The Centers for Medicare & Medicaid Services (CMS) may require you to pay a late-enrollment penalty (LEP) when enrolling in Medicare Part D if:
- You didn’t join a Medicare Part D plan when you were first eligible
- You didn’t have other “creditable prescription drug coverage,” such as coverage through your employer, for 63 continuous days
Qualifying for an LEP review
If you meet 1 or more of the below conditions, you can appeal CMS’s LEP decision by requesting a reconsideration.
- You think Medicare missed that you had creditable prescription drug coverage. Coverage is creditable if it is at least as good as Medicare’s standard prescription drug coverage. You can get this coverage through sources such as an employer, the Department of Veterans Affairs, a union or the Indian Health Service.
- You had prescription drug coverage but didn't get a notice that clearly explained if the drug coverage was creditable.
- You received or still receive Extra Help from Medicare to pay for prescription drug coverage (Low-Income Subsidy).
- You received or still receive assistance from a State Pharmaceutical Assistance Program and the coverage is considered creditable.
- You couldn’t enroll in a Medicare Part D plan due to a serious medical emergency.
- You couldn’t enroll in a Medicare Part D plan during the period stated by your current Medicare drug plan.
How to appeal an LEP decision
You or someone you name to act for you—your representative—can request an appeal. You must appeal within 60 days of the date on the letter you received informing you of an LEP.
If you’ve asked someone to act for you, that person must send proof of his or her right to represent you with the appeal form. Proof can be:
- A power of attorney form
- A court order
- An Appointment of Representative Form
The Appointment of Representative Form can be found on , opens new window. You can also call the Medicare helpline number on the back of your member ID card and ask for Form CMS-1696.
Appeals made after 60 days may only be considered if CMS decides there was a valid reason for the delay.
Fill out the request form below and mail it to the address shown on the form or fax it to the number on the form. Make sure to keep a copy for your personal records. In addition, you should send proof that supports your case, like information that shows you meet the requirements for the appeal as indicated in the Qualifying for an LEP review section on this page.
NOTE: Please don’t send original documents. Always send copies.
Visit the C2C website
If you need more information, visit the C2C website: , opens new window.
C2C is an independent contractor that works with CMS to review and resolve disputes between CMS and Medicare plan members.
Call the number on the back of your member ID card.
We are available Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
If you call outside these hours, please leave your name and phone number and a Customer Care representative will return your call by the end of the next business day.