What happens if I am unable to provide creditable coverage?

Question

Tracy Davis · Accepted Answer

If you are unable to provide credible coverage through a group plan, then I would suggest getting on Medicare as soon as possible to avoid any penalties for now and the future

Answered by Jonathan Potter on September 29, 2025

Broker Licensed in UT, AZ, CA & 14 other states

Answered by Jonathan Potter Medicare Insurance Agent

Gary Church · Answer

Question: What happens if I'm unable to provide critical coverage?

Well, you could be faced with a penalty with Medicare. Hopefully, that's what you're referring to. If you're currently working and your employer has at least 20 or more employees that you're working for, you're not required to apply for your Medicare. But if there are less than 20 employees, you are going to be able to provide credible coverage. That's determined by Medicare at the point that you're signing up.

If you're ever in doubt, the best thing to do is either reach out to Medicare directly or sit down with a licensed Medicare agent who can help evaluate your current situation. But you do not want to hesitate. You want to make sure that you're making an informed decision. And that's what's important about sitting down with a licensed Medicare agent who can advise you and help you understand what your options are.

So hopefully, that answers your question.

Lt Col Tim Brown · Answer

Usually, you just answer the letter or form they send to you asking you about it.  You check off the box that says you had it.  If they pursue that further, there is a form the employer has and fills out stating you had it.  If you had an individual plan, you can use that to provide proof.  If you have nothing to back it up (should they ask for that) you will be paying a penalty forever.  

Lt Col Tim Brown  
Agent / Broker
Contact me

Charise Karjala · Answer

So the question is, what happens when we can't have proof of credible coverage when we apply for Medicare? Well, the fact of the matter is that this problem doesn't really occur very frequently because most people don't want to go without insurance. Right? They just don't. So they stay on their employer-sponsored plan until after they're 65, or they stay with their spouse, and their spouse has planned for as long as they can. So, the spouse retires, or maybe they live in a different country and they have that kind of coverage that's in France, Japan, Canada, or the UK, and all of those are credible coverage.

So the credible coverage requirements are generally speaking, do you get to see a doctor, or do you go to see specialists? Do you get prevention? Is there medications? Is there surgery involved? And if any of the answers to that are no, then, well, you don't have credible coverage. But most policies, legitimate policies, have credible coverage.

Now, I want those of you who think you can go and save a little bit of money. Right? And you listen to these people who call you on the telephone and give you high-pressure sales, do not listen to them. These people will sell you ice cubes to an Eskimo, and they'll say, "Oh yeah, it's all good." And you are so in trouble because they're lying to you. Don't listen to anybody who calls you up out of the blue saying they're from Medicare and they have a policy to sell you. Do not listen to them because those are not credible coverage. They have preexisting conclusions and preexisting conditions that are precluded. Most don't include drug plans, or they have a discount policy. It's not real insurance.

So be well-informed and be protected. And when in doubt, you know where you can find me. I'm happy to assist you.

Jonathan Potter · Answer

If you are unable to provide credible coverage through a group plan, then I would suggest getting on Medicare as soon as possible to avoid any penalties for now and the future

Ronnie Robinson Jr · Answer

You may be subject to penalties without proof that you had creditable coverage prior to being eligible for Medicare, especially if outside of your initial enrollment period around your 65th birthday. Those penalties could last for the rest of your life.

Answered by Ronnie Robinson Jr on August 12, 2025

Broker Licensed in FL, AL, GA & 9 other states

Answered by Ronnie Robinson Jr Medicare Insurance Agent

Kelsey Hentzen · Answer

If you are unable to provide creditable coverage when you move to Medicare, it is possible you would be subjected to a lifetime penalty. The penalty depends on how long you have gone without health coverage.

Answered by Kelsey Hentzen on September 30, 2025

Broker Licensed in KS & MO

Answered by Kelsey Hentzen Medicare Insurance Agent

James Carlson · Answer

Depending on what type of insurance you had, and how long you have been covered by the plan will help verify if you would be subject to a penalty.

