I posted a while back where I wrote a 74 year old lady who just retired SilverScript and she is still trying to prove prior coverage to CMS. Now I have an 81 year old man who is covered by his wife's employer until 12/1 and am having the same issue. The employer wrote a letter for me stating coverage since Part D started, but CMS wants more proof. Any suggestions?
What am I doing wrong?
- Thread starter billyb
- Start date
Part D letters of creditable coverage are often initiated by carriers. Employer plan administrators can provide creditable coverage information if they wish.
The Medicare Modernization Act (MMA) requires entities (whose policies include prescription drug coverage) to notify Medicare eligible policyholders whether their prescription drug coverage is creditable coverage, which means that the coverage is expected to pay on average as much as the standard Medicare prescription drug coverage.
Creditable Coverage - Centers for Medicare & Medicaid Services
Here is an instructional notice to employers about their responsibility.
https://www.bcbsm.com/pdf/medicare_part_d_creditable_covergve_for_groups.pdf
The Medicare Modernization Act (MMA) requires entities (whose policies include prescription drug coverage) to notify Medicare eligible policyholders whether their prescription drug coverage is creditable coverage, which means that the coverage is expected to pay on average as much as the standard Medicare prescription drug coverage.
Creditable Coverage - Centers for Medicare & Medicaid Services
Here is an instructional notice to employers about their responsibility.
https://www.bcbsm.com/pdf/medicare_part_d_creditable_covergve_for_groups.pdf
Like Somarco mentioned, it's the carriers collecting the Part D history info, but you're mentioning CMS. So I'm not sure if you're referring to picking up Part B after delaying that due to having employer (through a spouse) coverage. The carrier attestation couldn't be easier. The SSA/CMS form for Part B takes a bit more work. So until you know exactly what you need help with and who's requesting what from the client, you'll always be doing the wrong thing.
- 6,446
The experience I had with taking Part B and Part D with a retirement x years after T65 did not involve proving anything to CMS.
First, it involved providing Part B application information to Social Security, USING THEIR FORMS, including employer attestations of health insurance coverage, WRITTEN ON THE SOC SEC APPROVED FORMS.
It then involved providing the names of the specific carriers who provided the coverage to the Part D carrier, Silver Script, USING THEIR APPROVED FORMS. In the case of Silver Script, I was able to handle providing the information by making a phone call to a number including with the documentation for the form. Unless it shows all the specific carriers who provided health coverage, a letter from an employer just stating creditable coverage was present is unlikely to satisfy the recordkeeping requirements of the Part D carrier.
Basically you need to look at the dates on the form(s) L564 filed for the Part B application with Social Security, make a list of all the health insurance carriers who provided the applicant's group health coverage in that time frame (along with the to and from dates for each carrier) and get that information to Silver Script. In my case, that information is available in my MyMedicare account.
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- 6,446
I was thinking about this, and have two other comments.
If the issue is documenting coverage with SilverScript, it might help you if you could get a copy of the form they send out requesting that information from the applicants. That would show you exactly what they are looking for.
The other thing, I think in the threads about your other client someone gave you the name of an organization that helps with appeals on Part D plans. I can never remember the name of it, but if you keep feeling like you and SilverScript people are just continuing to talk past each other, perhaps that appeal organization could help in this situation as well.
(and again, as others said, to keep your thinking clear, remember that you are dealing with the Part D carrier, not CMS.)
If the issue is documenting coverage with SilverScript, it might help you if you could get a copy of the form they send out requesting that information from the applicants. That would show you exactly what they are looking for.
The other thing, I think in the threads about your other client someone gave you the name of an organization that helps with appeals on Part D plans. I can never remember the name of it, but if you keep feeling like you and SilverScript people are just continuing to talk past each other, perhaps that appeal organization could help in this situation as well.
(and again, as others said, to keep your thinking clear, remember that you are dealing with the Part D carrier, not CMS.)
Good catch. I missed the CMS reference.
I think you are on to something. It would appear she neglected to get CMS L564 that waives the LEP.
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-L564E.pdf
That would be MAXIMUS. They only review an LEP appeal once the LEP has been assessed. If there's no LEP in place, there's nothing for them to review.
- 6,446
Ok, thank you for the clarification there. I will try to remember.
I really wish I'd kept the letter I got from SilverScript, because with threads like this I'd like to look at that form they sent. I actually can't remember for sure whether all I had to give them was the employer info from the L564, or whether I had to go through the complete list of carriers.
It just seems like this particular situation is coming up extra difficult when it shouldn't and I wish I knew the answer to help with.
Because I know this will continue to bother you and you probably don't have anything better to do here is the CMS guidance for collecting creditable coverage https://www.cms.gov/Medicare/Eligib...CreditableCoverageandLEPGuidance_01_05_18.pdf. The sample letters which all plans base their own letters on start on pg 45.
Got it.
But OP has two situations as I read it.
74 yr old lady that "just retired" (no date given); and 81 yr old man who is covered under spouse plan until 12/1.
Depending on when "just retired" is, seems like it might be a bit early for an LEP, but I could be wrong.
The old man still has coverage under the spouse group plan, so no LEP there either unless I am missing something.
The 81 yr old should have time to get the L564 to avoid any penalties.
Perhaps the 74 yr old woman can do the same.
And thanks for the CMS Creditable Coverage link, but I really do have better things to do. Might need that info at some point in the future, so again, thanks.
