Part D Late Enrollment Penalties (LEP) Appeals: What Beneficiaries Need to Know
Missing the Medicare Part D Initial Enrollment Period (IEP) can lead to costly consequences. Medicare charges those who go more than 63 consecutive days without creditable prescription drug coverage Part D Late Enrollment Penalties. CMS will add the (LEP) to the Part D plan premium.
Fortunately, those who are assessed this penalty, have the right to appeal through the Part D LEP Reconsideration process. Here’s what beneficiaries and agents should know.
When Does the LEP Apply
A Late Enrollment Penalty is typically added when:
A beneficiary delays enrolling in a Part D plan during their Initial Enrollment Period, and they didn’t have other creditable coverage for 63 consecutive days.
If a Part D plan determines there is a lapse in creditable coverage, they must send a written notice explaining the penalty. This notice will include the LEP Reconsideration Request Form, which gives you the option to appeal.
Your Right to Appeal
When you receive a reconsideration notice, it will outline your right to request an LEP review. Either you or an authorized representative can file the appeal. The reconsideration form also lists examples of situations that may qualify for review.
Important: If a beneficiary receives Extra Help (Low-Income Subsidy), they do not have to pay the Late Enrollment Penalty at all.
Watch a YouTube video on the drug cap, please note; CMS adjusts the drug cap amount annually.
How to File an LEP Appeal
To request a reconsideration, you must complete the Part D LEP Reconsideration Request Form (C2C) and submit it through one of the following methods:
By mail:
- Standard mail – C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
P.O. Box 44165
Jacksonville, FL 32231-4165 - Courier/tracked mail – C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
301 W. Bay St., Suite 600
Jacksonville, FL 32202
By fax:
- 833-946-1912
Online submission (fastest option):
- Visit C2C Innovative Solutions to create an account and securely upload the completed form.
If someone such as a family member, doctor, or agent files the request on your behalf, they must be designated as your representative by completing the final section of the reconsideration form.
The Appeal Review Process
- LEP appeals are reviewed by an Independent Review Entity (IRE) contracted by Medicare.
- The IRE will notify you of their decision within 90 days of receiving your request.
- The outcome may include upholding the penalty, overturning it, or dismissing the request.
If you are a Medicare agent who is ready to join the team at Crowe, click here for online contract.
Key Takeaways
- Missing Part D enrollment without creditable coverage for more than 63 days can lead to an LEP.
- Beneficiaries have the right to appeal the penalty through a reconsideration request.
- Appeals can be filed by mail, fax, or online with C2C Innovative Solutions.
- Those who qualify for Extra Help never have to pay the LEP.
Understanding the appeals process helps beneficiaries avoid unnecessary costs and ensures fair review of their coverage history.
Agents: Educating clients about timely Part D enrollment and LEP appeals is an important way to protect them from unexpected penalties—and to strengthen your role as a trusted Medicare advisor.