The Centers for Medicare and Medicaid Services (CMS) provides the following guidance explaining how Medicare beneficiaries can receive a refund or repayment of their overpaid copayments and premiums from their Medicare Part D drug plan or Medicare Advantage plan.

How to get reimbursed [from a Medicare plan] for incorrect copayment amounts

Question:  What should people with Medicare do if they paid out-of-pocket for drug costs because they needed to fill a prescription before they got their plan membership card or confirmation letter?

A Medicare [Part D] drug plan will reimburse people with Medicare who pay for prescriptions that should be covered by their plan. To get reimbursed, the person should take the following steps:

1. Save the original receipt from the drug purchase. If the person no longer has the original receipt, he or she can contact the pharmacy and ask for a replacement receipt or other proof of purchase.
   
   
2. Call the plan's customer service [or Member Services] number on the membership [or Member ID] card, read the plan's printed materials, or look on the plan's member website to find out about the reimbursement process.
   
   
3. Get a copy of the plan's claim submission or reimbursement form, if needed.
   
   
4. Fill out the form and submit it to the plan with the original or replacement receipt [and make a photocopy of all of the printed information submitted to your plan].

You can also check your Medicare plan's Evidence of Coverage for more information on getting reimbursed for out-of-pocket costs.


Question:  What if someone who qualifies for the low-income subsidy (LIS), but doesn't have proof is charged an incorrect deductible or copayment amount?

To avoid paying incorrect amounts, people who qualify for LIS should provide the pharmacy with the following documents as proof they qualify:

• A copy of their yellow, green, or purple automatic enrollment letter [that they received in the mail] from Medicare
  
  
• Their "Notice of Award" from Social Security
  
  
• Their Medicaid card (if they have one) or any document that shows they have Medicaid
  
  
• A bill from an institution (like a nursing home) or a copy of a state document showing Medicaid payment to the institution for at least a month
  
  
• A screen print from their state's Medicaid systems showing that they lived in the institution for at least a month
  
  
• Effective January 1, 2012, a document from their state that shows they have Medicaid and get home and community-based services
  

If proof [of Medicaid coverage] isn't available, a person who qualifies for LIS should contact their State Medical Assistance (Medicaid) office or Social Security to get at least one of the documents mentioned here. The person can call 1-800-MEDICARE (1-800-633-4227) to get the telephone number for their Medicaid office. TTY users should call 1-877-486-2048.

[People who qualify for LIS who aren't charged the correct deductible or copayment amount should contact their Medicare drug plan to find out how to submit a claim for reimbursement. They should save the original receipt from the purchase in case they need to submit it with the claim. The Medicare drug plan will refund any amount that is due.]

People who qualify for LIS [retroactively] after they enrolled in a Medicare drug plan may be due refunds from their plan for premiums and copayments paid during months they qualified for LIS retroactively.  If people paid premiums or copayments in excess of LIS amounts during a period of retroactive LIS coverage, they should contact their Medicare drug plan to find out how to submit a claim for reimbursement. They should save the original receipt from the purchase in case they need to submit it with the claim. Their drug plan should give them a refund within 45 days.

Note: When Medicare records show that a person’s Medicaid or Supplemental Security Income (SSI) eligibility is retroactive to past months, their LIS and automatic Medicare drug coverage (if they aren’t already enrolled in a Medicare drug plan) is retroactive for the same period. People with retroactive coverage can get reimbursed for covered Part D prescriptions they paid for during any past months they were entitled to retroactive coverage. For more information about retroactive coverage, visit [ as og 05/17/2024: https://www.hhs.gov/guidance/sites/default/files/ hhs-guidance-documents/11401-P-LI-Net.pdf] to view the tip sheet “The Limited Income NET Program for People With Retroactive Medicaid & SSI Eligibility.”

Question [from 2007 edition]:  How will pharmacies be reimbursed for payments they made on behalf of people with Medicare and Medicaid who live in long-term care facilities and qualify for the $0 copayment?

People with Medicare and Medicaid who reside in long-term care facilities may not have to pay copayments for their prescription drugs.

Pharmacies will receive a one-time payment for the amount of any uncollected copayments for people who were mistakenly identified as having to pay copayment amounts. The pharmacy will need to send the prescription drug plan a spreadsheet with claim information. Processes may vary among Medicare drug plans. Following the Medicare drug plan's directions will help ensure timely reimbursements.



Question:  What should people do if a higher premium amount is deducted from their Social Security benefit or Railroad Retirement Board (RRB) benefit?

If there is a premium over-payment, such as when a person changes to a lower premium plan and the premium change doesn't immediately go into effect, Social Security or RBB will automatically refund the premium over-payment. The person will get a refund check separate from his or her regular monthly Social Security benefit or RBB benefit.  It may take two to three months [or longer] to get a refund.  After [waiting] 3 months [without receiving a refund], people should contact 1-800-MEDICARE.


