Late Enrollment Penalty FAQ

Important Information About Late Enrollment Penalties

Wellcare is thankful for the opportunity to provide you with your Medicare Part D prescription drug benefit for 2025. As your prescription drug provider, it is our priority to ensure you have access to your medications.

As a Wellcare Medicare member with Part D coverage, you may still be subject to a monthly Late Enrollment Penalty (LEP) if you didn’t sign-up for Medicare Part D coverage when you were first eligible or did not have coverage for periods of time since becoming eligible. This penalty applies and will continue for as long as you have Medicare Part D coverage, no matter the plan sponsor. For example, if your premium is $0 and you have a LEP, you are still responsible for the monthly Medicare payment. If unpaid, it can result in a loss of your drug coverage.

Below are some helpful frequently asked questions about LEPs.

What is a Late Enrollment Penalty (LEP)?

Under Centers for Medicare and Medicaid (CMS) requirements, eligible Medicare members are required to have prescription drug coverage. When a beneficiary does not have acceptable coverage, CMS assesses the LEP, and we are required to include the LEP in your monthly premium charges.

A LEP is an amount added to your Medicare Part D monthly premium, as directed by CMS. The amount of the LEP depends on how long you went without Part D or creditable prescription drug coverage. Members may owe a Late Enrollment Penalty for any continuous period of 63 days or more after their Initial Enrollment Period is over, or go without one of the following:

• Medicare Prescription Drug Plan (Part D);
• A Medicare Advantage Plan (Part C) (like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drug coverage; or
• Creditable prescription drug coverage (current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, CHAMPVA, or health insurance coverage).

When you enroll in a Part D plan, it is important to provide information about prior coverage if you are not enrolling upon turning age 65.

  Learn more about Late Enrollment Penalties

How can I provide information regarding prior Part D coverage?

• If you are within the 60-days of the date on the letter advising of LEP, you can provide us with this information by completing the Declaration of Prior Prescription Drug Coverage form online. You can also complete the Declaration of Prior Prescription Drug Coverage form that was mailed to you when we provided notification of the LEP, or telephonically by contacting Member Services.
• If you are outside of the 60 days or disagree with the LEP decision you can complete and submit the Part D LEP Reconsideration Request Form located at the bottom of this page. 

How will I know if I owe a penalty?

• We will mail you a letter if you have a penalty. In general, you will have to pay this penalty for as long as you have a Medicare drug plan.

How long will I pay this penalty?

• You must pay the LEP as long as you are enrolled in the Medicare prescription drug benefit regardless of the part D plan you are enrolled in.
• Your LEP is a lifetime penalty and continues even when you change Medicare plans.
• LEP may stop in specific circumstances including when you turn 65 (if you had been assessed LEP in connection with Medicare benefits prior to that age, and when you become eligible for Extra Help (also known as Low Income Subsidy).

What if I have Extra Help, do I still owe the penalty payment?

• If you receive Extra Help, you may be subject to an LEP, depending upon when you enroll into your plan. In most cases, when you qualify for Extra Help, also known as a Low-Income Subsidy, LEP is not charged.

Why did my LEP amount increase?

• LEP amounts will change each calendar year in accordance with the Centers for Medicare and Medicaid (CMS) guidelines. Be sure to review your coupon book or AutoPay/EFT statement for the new amount. If you have a Social Security or Railroad deduction, you may view your new amount in your member portal.
• CMS determines the national plan premium average each year, which is used to calculate the amount of the monthly LEP.

Do I have to pay the LEP even if I do not agree with it?

• By law, the LEP is part of your premium, therefore payment is required. You must also pay the penalty even if you have asked for a reconsideration. If you fail to pay your LEP, you subsequently can be disenrolled from your plan resulting in loss of drug coverage. You can complete an attestation form if you disagree with the late enrollment penalty.

What if I do not agree with the LEP?

• You may provide information about your prior prescription drug coverage online, over the phone or in writing. If you would like to complete it in writing, you must complete the LEP form and return it to the address or fax number listed. This must be done within 60 days from the date on the letter telling you that you owe a LEP. Also, send any proof such as a copy of your notice of creditable drug coverage from an employer or union plan. A copy of the Prior PDP Coverage and Reconsideration forms are linked at the bottom of this page and was included in the letter you received.

How soon will I get a reconsideration decision?

• Reconsideration decisions are made within 90 days. All decisions are subject to Medicare’s approval. We have no input in the final decision.

What happens if Medicare decides the penalty is wrong?

• Medicare will send you a letter explaining the decision. If reversed, we will remove or reduce your LEP and send you a letter that shows the correct premium amount and explanation on whether you will receive a refund.
• In many cases, the decision results in a partial reduction in the amount of LEP that you are required to pay.

What happens if Medicare decides the penalty is correct?

• If Medicare decides that your late enrollment penalty is correct, you will be sent a letter explaining the decision, and you must pay the penalty.

What if I don’t have many prescriptions and I just want to pay directly instead of having a prescription drug plan?

• Under Federal law, CMS requires that Medicare eligible beneficiaries have a qualifying prescription drug plan. If you subsequently enroll in a prescription drug plan you will be assessed LEP for all gaps in coverage (more than 63 days).
• Low-cost drug plans that have creditable coverage are available in most regions, which may be preferable to paying a large penalty in the future. For example, a 12-month gap in coverage will result in a penalty of approximately $4.00 per month, and if you wait 5-years to enroll the LEP will be more than $20.00 per month.

Have additional questions? We’re here to help!

• You can chat live with a representative in our Member Portal or call us at 1-888-550-5252 (TTY: 711). Representatives are available to take your call Monday-Friday from 8 a.m. to 8 p.m. (Between October 1 and March 31, representatives are available Monday-Sunday, 8 a.m. to 8 p.m.).