Jane Dotson
Medicare creditable coverage is qualifying health insurance or drug plans that meet a list of requirements. If you have creditable coverage, you can delay signing up for Medicare without penalty. However, if you lose your creditable coverage, you must sign up for Medicare within 8 months, or penalties and late fees may apply. Creditable coverage refers to health insurance that covers as much as or more than Medicare Part A and Part B. Claims may be electronically submitted to a Medicare Administrative Contractor (MAC) from a provider using a computer with software that meets the HIPAA claim standard and CMS requirements.
| Characteristics | Values |
|---|---|
| What is creditable coverage? | Health insurance that meets or exceeds what Medicare Part A and Part B covers. |
| Who needs to submit it? | Individuals who have prescription drug coverage and are eligible for Medicare. |
| How often is it submitted? | Annually, no later than 60 days from the beginning of a plan year. |
| When to submit? | Within 30 days after any change in creditable coverage status or termination of a prescription drug plan. |
| Who provides the notice? | The insurer or employer is required to notify if the insurance provides creditable coverage for prescription drugs. |
| What is the notice called? | Notice of Creditable Coverage or a creditable coverage disclosure notice. |
| What to do with the notice? | Keep the notice, as it works as proof of coverage when first becoming eligible for Medicare. |
| How to submit a claim? | Claims can be submitted electronically to a Medicare Administrative Contractor (MAC) or by mail. |
| What to submit with the claim? | A letter explaining the claim, supporting documents, itemized bill, and claim form. |
| Where to get help? | Call 1-800-MEDICARE (1-800-633-4227) or visit shiphelp.org for free health insurance counselling. |
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What You'll Learn
Understanding what counts as creditable coverage
Creditable coverage is typically associated with prescription drug plans. Companies offering these plans to Medicare-eligible individuals must disclose whether their coverage is creditable or non-creditable. This disclosure is mandatory and provides valuable information for beneficiaries regarding their Medicare Part D enrollment. If your prescription drug coverage is deemed creditable, you may be eligible for subsidies, and you can avoid paying late enrollment penalties for Medicare Part D.
To be considered creditable, a coverage plan's prescription drug benefits must be equal to or greater than those offered by Medicare Part D. This means that the policy is expected to pay, on average, as much as or more than the standard Medicare prescription drug coverage. Most companies are required to disclose their status as creditable or non-creditable coverage providers.
It's important to note that creditable coverage also applies to health insurance plans. These plans must meet a minimum set of qualifications to be considered creditable. Types of creditable coverage plans can include group and individual health plans, student health plans, and various government-sponsored or provided plans.
If you have creditable coverage, you can delay enrolling in Medicare without incurring late fees or penalties. However, if you lose your creditable coverage, you must sign up for Medicare within 8 months to avoid these penalties. Additionally, if you receive a late enrollment penalty and believe you had creditable coverage, you have the right to appeal within 60 days of receiving the notification.
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How to appeal late enrolment penalties
Late enrolment penalties can occur when an individual fails to sign up for Medicare coverage during their Initial Enrollment Period (IEP). The IEP is the period when an individual can first sign up for Part A (Hospital Insurance) and Part B (Medical Insurance). It starts 3 months before the individual turns 65 and ends 3 months after the month they turn 65.
If you were without Part B or job-based insurance for more than 12 months while eligible for Medicare, you may face a Part B late enrollment penalty (LEP). The penalty is 10% of the Part B premium for every 12-month period you did not have Part B or job-based insurance that allowed you to delay enrolment.
Similarly, if you were without Part D or creditable drug coverage for more than 63 days while eligible for Medicare, you may face a Part D late enrollment penalty (LEP). The penalty is 1% of the national base beneficiary premium for each month you did not have Part D or certain other types of drug coverage while eligible.
If you disagree with a late enrollment penalty, you have the right to file an appeal. The appeals process varies based on the type of coverage you have, but there are generally five levels of appeals. At each level, you will receive a decision letter with instructions on how to proceed to the next level.
To appeal a Part B late enrollment penalty, follow the directions provided in the letter informing you about the penalty. If you do not have an appeal form, you can use the Social Security Administration's (SSA) request for reconsideration form. You can appeal to remove the penalty if you had continuous coverage through Part B or job-based insurance. You can also appeal to lower the penalty if you believe it was calculated incorrectly. Supporting evidence for your appeal may include a letter from your former employer or plan confirming your enrolment in coverage, income tax returns showing health insurance premiums paid, and pay stubs reflecting health insurance premium deductions.
To appeal a Part D late enrollment penalty, you can use the "Part D LEP Reconsideration Request Form C2C" to request an appeal of the decision. Send the completed and signed form to the Independent Review Entity (IRE) as instructed. You should also attach any evidence you have, such as proof of previous creditable coverage.
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Submitting claims to a Medicare Administrative Contractor
If you have Original Medicare, you'll need to mail your claim form, itemized bill, and supporting documents to the address for your state, which is listed on the Medicare Administrative Contractor Address Table within the claim form. You can also contact Medicare for help by calling 1-800-MEDICARE (1-800-633-4227) or by live chat, 24 hours a day, 7 days a week (except some federal holidays).
