Medicare Part D Creditable Coverage - CMS Final Rule for 2027 Plan Years

Employers are not required to offer creditable prescription drug coverage, but they are required to determine and communicate creditable (or non-creditable) status to eligible individuals. This information assists Medicare Part D eligible individuals in making informed decisions about enrolling in Medicare Part D and helps avoid late enrollment penalties.

Determining Creditable Coverage Status

Prescription drug coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of Medicare Part D prescription drug coverage. Employers often rely on insurance carriers or third-party administrators (TPAs) to provide the creditable determination. If such information is not provided, the employer must make the determination themselves.

Employers who do not apply for the retiree drug subsidy may use the “simplified method” for determining whether prescription drug coverage is creditable. If a plan does not meet the criteria under the simplified determination method, the employer could assume the plan is non-creditable, or the employer could obtain an actuarial determination to confirm.

Simplified Method for Determining Creditable Status

For 2026 plan years, employers may choose to use either the existing simplified method per CMS 2009 instructions or the newly revised simplified method for determining creditable status. Beginning in 2027, only the revised simplified method may be used.

Revised Simplified Method (available beginning in 2026)
To be deemed creditable, the plan must meet the following criteria:

• Provide reasonable coverage for brand name and generic prescription drugs and biological products;
• Provide reasonable access to retail pharmacies; and
• Pay on average at least 72% (73% for 2027 plan years) of participants’ prescription drug expenses.

Existing Simplified Method
To be deemed creditable, the plan must meet the following criteria:

• Provide reasonable coverage for brand-name and generic prescription drugs;
• Provide reasonable access to retail pharmacies;
• Pay on average at least 60% of participants’ prescription drug expenses; and
• Depending upon whether the plan is integrated (most plans are non-integrated):
  • A non-integrated drug plan must have either no annual benefit maximum or a minimum annual benefit of $25,000; OR have an actuarial expectation that the amount payable by the plan will be at least $2,000 annually per Medicare-eligible individual.
  • An integrated plan must: have a maximum annual deductible of $250; have either no annual benefit maximum or a minimum annual benefit of $25,000; AND have a lifetime combined benefit maximum of at least $1 million.

Disclosure of Creditable Status to Eligible Participants

The creditable status of the plan must be disclosed to Medicare Part D eligible individuals who are eligible to enroll in the plan sponsor’s prescription drug plan. This includes employees, COBRA participants, retirees, as well as their spouses and dependents. Individuals are eligible for Medicare Part D if they are enrolled in either Medicare Part A or Part B and live in the service area of a Medicare Part D plan. Due to difficulties in identifying eligible individuals, many employers choose to provide the disclosure notice to everyone eligible for their prescription drug plan.

Timing

Employers can satisfy the annual disclosure requirement by providing the notice each year during the employer’s open enrollment period or in the fall to coincide with the Medicare Part D open enrollment period. The notice must also be provided when individuals are first eligible for prescription drug coverage (e.g., new hires). Additionally, employers must provide notice whenever the employer no longer offers prescription drug coverage, when the creditable status changes, and upon request.

Delivery Method

CMS recommends employers mail paper copies. However, notices may be provided electronically if the DOL’s electronic delivery safe harbor is satisfied. Employers may provide a single notice to eligible individuals and their dependents residing at the same address. If the notice is incorporated with other information or notices (e.g., benefits booklet or enrollment packet), the disclosure should be on its own page, and a prominent reference (in 14-point font) should be included on the first page of the materials listing the notice’s specific page number.

Reporting to CMS

In addition to individual disclosures, employers must report the creditable status of their coverage to CMS annually, within 60 days of the start of the plan year. This reporting is most often completed by the employer and not the insurance carrier or TPA. Information necessary to complete the reporting includes employer identification number, type of coverage, number of plan options, estimated number of Medicare-eligible individuals covered, and the date the notice was distributed to participants.

CMS instructions are available here.

Author