Appealing Part D late charge

[LostDollar]

He doesn't need to submit proof. Let's say client turned 65 on 1/1/23 and kept working and didn't need to pick up Part D. Then he retires and joins Part D 1/1/24. CMS and the plan would see that as a 12-month gap that needs to be accounted for. The plan sends a letter "hey did you have creditable coverage during these 12 months? If yes, pick the source from this form and fill in the dates." The form can be returned or the info can even be given over the phone.

You're missing a piece of the puzzle here.

Learned this recently, but all they have to do is say, yes I’ve had coverage. You don’t have to prove it. I always thought you had to show proof.

I finally found the form I received from SilverScript. On the form I received, In addition to checking the box, there was also a specific request for the name of the coverage.

See the first section after heading information on page 52 of this link:

https://www.cms.gov/Medicare/Eligibility-and-Enrollment/MedicarePresDrugEligEnrol/Downloads/FINAL_CY2010_MedicarePrescriptionDrugBenefitManualChapter4_Dec2009.pdf

That is what the form I received from SilverScript looked like.

 

[LostDollar]

On the other hand, here's a Humana form I found online:

https://docushare-web.apps.external.pioneer.humana.com/Marketing/docushare-app?file=3250130

It LEAVES OUT the Name request line in the first box after the heading information. However, in fine print at the end of the form it says:

I understand that if I didn't have creditable coverage and/or don't give proof of creditable prescription drug coverage if asked, my premium may be higher.

so different carriers apparently approach the level of required detail differently.

 

[somarco]

But does that apply, now that they have received an appeal form?

I don't know but Murphy says they are probably screwed because they did not complete and return the creditable coverage form.

I don't recall ever having a situation like yours where documentation was not available . . . by the same token, none have ever been asked for documentation.

Call it luck . . .

 

[TwoCents]

But does that apply, now that they have received an appeal form?

No, the CMS contractor will likely want proof. Client is likely SOL.

 

[TwoCents]

Caveat, I am not an agent but I am a Medicare Beneficiary who took part A at 65 and delayed Part B for several years using forms L564.

If this is just a final warning before the penalty is actually physically assessed and steps are taken to add it to the monthly premium, I think one might still get away with just providing the prior drug coverage form, or its information, to the PDP carrier, which your client could do if they could come up with the carrier name(s) for that four year period.

It feels to me like you are ignoring my question and it still stands. Did client take part A at 65?

The plan wouldn't send the appeal form if there was nothing to appeal. Sounds like the LEP has been assessed and now the only way to get rid of it is a successful appeal to the CMS contractor.

If the client didn't take Part A at 65 (or prior to Part B), they probably wouldn't be in this spot.

I think I know what you're thinking, but it wouldn't matter. Credible for Part B enrollment without an LEP is different from creditable for Part D. The Part B paperwork doesn't provide creditable drug coverage info even if SSA had it on record still.

 

[LostDollar]

A piece of information I have just come on to.

Mandatory Insurer Reporting for Group Health Plans (GHP) | CMS

Mandatory Insurer Reporting for Group Health Plans (GHP), Who Must Report, Reporting, Reporting Requirements – GHP User Guide and Alerts, Registration and the Section 111 COBSW, Reporting Assistance, Unsolicited Response File, Compliance

www.cms.gov

Mandatory Insurer Reporting for Group Health Plans (GHP)

"Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements..."

Who Must Report​

A GHP organization that must report under Section 111 is an entity serving as an insurer or third party administrator (TPA) for a group health plan.

Reporting​

".................... On a quarterly basis, an RRE must submit a file of information about employees and dependents who are Medicare beneficiaries with employer GHP coverage that may be primary to Medicare. In exchange, CMS provides the RRE with Medicare entitlement and enrollment information for those individuals in the GHP that can be identified as Medicare beneficiaries."

A definition from elsewhere in the link"

"...who must report, referred to as a responsible reporting entity (RRE),,,"

 

[somarco]

A piece of information I have just come on to.

