How to Fill Out Medicare Form CMS-L564 and CMS-40B

If you have group health plan coverage through your or your spouse’s current employment and are planning to delay enrolling in Medicare Part B past age 65, there are two forms you may need to know about:

CMS-L564 and CMS-40B. 

Yes, we know this isn’t the most exciting topic. 

However, the only thing worse than boredom is permanent penalties! 

So let’s get this figured out for you, and get you back to enjoying your life.

Once your employment ends or your employer-provided coverage ends, these two forms may help you enroll in Medicare Part B without a late enrollment penalty if you qualify for the Special Enrollment Period and apply within the required timeframe.

However, some people may find these forms confusing. 

Which is why in this article, we’ll guide you through both of these forms, show you what’s needed line-by-line, and show you where to submit these forms.

What is Form CMS-L564?

Form CMS-L564, also called the “Request for Employment Information,” helps prove that you had group health plan coverage through your or your spouse’s current employment, which may allow you to enroll in Medicare Part B after your Initial Enrollment Period without a late enrollment penalty.

Most people enroll in Medicare during their Initial Enrollment Period (IEP), which is a seven-month window around the time they turn 65. If you miss your IEP, you may be subject to late enrollment penalties unless you qualify for a Special Enrollment Period (SEP). 

If you are 65 or older and have group health plan coverage through your or your spouse’s current employment, you may qualify for an SEP for Part B when the employment or employer-provided coverage ends.

When you enroll in Medicare Part B through this Special Enrollment Period, you can submit CMS-L564 with CMS-40B to show that you qualify and help avoid a Part B late enrollment penalty.

What is Form CMS-40B?

Form CMS-40B is used if you already have Medicare Part A and want to enroll in Medicare Part B, including during an Initial Enrollment Period, General Enrollment Period, or Special Enrollment Period.

If you’re using CMS-40B to enroll during a Special Enrollment Period, the form lets you request when your Part B coverage begins, but your available start date depends on when you apply during the SEP.

How to Fill Out Form CMS-L564 (Request for Employment Information)

You can download and print the CMS-L564 form on CMS’s website. Here’s how to fill it out: 

Section A

You are responsible for filling out Section A. 

1. Employer’s Name

2. Employer’s Address

3. Applicant’s Name – Your name

4. Applicant’s Social Security Number – Your Social Security Number

5. Employee’s Name – If you were covered through someone else’s current employment, put that employee’s name here. If you were covered through your own employment, leave this blank unless the form asks for it.

6. Employee’s Social Security Number – If you were covered through someone else’s current employment, put that employee’s Social Security number here. If you were covered through your own employment, leave this blank unless the form asks for it.

Section B

Section B is to be completed by your employer. 

For Employer Group Health Plans ONLY: 

1. Is (or was) the applicant covered under an employer group health plan? – Yes

2. If yes, give the date the applicant’s coverage began. – Ask your employer to put the date your health coverage first began (not the latest date it was renewed). 

3. Has the coverage ended? – Yes, if you are no longer covered by your employer’s health plan. No, if you are still covered by your employer’s health plan. 

4. If yes, give the date the coverage ended – Month and year when your employer’s health coverage ended.

5. When did the employee work for your company? – This section should have two dates, either from and to, or from and still employed:
   1. From – add the date you started working for the company
   2. To – add the date you stopped working for the company, if applicable
   3. Still Employed – if the employee is still employed, the employer should check ‘Yes.’

6. 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 the primary payer. – Leave blank if not applicable

For Hours Bank Arrangements ONLY

Note: this section of form CMS-L564 is rarely used. However, if you are covered under an hours bank arrangement, be sure to have your employer list that here. 

1. Is (or was) the applicant covered under an Hours Bank Arrangement? – Yes or no

2. If yes, does the applicant have hours remaining in reserve? – Yes or no

3. Date reserve hours ended or will be used? – Add dates

All Employers

1. Signature of Company Official 

2. Date Signed

3. Title of Company Official 

4. Phone Number

What If You Have Had Multiple Employers?

If you have had multiple employers since turning 65, you’ll need to fill out one CMS-L564 form for each of your employers. 

The goal is to show that you had creditable group health plan coverage based on current employment and that you are applying within the allowed Special Enrollment Period. This typically helps you avoid the late enrollment penalty.

How to Fill Out Form CMS-40B 

You can download and print CMS-40B from CMS’s website. Here’s how to fill it out: 

1. Your Medicare Number – If you don’t have a Medicare number yet, add your Social Security Number here

2. Your Name

3. Mailing Address

4. City

5. Phone Number

6. Do you wish to sign up for Medicare Part B (Medical Insurance)? – Yes

7. 1. Do you currently have (or did you have) coverage through an employer or union group health plan? – Yes, if enrolling using your Special Enrollment Period

2. Are you currently (or were you) an international volunteer for a non-profit organization, and have or had health coverage provided to you? – Yes or no

3. Enter dates of employment (or volunteer work) and health coverage below – Add the start and end dates of your employment and the start and end dates of your health coverage.