Question:  What happens if a person is in a Medicare Advantage plan that lowers the Medicare Part B premium, but the person is charged the full premium amount?

Some Medicare Advantage Plans pay some or all of their members' Medicare Part B premium as part of the plan's enrollment [such as Give-back or Dividend plans]. It may take up to 2 months for a member to see an increase in his or her Social Security check equal to the amount of the reduction in the Part B premium. If a member didn't see an increase, the incorrect withholding amount will be repaid to the member all at [one time]. Depending on the payment method a member selected, one of the following will occur:

• They will have their regularly scheduled Social Security benefit payment increased.
• They will get a refund check from the plan or from Social Security.

The member should call his or her plan if the increase isn't received or refunded.

Question:  What happens if a person who qualified for the low-income subsidy (LIS) is charged a premium?

People who qualified for the full LIS should generally pay no monthly prescription drug premium [if they choose a Medicare Part D plan that qualifies for their state's $0 premium LIS benchmark]. However, if they select a plan that doesn't have a $0 premium for people qualifying for the full LIS, they will have to pay a small premium amount.

Also, if they join a Medicare drug plan with supplemental benefits, they will pay the plan's supplemental premium.

People who qualified for the partial subsidy may pay no premium or a reduced premium for a basic plan, depending on income.

Drug plan sponsors have been instructed not to bill a new member until Medicare tells the plan what the member's premium should be. However, in some cases, plans might mistakenly send bills for full plan premiums to certain members who qualify for LIS or to members who qualify retroactively for LIS.

If a person with LIS receives a bill in error, they should call their plan.

Plans have the option to not disenroll members for failure to pay their premium bill if the person might qualify for the full or partial LIS amount.

People who get a notice that says they will be disenrolled for non-payment of premiums should call their plan.

If the Medicare drug plan billed a member who should have a reduced or $0 premium and the member paid the premium, the Medicare drug plan will refund the amount overpaid. The member can call the customer service number on the membership card, read the plan's printed materials, or look on the plan's member website to find out about the reimbursement process.

More about premium withholding

Question:  Why would someone have two premiums deducted in one month?

People who enroll in a Medicare drug plan at the end of the month [or late in the annual Open Enrollment Period] may be charged in one month for multiple premium payments.

[For instance, people who enrolled in a Medicare drug plan on December 7th at the close of the annual Open Enrollment Period with new plan coverage starting January 1, 20[2x], may be billed in February for both January and February premiums.  Likewise, depending on the how quickly the enrollment is processed, a person who is changing Medicare plans may be charged a premium from the "old" plan and a premium for the newly-chosen" Medicare plan.  In short, the enrollment was not recorded before the "old" plan received notice that the person had changed plans for the following month. ]

Depending on which payment method was selected, one of the following will occur:

• They will get a bill for 2 months of premiums. [Note:]  Plans generally send bills at either the beginning or the end of the month. It varies by plan.
  
  
• They will have 2 months of premiums withdrawn from the selected account. This could show as two separate withdrawal amounts, or one withdrawal at double the amount, depending on the plan. [Note:]  These withdrawals generally happen at either the beginning or the end of the month.
  
  
• Depending on when the withholding request gets processed by the withholding agency (Social Security or RRB), they may have 2 months of premiums withheld from their monthly Social Security or RRB benefit payment.
  
  
• [In addition, if the Medicare beneficiary's request] to have premiums withheld beginning January 1, 20[25] [was] received after December 7, 20[24], they will be converted to direct bill for the January premium. Plans should then resubmit a person’s election for premium withholding prospectively.
  

Question:  What happens if people choose the premium withholding, but they also have a secondary insurer that pays part of the drug plan premium?

People who get a premium benefit from a secondary insurer (a plan other than their Medicare drug plan), such as an employer health plan or a State Pharmacy Assistance Program (SPAP), will have the entire monthly premium withheld if they choose the Social Security premium withholding option. The Medicare drug plan will give the member a refund for the amount the employer health plan or SPAP would have paid.

For example, if a member with a $20 drug plan premium has a SPAP premium benefit of $10 per month and the member chooses premium withholding, Social Security will withhold the full $20. The Medicare drug plan will refund the member $10.

Plans shouldn't convert a member with secondary coverage to direct billing, unless the member requests it, but they may encourage members to choose this method of billing. If a member chooses direct billing, he or she will get a bill for the correct premium amount. Generally, the SPAP or employer will pay its share directly to the plan.


Source:
CMS Pub no.11246-P, "Repayment of Premiums and Copayments Paid Out-of-Pocket", June 2007 (updated September 2011) (with our additions, links, and emphasis)