a state’s

Medicaid program or SPAP, where applicable.

NEW Exhibit 1B: Model Notice for Beneficiary Attestation of Creditable Prescription Drug

Coverage—FINAL NOTICE [HPMS code: 8001]

Exhibit 2: Model Notice—Beneficiary Notice of Late Enrollment Penalty [HPMS code 8003]

The following changes were made to this notice:

• Added language after the first sentence applicable to beneficiaries in premium withhold.

• Added language in second paragraph for beneficiaries who owe a “lump sum” amount

retroactive to the date of their enrollment in the plan.

• Modified language to reflect change to LEP Reconsideration Request Form.

• Modified optional language for employer/unions to also include State Pharmaceutical

Assistance Programs (SPAPs), as these organizations can attest to their members’

coverage, as described above.

• Provided optional language so that the notice can be used for beneficiaries who are

enrolling in the Part D prescription drug program for the first time, as well as those who

have incurred an additional LEP since prior plan enrollment.

NEW Exhibit 3: Model Notice—Beneficiary Notice of Existing Late Enrollment Penalty

[HPMS code: 8008]

This new model notice is sent to inform beneficiaries of an existing LEP. This notice does not

include information concerning a beneficiary’s right to appeal. (Please see section above

entitled, “LEP for New Members”.)

NEW Exhibit 4: Model Notice—Removal of Late Enrollment Penalty Due to Subsequent IEP

[HPMS code: 8009]

This new model notice is sent to beneficiaries whose LEP is being removed because they

obtained a second IEP based on turning age 65. (Please see section above entitled, “Reporting

Adjustments to the LEP Based on Subsequent IEPs”.)

NEW Exhibit 5: Model Letter—Removal of the LEP Due to LIS Eligibility [HPMS code 8010]

This new model notice is sent to beneficiaries whose LEP is being removed due to their attaining

LIS eligibility. (Please see section above entitled, “Removal of the LEP Due to LIS Eligibility”.)

NEW Exhibit 6: Model Notice—LEP Adjustment Due To Plan Error [HPMS code: 8011]

This new model notice is sent to beneficiaries whose LEP has been adjusted because the plan has

corrected an error in the number of uncovered months reported to CMS, transmission, etc.

(Please see section above entitled, “Corrections to Reports of Creditable Coverage Period

Determinations”.)

Exhibit 7: Model Notice—Confirm Adjustment of Premium After Reconsideration of Late

Enrollment Penalty [HPMS code: 8004]

This revised model notice is sent to inform a beneficiary of the adjusted amount of his/her LEP

as a result of the LEP reconsideration decision. (Please see section above entitled, “LEP

Reconsideration Process”.)

Exhibit 8: Model Notice—Return of Creditable Coverage Information Received Without an

Accompanying Enrollment Request [HPMS code: 8005]

This revised model notice was revised to incorporate minor editorial changes.

OLD Exhibit 9: Model Notice—Creditable Coverage Information Received After Deadline

Date

Since plans are now required to submit corrections when they receive a late attestation form, this

notice is no longer needed and has been removed. (Please see section above entitled,

“Corrections to Reports of Creditable Coverage Period Determinations”.)

NEW Exhibit 9: Model Notice—Yearly Change to LEP Amount [HPMS code: 8012]

This new model notice is sent to beneficiaries to inform them of the change in their LEP amount

for the upcoming year due to the adjustment of the National Base Beneficiary Premium. (Please

see the section above entitled, “LEP and the National Base Beneficiary Premium”.)

NOTE: In conjunction with our revised policy that requires plans to submit corrections when

they receive a late attestation, we have deleted the Model Notice—Creditable Coverage

Information Received After Deadline Date. (Please see the section above entitled, “Corrections

to Reports of Creditable Coverage Period Determinations”.)

Chapter 18

Appendix 14 – Model Part D Late Enrollment Penalty Reconsideration Notice [HPMS code:

8006]

This notice has been modified to clarify the reasons enrollees may file for LEP reconsideration,

as described further above in the section, “LEP Reconsideration Process.” Also, the formatting

of this notice has been made consistent with the Model Attestation Form (Chapter 4, Exhibit 1A)

and Model LEP Reconsideration Request Form (see below).

Appendix 15 – Model Part D Late Enrollment Penalty Reconsideration Request Form [HPMS

code: 8007]

The Model LEP Reconsideration Request Form has been revised to solicit additional information

about prior drug coverage and to clarify the specific reasons enrollees may request a

reconsideration of their Part D LEP. Additionally, the reasons a beneficiary may file for

reconsideration (i.e., the checkboxes) have been reordered for consistency with the Model

Attestation Form (Chapter 4, Exhibit 1) and so that the most common reasons enrollees file for

reconsideration appear earlier on the form. The formatting of this form also has been made

consistent with the Model Attestation Form (Chapter 4, Exhibit 1) and Model LEP

Reconsideration Notice.

