Creditable Coverage Template Letter For Employers (2018) (Page 2 of 2) in pdf

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly

premium may go up by at least 1 percent of the Medicare base beneficiary premium per month for

every month that you did not have that coverage. For example, if you go nineteen months without

creditable coverage, your premium may consistently be at least 19 percent higher than the Medicare

base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have

Medicare prescription drug coverage. In addition, you may have to wait until the following October to

join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact our office for further information. {HR Contact Information}

NOTE: You’ll get this notice each year. You will also get it before the next period you can join a

Medicare drug plan, and if this coverage changes. You also may request a copy of this notice at any

time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the

“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare.

You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

 Visit

 Call your State Health Insurance Assistance Program (see the inside back cover of your copy

of the “Medicare & You” handbook for their telephone number) for personalized help

 Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

You can call 24 hours a day, 7 days a week.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage

is available. For information about this extra help, visit Social Security on the web at

, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare

drug plans, you may be required to provide a copy of this notice when you join to show

whether or not you have maintained creditable coverage and, therefore, whether or not you

are required to pay a higher premium (a penalty).

Creditable Coverage Template Letter For Employers (2018) Page 2