Important Information About Late Enrollment Penalties
If you received a notice about a late enrollment penalty (LEP) from Wellcare, you’re in the right place. As your prescription drug provider, our priority is to ensure you have access to your medications. This page explains what the penalty is, why it happens, and what you can do next.
On this Page
- Understanding Your Late Enrollment Penalty
- Why We May Need More Information From You
- Paying Your Late Enrollment Penalty
- If You Disagree With the Penalty
- After Medicare Reviews Your Case
- Need More Help?
What is a Late Enrollment Penalty (LEP)?
Centers for Medicare and Medicaid (CMS), requires all Medicare members to have prescription drug (Part D) coverage. If you went 63 or more consecutive days without Part D or other qualifying drug coverage after your initial enrollment period ended, Medicare requires us to add a Late Enrollment Penalty to your monthly premium.
Even if your monthly premium is $0, the penalty is still owed. Leaving it unpaid can result in loss of your drug coverage. | Return to top
What counts as qualifying coverage?
- Medicare Prescription Drug Plan (Part D);
- A Medicare Advantage Plan (Part C) (like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drug coverage; or
- Creditable prescription drug coverage (current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, CHAMPVA, or health insurance coverage).
*If you had any of this coverage but didn't report it when you enrolled, you may be able to have the penalty reduced or removed. See the dispute options below.
How will I know if I owe a penalty?
- We will mail you a letter if you have a penalty. In general, you will have to pay this penalty for as long as you have a Medicare drug plan.
How long will I pay this penalty?
- You’ll usually pay the penalty for as long as you have Medicare drug coverage. This also applies to plans with a $0 monthly premium..
- This is not a one-time fee. Your LEP is a lifetime penalty and continues even when you change Medicare plans.
- LEP may stop in specific circumstances including when you turn 65 (if you had been assessed LEP in connection with Medicare benefits prior to that age, and when you become eligible for Extra Help (also known as Low Income Subsidy).
Why did my LEP amount increase?
- LEP amounts will change each calendar year in accordance with the Centers for Medicare and Medicaid (CMS) guidelines. Be sure to review your coupon book or AutoPay/EFT statement for the new amount. If you have a Social Security or Railroad deduction, you may view your new amount in your member portal.
- CMS determines the national plan premium average each year, which is used to calculate the amount of the monthly LEP. Learn more about how it’s calculated (PDF).
How can I provide information regarding prior Part D coverage?
When you enroll in a Part D plan, it is important to provide information about prior coverage if you are not enrolling upon turning age 65.
- If you are within the 60 days of the date on the letter advising of LEP, you can provide us with this information by completing the Declaration of Prior Prescription Drug Coverage form online. You can also complete the Declaration of Prior Prescription Drug Coverage form that was mailed to you when we provided notification of the LEP, or by calling Member Services.
- If it has been more than 60 days or you disagree with the LEP decision you can complete and submit the Part D LEP Reconsideration Request Form below.
Note: If more than 60 days have passed, write the reason for the delay on a separate sheet and include it with this form. Declaration of Prior PDP Coverage Form (PDF)
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Why am I getting repeated requests for attestation information?
- There are several reasons that it can take some time to resolve your request to remove (or reduce) your LEP. It is important to make sure that the information is complete and everything required is provided. Did you sign the form? Did you provide coverage information for the entire period listed in the letter that was sent? Did you list prescription plans or services (such as Good Rx) that do not satisfy Medicare requirements for creditable coverage?
Do I have to pay the LEP even if I do not agree with it?
- Even if you disagree with the penalty, you should keep paying it while your request is being reviewed. If you do not pay it, you could lose your prescription drug coverage. You can complete an attestation form if you disagree with the late enrollment penalty. | Return to top
What if I have Extra Help, do I still owe the penalty payment?
- If you receive Extra Help, you may be subject to an LEP, depending upon when you enroll into your plan. In most cases, when you qualify for Extra Help, also known as a Low-Income Subsidy, an LEP is not charged.
What if I don’t have many prescriptions and I just want to pay directly instead of having a prescription drug plan?
- Under Federal law, CMS requires that Medicare eligible beneficiaries have a qualifying prescription drug plan. If you subsequently enroll in a prescription drug plan you will be assessed LEP for all gaps in coverage (more than 63 days).
- Low-cost drug plans that have creditable coverage are available in most regions, which may be preferable to paying a large penalty in the future. For example, a 12-month gap in coverage will result in a penalty of approximately $4.00 per month, and if you wait 5-years to enroll the LEP will be more than $20.00 per month.
What if I do not agree with the LEP?
If you disagree with the Late Enrollment Penalty, you can ask Medicare to review the decision. You may need to provide proof that you had past prescription drug coverage.
- You can send information about your prior prescription drug coverage online, by phone, or in writing.
- If you send it in writing, complete the form listed in your LEP letter and return it to the address or fax number on the form. This must be done within 60 days from the date on the letter telling you that you owe an LEP.
- Please include any proof you have, such as a notice of creditable drug coverage from an employer or union plan.
- Copies of the Prior PDP Coverage Form and the Part D LEP Reconsideration Request Form are linked at the bottom of this page. These forms were also included with the letter you received.| Return to top
Which form should I use?
- Use the Declaration of Prior PDP Coverage Form if you are sending information about past prescription drug coverage within 60 days of your LEP letter.
- Use the Part D LEP Reconsideration Request Form if you missed the 60-day deadline or disagree with the LEP decision.
Who make the decision about my penalty?
- C2C is an agency that works on behalf of CMS to review and determine outcomes for redetermination requests. You can review the status of your request by calling 1-(833) 919-0198 (Toll Free), (TTY: 1-800-725-9216), between 9:00 AM to 6:00 PM (EDT), Monday through Friday.
You can also reach out to C2C about your LEP Reconsideration by:
- Fax: 1 (833) 946-1912
- Mail:
- UPS / FedEx ONLY:
C2C Innovative Solutions, Inc.
Part D QIC
301 W. Bay St., Suite 1110
Jacksonville, FL 32202
- United States Postal Service (USPS):
C2C Innovative Solutions, Inc.
Part D Drug Reconsiderations
P.O. Box 44166
Jacksonville, FL 32231-4165
How soon will I get a reconsideration decision?
- Reconsideration decisions are made within 90 days. All decisions are subject to Medicare’s approval. We have no input in the final decision.
- C2C may contact you during your appeal process to request additional information, it’s important that you respond with the information timely.
- For updates contact C2C directly at 1-(833) 919-0198 (Toll Free).
What happens if Medicare decides my penalty is wrong?
- Medicare will send you a letter explaining the decision. If reversed, we will remove or reduce your LEP and send you a letter that shows the correct premium amount and explanation on whether you will receive a refund.
- In many cases, the decision results in a partial reduction in the amount of LEP that you are required to pay. | Return to top
What happens if Medicare decides the penalty is correct?
- If Medicare decides that your late enrollment penalty is correct, you will be sent a letter explaining the decision, and you must pay the penalty.
Have additional questions? We’re here to help!
- You can chat live with a representative in our Member Portal or call us at 1-888-550-5252 (TTY: 711). Representatives are available to take your call Monday-Friday from 8 a.m. to 8 p.m. Between October 1 and March 31, representatives are available Monday-Sunday, 8 a.m. to 8 p.m. | Return to top
Helpful Forms
Wellcare is thankful for the opportunity to provide you with your Medicare Part D prescription drug benefits.