Appendix 1: Special Opportunity to Enroll

in 2006, 2007, and 2008 without LEP

Medicare beneficiaries who qualify for the low-income subsidy for Medicare prescription drug

coverage may enroll in a Medicare prescription drug plan with no penalty through December 31,

2008. As long as these individuals stay continuously enrolled in a Medicare drug plan, they will

not be assessed an LEP in 2006, 2007, 2008, or afterwards. If these individuals disenroll after

2008, and then have a continuous period of 63 days or more since the end of their IEP without

creditable prescription drug coverage, they will incur an LEP upon re-enrollment into a Medicare

drug plan; however, their uncovered months in 2006, 2007, and 2008 will not be a factor in the

calculation of their LEP.

Certain Medicare beneficiaries who were affected by Hurricane Katrina were allowed to enroll in

a Medicare prescription drug plan with no penalty through December 31, 2006. As long as these

individuals stay continuously enrolled in a Medicare drug plan, they will not be assessed an LEP

in 2006 or afterwards. If these individuals disenroll after 2006 and then have a continuous period

of 63 days or more without creditable prescription drug coverage, they will incur an LEP upon

re-enrollment into a Medicare drug plan; however, their uncovered months in 2006 will not be a

factor in the calculation of their LEP.

Appendix 2: *Summary of MARx Transactions to Add, Change, or

Remove the Number of Uncovered Months for an Enrolled Beneficiary

Action Creditable

Coverage Flag

Value

Number of

Uncovered Months

Field Value

Effective Date on

Transaction Code

Submit a new

number of

uncovered months

N Number greater than

Equal to existing

enrollment effective

date

Note: This

information may

also be provided on

an enrollment

transaction

(60/61/62/71),

N Revised number

greater than 0

Equal to existing

enrollment effective

date

Change an existing

number of

uncovered months

due to plan error or

reconsideration

decision

Y 0 Equal to existing

enrollment effective

date

Reset the existing

number of

uncovered months

to 0 due to another

IEP for Part D

R 0 Equal to the

effective date of the

month of the new

IEP for Part D

Reset the existing

number of

uncovered months

to 0 due to an

individual becoming

LIS eligible.

R 0 Equal to the

effective date of the

start of LIS

eligibility.

Correct Erroneous

Reset action already

submitted

U 0 Effective date is

equal to the date of

the reset “R”

transaction. (Page 5

of Fall Memo).

*For more information about MARx transactions, please consult the October 9, 2007 HPMS

Memo re: Announcement of Fall Software Changes and the current CMS Plan Communications

User Guide (Version 3.0).

Exhibit 1A: Model Notice for Beneficiary Attestation of Creditable

Prescription Drug Coverage

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE AND MEDICAID SERVICES

Important:

Medicare Needs More Information from You

You recently enrolled in a plan and you may owe a

penalty.

Do any of these statements apply to you for 2006, 2007, or 2008?

•

I had drug coverage from an employer or union plan

•

I had drug coverage from Medicaid, a State Pharmaceutical

Assistance Program (SPAP), or another plan sponsored by my state

•

I had VA benefits

•

I had TRICARE or other military drug coverage

•

I had a Medigap policy with drug coverage

•

I had drugs through the Indian Health Service or a tribal organization

•

I had drug coverage through PACE (Program of All-Inclusive Care

for the Elderly)

•

I had drug coverage from a different source not listed here

•

I have/had extra help from Medicare to pay for my drug coverage

•

I lived in an area affected by Hurricane Katrina

If any of these circumstances apply, you may not owe a late enrollment

penalty as part of your Medicare prescription drug plan premium.

What You Need to Do Now

Medicare needs more information from you to see if you will owe a penalty.

If you fail to respond, you will owe a penalty

. So, please fill out the

“Beneficiary Attestation of Creditable Prescription Drug Coverage” form

enclosed with this letter [insert if plan offers telephonic attestation: or call

your plan to provide them with additional information they need]. To avoid a

late enrollment penalty, you must [insert if plan offers telephonic attestation:

call or] send back the enclosed form by the date stated on the form. If you

have questions, or if you aren’t sure about the answers to the questions above,

call your health plan at the telephone number listed on the form.

