Updated Attestation Forms for Reporting Creditable Coverage
This file provides updated model attestation forms and materials for Medicare beneficiaries. It outlines steps to determine whether beneficiaries had creditable coverage before enrolling in a Medicare prescription drug plan. The updated materials aim to generate timely and accurate responses to the attestation form.
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How do I fill this out?
To fill out this form, carefully read the instructions provided. Gather all necessary information regarding your prior prescription drug coverage. Complete the form accurately and submit it by the specified deadline.
How to fill out the Updated Attestation Forms for Reporting Creditable Coverage?
1
Read the instructions carefully.
2
Gather information on your prescription drug coverage history.
3
Complete the attestation form with accurate details.
4
Submit the form by the specified deadline.
5
Keep a copy of the completed form for your records.
Who needs the Updated Attestation Forms for Reporting Creditable Coverage?
1
Individuals enrolling in Medicare for the first time need this file to report their prior drug coverage.
2
Beneficiaries who have experienced a break in prescription drug coverage need this file to prevent potential penalties.
3
Families of Medicare beneficiaries can use this form to ensure accurate reporting of coverage.
4
Healthcare providers assisting patients with enrollment need this file for accurate paperwork completion.
5
Medicare plan sponsors require this information to assess beneficiaries' eligibility for reduced premiums.
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What are the instructions for submitting this form?
To submit this form, you may email it to LEP@cms.hhs.gov or fax it to (410) 786-7579. Alternatively, you can submit it via standard mail to the address indicated on the cover letter. Make sure to meet the deadline provided in order to ensure timely processing of your enrollment.
What are the important dates for this form in 2024 and 2025?
Beneficiaries must begin using these new models for enrollments received on or after April 1, 2009. It is encouraged to adopt the new models as soon as possible. Accurate and timely submission is crucial to avoid delays.
What is the purpose of this form?
The purpose of this form is to collect information from beneficiaries regarding their prior prescription drug coverage. It aims to ensure that beneficiaries enrolled in Medicare can accurately report their drug coverage status. Proper completion of the form helps mitigate penalties for late enrollment due to previous coverage gaps.
Tell me about this form and its components and fields line-by-line.
- 1. Date: The date when the form is filled out.
- 2. Beneficiary Name: The full name of the beneficiary.
- 3. Beneficiary Address: The mailing address of the beneficiary.
- 4. Coverage Gap Dates: Dates indicating any gaps in coverage.
- 5. Plan Address: The address of the Medicare plan.
- 6. Contact Information: Contact details for further queries.
- 7. Deadline: The completion deadline for the form.
What happens if I fail to submit this form?
Failure to submit this form may result in penalties and delays in coverage. Beneficiaries could lose access to necessary medication due to improper reporting of their coverage history.
- Penalties: Potential late enrollment penalties could incur if the form is not submitted.
- Coverage Delays: Medicare coverage may be delayed, affecting access to prescription drugs.
- Inaccurate Records: Failing to report accurately can lead to complications during future enrollment.
How do I know when to use this form?
- 1. New Medicare Enrollment: Use when enrolling in Medicare for the first time.
- 2. Break in Coverage: Applicable for individuals who have experienced a coverage gap of 63 days or more.
- 3. Updating Coverage Information: Necessary when updating or confirming existing coverage details.
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