Form CMS-L564

The process of enrolling in Medicare Part B can be more complicated than it may seem. For instance, individuals are only able to apply during certain parts of the year and must also prove they have lost current group health plan coverage with a lapse no longer than eight months. To facilitate this process, the Social Security Administration (SSA) provides form CMS-L564 for verification of employment and health insurance coverage. This form is used to grant Special Enrollment Periods for Medicare Part B outside the Initial Enrollment Period and General Enrollment Period.

For retirees wishing to use an SEP, the SSA requires them to complete form CMS-L564 along with their Medicare enrollment application. Retirees must complete Section A of the form, while their employer must fill out Section B with some basic information addressing the retiree’s periods of employment and health coverage. Individuals must submit the completed form to their local SSA office. The SSA will then check to make sure the data is accurate and complete before processing the application. Those who do not provide accurate information or fail to complete the form may face delays in their application or be subject to late enrollment penalties. This is particularly true if they were already receiving group health benefits from their or their spouse’s employer. Individuals may avoid these penalties by using an SEP if they were involuntarily excluded from Medicare due to loss of group health coverage.

How to Fill out Form CMS-L564?

The Social Security Administration designed form CMS-L564 to verify an individual’s group health plan coverage from their or their spouse’s current employment. The retiree must fill out Section A, and the employer must complete Section B of the form. If the employee doesn’t have this documentation when they apply for Medicare, they may be assessed a Part B late enrollment penalty.

To avoid these penalties, it is important that the form be filled out correctly. However, one question, in particular, seems to trip people up – Question #2. The answer to this question can greatly impact whether or not the employee is granted a Special Enrollment Period and thus can avoid a penalty when they enroll in Medicare Part B.

Our CMS L564 template makes it easy to ensure that the form is filled out correctly. This is because you can add pre-filled fields, insert images, highlight or blackout data for discretion, and even capture a signature digitally using a webcam or mobile phone camera. The template can then be emailed, faxed, downloaded, or shared via a link. This makes it a valuable tool for employers who have employees approaching retirement age and need to be sure they can qualify for a SEP when they enroll in Medicare.