<Date>

<Name of Member>:

You recently enrolled in our plan and Medicare’s records show that

you may owe a late enrollment penalty.

[Insert the following if beneficiary was previously enrolled in a plan:]

You were first eligible to join a Medicare drug plan through <insert last

month of IEP in mm/yyyy format>. From the time your enrollment ended with

[insert one of the following: us/your last plan] until your current enrollment

in our plan, you did not have Medicare prescription drug coverage or other

coverage as good as Medicare’s (creditable coverage) during the following

period(s):

<INSERT PERIOD(S) HERE>.

[OR insert the following:]

You were first eligible to join a Medicare drug plan through <insert last

month of IEP in mm/yyyy format>. You did not have Medicare prescription

drug coverage or other coverage as good as Medicare’s (creditable coverage)

during the following period(s):

<INSERT PERIOD(S) HERE>.

Please complete this form and return it immediately to <insert Plan Name> at

<insert Plan Address> [insert the following if you offer telephone attestation:

or call us at <insert Plan Toll-free Number> to provide us with the

information] by <insert the date that is 30 days from the date of this letter in

mm/dd/yyyy format>.

If you don’t contact us by <insert the date that is 30 days from the date of this

letter in mm/dd/yyyy format>, we will assume the above information is

correct and you will owe a late enrollment penalty.

Please check all boxes that apply to you.

⁭ I had creditable prescription drug coverage from the source(s) listed below:

(Give the date(s) of your coverage. Use another sheet if necessary).

⁭ I had drug coverage from an Employer/Union, including the Federal

Employees Health Benefits Program (FEHBP)

Name: ______________________________________________

from (month/year): _____________

to (month/year):________________

⁭ I had drug coverage from Medicaid, State Pharmaceutical

Assistance Program (SPAP), or another plan sponsored by my state

from (month/year):______________

to month/year):_________________

Name of SPAP:________________________________________

If you are in an SPAP, what state do you live in:

____________________

⁭ I had VA benefits (veterans, survivor, or dependent benefits)

from (month/year): _____________

to (month/year):____________

⁭ I had TRICARE or other military coverage

from (month/year): _____________

to (month/year):_______________

⁭ I had a Medigap (Medicare Supplemental) policy with drug coverage

from (month/year): _____________

to (month/year):_________________

⁭ I had drug coverage through the Indian Health Service, a Tribe or

Tribal organization, or an Urban Indian organization (I/T/U)

from (month/year): _____________

to month/year):_________________

⁭ I had drug coverage through PACE (Program of All-Inclusive

Care for the Elderly) from (month/year): ___________

to (month/year):__________________

⁭ I had drug coverage from a different source not listed above.

Name of other source: _________________________________________

from (month/year):_________

to: (month/year):_____________________

⁭ I have/had extra help from Medicare to pay for my prescription drug

coverage. Date(s) of extra help: from (month/year):_________

to:

(month/year):_____________

⁭ I lived in an area affected by Hurricane Katrina at the time of the hurricane

(August 2005) and I joined a Medicare drug plan before December 31, 2006.

Name of Parish: __________________________________________

⁭ I never had creditable drug coverage.

Please complete this section: “I attest (promise) that the information on this

form is true and correct to the best of my knowledge. I understand that if I

didn’t have creditable prescription drug coverage and/or don’t give proof of

creditable drug coverage if asked, my premium may be higher.

I understand that my signature (or the signature of the person authorized to act

on behalf of the individual under the laws of the State where the individual

resides) on this document means that I have read and understand the contents

of this attestation. If signed by an authorized individual (as described above),

this signature certifies that: 1) this person is authorized under State law to

complete this enrollment and 2) documentation of this authority is available

upon request by <Plan Name> or by Medicare.”

Signature:_____________________________________

Date: (month/day/year): _________________________________

If you are the authorized representative, you must provide the following

information:

Name:______________________________________

Address:___________________________________

City: ____________________________ State: __________ Zip:________

Phone Number: (______) _______- _________

Relationship to Enrollee: __________________________________

Contact Information

If you have questions about the information in this form, the late

enrollment penalty, [insert the following if you provide the telephone

attestation option: or would like to complete this form over the

telephone,] call <Plan Name> at <toll-free number> <days and hours

of operation>. TTY users should call <toll-free TTY number>. You

can also get information by visiting www.medicare.gov on the web or

by calling 1-800-MEDICARE (1-800-633-4227). TTY users should

call 1-877-486-2048.

Exhibit 1B: Model Notice for Beneficiary Attestation

of Creditable Prescription Drug Coverage

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE AND MEDICAID SERVICES

FINAL NOTICE

YOUR IMMEDIATE RESPONSE IS REQUESTED

You recently enrolled in a plan and you may owe a

penalty.

