Creditable Coverage

What is Creditable Coverage?

If a Medicare eligible member does not maintain creditable coverage for 63 days or longer (following their initial enrollment period for Medicare Part D) a late enrollment penalty will be applied through the Medicare Modernization Act (MMA).

Employer Groups are responsible for determining if coverage is creditable and notifying their employees.

Quartz provides creditable coverage determinations for Small Group ACA products. This determination is posted on the website by October 15 for the following year plans.  See the link below for the 2019 Small Group creditable coverage determination.

Most of Quartz’s Small Group plans meet CMS’s requirements for creditable coverage. Some HSA plans have higher deductibles ($5,000 and above) and may not meet creditable coverage requirements.

The Medicare Modernization Act, 42 CFR § 423.56
Procedures to determine and document creditable status of prescription drug coverage

  • This rule requires entities that offer prescription coverage to notify their Medicare-eligible policyholders whether their coverage is creditable. This means that the coverage is expected to pay on average as much as the standard Medicare Part D coverage.
  • This is determined using generally accepted actuarial principles and in accordance with Centers for Medicare and Medicaid Services (https://www.cms.gov/) (CMS) actuarial guidelines.

For more information on creditable coverage –

For more information about the CMS late enrollment penalty –

For more information on who is supposed to provide disclosure –