Fillable Part D Late Enrollment Penalty (LEP) Reconsideration Request (Medicare & Medicaid)

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Part D Late Enrollment Penalty (LEP) Reconsideration Request (Medicare & Medicaid)

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The Part D Late Enrollment Penalty (LEP) Reconsideration Request (Medicare & Medicaid) form is 3 pages long and contains:

  • 5 signatures
  • 5 check-boxes
  • 44 other fields

Country of origin: US
File type: PDF

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Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
Page 1 of 2
v1.0
Medicare Appeal #:
(For C2C use only)
Please use one (1) Reconsideration Request Form for each Enrollee.
Date:
Enrollee Name:
First Name Last Name
Address: City:
State: Zip Code:
Phone: ( )
Medicare Number:
Date of Birth (MM/DD/YYYY):
Name of current Part D Drug Plan:
IMPORTANT: A signature by the enrollee is required on this form in order to process an appeal. Complete,
sign and mail this request to the address at the end of this form, or fax it to the number listed on this form
within 60 days from the date on the letter you received stating you have to pay a late enrollment penalty. If it
has been more than 60 days, explain your reason for delay on a separate sheet and send it with this form.
Check all boxes that apply to you:
□ I had other prescription drug coverage as good as Medicare’s (creditable coverage).
Please provide evidence of prior creditable prescription drug coverage. For example:
• If you had drug coverage from an employer or union plan, provide a copy of the Notice of
Creditable Prescription Drug Coverage or Certificate of Prior Creditable Prescription Dr
ug
C
overage from the employer or union plan.
• If you had/have drug coverage with the Department of Veterans Affairs (VA), please provid
e
an
y of the following: Notice of Creditable Prescription Drug Coverage; a copy of your VA Healt
h
B
enefit Card; a letter from the VA certifying eligibility; or an Explanation of Benefits (EOB).
• If you have drug coverage through the Indian Health Service, a Tribe or Tribal organization, or
an Urban Indian Organization (I/T/U), please provide a copy of any of the following: IHS
registration card; letter verifying eligibility and/or enrollment.
Name of former employer/union/other insurer:
Dates of coverage (MM/DD/YYYY) from to
Plan Address & Phone:
Contact Name: Phone:
□ I had prescription drug coverage but I didn’t get a notice that clearly explained if my drug coverage was
creditable coverage.
Reminder: Most non-Medicare plans that offer prescription drug coverage, like employer or unio
n
c
overage, must send enrollees a notice explaining how their prescription drug coverage compares t
o
Medicare prescription drug coverage. Plans may provide this information in their benefits handbook or
as a separate written notice.
Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
Page 2 of 2
v1.0
Medicare Appeal #:
(For C2C use only)
If you don’t know if your prescription drug coverage was creditable:
To help your case, you may want to send a letter to your previous plan and ask if your coverage was
creditable. Attach your letter and any response to this form. You shouldn’t wait to receive a response
before you send this request form, and there is no need to send a letter if your prior coverage was with
a Medicare Part D plan.
□ I believe the LEP is wrong because I was not eligible to enroll in a Medicare Part D plan during the
period stated by my current Medicare Part D plan. Example: You lived outside of the United States
during the initial enrollment period stated by your Medicare Part D plan. You must submit proof why
you believe the LEP is wrong, such as proof of overseas residency.
□ I believe the LEP is wrong because I was unable to enroll in a Medicare Part D plan due to a serious
medical emergency. You must submit proof that you experienced a serious medical emergency (e.g.
unexpected hospitalization) that affected your ability to timely enroll in a Medicare Part D plan.
□ I have/had extra help from Medicare to pay for my prescription drug coverage.
• Dates of extra help: from to
• Use a separate sheet if necessary.
By signing this form, I give permission to any entity to release information needed by Medicare or its
independent contractor (C2C Innovative Solutions Inc.) to review my Medicare Part D late
enrollment penalty appeal.
I certify that the information on this form is true, accurate and complete. I understand that if I have submitted
any false documents, made any false claims or statements, or concealed any material facts, I may be
subject to civil or criminal liability.
Signature of Enrollee Date
• Be sure to include your Medicare Health Insurance Claim number or Medicare Beneficiary
Identifier on any materials you send.
• Do not send original documents.
• Please make sure the enrollee and representative, if applicable, have signed this form.
Send this form and any extra pages to:
Standard Mail:
C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
P.O. Box 44165
Jacksonville, FL 32231-4165
Note about Representatives:
If you want another individual, such as a family member, friend, or your doctor to request a
reconsideration for you, that individual must be your representative.
Complete the attached Appointment of Representative form only if you wish to have another
individual represent you for this appeal.
Courier or Tracked Mail:
C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
301 W. Bay St., Suite 600
Jacksonville, FL 32202
Toll Free fax for enrollees:
(833) 946-1912
Web Portal Address:
https://www.c2cinc.com//Appellant-Signup
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Department of Health and Human Services
Centers for Medicare & Medicaid Services
