Social Security Form CMS-L564: Verifying Employment Information

The process of applying for Medicare benefits can be more complicated than it initially seems, especially if you delay enrolling in Medicare Part B. While Medicare has specific enrollment periods, you may qualify for a Special Enrollment Period (SEP) if you had eligible group health coverage through your or your spouse’s current employment. In that case, Form CMS-L564 can be used to document your employment and health coverage when applying for Part B.

Consider working with a financial advisor as you create a retirement plan and think about future healthcare expenses.

What Is Form CMS-L564?

Form CMS-L564 is an employment information form from the Centers for Medicare and Medicaid Services. Applicants use it alongside Form CMS-40B when applying for Medicare Part B during a special enrollment period (SEP). You complete one portion, and your employer completes the other.

You are eligible for the SEP under a specific set of circumstances:

You are currently enrolled in Medicare Part A.
You’ve received group health benefits from an employer, either yours or your spouse’s.

If you receive employer group health benefits or if those benefits ended within the last eight months, you qualify for the Special Enrollment Period. If the employment and/or the coverage has ended, the SEP extends for eight months after the month that the benefits ended.

You use Form CMS-L564 to verify that you meet these conditions. It verifies both the employment and group health plan coverage necessary for eligibility.

When Can You Apply for Medicare Part B?

If you haven’t enrolled in Part A, contact the SSA to begin the process. Medicare Part A is free once you turn 65, and most people enroll soon after their birthday. Part B, however, requires you to pay premiums like traditional health insurance.

You have a few options for when to apply for enrollment in Medicare Part B.

The Initial Enrollment Period (IEP): This starts three months before the month you turn 65, and ends three months after the month you turn 65. This is when most people apply for Medicare Part A, and when many also elect to enroll in Part B.
The General Enrollment Period (GEP): If you didn’t enroll during your IEP, you can enroll during this period. It takes place every year between January 1 and March 31. Opting for this path could lead to higher premiums, however.
The Special Enrollment Period (SEP): This only applies if you’re currently receiving group health benefits from an employer; or if those benefits ended within the last eight months.

Usually, you don’t pay a late enrollment penalty if you sign up during the SEP. To prove your eligibility for an SEP, you must fill out and send Form CMS-L564 with your application. This form provides information about your or your spouse’s employment-sponsored group health plan.

How to Fill Out Form CMS-L564

Two women review Social Security Form CMS-L564.

The CMS-L564 form is split into two sections. Section A is completed by the applicant, and Section B must be filled out by the employer. Here’s how to complete each part:

Step 1: Download the Form

Visit the official Medicare website or contact Social Security to obtain the CMS-L564 form.

Step 2: Complete Section A (Applicant)

In Section A, enter your full name, Social Security number, and the name of your current or former employer. Indicate whether the group health coverage was through your own employment or your spouse’s. Then sign and date the form to confirm the information provided.

Step 3: Ask Your Employer to Complete Section B

Your employer fills out Section B. An authorized representative will verify the dates your group health coverage was active and specify whether it was connected to current employment. They must also provide the company’s official name, their own contact details, and then sign and date the form.

Step 4: Submit the Completed Form

Send CMS-L564 along with Form CMS-40B to your local Social Security office. Submission can typically be done by mail, fax or in person. Check with the Social Security Administration for current submission options. Make sure all sections are filled out and signed to avoid processing delays.

Contact Social Security at 1-800-772-1213 if you have questions.

How to Find Your Social Security Office

The SSA website has a tool that allows you to find the Social Security office nearest to you. Once you type in your zip code and click Locate, the nearest office or a list of the nearest offices should appear.

Note that three cities – New York City, Philadelphia and Phoenix – have separate locations dedicated to card services. If you live in one of those cities, then, you’ll have to indicate whether you’re looking for Card Services or Other Services. Since you’re applying for Medicare Part B, be sure to choose Other Services.

Frequently Asked Questions About Form CMS-L564

Form CMS-L564 is used to verify employer-sponsored health coverage when you apply for Medicare Part B during a qualifying Special Enrollment Period (SEP). Because the form involves both Medicare enrollment and employment information, questions often come up about who needs to complete it, how to submit it and what types of health coverage qualify.

Can I submit CMS-L564 online?

You may be able to apply for Medicare Part B during a Special Enrollment Period online through the Social Security Administration. You can also submit Form CMS-L564 and Form CMS-40B by mail or fax to your local Social Security office. CMS instructs applicants who use the paper forms to complete Section A of CMS-L564, have their employer complete Section B and submit the completed form with their Part B application.

Do I need CMS-L564 if I’m still working?

You may need Form CMS-L564 if you’re still working and applying for Medicare Part B during a Special Enrollment Period based on employer group health coverage. The form provides proof that you have or had qualifying group health plan coverage based on your current employment or your spouse’s current employment.

Does my spouse’s employer fill out CMS-L564?

Yes, if your Medicare Special Enrollment Period is based on health coverage through your spouse’s current employment, the employer that provided the group health plan generally completes Section B of CMS-L564. You complete Section A and identify your spouse as the employee through whom you received the health coverage.

Can I fill out CMS-L564 myself if my employer is out of business?

You should complete Section A of CMS-L564 yourself, while Section B is generally completed by the employer that provided your group health coverage. If the employer is no longer in business or you can’t get an employer to complete the form, contact the Social Security Administration for instructions on documenting your coverage.

Can I use CMS-L564 for COBRA coverage?

COBRA coverage by itself generally does not qualify you for the Medicare Part B Special Enrollment Period based on current employment. CMS does not consider COBRA to be group health plan coverage based on current employment for purposes of this SEP.

Do I need CMS-L564 if I already have Medicare Part A?

You may need CMS-L564 even if you already have Medicare Part A. In fact, the form is commonly used by people who already have Part A but delayed enrolling in Part B because they had qualifying health coverage through their own or their spouse’s current employment.

Bottom Line

A senior meets with his healthcare provider.

Form CMS-L564 serves a specific purpose, but it can play an important role for people who delayed Medicare Part B because they had qualifying health coverage through their or their spouse’s employment. The form helps verify that employment and coverage to the Social Security Administration when you apply during a qualifying Special Enrollment Period. Filing during the appropriate SEP can also help you avoid a Part B late-enrollment penalty and coordinate the transition from employer-sponsored insurance to Medicare.

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