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How To Appeal the Medicare Part D Late Enrollment Penalty

 If you don’t join a Medicare drug plan when you’re first eligible, you may have to pay a late enrollment penalty unless you had other "creditable prescription drug coverage," which means that your prescription drug coverage met Medicare’s minimum standards. In some cases, you have the right to ask Medicare to review your late enrollment penalty. This is called a "reconsideration." You might ask for a reconsideration if one of the following are true:
  • You don’t think Medicare counted all of your previous creditable prescription drug coverage.
  • You didn’t get a notice that clearly explained whether your previous drug coverage was creditable.

Part D Late Enrollment Penalty Reconsideration Notice

 The Part D Late Enrollment Penalty reconsideration notice provides a detailed explanation of your right to request a reconsideration of your Late Enrollment Penalty. Your Medicare Part D plan must send you this notice when the plan first sends you a letter notifying you about the imposition of a Late Enrollment Penalty. Sample Part D Late Enrollment Penalty Reconsideration Notice

Who Can Ask for a Reconsideration?

You or someone you name to act for you (your representative) can ask for a reconsideration. If someone requests a reconsideration for you, he or she must send proof of his or her right to represent you with the request form. Proof could be a power of attorney form, a court order, or Form CMS-1696 (Appointment Of Representative).

How Do I Ask for a Reconsideration?

The reconsideration request form should have been sent with the Late Enrollment Penalty Reconsideration Notice (if you cannot find the reconsideration request form, please call the member services department for your Medicare Part D plan). Complete the form. Mail it to the address or fax it to the number listed on the form within 60 days from the date on the letter you got stating you had to pay a late enrollment penalty. You should also send any proof that supports your case, like information about previous creditable prescription drug coverage -- send only copies of your original support documents.

If you wait more than 60 days, you must explain why your request is late. Medicare will decide if you had good cause to send a late request.

What Do I Need to Include with My Late Enrollment Penalty (LEP) Reconsideration Request?

  1. A completed, signed Late Enrollment Penalty (LEP) reconsideration request (keep a copy).

  2. Copies of information you believe may help your case.

  3. If you’ve named someone to act for you, a copy of the proof the individual can represent you.
NOTE: Do not send original documents.

Your Medicare drug plan will give you a reconsideration request form when it sends you the letter telling you that you have to pay a late enrollment penalty. Mail the completed form to the address, or fax it to the number listed on the form within 60 days from the date on the letter. You should also send any proof that supports your case, like information about previous creditable prescription drug coverage.

Reconsideration of a Late Enrollment Penalty (LEP) is processed by an Independent Review Entity (IRE) which is also known as a Qualified Independent Contractor (QIC). The IRE/QIC handling Late Enrollment Penalty Reconsiderations is determined based on your initial and follow-up appeals dates:

As noted on the C2C Innovative Solutions, Inc. website (c2cinc.com),
"Effective February 1, 2021, C2C Innovative Solutions, Inc. (C2C), is the Part D QIC; therefore, [C2C is] adjudicating new reconsideration requests received on and after February 1, 2021. There will be a short period in which both C2C and Maximus, the outgoing QIC, are processing reconsiderations. Maximus will continue posting effectuation, case file submission information, and appeals received/decided for reconsideration requests received on or before January 31, 2021 and reopening requests for drug benefit appeals received on or before March 31, 2021 and reopening requests for LEP appeals received on or before April 16, 2021. PDP and MA-PDP Plans should return case files to Maximus, when Maximus has requested the case file."

via United States Postal Service (USPS):
C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
P.O. Box 44165
Jacksonville, FL 32231-4165

via UPS / FedEx ONLY:
C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
301 W. Bay St., Suite 600
Jacksonville, FL 32202

Telephone for Enrollees Only: (833) 919-0198 (Toll Free)
Fax for Enrollees Only:(833) 946-1912 (Toll Free)

For more information: C2C Appeal Instructions and links

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

Fax numbers: (585) 869-3320
Toll free fax: (866) 589-5241
Customer Service: 585-425-5300
Toll Free Customer Service: 877-456-5302

If you need more information about requesting a reconsideration of your late enrollment penalty, call your Medicare drug plan. You also may visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) for help. TTY users should call 1-877-486-2048.


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