Fillable Part D Late Enrollment Penalty Reconsideration Request form

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Part D Late Enrollment Penalty Reconsideration Request form

On average this form takes 8 minutes to complete

The Part D Late Enrollment Penalty Reconsideration Request form form is 2 pages long and contains:

  • 1 signature
  • 6 check-boxes
  • 24 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:
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 the 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 (your case will only be reviewed for one or more of the following reasons):
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 Drug Coverage from the
employer or union plan.
• If you had 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.
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 union coverage,
must send enrollees a notice explaining how their prescription drug 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.
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.
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.
• Name of Parish:
By 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 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:
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 704
Pittsford, NY 14534-1302
Fax number: (585) 869-3320
Toll Free fax number: (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.
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Late Enrollment Penalty Reconsideration Request form

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Completed 18 September 2019

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