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MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL 1, 2011, Important Notice From Insert Name of Entity About Your Prescription Drug Coverage and Medicare

How to fill out model non-creditable disclosure notice

How to fill out model non-creditable disclosure notice:

1. Begin by providing the name and contact information of the entity issuing the notice. This could be a healthcare provider, insurance company, or any covered entity.
2. Next, include the name of the individual or group that is receiving the notice. This could be an employee, member, or beneficiary.
3. Clearly state the purpose of the notice, which is to inform the recipient that the prescription drug coverage offered by the entity is not considered creditable under Medicare guidelines.
4. Include a brief explanation of what creditable coverage means, emphasizing that it refers to prescription drug coverage that is expected to pay, on average, as much as the standard Medicare prescription drug coverage.
5. If applicable, mention that the entity is offering prescription drug coverage under a different program that is creditable and provide details on how to access this coverage. This may include providing a separate document or directing the recipient to a specific website or phone number.
6. Encourage the recipient to carefully review the notice and to contact the entity if they have any questions or concerns. Include the contact information for the entity's customer service department or designated representative.

Who needs model non-creditable disclosure notice:

1. Employers offering prescription drug coverage to their employees that is not considered creditable under Medicare guidelines.
2. Health insurance companies providing individual or group health insurance plans that do not meet the creditable coverage criteria.
3. Healthcare providers or entities that offer prescription drug coverage to their members or beneficiaries that is not creditable. This could include government programs, non-profit organizations, or any other entity providing healthcare services.

It is important for these entities to provide the model non-creditable disclosure notice to their employees, members, or beneficiaries in a timely manner to ensure they are aware of the coverage status and to give them the opportunity to explore alternative creditable coverage options if needed.

For pdfFiller’s FAQs

What is model non-creditable disclosure notice?

Model non-creditable disclosure notice is a document that provides information to individuals regarding whether the prescription drug coverage they have is creditable or non-creditable.

Who is required to file model non-creditable disclosure notice?

Employers who offer prescription drug coverage to Medicare-eligible individuals are required to file model non-creditable disclosure notice.

How to fill out model non-creditable disclosure notice?

Model non-creditable disclosure notice can be filled out by providing information about the prescription drug coverage being offered and whether it is creditable or non-creditable.

What is the purpose of model non-creditable disclosure notice?

The purpose of model non-creditable disclosure notice is to inform Medicare-eligible individuals whether their prescription drug coverage is creditable or non-creditable, so they can make informed decisions about their coverage.

What information must be reported on model non-creditable disclosure notice?

Model non-creditable disclosure notice must include information about the prescription drug coverage being offered, whether it is creditable or non-creditable, and contact information for further questions.

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