Disclosure to CMS

The Centers for Medicare and Medicaid Services (CMS) requires entities that provide prescription drug coverage to Medicare beneficiaries to disclose whether the entity’s coverage is “creditable prescription drug coverage”. This notice, referred to as a Creditable Coverage Disclosure Notice or a Noncreditable Coverage Disclosure Notice, can be found on the CMS Website.

A prescription drug plan is deemed to be creditable if it:

  1. Provides coverage for brand and generic prescriptions;
  2. Provides reasonable access to retail providers and, optionally, for mail order coverage;
  3. The plan is designed to pay on average at least 60% of participants’ prescription drug expenses; and
  4. For entities that have integrated health coverage, the integrated health plan has no more than a $250 deductible per year, has no annual benefit maximum or a maximum annual benefit payable by the plan of at least $25,000 and has no less than a $1,000,000 lifetime combined benefit maximum.

Entities are to provide the disclosure to Part D eligible individuals at the following times:

  1. Prior to the Medicare Part D Annual Coordinated Election Period (ACEP) – beginning November 15th through December 31st of each year;
  2. Prior to an individual’s Initial Enrollment Period (IEP) for Part D;
  3. Prior to the effective date of coverage for any Medicare eligible individual that joins the plan;
  4. Whenever the entity no longer offers prescription drug coverage or changes the coverage offered so that it is no longer creditable or becomes creditable; and
  5. Upon request by the individual.

If the creditable coverage disclosure notice is provided to all plan participants annually, prior to November 15th each year, CMS will consider items 1 and 2 to be met.

In addition, most entities that provide prescription drug coverage to Medicare Part D eligible individuals must also disclose to CMS whether the coverage is “creditable prescription drug coverage”. This Disclosure to CMS can be completed on the CMS Website.

Disclosure to CMS must be made at the following times:

  1. Within 60 days after the beginning date of the plan year for which the entity is providing the Disclosure to CMS Form;
  2. Within 30 days after the termination of the prescription drug plan; and
  3. Within 30 days after any change in the creditable coverage status of the prescription drug plan.