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Medicare Form CMS-L564

Medicare Form CMS-L564 | Your Guide to Requesting Employment Information

How Does Delayed Medicare Enrollment Work?

When you first become eligible for Medicare, typically at age 65, there is a seven-month Initial Enrollment Period (IEP).  This period includes your birthday month, as well as the three months before and after.

Missing this period could lead to enrollment during the General Enrollment Period (GEP).  The GEP occurs from January 1st to March 31st each year but could result in late enrollment penalties.

Special Enrollment Periods (SEPs) ─ If you or your spouse is still working and you’re covered by a group health plan through that employment, you might not need Medicare when you first become eligible.  In such instances, you can enroll in Medicare during a Special Enrollment Period without facing late penalties.

Here’s how SEPs work:

  • Qualifying for SEP ─ You qualify for a SEP if you have creditable coverage under a group health plan with an employer of 20 or more employees.
  • Enrollment Timing ─ The SEP for Medicare Part A and/or Part B lasts for eight months, starting the month after active employment ends or the group health plan insurance based on current employment ends, whichever happens first.

Important Considerations:

  • Proof of Coverage ─ You’ll need to provide evidence of your continuous coverage through an employer using a form CMS-L564, which is the subject of this article.
  • Avoiding Penalties ─ It’s imperative to enroll during your SEP to avoid late penalties that might increase your Part B premium by 10% for each full 12-month period you could have had Part B.
  • Employer Size ─ The rules applicable to SEPs can differ depending on whether your employer has 20 or more employees.  Always check with your employer’s benefits administrator to confirm how your coverage works with Medicare.

What is the Medicare Form to Prove Creditable Coverage?

Medicare requires individuals moving from employer-sponsored health plans to prove they have creditable coverage.  It’s needed to enroll in Medicare without facing late enrollment penalties.

Form CMS-L564, also known as the Request for Employment Information form, accomplishes that purpose.

Eligibility Requirements for CMS-L564

To be eligible to complete the Medicare Form CMS-L564, you must meet the following criteria:

  • You’re applying for Medicare and have not yet received Social Security benefits.
  • You or your spouse (or family member if you’re disabled) are actively employed.
  • The employer you are completing the form with has group health plan coverage you are enrolled in.

Here’s a breakdown of specific qualifications:

  • Age and Employment:
    • You’re 65 or older.
    • You or your spouse are actively working.
  • Health Plan Coverage:
    • The employer has 20 or more employees.
    • The health plan with the employer must be active.

How to Obtain Form CMS-L564

To get Form CMS-L564 follow these steps:

  • Visit the Social Security website ─ Go to the official Social Security website and use the search tool to find Form CMS-L564.
  • Easy WayUse THIS LINK to download Form CMS-L564 directly to your computer in PDF format.

Alternatively, you can:

  • Call Social Security if you have a lot of extra time to wait on hold.  You can request a copy of the form by calling 1-800-772-1213.  Operating hours are typically from 7 AM to 7 PM ─ Monday through Friday.
  • Visit your local Social Security office ─ If you prefer to collect the form in person, visit your local Social Security office.

How to Fill Out Form CMS-L564

Form CMS-L564 is critical for documenting your employment history and health plan coverage to ensure you can enroll in Medicare without incurring late penalties.

When you complete the CMS-L564, you’ll need to provide specific details about your previous employer’s health plan.  The form confirms the dates of your insurance coverage with that group health plan.  This verifies your eligibility for Medicare and that the coverage met the standards set by Medicare, thereby avoiding late fees or delays.

Section A: Information About the Worker

In Section A, provide your personal details as the worker.  This includes:

  • Social Security Number ─ Your unique identification number.
  • Name ─ Your legal first name, middle initial, and last name.
  • Birth Date ─ Enter in MM/DD/YYYY format.
  • Phone Number ─ Include a phone number where you can be reached.
  • Address ─ Your current residence, with street, city, state, and ZIP code.

Section B: Information About the Employer

Continue to Section B, where you’ll detail your previous employment and health plan coverage:

  • Employer’s Name ─ The legal name of the company where you were employed.
  • Employer’s Address ─ Complete address with street, city, state, and ZIP code.
  • Group Health Plan Coverage ─ State whether you had a group health plan during your employment.
  • Health Plan Start and End Dates ─ Specific dates indicating your health plan coverage duration.