Fine and good . . . but the person @yorkriver1 is working with does not have the information from his first employer and we don't know if he ever had it. That employer is no longer in business.

Blood out of a turnip . . .

 

[LostDollar]

One other link I discovered:

Coordination of Benefits and Recovery Overview | Guidance Portal

Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will...

www.hhs.gov

excerpts from link:

Guidance for Coordination of Benefits (COB) process that allows for plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities.

COB Data Sources​

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) – This law added mandatory reporting requirements for Group Health Plan (GHP) arrangements and for liability insurance, including self-insurance, no-fault insurance, and workers' compensation. Insurers are legally required to provide information.

COB Entities​

Benefits Coordination & Recovery Center (BCRC)

The BCRC is responsible for the following activities:

• Establishing MSP occurrence records on CWF to keep Medicare from paying when another party should pay first. The CWF is a single data source for fiscal intermediaries and carriers to verify beneficiary eligibility and conduct prepayment review and approval of claims from a national perspective. It is the only place in the fee for service claims processing system where full individual beneficiary information is housed.
• Transmitting other health insurance data to the Medicare Beneficiary Database (MBD) for the proper coordination of Rx benefits

 

[LostDollar]

I don't know but Murphy says they are probably screwed because they did not complete and return the creditable coverage form.

I don't recall ever having a situation like yours where documentation was not available . . . by the same token, none have ever been asked for documentation.

Call it luck . . .

There is a data gathering approach which might provide the missing information. You could easily do a factual cross check on it. My data says it would work. Yours might or might not say it would work. If your data shows it would, you could validate that with Phyliss and she would accept from you what she would not accept from me.

I have deleted all my requests for help to you because the way I presented them skirted forum privacy rules.

I am being pushier on presenting and idea this time, and trying to get feedback on it, because I have now been here for 6 years instead of just 2.

This is an approach no agent under 65 would ever have a possibility of even being aware of unless they were managing affairs for a relative who had had EGH coverage post T65, had had claims on it, had a MyMedicare Account, and the agent had access to that MyMedicare account. And even in that situation it is most unlikely the agent would have had reason to stumble on to this particular data set and think about PDP LEP's in relation to it.

It is an approach most serious medicare agents over 65 would also be unlikely to be able to see because they probably would not have had EGH type coverage post their Part A effective date.

And even further, the few agents that might have seen this would most likely have done so in a context far removed from Part D and it would not come to mind for a thread like this where it could be applicable.

I am out of time for tonight. I will post the precise information for Phyliss tomorrow. You can decide whether you want to continue being arrogant and putting me in my place because I am not an agent, or want to use your knowledge, skill and experience to provide some checking of an idea that might be of help to other agents in ops specific place.

Regards.
LD

 

[LostDollar]

I don't know but Murphy says they are probably screwed because they did not complete and return the creditable coverage form.

I don't recall ever having a situation like yours where documentation was not available . . . by the same token, none have ever been asked for documentation.

Call it luck . . .

There is a data gathering approach which might provide the missing information. You could easily do a factual cross check on it. My data says it would work. Yours might or might not say it would work. If your data shows it would, you could validate that with Yorkriver and she would accept from you what she would not accept from me.

I have deleted all my requests for help to you because the way I presented them skirted forum privacy rules.

I am being pushier on presenting and idea this time, and trying to get feedback on it, because I have now been here for 6 years instead of just 2.

This is an approach no agent under 65 would ever have a possibility of even being aware of unless they were managing affairs for a relative who had had EGH coverage post T65, had had claims on it, had a MyMedicare Account, and the agent had access to that MyMedicare account. And even in that situation it is most unlikely the agent would have had reason to stumble on to this particular data set and think about PDP LEP's in relation to it.

It is an approach most serious medicare agents over 65 would also be unlikely to be able to see because they probably would not have had EGH type coverage post their Part A effective date.

And even further, the few agents that might have seen this would most likely have done so in a context far removed from Part D and it would not come to mind for a thread like this where it could be applicable.