Completing Form CMS-L564: Request for Employment Information

Form CMS-L564, the Request for Employment Information, is the one-page form your employer fills out to confirm you had group health plan coverage while you were eligible for Medicare Part B. You complete Section A, your employer completes Section B, and you submit it together with Form CMS-40B to the Social Security Administration during your Special Enrollment Period. SSA uses the completed L564 to verify you qualify to enroll in Part B without a late enrollment penalty.

Who Needs to File It

You need Form CMS-L564 if you delayed Part B because you had health coverage through an employer-sponsored group health plan based on current employment — your own, a spouse’s, or (for people under 65 with a disability) a family member’s.1Centers for Medicare & Medicaid Services. Original Medicare (Part A and B) Eligibility and Enrollment

The Special Enrollment Period lasts eight months and starts the month after your employment ends or your group health coverage ends, whichever happens first.2Centers for Medicare & Medicaid Services. Request for Employment Information You must have had continuous group health plan coverage since you first became eligible for Part B. Miss that window and you can only enroll during the General Enrollment Period from January 1 through March 31, with coverage starting July 1.3Medicare. When Does Medicare Coverage Start?

Filling Out Section A

Section A is your part. Complete it before handing the form to your employer. The fields are:4Centers for Medicare & Medicaid Services. Medicare Request for Employment Information

  • Applicant’s name — your full legal name as it appears on your Social Security records.
  • Applicant’s Social Security Number.
  • Employee’s name — if your coverage came through a spouse’s or family member’s job, put that person’s name here. If it was your own job, leave blank or repeat your name.
  • Employee’s SSN — same logic; enter the employee’s number if different from yours.
  • Employer’s name and address — the company that provided the group health plan.

Match your name and SSN to your Social Security records exactly. A missing middle initial can hold up processing because SSA cannot link the form to your file.

Getting Section B Completed by Your Employer

Section B has to be filled out by someone who can verify your coverage from payroll or benefits records — usually an HR manager or benefits administrator.2Centers for Medicare & Medicaid Services. Request for Employment Information

The employer answers four questions:4Centers for Medicare & Medicaid Services. Medicare Request for Employment Information

  • Whether you were covered under the employer group health plan (yes or no).
  • The date coverage began (month and year).
  • Whether coverage has ended (yes or no).
  • If ended, the date it ended (month and year).

The employer also enters the dates you worked there and whether you’re still employed. An authorized representative signs and dates the form and provides a title and phone number. SSA may call to confirm what’s on the form, so the contact needs to be someone who can actually answer questions about your benefits records.

If Your Employer Won’t or Can’t Sign

Employers sometimes go out of business, lose records, or refuse to help. Fill out Section B as best you can and attach secondary evidence. SSA accepts:5Social Security Administration. How to Apply for Medicare Part B (Medical Insurance) During Your Special Enrollment Period

  • Income tax returns showing health insurance premiums paid
  • W-2s reflecting pre-tax medical contributions
  • Pay stubs showing health insurance premium deductions
  • Health insurance cards with a policy effective date
  • Explanations of benefits paid by the group health plan
  • Statements or receipts reflecting payment of premiums

Send as much as you can gather. If the former employer closed years ago, old tax returns and W-2s are usually the most reliable substitutes, and prior-year W-2s can be retrieved from the IRS.

Coverage That Does Not Qualify

Not every kind of health insurance counts as coverage based on current employment, and getting this wrong is what causes penalties. These do not qualify for the Special Enrollment Period:5Social Security Administration. How to Apply for Medicare Part B (Medical Insurance) During Your Special Enrollment Period

  • COBRA continuation coverage. Your eight-month SEP window starts when your employment or employer coverage ends, not when COBRA runs out.6Medicare. COBRA Coverage
  • Retiree health coverage. A retiree plan is not tied to current employment even if a former employer provides it.
  • VA coverage. Veterans Affairs benefits do not substitute for employer group coverage for SEP purposes.
  • Individual or Marketplace coverage.

COBRA is where most people get caught. You can be on COBRA and still enroll in Part B, but don’t assume the SEP deadline waits for COBRA to expire — the clock has been running since your employment ended.

One other eligibility point: for the SEP based on age, the group health plan generally has to be sponsored by an employer with 20 or more employees. If your employer had fewer than 20 and offered a single-employer plan, Medicare was already your primary payer and you should have signed up for Part B when first eligible.7Centers for Medicare & Medicaid Services. Small Employer Exception

Submitting the Form

Submit the completed L564 together with Form CMS-40B, the Application for Enrollment in Medicare Part B. The L564 proves prior coverage; the CMS-40B is the actual enrollment request. One without the other won’t get you enrolled.8Centers for Medicare & Medicaid Services. Medicare Request for Employment Information Both forms are free to download from the CMS website.9Centers for Medicare & Medicaid Services. CMS 40B – Request for Enrollment in Medicare Part B (Medical Insurance)

There are three ways to send them:

  • Online. If you already have Part A and are applying during a Special Enrollment Period, use SSA’s online tool at ssa.gov/Medicare-PartB-SEP. The portal accepts uploads of your completed L564 and supporting documents.10Social Security Administration. How Do I Sign Up for Medicare Part B if I Already Have Part A?
  • Fax. Fax both forms to your local Social Security office. Find the office and fax number at ssa.gov/locator.
  • Mail or in person. Mail or hand-deliver both forms to your local Social Security office.4Centers for Medicare & Medicaid Services. Medicare Request for Employment Information

If you mail, use certified mail with a return receipt. The date SSA receives your application can affect when your coverage starts, and a paper trail is useful if anything goes missing.

Why the Form Matters

The whole point of Form CMS-L564 is proving you don’t owe the Part B late enrollment penalty. For every full 12-month period you were eligible for Part B but didn’t sign up and didn’t have qualifying employer coverage, Medicare adds 10% to your standard monthly premium, and that surcharge lasts as long as you have Medicare.11Medicare. Avoid Late Enrollment Penalties A two-year gap means a 20% permanent surcharge; a five-year gap means 50%. If you qualify for the SEP and can document your employer coverage on the L564, you owe nothing extra.