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

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Part D Late Enrollment Penalty (LEP) Reconsideration Request (Medicare Part D Appeals)

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The Part D Late Enrollment Penalty (LEP) Reconsideration Request (Medicare Part D Appeals) form is 2 pages long and contains:

  • 1 signature
  • 6 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
Please use one (1) Reconsideration Request Form for each Enrollee.
Date: Medicare Appeal #:
(For MAXIMUS Federal Services use only)
Enrollee Name:
Address:
City, State, Zip code:
Phone: ( )
Medicare Number:
(From red, white and blue Medicare card):
Date of Birth (MM/DD/YYYY):
Name of current Part D Drug Plan:
I
MPORTANT: 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).
P
lease provide evidence of prior creditable prescription drug coverage. For example:
•
•
•
I
f 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 Drug
Coverage from the employer or union plan.
If you had/have drug coverage with the Department of Veterans Affairs (VA), please provide
any of the following: Notice of Creditable Prescription Drug Coverage; a copy of your VA Health
Benefit 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.
N
ame 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 pl ans that offer prescription drug coverage, like employer or union
coverage, must send enrollees a notice explaining how their prescription dr ug coverage compares to
Medicare prescription drug coverage. Plans may provide this information in their benefits handbook or
as a separate written notice.
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.
Page 1 of 2
v9.2
□ 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 ____________________________
•
U
se a separate sheet if necessary.
□ I lived in an area affected by Hurricane Katrina at the time of the hurricane (August 2005) and I joined
a Medicare drug plan before December 2006.
•
I
am attaching evidence of my residency in 2005.
• N
ame of Parish:
B
y signing this form, I give permission to any entity to release information needed by Medicare or its
independent contractor (MAXIMUS Federal Services) 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 or iginal documents.
• Please make sure the enrollee and representative, if applicable, have signed this form.
Send this form and any extra pages to:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 704
Pittsford, NY 14534-1302
Fax for enrollees: (720) 462-7578
Toll Free fax for enrollees: (866) 589-5241
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.
P
age 2 of 2
v9.2
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Part D Late Enrollment Penalty (LEP) Reconsideration Request (Medicare Part D Appeals)

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Completed 31 January 2021

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