Paul Potter · Answer

I usually get this question from stay at home spouses because they did not work as much out of the home. So the first question I ask is "are you married, or were you married for 10 years to one person?" If so, you can claim your spouses creditable coverage. If not, you do have the ability to buy into Medicare. Finally, and this one gets tricky, you might be eligible for ACA coverage.

Answered by Paul Potter on September 12, 2025

Broker Licensed in FL

Answered by Paul Potter Medicare Insurance Agent

Nicholas Depke · Answer

If you cannot show proof of creditable coverage for a period when you were eligible for Medicare but did not enroll, you face permanent premium penalties that never go away. The Part B penalty adds 10 percent to your premium for every 12 months you went without coverage, and the Part D penalty is calculated on how long you went without creditable drug coverage and gets tacked onto your monthly premium for life. Not all insurance qualifies, so never assume your retiree coverage or other plan meets the standard without verifying it first. If you have a gap or are unsure where you stand, talk to a Medicare agent or your local SHIP counselor before your enrollment deadlines, because fixing this before you enroll is always easier than dealing with penalties after the fact.

Answered by Nicholas Depke on March 29, 2026

Broker Licensed in NE, AZ, FL & 15 other states

Answered by Nicholas Depke Medicare Insurance Agent

Mark Holmes · Answer

Without a Special Enrollment Period, you will need to wait for Open Enrollment for the type of plan you would like to apply for.

Calvin Vo · Answer

If you are unable to provide proof that you had creditable coverage for Part B and/or Part D, you will face a lifetime penalty when you want to sign up for Medicare Part B and Part D.

The penalty is a 10% increase in the Part B premium for each 12-month period that you did not have a creditable plan equivalent to Part B, and a 1% penalty for each month you did not have a creditable prescription drug plan.

Please note that COBRA coverage is not considered creditable for Part B, and you should find another plan to bridge the gap from your retirement to Medicare.

Andrew Zurbuch, MBA · Answer

If it is for Medicare Part D, then you would be access a Late Enrollment Penalty if you do have proven creditable coverage. If you enroll in a Medicare Part D plan, then Medicare would add the Penalty to your premium. If it is medical insurance, then if you break the creditable coverage chain, then your preexisting conditions, if you have any, would not be covered in the event of a medical claim. Call your Insurance Company if you have a Insurance Policy to get a copy of Certificate Of Creditable Coverage mailed to you. Please contact a Broker  
for assistance.

Plans are insured or covered by a Medicare Advantage (HMO, PPO and PFFS) organization with a Medicare contract and/or a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Diana Garner · Answer

If you are eligible for Medicare and cannot provide proof of creditable coverage when you enroll, you will likely face permanent late enrollment penalties. Creditable coverage is prescription drug coverage from another plan (like an employer plan) that is at least as good as the standard Medicare Part D plan. 

If you were covered by another plan that was not creditable and did not enroll in Medicare during your Initial Enrollment Period, Medicare will impose penalties for the delay. The penalty is added to your monthly Medicare premiums for as long as you have Medicare drug coverage.

Steve Houchens · Answer

If you are unable to prove credible coverage you may incur additional costs penalty of either Medicare  part B or part D if you didn’t enroll when you were first eligible.

Jim Tretola · Answer

If you cannot provide proof of creditable coverage, you may be assessed a penalty.
These penalties can go for life, unless you meet certain criteria that waive the penalty.

Leslie Kaz · Answer

If you go without creditable coverage for too long, you could face a late enrollment penalty when you sign up for Medicare Part B or Part D.

Part B (Medical Insurance) – If you don’t have creditable coverage and delay enrolling, your premium may go up 10% for every 12 months you were eligible but didn’t sign up. This penalty is permanent.

Part D (Prescription Drug Coverage) – If you go 63 days or more without creditable drug coverage, you may pay an extra monthly penalty for as long as you have Part D.

