Disclosure to CMS Form

You are accessing a U.S. Government information system, which includes: (1) this computer, (2) this computer network, (3) all computers connected to this network, and (4) all devices and storage media attached to this network or to a computer on this network. This information system is provided for U.S. Government-authorized use only. - Unauthorized or improper use of this system may result in disciplinary action, as well as civil and criminal penalties. - By using this information system, you understand and consent to the following: * You have no reasonable expectation of privacy regarding any communication or data transiting or stored on this information system. At any time, and for any lawful Government purpose, the Government may monitor, intercept, and search and seize any communication or data transiting or stored on this information system. * Any communication or data transiting or stored on this information system may be disclosed or used for any lawful Government purpose.

Entities that are required to provide a disclosure of creditable coverage status to CMS must complete the following online Disclosure to CMS Form. To further assist you in completing this form, the link on the left side of this webpage may help: Disclosure to CMS Guidance and Instructions.

Entities that claim the RDS should not fill out this form for their RDS plan participants. If a plan option has 100 retired beneficiaries and the plan claims RDS for 97 of them, the plan must report 3 non-RDS participants on this form.

The disclosure submission process is composed of the following steps to complete the online Creditable Coverage Disclosure Form:

  • Step 1 -Enter the Disclosure Information
  • Step 2 -Verify and Submit Disclosure Information
  • Step 3 -Receive Submission Confirmation

Note: All fields are required unless otherwise indicated.

Step 1 - Enter Disclosure Information

Please complete the following information for each Type of Coverage offered by the Entity/Plan Sponsor.

Entity/Plan Sponsor Information:
Entity Name
Entity Federal ID Number (Format: ##-#######)
Entity Street Address
City
State (US Only)
Zip Code
Country
Phone Number (Format: ###-###-####)
Coverage Type

If you select "STATE-SPONSORED PLANS: Other State-Sponsored" or "OTHER TYPE OF COVERAGE OFFERED TO MEDICARE PART D ELIGIBLE INDIVIDUALS" option, please explain in the Description of Other Type of Coverage below.

Description of Other Type of Coverage
Creditable/Non-Creditable Offer:

Please select ONE of the following to continue and complete the required disclosure information.

  • All Options Offered Are Creditable
  • All Options Offered Are Non-Creditable
  • There are Some Creditable and Non-Creditable Options Offered

You have selected  . Please complete the following information pertaining to this option.

 :

* Note: A plan year should contain a maximum of 365 days; unless it is a leap year then there would be a maximum of 366 days. Example, if a plan year beginning date is 10/01/2010 then the plan year ending date should be no later than 09/30/2011.

Plan Year Beginning Date (Format: MM/DD/YYYY)
Plan Year Ending Date (Format: MM/DD/YYYY)
How many Options offered under this Plan are creditable? (Please enter a numeric value ONLY.)
Total Number of Medicare Part D Eligible Individuals expected to be covered under these creditable Benefit Option(s) as of the Plan Year Beginning Date stated above (Please enter a numeric value ONLY.)
Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Health Plan (Please enter a numeric value ONLY.)
How many Options offered under this Plan are not creditable? (Please enter a numeric value ONLY.)
Total Number of Medicare Part D Eligible Individuals expected to be covered under these non-creditable Option(s) as Plan Year Beginning Date stated above (Please enter a numeric value ONLY.)
Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Health Plan (Please enter a numeric value ONLY.)
Date that the Annual Creditable Coverage Disclosure notice to Eligible Individuals form was provided by the Entity
Has your Creditable Coverage Status (Creditable, Non-Creditable, Creditable/Non-Creditable Options Offered) changed from the last plan year?

Example 1: Last year Company ABC had creditable coverage through Carrier 123. This year they have non-creditable coverage through Carrier 123. This is a change in the status, since the coverage was creditable and now is non-creditable.
Example 2: Last year Company ABC had creditable coverage through Carrier 123. This year they have creditable coverage through Carrier 456. Even though the company changed carriers, this is not a change in the status of the creditable coverage. It was creditable last year and it remains creditable, so there is no change in the status.

Yes No
If yes, include the effective date(s) of this change (Format: MM/DD/YYYY)
If yes, enter the date this Entity disclosed to Medicare Part D Eligible Individuals about this change in Creditable Coverage (Format: MM/DD/YYYY)
PRA Disclosure Statement:

According to the Paperwork Reduction Act of 1995, no persons are required to respond toa collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1013 (Expires: December 31, 2020). The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have any comments, concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

I understand and agree to the following statements:
  1. That this submission supersedes any previous submission of this information with dates prior to the date below;
  2. That the entity/plan sponsor agrees to disclose to CMS and all Medicare Part D eligible individuals any changes that would affect the creditable status of the above coverage as outlined under §423.56.
  3. That I am authorized to supply this disclosure of creditable coverage on behalf of the Entity; and
  4. That the information provided in this disclosure is true, correct, and complete to the best of my knowledge and belief.
Entity's Authorized Individual Name
Entity's Authorized Individual Title
Entity's Authorized Individual Email (If no email address is available, Please enter: CCDBnoisp@cms.hhs.gov)
Today's Date (Format: MM/DD/YYYY)

Preview your information. Click the Edit button to go back to the form or click submit to submit the information. Please print a copy for your records.
Entity/Plan Sponsor Information:
Entity Name:
N/A
Entity Federal ID Number:
N/A
Entity Street Address:
N/A
City:
N/A
State:
N/A
Zip Code:
N/A
Country:
United States
Phone Number:
N/A
Coverage Type:
N/A
Description of Other Type of Coverage:
N/A
Creditable/Non-Creditable Offer:
Creditable/Non-Creditable Offer:
N/A
Plan Year Beginning Date:
N/A
Plan Year Ending Date:
N/A
How many Options offered under this Plan are creditable?:
N/A
Total Number of Medicare Part D Eligible Individuals expected to be covered under these creditable Benefit Option(s) as of the Plan Year Beginning Date stated above:
N/A
Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Health Plan:
N/A
How many Options offered under this Plan are not creditable?:
N/A
Total Number of Medicare Part D Eligible Individuals expected to be covered under these Option(s) as Plan Year Beginning Date stated above:
N/A
Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Health Plan:
N/A
Date that the Annual Creditable Coverage Disclosure notice to Eligible Individuals form was provided by the Entity:
N/A
Has your Creditable Coverage Status (Creditable, Non-Creditable, Creditable/Non-Creditable Options Offered) changed from the last plan year?:
N/A
If yes, include the effective date(s) of this change:
N/A
If yes, enter the date this Entity disclosed to Medicare Part D Eligible Individuals about this change in Creditable Coverage:
N/A
I understand and agree to the following statements:
Entity's Authorized Individual Name:
N/A
Entity's Authorized Individual Title:
N/A
Entity's Authorized Individual Email:
N/A
Today's Date:
N/A
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Page Last Modified:
06/19/2019 02:59 PM
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