CMS-L564 Application Form Pdf Download 2023-24

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CMS-L564 Application Form
CMS-L564 Application Form

CMS-L564 Application Form:- The CMS-L564 form is utilized by individuals who are delaying enrollment in Medicare Part B due to current employment and have employer-sponsored health coverage. It requires verification from the employer, confirming the individual’s current employment status and health coverage, allowing them to delay Medicare Part B enrollment without penalties.

The form facilitates the coordination of benefits between employer-sponsored health coverage and Medicare, ensuring a smooth transition when the individual decides to enroll in Medicare Part B. Once completed and signed by the employer, the CMS-L564 form is submitted to the Social Security Administration (SSA) for processing, enabling the individual to enroll in Medicare Part B without late enrollment penalties.

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WHAT IS THE PURPOSE OF THIS FORM?

In order to apply for Medicare in a Special Enrollment Period, you must have or had group health plan coverage within the last 8 months through your or your spouse’s current employment. People with disabilities must have large group health plan coverage based on your, your spouse’s or a family member’s current employment.

This form is used for proof of group health care coverage based on current employment. This information is needed to process your Medicare enrollment application. The employer that provides the group health plan coverage completes the information about your health care coverage and dates of employment.

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HOW IS THE FORM COMPLETED? : CMS-L564 Application Form

  • Complete the first section of the form so that the employer can find and complete the information about your coverage and the employment of the person through which you have that health coverage.
  • The employer fills in the information in the second section and signs at the bottom.

WHAT DO I DO WITH THE FORM? : CMS-L564 Application Form

Fill out Section A and take the form to your employer. Ask your employer to fill out Section B. You need to get the completed form from your employer and include it with your Application for Enrollment in Medicare (CMS-40B). Then you send both together to your local Social Security office. Find your local office here: www.ssa.gov.

CMS-L564 Application Form Pdf Download 2023-24

STEP BY STEP INSTRUCTIONS FOR THIS FORM

The person applying for Medicare completes all of Section A.

  1. Employer’s name: Write the name of your employer.
  2. Date: Write the date that you’re filling out the Request for Employment Information form.
  3. Employer’s address: Write your employer’s address.
  4. Applicant’s Name: Write your name here.
  5. Applicant’s Social Security Number: Write your Social Security Number here.
  6. Employee’s Name: If you get group health plan coverage based on your employment, write your name here. If you get group health plan coverage through another person, like a spouse or family member, write their name.
  7. Employee’s Social Security Number: If you get group health plan coverage based on your employment, write your Social Security Number here. If you get group health plan coverage through another person, like a spouse or family member, write their Social
    Security Number

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Once you complete Section A:
Once Section A is completed, give this form to your employer to complete Section B. Once Section B has been completed by your employer, return this form along with your Part B application to your local Social Security office.

SECTION B:
The employer completes all of Section B. If you’re an employer without an hours bank arrangement, complete the section called “For Employer Group Health Plans ONLY”

  1. Is (or was) the applicant covered under an employer group health plan? Please check yes or no if the applicant was covered under
    your group health plan offered by your company. The applicant may be the employee or another person related to the employee, such as a spouse or family member with disabilities. If your company doesn’t offer a group health plan, please check No.
  2. A group health plan is any plan of one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees, the employer, or their families.
  3. If yes, give the date the coverage began. Write the month and year the date the applicant’s coverage began in your group health plan.
  4. Has the coverage ended? Check yes or no if the group health plan coverage for the applicant has ended.
  5. If yes, give the date the coverage ended. Write the month and year the group health plan coverage ended for the applicant.
  1. When did the employee work for your company? Write the start and end dates of the employment for the employee in which the applicant is related. It may be the applicant or another person related to the employee, such as a spouse or family member with disabilities. Enter the month and year of the start of the employment in the “From” box. Enter the month and year of end of the employment in the “To” box. If the employee is still employed, enter the month and year of the current date. Current employment is active working status. It is not disability or retirement.
  2. If you’re a large group health plan and the applicant is disabled, please list the timeframe (all months) that your group health plan was primary payer. Write the start and end dates that your group health plan was primary payer for the applicant.

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If you’re an employer with an hours bank arrangement, complete the section called “For Hours Bank Arrangements ONLY”

  1. Is (or was) the applicant covered under an hours bank arrangement?
    Please check yes or no if the applicant was covered under an hours bank arrangement. If you check no, please also fill out the section for “Employer Group Health Plans ONLY”.
  2. If yes, does the applicant have hours remaining in reserve?
    Please indicate if the applicant currently has health coverage based on the remaining hours in the employee’s hours bank account.
  3. Date reserve hours ended or will be used?
    Please write the month and year for when the remaining hours in the employee’s hours bank account expired or will expire

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All employers need to complete the bottom of Section B. : CMS-L564 Application Form

  • Signature of Company Official: An official representative of the company needs to sign this document. Please do not print.
  • Date Signed: Write the date that you sign the form in this field.
  • Title of Company Official: Print the title of the company official who signed the form in this field.
  • Phone Number: Write the phone number of the company official who signed the form in this field. If there are questions regarding the information on this form, a representative from Social Security will contact you.

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CMS-L564 Application Form Eligibility : CMS-L564 Application Form

The CMS-L564 form is used for individuals seeking to delay enrollment in Medicare Part B due to active employment with employer-sponsored health coverage. Eligibility to use the form generally includes:

  1. Active Employment: Individuals who are currently employed and covered by an employer-sponsored health plan.
  2. Qualifying Health Coverage: Eligibility is often tied to having health coverage through the employer, which allows delaying enrollment in Medicare Part B without incurring late penalties.
  3. Meeting Medicare Criteria: The applicant should meet the criteria set by Medicare for delaying enrollment, including having credible employer-sponsored health coverage.
  4. Intent to Enroll in Medicare Part B: Individuals eligible for the CMS-L564 form intend to enroll in Medicare Part B once their employment or employer-sponsored health coverage ends.

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information about common questions related to the CMS-L564 form:

Q 1. What is the CMS-L564 Form?

The CMS-L564 form is used for individuals seeking to delay enrollment in Medicare Part B due to active employment with employer-sponsored health coverage.

Q 2. Who Should Complete the Form?

Individuals who are currently employed and covered by an employer-sponsored health plan, intending to delay Medicare Part B enrollment without incurring late penalties.

Q 3. What Information is Required?

The form typically requires personal information, details about current employment, and employer verification confirming the individual’s health coverage status.

Q 4. How Does the Form Affect Medicare Enrollment?

Completion of the CMS-L564 form allows individuals to delay Medicare Part B enrollment without late penalties. It’s a mechanism to coordinate benefits with employer-sponsored health coverage.

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