8. Has an employer, health insurance provider, or other entity requested or required you to enroll in Part B? – Yes or no. Usually, no, if your employer has 20 or more employees.

9. Remarks – write down when you want your Medicare coverage to begin. You can choose anytime within the next three months. Medicare coverage always begins on the first day of a month. 

10. Written Signature

11. Date Signed

12. Signature of Witness – Leave blank if not applicable.

13. Date Signed – Leave blank if not applicable.

14. Address of Witness – Leave blank if not applicable.

Note: You can also write “SEP” on top of your form to indicate to CMS that this is a Special Enrollment Period application. This is not necessary, but can be helpful. 

How to Submit Forms CMS-L564 and CMS-40B

If You Already Have Medicare Part A

If you signed up for Medicare Part A only during your Initial Enrollment Period, simply submit the forms CMS-L564 and CMS-40B to Social Security. 

You can mail or fax your documents to your local Social Security office. To find your nearest Social Security office, check Social Security’s website. 

If You Don’t Have Medicare Part A

If you want to enroll for both Medicare Part A and Part B, you’ll first want to sign up for Medicare online on Social Security’s website, or by calling Social Security at +1 800-772-1213 (TTY: +1 800-325-0778). 

Once you’ve signed up for Medicare, a Social Security representative should reach out to you by phone or through mail, asking you to submit the forms CMS-L564 and CMS-40B. 

Note: You don’t have to wait for a Social Security representative to contact you before submitting the forms. You can submit the forms right after signing up for Medicare. 

6 Key Things to Keep In Mind

#1 You Can Incur Late Enrollment Penalties Without These Forms

Medicare doesn’t keep track of your employer’s health coverage. If you don’t show them that you’ve been covered past your Initial Enrollment Period, you may incur late enrollment penalties. 

The late enrollment penalty for Medicare Part B is an extra 10% added to your Part B premium for every year that you delay. This is a permanent penalty, so you pay this penalty for as long as you have Medicare. 

#2 Your Special Enrollment Period is Only 8 Months Long

Once you retire or your health coverage ends, you have eight months to enroll in Medicare Part B without getting penalties. 

#3 You Should Submit Multiple Forms if You’ve Had Several Employers

If you’ve had multiple employers since your Initial Enrollment Period, you’ll need to submit one CMS-L564 form for each of your employers. 

This is to show Medicare that you haven’t gone without creditable coverage for more than eight months since your Initial Enrollment Period ended. 

#4 You and Your Spouse Should Submit Separate Forms

If you and your spouse are both going on Medicare and were both covered by the same employer plan, you should both submit the CMS-L564 and CMS-40B forms when enrolling. 

Keep in mind that in Section A of CMS-L564, lines 4 and 5 are the details of the person applying for Medicare, while lines 6 and 7 are the details of the employee of the company sponsoring the health insurance. 

#5 You Can Also Use IRS Form 1095-B to Prove You’ve Had Coverage

Section B of the CMS-L564 form is supposed to be filled out by your employer. If you cannot have them fill this out for you, you may also present your IRS Form 1095-B for every year that you’ve delayed enrolling in Medicare to prove you’ve had creditable coverage. 

#6 You Shouldn’t Delay Enrolling in Medicare if You’re Part of a “Small Group”

If your company has fewer than 20 employees, you typically want to enroll in Medicare during your Initial Enrollment Period. 

This is because if your company has fewer than 20 employees, it is considered a “small group” by Medicare. 

Small group coverage pays second to Medicare once you turn 65. If you aren’t enrolled in Medicare, this essentially means you become the first payer. 

Watch: Mistakes to Avoid When Working Past 65 

EMBED: https://www.youtube.com/watch?v=G9YpcWPCOYc 

Avoid Other Expensive Medicare Penalties

Getting a late enrollment penalty for Medicare Part B is not only frustrating, but it can also be very expensive. 

That’s why knowing which forms you need to fill out (and how to fill them properly) is crucial if you’re planning to delay enrolling in Medicare past your Initial Enrollment Period. 

These two forms, CMS-L564 and CMS-40B, might seem complicated at first. But if you follow the instructions above, you should be able to enroll without penalties. 

If you found this helpful, feel free to text or call our team of professional licensed insurance agents at +1 877-360-6565 (TTY: 711) and we’ll answer any Medicare question you have, at no cost to you. 

Or, if you’d like to learn more about how Medicare works, what you need to sign up for, and how to avoid other expensive penalties, then check out our free Medicare workshop below: