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Form CMS-L564 is used to prove that you or your spouse had group health plan coverage based on current employment when you apply for Medicare Part B during a Special Enrollment Period (SEP). This form is essential to avoid the late enrollment penalty that applies when you sign up for Medicare Part B outside the general enrollment period.
Section A (completed by the individual): Enter your name, Medicare number (or SSN), date of birth, and address.
Indicate whether the group health plan coverage was based on your own or your spouse's current employment.
Enter the date the employer coverage ended (or will end).
Section B (completed by the employer): Enter the employer's name, EIN, address, and phone number.
Confirm the dates the individual was covered under the employer's group health plan.
Confirm the dates of active employment.
The employer representative signs and dates the form with their title.
Submit the completed form to your local Social Security office along with your Medicare Part B application.
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The penalty is an additional 10% of the Part B premium for each full 12-month period you could have had Part B but didn't enroll. This penalty lasts for as long as you have Part B. Form CMS-L564 helps you avoid it.
No. COBRA continuation coverage does not count as coverage based on current employment for Medicare SEP purposes. The 8-month SEP window begins when the active employer coverage ends, not when COBRA ends.
If your former employer is no longer in business, you can provide alternative evidence of coverage, such as W-2s showing employer contributions, old insurance cards, or pay stubs showing health insurance deductions. Contact your local Social Security office for guidance.
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