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Late Enrollment Penalty (LEP) Appeals

Overview


Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual's Part D initial enrollment period during which the individual was eligible to enroll, but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage.  For more information on creditable coverage and on how an LEP is assessed, please see the Creditable Coverage and Late Enrollment Penalty webpage on CMS.gov.

A Medicare Part D plan notifies an enrollee in writing if the plan determines the enrollee has had a continuous period of 63 days or more without creditable prescription drug coverage at any time following his or her initial enrollment period for the Medicare prescription drug benefit..The enrollee will receive an LEP Reconsideration Notice and an LEP Reconsideration Request Form with the written notification. The enrollee or his or her representative may request a review, or reconsideration, of a decision to impose an LEP.  An enrollee may only obtain review under the circumstances listed on the LEP Reconsideration Request Form.

LEP Reconsideration (Appeal) Process

The LEP reconsideration is conducted by an Independent Review Entity (IRE) under contract with Medicare.   The IRE generally will notify the enrollee of the final LEP reconsideration decision (including a decision to dismiss the reconsideration request), within 90 calendar days of receiving a request for reconsideration. For more information, plans may view the Part D QIC Reconsideration Procedures Manual (click on "Part D QIC Manual" in the "Related Links" section below) on the IRE’s website, which can also be accessed by using the "Maximus Part D Appeals Website" link below in "Related Links".

Part D Late Enrollment Penalty Reconsideration Notice

The Part D Late Enrollment Penalty reconsideration notice provides a detailed explanation of an enrollee's right to request a reconsideration of his or her Late Enrollment Penalty. A Part D plan sponsor must complete the notice and send it to an enrollee when the plan first sends the enrollee a letter notifying him or her about the imposition of a Late Enrollment Penalty. The notice is contained in Appendix 14 to Chapter 18 of the Prescription Drug Benefit Manual. You may also download a Microsoft Word version of this notice by clicking on the link in the "Downloads" section below.

Part D Late Enrollment Penalty Reconsideration Request Form

An enrollee may use this form to request an appeal of a Late Enrollment Penalty decision. The enrollee must complete the form, sign it, and send it to the Independent Review Entity as instructed in the form. The form is contained in Appendix 15 to Chapter 18 of the Prescription Drug Benefit Manual. A fillable Adobe PDF version of this form is available by clicking on the link in the "Downloads" section below.

Fact Sheet: Part D Late Enrollment Penalty Reconsideration Appeals Data

These reports summarize and highlight some of the key data on LEP reconsiderations effective with calendar year 2015. To view the Fact Sheets, click on the link "Fact Sheets Part D LEP Reconsideration Appeals Data" link in the "Downloads" section below.

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