Do any of these statements apply to you for 2006, 2007, or 2008?

•

I had drug coverage from an employer or union plan

•

I had drug coverage from Medicaid, a State Pharmaceutical

Assistance Program (SPAP), or another plan sponsored by my state

•

I had VA benefits

•

I had TRICARE or other military drug coverage

•

I had a Medigap policy with drug coverage

•

I had drugs through the Indian Health Service or a tribal organization

•

I had drug coverage through PACE (Program of All-Inclusive Care

for the Elderly)

•

I had drug coverage from a different source not listed here

•

I have/had extra help from Medicare to pay for my drug coverage

•

I lived in an area affected by Hurricane Katrina

If any of these circumstances apply, you may not owe a late enrollment

penalty as part of your Medicare prescription drug plan premium.

What You Need to Do Now

Medicare needs more information from you to see if you will owe a penalty.

If you fail to respond, you will owe a penalty

. So, please fill out the

“Beneficiary Attestation of Creditable Prescription Drug Coverage” form

enclosed with this letter [insert if plan offers telephonic attestation: or call

your plan to provide them with additional information they need]. To avoid a

late enrollment penalty, you must [insert if plan offers telephonic attestation:

call or] send back the enclosed form by the date stated on the form. If you

have questions, or if you aren’t sure about the answers to the questions above,

call your health plan at the telephone number listed on the form.

<Date>

<Name of Member>:

You recently enrolled in our plan and Medicare’s records show that

you may owe a late enrollment penalty.

[Insert the following if beneficiary was previously enrolled in a plan:]

You were first eligible to join a Medicare drug plan through <insert last

month of IEP in mm/yyyy format>. From the time your enrollment ended with

[insert one of the following: us/your last plan] until your current enrollment

in our plan, you did not have Medicare prescription drug coverage or other

coverage as good as Medicare’s (creditable coverage) during the following

period(s):

<INSERT PERIOD(S) HERE>.

[OR insert the following:]

You were first eligible to join a Medicare drug plan through <insert last

month of IEP in mm/yyyy format>. You did not have Medicare prescription

drug coverage or other coverage as good as Medicare’s (creditable coverage)

during the following period(s):

<INSERT PERIOD(S) HERE>.

Please complete this form and return it immediately to <insert Plan Name> at

<insert Plan Address> [insert the following if you offer telephone attestation:

or call us at <insert Plan Toll-free Number> to provide us with the

information] by <insert the date that is 30 days from the date of this letter in

mm/dd/yyyy format>.

If you don’t contact us by <insert the date that is 30 days from the date of this

letter in mm/dd/yyyy format>, we will assume the above information is

correct and you will owe a late enrollment penalty.

Please check all boxes that apply to you.

⁭ I had creditable prescription drug coverage from the source(s) listed below:

(Give the date(s) of your coverage. Use another sheet if necessary).

⁭ I had drug coverage from an Employer/Union, including the Federal

Employees Health Benefits Program (FEHBP)

Name: ______________________________________________

from (month/year): _____________

to (month/year):_________________

⁭ I had drug coverage from Medicaid, State Pharmaceutical

Assistance Program (SPAP), or another plan sponsored by my state

from (month/year):______________

to month/year):_________________

Name of SPAP:________________________________________

If you are in a SPAP, what state do you live in:

____________________

⁭ I had VA benefits (veterans, survivor, or dependent benefits)

from (month/year): _____________

to (month/year):_________________

⁭ I had TRICARE or other military coverage

from (month/year): _____________

to (month/year):_______________

⁭ I had a Medigap (Medicare Supplemental) policy with drug coverage

from (month/year): _____________

to (month/year):_________________

⁭ I had drug coverage through the Indian Health Service, a Tribe or

Tribal organization, or an Urban Indian organization (I/T/U)

from (month/year): _____________

to month/year):_________________

⁭ I had drug coverage through PACE (Program of All-Inclusive

Care for the Elderly) from (month/year): ___________

to (month/year):___________

⁭ I had drug coverage from a different source not listed above.

Name of other source: _________________________________________

from (month/year):_________

to: (month/year):_____________________

⁭ I have/had extra help from Medicare to pay for my prescription drug

coverage. Date(s) of extra help: from (month/year):_________

to:

(month/year):_____________

⁭ I lived in an area affected by Hurricane Katrina at the time of the hurricane

(August 2005) and I joined a Medicare drug plan before December 31, 2006.

Name of Parish: __________________________________________