April 16, 2023

What is a Notice of Exclusion From Medicare Benefits?

notice of exclusion from medicare benefits

The notice of exclusion from medicare benefits informs the beneficiary of a Medicare plan decision to end coverage. It also provides information about how to appeal the decision.

The notice may be issued at any time if a Medicare plan denies or rejects an individual’s request for medical coverage and a person has a right to appeal that denial. Usually, a person needs to provide proof of why their coverage is denied.

In the case of Medicare Part D, this notice may be provided in an employer's drug coverage plan materials or a separate mailing to all Medicare eligible participants prior to the annual October 15th Open Enrollment period for that year. Alternatively, the notice can be provided by an electronic means, such as a computer.

This is done to ensure the participant has a choice of a Medicare Part D plan that is at least as good as Medicare's prescription drug coverage. This requirement is in place to protect beneficiaries from the risks associated with non-creditable prescription drug coverage.

If a participant has other creditable prescription drug coverage from a previous employer-sponsored health plan, a reasonable portion of the employer's HRA contribution should be allocated to that previous health plan. This amount could be based on average reimbursement data and/or other facts and circumstances.

Effective April 1, 2019, Medicare Advantage (MA) and Part D plans will begin rejecting or denying claims submitted for payment for Part D drugs and MA services and items prescribed or furnished by an individual or entity on the Preclusion List. The Preclusion List is maintained by the Office of the Inspector General (OIG).

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