Be precise with dates to verify your coverage period.

Section C: Employer Acknowledgment

In Section C, your employer must acknowledge your provided information:

  • Employer’s Signature ─ A signature from an authorized representative.
  • Date ─ When the company representative signed the form.
  • Title ─ Position of the signing representative within the company.
  • Phone Number ─ A contact number for the company or representative.

Required Documentation to Accompany CMS-L564

When you submit Form CMS-L564, certain documents must be provided to verify your employment and group health plan coverage.  It’s essential that you supply the required documentation to avoid delays in your Medicare application process.  Here is what you need to include:

  • Proof of Employment ─ If recently retired, present a letter from your employer verifying your current employment status or the dates of previous employment.  The letter should be on company letterhead.
  • Proof of Group Health Plan Coverage ─ Provide a statement or certificate that confirms your enrollment in the employer’s group health plan.  This should indicate the exact dates of coverage.
  • Proof of End of Group Health Plan Coverage ─ If applicable, provide documentation showing the termination date of your group health plan coverage.

Ensure that all documents clearly display your name and coincide with the employment information on Form CMS-L564.  The information should be current and accurate to ensure seamless processing of your application.

Remember that incomplete or incorrect document submissions may result in the need to resubmit or additional requests for information, potentially delaying your Medicare enrollment.  It’s in your best interest to double-check that all necessary documentation is gathered and accurately reflects your employment and coverage status before submitting Form CMS-L564.

How to Submit Form CMS-L564

Correctly submitting Form CMS-L564 is essential to ensure you can utilize the Special Enrollment Period without incurring late penalties.  Follow the steps below to submit your form to the appropriate place within the required timeframe and to track its progress.

Where to Submit the Form

Take your completed Form CMS-L564 to your local Social Security office.  Each office is equipped to process your form and forward it for enrollment in Medicare Part B.  You can find the closest office using the Social Security Office Locator, which requires your ZIP code for the most accurate results.

Deadlines for Submission

It is imperative to submit Form CMS-L564 during the Special Enrollment Period.  The period typically spans 8 months following the month you or your spouse’s employment ends or when the current work-based health coverage ends, whichever happens first.  Submitting within this timeframe prevents penalties and delays in coverage.

Tracking Your Submission

  • After submitting your form, obtain a receipt as proof of your submission.
  • Follow up with your local Social Security office if necessary.
  • It’s also helpful to create or log in to your My Social Security account online to check the status of your Medicare enrollment and to view any updates or required actions.

Potential Issues and Resolutions

Navigating the completion and submission of Form CMS-L564 can sometimes entail challenges.  Addressing these effectively ensures the process goes smoothly.

What if my employer won’t fill out CMS-L564 ?

If your employer refuses to complete Form CMS-L564, you should first understand their reasons.  It might be due to a misunderstanding of the form’s importance or requirements.  You can often resolve this by explaining that the form is necessary for your Medicare enrollment waiver for Part B.

If your employer remains uncooperative, contact the Social Security Administration (SSA) for guidance on alternative documentation that may be accepted.

Common Mistakes to Avoid

Avoid common mistakes on the form to prevent delays:

  • Incomplete Information ─ Ensure all fields are filled out ─ missing data can result in processing hold-ups.
  • Incorrect Dates ─ Verify employment and health coverage start and end dates are accurate.

Correcting Errors on the Form

In case errors are discovered on the form after submission:

  1. Retrieve the form by contacting the SSA.
  2. Correct the errors in ink and initial any changes made.
  3. Resubmit the corrected form promptly to avoid further delays in your Medicare enrollment process.

Contact Information for Assistance

Should you require assistance with Form CMS-L564:

  • Social Security Administration (SSA) ─ Visit the SSA website or call 1-800-772-1213.
  • Medicare ─ Contact Medicare directly at 1-800-MEDICARE (1-800-633-4227).

Final Thoughts

Accuracy is key in completing your Form CMS-L564.  Ensure all sections are filled out correctly to avoid unnecessary delays.  Doing so enhances the likelihood of a smooth application process.  Finally, keep a copy of the completed form for your records.

Medicare involves lots of complexities ─ rules, options, and deadlines.  I’m here to help you make informed choices that align with your healthcare needs and financial circumstances.


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