Creditable Part B coverage but Not Creditable Part D Coverage
- Thread starter Tscholar
- Start date
straightnochaser
Guru
- 939
Pretty sure if the coverage was creditable in 2024 it will remain so next year even if technically it is no longer creditable.
What are you basing that on?
CMS verifies the creditable coverage once the beneficiary enrolls in a Part D plan. If they did not have creditable coverage for any period of time, they will pay a 1% penalty for each month they didn't have the coverage. The 1% is based on the national base beneficiary premium.
CMS receives annual disclosures from entities that provide Rx coverage to Medicare beneficiaries. So there is no real way to "hide" the fact that your customer may not have creditable coverage.
He would be well advised to buy a stand alone Part D plan. Even if it only costs $0.50/mo, as the penalty will cost significantly more in the long run.
- 6,896
Caveat, not an agent.
Per discussions here in the last 2-3 months, Part D carriers are the ones who evaluate for presence of creditable coverage between T65 and Part D effective date. Also, comments in those threads suggest that in the experience of posting agents, the carriers have not made a significant effort to evaluate whether or not the employer coverage was actually creditable, rather they (the carriers) have just been concerned that the Part D policy holder could provide carrier names and dates of coverage for the various employer plans preceding Part D enrollment.
Jim Wright
Super Genius
- 183
For 2025, they will allow employers to use the Simplified determination to verify creditability. Most group health plans for 2025 will be considered creditable. If the plan is not, notices will go out to the medicare eligible employee stating that it is not.
When they move to the new calculation in 2026 it's important to remember that the determination is not based on the insured paying $2000 or less for their drugs. It is based on the actuarial value of the drug coverage compared to the actuarial value of Medicare drug coverage. i.e. how much does the plan pay for drugs and how much does Medicare pay for drugs, not the MOOP
When they move to the new calculation in 2026 it's important to remember that the determination is not based on the insured paying $2000 or less for their drugs. It is based on the actuarial value of the drug coverage compared to the actuarial value of Medicare drug coverage. i.e. how much does the plan pay for drugs and how much does Medicare pay for drugs, not the MOOP
Jim Wright
Super Genius
- 183
It's going to come from the carriers. I work with a lot of groups and their HR depts. Most will not know what they are talking about.
Calling the carrier will get them the answer. But they likely will be fine for 2025.
Calling the carrier will get them the answer. But they likely will be fine for 2025.
carriers verify via CMS. And although significant efforts may not at times be made, it is still best practice to advise as if the efforts were being made. Otherwise one may end up with an E&O claim.
Luckily for you, you are not an agent, and advising a client to try and "game" the system will not have any negative repercussions on you.
