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MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 09380990 FOR USE ON OR AFTER JANUARY 1, 2009, Important Notice From Insert Name of Entity About Your Prescription Drug Coverage

How to fill out model non-creditable coverage notice

How to fill out model non-creditable coverage notice:

1. Gather the necessary information: Begin by collecting all the relevant details required to complete the notice. This may include the name of the employer, the name of the health plan, and the effective date of the coverage.
2. Identify the recipient: Determine who will be receiving the notice. This could be employees, plan participants, or beneficiaries who are covered under the health plan.
3. Understand the purpose: Familiarize yourself with the purpose of the model non-creditable coverage notice. This notice is used to inform individuals that the health coverage being offered is not considered creditable coverage for Medicare Part D prescription drug coverage.
4. Fill in the employer's information: Enter the employer's name and contact information in the appropriate sections of the notice. This ensures that the recipients can easily identify the source of the notice.
5. Provide details about the health plan: Fill out the section containing information about the health plan. Include details such as the plan name, coverage start date, and description of the coverage being offered.
6. Signal non-creditable coverage: Clearly state that the coverage being provided is not considered creditable coverage for Medicare Part D prescription drug coverage. This alerts the recipients that they may face potential penalties if they enroll in Medicare Part D later, without having other creditable prescription drug coverage.
7. Explain implications and alternative options: Offer a brief explanation regarding the implications of non-creditable coverage and discuss alternative coverage options that the individual may consider.

Who needs model non-creditable coverage notice:

1. Employers offering health coverage: Employers who provide health coverage to their employees or beneficiaries need to provide the model non-creditable coverage notice. This helps inform individuals about the creditability of the coverage for Medicare Part D prescription drug coverage.
2. Individuals covered under the health plan: Plan participants, employees, and beneficiaries who are covered under the health plan also need to receive the model non-creditable coverage notice. This allows them to make informed decisions regarding their Medicare Part D coverage options.

Note: It is important to comply with any specific legal requirements or guidelines set forth by the relevant authorities when filling out and distributing the model non-creditable coverage notice.

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What is model non-creditable coverage notice?

The model non-creditable coverage notice is a communication that informs individuals who are eligible for Medicare Part D prescription drug coverage whether their current prescription drug coverage is creditable or non-creditable.

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

Employers and plan sponsors who offer prescription drug coverage to Medicare-eligible individuals are required to file the model non-creditable coverage notice.

How to fill out model non-creditable coverage notice?

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

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

The purpose of the model non-creditable coverage notice is to help individuals make informed decisions about whether to enroll in Medicare Part D prescription drug coverage.

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

The model non-creditable coverage notice must include details about the prescription drug coverage offered, whether it is creditable or non-creditable, and the contact information for the entity providing the coverage.