Form Approved OMB No.0938-0950
Appointment of Representative
Name of Party Medicare Number (beneficiary as party) or National
Provider Identifier (provider or supplier as party)
Section 1: Appointment of Representative
To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier):
I appoint this individual, , to act as my representative in connection with my claim or asserted
right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act. I authorize this
individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in
connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information
related to my request may be disclosed to the representative indicated below.
Signature of Party Seeking Representation Date
Street Address Phone Number (with Area Code)
City State Zip Code
Email Address (optional)
Section 2: Acceptance of Appointment
To be completed by the representative:
I, , hereby accept the above appointment. I certify that I have not been disqualified,
suspended, or prohibited from practice before the Department of Health and Human Services (HHS); that I am not, as a
current or former employee of the United States, disqualified from acting as the party’s representative; and that I recognize
that any fee may be subject to review and approval by the Secretary.
I am a / an
(Professional status or relationship to the party, e.g. attorney, relative, etc.)
Signature of Representative Date
Street Address Phone Number (with Area Code)
City State Zip Code
Email Address (optional)
Section 3: Waiver of Fee for Representation
Instructions: This section must be completed if the representative is required to, or chooses to, waive their fee for
representation. (Note that providers or suppliers that are representing a beneficiary and furnished the items or services
may not charge a fee for representation and must complete this section.)
I waive my right to charge and collect a fee for representing before the Secretary of HHS.
Signature Date
Section 4: Waiver of Payment for Items or Services at Issue
Instructions: Providers or suppliers serving as a representative for a beneficiary to whom they provided items or
services must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act.
(Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, or could not reasonably be
expected to know, that the items or services at issue would not be covered by Medicare.) I waive my right to collect payment
from the beneficiary for the items or services at issue in this appeal if a determination of liability under §1879(a)(2) of the Act
is at issue.
Signature Date
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Charging of Fees for Representing Beneficiaries before the Secretary of HHS
An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with
an appeal before the Secretary of HHS (i.e., an Administrative Law Judge (ALJ) hearing or attorney adjudicator review by
the Office of Medicare Hearings and Appeals (OMHA), Medicare Appeals Council review, or a proceeding before OMHA or
the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in
accordance with 42 CFR 405.910(f).
The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed
by the representative and filed with the request for ALJ hearing, OMHA review, or request for Medicare Appeals Council
review. Approval of a representative’s fee is not required if: (1) the appellant being represented is a provider or supplier;
(2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court
appointed representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in
a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or
reconsideration. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be
used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation
Approval of Fee
The requirement for the approval of fees ensures that a representative will receive fair value for the services performed
before HHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined
to be reasonable. In approving a requested fee, OMHA or Medicare Appeals Council will consider the nature and type of
services rendered, the complexity of the case, the level of skill and competence required in rendition of the services, the
amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried
the appeal and the amount of the fee requested by the representative.
Conflict of Interest
Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers, employees
and former officers and employees of the United States to render certain services in matters affecting the Government or to
aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from
being representatives of beneficiaries before HHS.
Where to Send This Form
Send this form to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal,
grievance or complaint if you are filing a grievance or complaint, or an initial determination or decision if you are requesting
an initial determination or decision. If additional help is needed, contact 1-800-MEDICARE (1-800-633-4227) or your
Medicare plan. TTY users please call 1-877-486-2048.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the
right to file a complaint if you believe you’ve been discriminated against. Visit https://www.cms.gov/about-cms/agency-
Information/aboutwebsite/cmsnondiscriminationnotice.html, or call 1-800-MEDICARE (1-800-633-4227) for more
information.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form,
complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA
Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-1696 (Rev 08/18)
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Part D Late Enrollment Penalty (LEP) Reconsideration Request (Medicare & Medicaid)

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Completed 20 January 2021

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