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Medicare Part D Creditable Coverage

What is Creditable Coverage?

 

Prescription drug coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard prescription drug coverage under Medicare Part D. In general, the actuarial equivalence test measures whether the expected amount of paid claims under the employer's prescription drug coverage is at least as much as the expected amount of paid claims under the standard Part D benefit. The criteria in the test changes annually as the baseline Medicare Part D benefits change.

 

Visit the Centers for Medicare and Medicaid’s (CMS)  Creditable Coverage website for more information about creditable coverage, including access to model disclosure communication templates. Check this site often for the most up-to-date information.

What do you need to do?

 

In order to meet your obligations required by CMS, you must notify all Medicare eligible individuals who are eligible for coverage under your plan at specific times regardless of whether your plan is creditable or non-creditable.  CMS requires that Notice of Creditable Coverage be sent to any Medicare Eligible employee at the following times:


 

a. Each year, prior to the Medicare Part D Annual Coordinated Election Period which begins October 15;
b. Prior to an individual's Initial Enrollment period for Part D;
c. Prior to the effective date of coverage for any Medicare eligible individual that joins the plan;
d. Whenever the individual's pharmacy plan changes creditable/non-creditable status or terminates; and
e. Upon request.

 

Additional information regarding the Notice of Creditable Coverage including a copy of the employee disclosure notice can be found at http://www.cms.gov/CreditableCoverage.

 

The Notice of Creditable Coverage employee disclosure is intended to assist Medicare-eligible individuals in determining if they should enroll in a Medicare Part D plan at the initial enrollment period (IEP) or at a later date.  For those individuals who do not enroll during the initial enrollment period and do not have creditable coverage under another pharmacy plan, a late enrollment penalty fee (assessed as part of the premium) accrues monthly for each month that the individuals delay enrollment in a Medicare Part D plan.  If individuals have creditable coverage and enroll in a Part D plan at a later date, the late enrollment penalty fee will not be assessed.   

If you have any questions regarding this information, please feel free to contact your Florida Blue sales representative or agent.
 

Annual Determination

 

Annually, Florida Blue tests of our prescription drug benefit designs to satisfy the actuarial value test of the creditable coverage determination. Below is a link to a listing of plans that have been determined to be Not Creditable. Although not listed in the table, Go Blue, Rx Discount Plans or plans that cover only Generic medications are also Not Creditable.

 

Current Non-Creditable plans (PDF)

 

If you do not see your plan(s) listed, your plan(s) is most likely Creditable. However, an additional step would be if you find a plan(s) on the list with the same Copays/Coinsurance and a less than or equal Deductible and/or Out–of-Pocket maximum, then your plan(s) is also Not Creditable. For example, if your plan has a copay structure of $10/$60/$100 and a $2,000 deductible, your plan would NOT be Creditable as the plan with a $10/$60/$100 and a $1,500 deductible is listed as Not Creditable. 

 

If you have any circumstances that might require a custom test, you should contact your Florida Blue service department and provide the deductible, copayments and/or coinsurance amounts plus any plan maximums. We will review the plan benefits and return a decision.