Creditable coverage means your existing insurance is at least as good as Medicare’s standard coverage. If you’re ever unsure whether your plan is creditable, ask your insurer for a written notice—keep it in your records in case Medicare ever asks for proof.

Gus Karigan · Answer

If you cannot provide **creditable coverage**—prescription drug insurance that’s at least as good as Medicare’s standard Part D benefit—it can affect your **Medicare Part D** enrollment. Without creditable coverage, delaying Part D enrollment may trigger a **permanent late enrollment penalty**, calculated as 1% of the national base Part D premium for each full month without coverage, added to your monthly premium when you join.

You may also face higher out-of-pocket costs for prescriptions until you enroll in Part D. If you lose other creditable coverage, you have a **63-day Special Enrollment Period** to sign up without penalty. Missing that window is when the late enrollment penalty applies, so timely enrollment is key to avoiding extra costs.

Pauline Weiland · Answer

If you are over the age of 65 with no proof of credible coverage since turning 65, you may incur a lifetime penalty. There are several scenarios that will dictate what and if you owe a penalty. Best to talk to your local broker for information.

Answered by Pauline Weiland on April 20, 2026

Agent Licensed in AZ, CA, MS, NV & TX

Answered by Pauline Weiland Medicare Insurance Agent

Constance Phillips · Answer

You incur Late Enrollment Penalty that is added to your Part D premium. This penalty is permanent, and it is 1% of the national base premium. The penalty is calculated for each month that you did not carry credible insurance coverage.

Answered by Constance Phillips on October 3, 2025

Agent Licensed in OH

Answered by Constance Phillips Medicare Insurance Agent

Shalonda Cave · Answer

You’ll face a monthly premium penalty that increases over time if you go without Medicare Part D. This can lead to gaps in coverage and higher out-of-pocket expenses for medications. Contact a local agent 3 months before your birthday or retirement to get help with your Medicare needs.

Answered by Shalonda Cave on December 29, 2025

Agent Licensed in OH, AZ & FL

Answered by Shalonda Cave Medicare Insurance Agent

Lloyd Griffin · Answer

Specifically as it applies to Part B & Part D rule of thumb is to get proof early as if there is no concrete evidence the possiblity of higher premiums are possible for life.

Gary Henderson · Answer

You only need to provide predible proof of coverage if you've not gone on to Medicare at age 65 
If you had no coverage or no creditable coverage, meaning like a hospital indemnity plan that doesn't meet the standards for creditable coverage, then you would pay a penalty annually of 10% per year for every year that you did not have credible coverage after 65 to your current age

Mary Brown · Answer

If you can’t provide proof of creditable prescription drug coverage when enrolling in Part D, you may face a late enrollment penalty, which increases your premiums for as long as you have Part D. It’s important to either show creditable coverage or enroll as soon as possible to avoid extra costs.

Answered by Mary Brown on March 30, 2026

Broker Licensed in NJ, DE, FL & NC, OH, PA & TX

Answered by Mary Brown Medicare Insurance Agent

Andrew Kramer · Answer

I assume your question is related to the LEP (Late Enrollment Penalty) for a Medicare Part D, drug plan. For those who don't know what that is, if after turning 65, you decide to stay on your employer health insurance, and you are able to do so because there are 20 or more employees on the group health insurance. And during that time, you only have Medicare Part A, which you get when you turn 65. But when you decide to leave your employer group health insurance and sign up for Medicare Part B, and then either join an Advantage plan which has Part D coverage, or buy a supplement + Part D plan, Medicare will send you a letter asking you to provide information about the drug coverage on your previous group health insurance. If you don't, or can't provide that info, you will pay an LEP every month for the time that you could not prove that you had a Rx coverage from when you turned 65. It amounts to close to $5 per month, for every year you did not have Rx coverage. So for example, if you stayed on your group health plan til age 70, and did not save your health card to prove your coverage, you will pay about $25 per month to Social Security, for the rest of your life!!! Moral of the story, don't throw away your prior employer health card!

Answered by Andrew Kramer on August 29, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Carol Thompson · Answer

Not having proof of creditable coverage can lead to Part B & Part D penalties that are retroactive back to the when you turned 65 years of age. Social Security administration would be able to provide you with this information.

Answered by Carol Thompson on October 30, 2025

Broker Licensed in FL, LA, MI & NC, SC, VA & WI

Answered by Carol Thompson Medicare Insurance Agent

Marcie Barnes · Answer

There are late enrollment penalties if you delay signing up for Medicare at age 65.

Check medicare.gov for information on late enrollment fees

Todd Bostic · Answer

You will probably be penalized, depending on if you have had it before. You can also get it waived if you have Medicaid or a Low Income Subsidy.

Jack Mayer · Answer

You need to sign up for Medicare part B and if you are coming off an employee group health plan, could be your spouses, you have 8 months to enroll without penalty

Pat Papson · Answer

Hello,

If your ate unable to provide creditable prior coverage.

You will be charged a penalty for as many months that you didn't have coverage

This is determined by the government rules.

Hope your able to provide that coverage

Julie Thompson · Answer

It will depend on the situation requiring the creditable coverage. I woild need more details. A good time to get with an agent for assistance.

Ken Banks · Answer

If you are unable to provide evidence of creditable coverage, the primary consequence is that you may face late enrollment penalties if you choose to enroll in Medicare Part B or Part D at a later date. These penalties are typically permanent and are added to your monthly premiums for as long as you have that coverage.

Answered by Ken Banks on November 17, 2025

Broker Licensed in GA, AL, DC & 5 other states

Answered by Ken Banks Medicare Insurance Agent

Adam Paul · Answer

Are you referring to credible prescription drug coverage? If so, you will be subject to paying a fine. Medicare Part D Late Enrollment Penalty, calculated as 1% of the national base premium for each month you didn't have creditable drug coverage, is added permanently to your monthly premium. For example, in 2025, the base premium is about $36.78, so 12 months of delay means an additional 12% of that, or about $4.41 (rounded), added to your bill.

Answered by Adam Paul on December 22, 2025

Broker Licensed in CA, NV, OK & OR

Answered by Adam Paul Medicare Insurance Agent

Natalee Nimmo · Answer

Unfortunately, you would have late enrollment penalties that you have to pay. Those late enrollment penalties you pay for as long as you are on Medicare. There is one option that would omit the late enrollment penalties and that would be if you qualify for a program through Social Security called extra help. When you talk to your agent, ask them about that.

Answered by Natalee Nimmo on November 17, 2025

Broker Licensed in SC, FL, GA & KY, MO, NC & TX

Answered by Natalee Nimmo Medicare Insurance Agent

Charlie Fitzgerald · Answer

If you delay Medicare enrollment without credible coverage, you may face a late enrollment penalty for Medicare Part B or Medicare Part D.

The penalty for Medicare Part D is 1% of the national base beneficiary premium times the number of months you went without creditable coverage. In addition, the Medicare Part B penalty is 10% for every 12-month period you go without coverage. Keep in mind, these penalties never go away. That’s why it’s important to know if your current coverage is creditable before you choose to delay enrolling in Medicare.

Many employees are under the impression that their group health plan through work will allow them to delay enrollment in Medicare until they retire. However, if you work for an employer with fewer than 20 employees, your group health insurance will not be creditable for Medicare.

Patricia Graham · Answer

I this case, there would be fines associated with coverage that is not credible after the age of 65.

Chauncey Bragg · Answer

If you are unable to provide proof of creditable coverage. You will face being accessed a 10% penalty on top of your normal medicare cost that is taken from your social security check. This penalty will be in effect every year until your death.

Answered by Chauncey Bragg on May 19, 2026

Broker Licensed in OH

Answered by Chauncey Bragg Medicare Insurance Agent

Robin Duffey · Answer

Unfortunately, when you enter Medicare and you cannot provide creditable coverage you will have Part B and Part D penalties forever.  robin

Al Saponar · Answer

In that case, you will be assessed a late enrollment penalty by CMS , which is 1% per month based on the national average PDP plan.
For every month since you became eligible for part D.
This is added to part D plan or MAPD premium every month.

Kathleen Gonzales-Byrd · Answer

You will incur permanent penalties if you have delayed enrollment for Part A, B, and D. The penalty fees vary for each part of Medicare. You should enroll in each of these Medicare groups as soon as possible to minimize enrollment delay.

Answered by Kathleen Gonzales-Byrd on February 9, 2026

Agent Licensed in PA, KS, MD, NJ & NY

Answered by Kathleen Gonzales-Byrd Medicare Insurance Agent

Lori Marion` · Answer

Thar depends on the situation.  You don't need to show coverage in order to get started on Medicare when you first become eligible. 
But if you wait to start Part B or Part D prescription coverage,  you could be penalized when you do begin coverage. 
It's always best to talk to am experienced agent when making any decisions regarding your Medicare choices so you don't risk getting hit with unexpected penalties.

Stanley Wittenberg · Answer

Then regarding prescription cost for coverage will cost 1% per month more depending on how long the coverage can’t be authenticated

Julie Hamilton, RN · Answer

If you are unable to provide proof of creditable coverage, you will likely face late enrollment penalties for both Part B and Part D. The Part B premium penalty is 10% for each full 12 month period you were eligible for Part B but didn't enroll and didn't have creditable coverage. For Part D, you may pay a penalty of an extra 1% of the national base premium for each full month you were eligible but didn't join a plan and didn't have creditable drug coverage. This amount is added to your monthly Part D premium for as long as you have the coverage and changes annually.

Answered by Julie Hamilton, RN on August 12, 2025

Broker Licensed in GA, AL, SC & TN

Answered by Julie Hamilton, RN Medicare Insurance Agent

Janelle Brown · Answer

If you’re unable to provide creditable coverage, which means your previous health or drug plan wasn’t considered equal to or better than Medicare’s standard coverage, you may face a late enrollment penalty when you eventually sign up for Medicare Part B or Part D. This penalty is added to your monthly premium for as long as you have Medicare, and the longer you go without creditable coverage, the higher the penalty becomes.

To avoid this, always keep proof of any prior insurance and enroll in Medicare during your Initial Enrollment Period or within 63 days of losing creditable coverage.

Jerry Naylor · Answer

If you lose creditable coverage there is normally a special enrollment period to enroll in Part D without penalty. 

If you don’t have creditable coverage and delay enrollment in Part D you may face a late enrollment penalty.

Christie Adcock · Answer

If you are approaching 65, creditable coverage is not required as long as you enroll in your initial enrollment period that starts three months before your 65th birth month, the month of your birth and continues three months after. Creditable coverage would only be required if you delayed your Part B. Then likely you would have a late enrollment penalty for Part B and D and the penalties last throughout your lifetime.

Answered by Christie Adcock on November 13, 2025

Agent Licensed in IN, AL, FL & 8 other states

Answered by Christie Adcock Medicare Insurance Agent

Artreanua Carr · Answer

By not providing creditable coverage you may be subject to a late enrollment penatly fee for Part B and Part D. If you are retiring from your place of employment that supplied you with health insurance, follow up with you human resource officer and have them fill out a CMS-L564 for proof of insurance. The CMS-L564 can be obtain from Medicare.gov or SSA.gov

Answered by Artreanua Carr on April 16, 2026

Agent Licensed in NC, AR, FL & 8 other states

Answered by Artreanua Carr Medicare Insurance Agent

What happens if I am unable to provide creditable coverage?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

What happens if I am unable to provide creditable coverage?

Agents: Share Your Expertise

Seniors: Ask a Question of Your Own

Related Questions

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website