If you have a separate Medicare drug plan (Part D), the pharmacy will file a claim directly with your plan. If you have a Medicare Advantage (Part C) plan, in-network doctors, suppliers, and pharmacies will usually submit a claim directly to your plan. You can also download and fill out a Patient Request for Medical Payment form (CMS-1490S). This form is also available in Spanish. Generally, you’ll need to submit the completed claim form, an itemized bill from your doctor, supplier, or other healthcare provider, and any supporting documents related to your claim (like notes from your doctor).
If your doctor, provider, or supplier hasn't filed a claim on your behalf, contact them and ask them to file a claim. If they still haven't filed your claim, you may need to submit your own claim. If you had to pay out of pocket because your doctor, provider, or supplier refused to submit a claim, you will need to submit your own claim. If you disagree with a decision by Medicare or your Medicare plan, you can file an appeal.
If you wish to appeal a decision by Medicare, you can fill out a "Redetermination Request Form" and send it to the Medicare Administrator Contractor (MAC). Your appeal must include your name, address, and Medicare Number, as well as a list of the specific items and/or services and dates you’re filing an appeal for. You can also ask your provider for information that may help your case. You can submit a written request to the MAC, and their address is listed on the last page of your MSN.
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What to do if your doctor doesn't file a claim
If your doctor or healthcare provider refuses to submit a claim to Medicare, there are several steps you can take to address the situation and potentially resolve the issue. Here is a guide on what to do if your doctor doesn't file a Medicare claim:
Firstly, understand the reasons why your doctor may be reluctant to file the claim. In some cases, providers may believe that Medicare will deny coverage, and they may ask you to sign an Advance Beneficiary Notice (ABN). Before signing, it is important to ask questions and understand if they consider the service medically necessary and if they will support your appeal. You can also request that they still file a claim with Medicare, even if they anticipate a denial.
If your provider has opted out of Medicare, they have likely signed an agreement to exclude themselves from the program, and you are responsible for the entire cost of care. In this case, do not submit a reimbursement request form to Medicare for these specific services. However, if your provider refuses to bill Medicare without a valid reason, this could be considered Medicare fraud and should be reported immediately. Contact 1-800-MEDICARE, the Senior Medicare Patrol (SMP) Resource Center at 877-808-2468, or the Inspector General's fraud hotline at 800-HHS-TIPS to report such instances.
If you had to pay out of pocket due to your doctor's refusal to submit a claim, you may need to file your own claim to seek reimbursement. You can download your Medicare claims data from your Medicare account and share it with a trusted source or representative who can assist you. Note that Medicare claims must generally be filed within 12 months (or one full calendar year) from the date the services were provided.
To file a claim, you will need to mail your claim form, itemized bill, and supporting documents to the address specified for your state in the Medicare Administrative Contractor Address Table within the claim form. You can also seek free, personalized health insurance counselling from the State Health Insurance Assistance Program (SHIP) by visiting shiphelp.org or calling 1-800-MEDICARE.
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The difference between Medicare Part A, B, and D
Medicare is a government-sponsored health insurance program for people aged 65 and over, as well as those with certain disabilities. There are four parts to Medicare: Part A, Part B, Part C, and Part D.
Part A
Part A provides inpatient hospital coverage, including hospital stays, hospice, and skilled nursing facility care. It also covers home health care services for those who are homebound and require skilled care. Most people do not pay a monthly premium for Part A because they or their spouse have worked and paid Medicare taxes for at least 10 years.
Part B
Part B provides outpatient medical coverage, including doctor visits, durable medical equipment, and lab services. Most people pay a monthly premium for Part B, which is set by the federal government and can vary based on income.
Part C
Part C, also known as Medicare Advantage, is an alternative to Parts A and B. It is a bundled plan offered by private companies that includes Parts A, B, and usually D. Medicare Advantage plans may offer additional benefits, such as dental, vision, and hearing coverage. These plans typically have network restrictions, limiting your choice of doctors and hospitals.
Part D
Part D helps cover the cost of prescription drugs, including certain shots or vaccines. It is typically included in Medicare Advantage plans but can also be obtained through a stand-alone Medicare drug plan.
It is important to note that Medicare does not usually cover the full cost of care, and beneficiaries are often responsible for cost-sharing, such as deductibles, coinsurance, and copayments. Supplemental coverage, such as Medigap policies, can help with these additional costs.
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Frequently asked questions
Creditable coverage is health insurance that meets or exceeds what Medicare Part A and Part B cover. It also refers to prescription drug benefits that are equal to or more than what Medicare Part D covers.
If you have health insurance through a large employer, it will likely qualify as creditable coverage. Most large employers include prescription drug coverage in their health insurance plans. You will receive a Notice of Creditable Coverage in the mail each year to confirm this.
Claims can be submitted electronically to a Medicare Administrative Contractor (MAC) by a provider using a computer with software that meets the HIPAA claim standard. If you have Original Medicare, you will need to mail your claim form, itemized bill, and supporting documents to the address for your state.
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