ComplyDIY · BenefitLab

At-a-Glance Purpose, who's involved, timing, and risk.−

What Employer completes Form CMS-L564 (Request for Employment Information) to confirm that the individual had group health coverage based on active employment, a required step for establishing a Medicare Special Enrollment Period.

Who All employers when an employee or retiree transitions from employer group health coverage to Medicare Part B.

When Upon request from the employee or retiree, during their Medicare transition or Special Enrollment Period window.

Risk No direct penalties on the employer, but delays or errors in completing the form can prevent the individual from qualifying for the SEP, potentially resulting in a coverage gap or a late enrollment penalty applied to their Medicare premiums.

Deadlines & Frequency No statutory deadline on the employer, but the employee's window is time-limited.+

Trigger	Timing	Who Completes	Notes
Employee or retiree requests employer section	Promptly; aim for 3 to 5 business days	Employer / HR	Delays can affect the employee's SEP window; treat as a priority request.
Employee submits Medicare enrollment packet to Social Security	Within the applicable SEP window (typically 8 months after coverage ends)	Employee / retiree	Employer form (CMS-L564) must be complete before the employee submits their full enrollment packet.

Trigger: Employee/retiree requests employer section

Timing: Promptly; aim for 3 to 5 business days (Employer / HR)

Notes: Delays can affect the SEP window; treat as a priority.

Trigger: Employee submits Medicare packet to Social Security

Timing: Within the SEP window (typically 8 months after coverage ends)

Notes: CMS-L564 must be complete before the packet is submitted.

What You Need: Docs & Data Everything needed is in your HR and benefits system.+

Employee or retiree's full name and Social Security number (as it appears on Medicare records).
Employer's legal name, address, and HR/benefits contact information.
Group health plan name and group or policy number.
Coverage start date and end date (or confirmation that coverage is still active).
Confirmation that coverage was based on the individual's current employment; this is the key field Medicare uses to establish SEP eligibility.
Form CMS-L564 (downloaded from CMS); see Templates & Resources below for the direct link.

How To Do It: Step-by-Step Most employers complete the employer section in under 30 minutes.+

1

Receive and acknowledge the requestWhen the employee or retiree reaches out, confirm receipt and let them know your expected turnaround (3 to 5 business days).

2

Pull the recordsLook up plan name, group number, and exact coverage start and end dates from your HR or benefits system. Confirm whether coverage was based on current employment.

3

Complete Form CMS-L564Fill in the employer section accurately: plan name, group number, coverage dates, and the employment-based coverage confirmation.

4

Sign and dateAn authorized HR or benefits representative must sign. Do not leave it unsigned; Medicare will reject an unsigned form.

5

Return to employeeDeliver via secure electronic delivery or first-class mail. Remind the employee to include the completed form with their Medicare enrollment packet.

6

Log and fileSave a copy of the completed form and note the date returned in your Medicare transition log.

Delivery Rules How to get the completed form back safely and on time.+

Return the completed form via secure electronic delivery (encrypted email or benefits portal) or first-class mail; confirm the employee's preferred method and current address.
Do not email an unsigned, incomplete form and ask the employee to follow up later; complete it fully before returning.
Include a brief cover note reminding the employee to submit the completed form to Social Security along with their Medicare Part B application (Form CMS-40B) before their enrollment window closes.
If the employee requests urgent processing (for example, their SEP window is closing), prioritize same-day or next-day return and consider offering overnight mail.

Proof & Recordkeeping Keep a record of each request and what was provided.+

Completed form copyCopy of the completed CMS-L564 (or equivalent form) returned to the employee.
Request logDate received, who handled it, date completed and returned, delivery method.
CorrespondenceAny correspondence clarifying coverage dates, plan details, or employment status.
RetentionRetain per ERISA norms for plan records; 6 years is a reasonable minimum.

Common Traps & FAQs Where employers stumble and quick answers.+

Common traps

Delaying the response: The employee's SEP window is typically 8 months after coverage ends. If HR sits on the request for two weeks, the employee may miss their window and face a lifetime late enrollment penalty on Medicare Part B premiums.

Incorrect coverage dates: Medicare uses the exact start and end dates to determine SEP eligibility. A date entered from memory rather than the system of record can invalidate the SEP.

Returning the form unsigned: Social Security will not process an employer form without an authorized signature. The form must be signed before it goes back to the employee.

Confusing the forms: CMS-40B is the employee's Medicare enrollment application. CMS-L564 is the employer's employment information form. Employers complete CMS-L564, not CMS-40B.

FAQs

What is the purpose of the employer form?
It confirms that the individual had employer group health plan coverage based on active employment. This documentation is required for Social Security to approve a Special Enrollment Period for Medicare Part B, which allows the employee to enroll without a late enrollment penalty.

What if the employee is still working when they enroll in Medicare?
Some employees enroll in Medicare Part A at 65 while continuing to work and keeping their employer coverage. In that case, no employer form is needed yet; the employer section is typically needed when the employee is actually ending employer coverage and enrolling in Part B. Confirm with the employee exactly what they are applying for before completing any forms.

What if we no longer have records of coverage for a former employee?
Do your best to reconstruct from available records: payroll history, benefits enrollment data, insurance carrier records. If records are truly incomplete, document what you were able to confirm and note the limitation in writing to the employee so they can seek additional documentation from the carrier if needed.

Official Guidance & Links The CMS forms and Medicare enrollment guidance employers need.+

CMS Form CMS-L564: Request for Employment Information: the form the employer completes to confirm group health coverage.
CMS Form CMS-40B: Medicare Part B Enrollment Application: the enrollment application the employee submits alongside CMS-L564.
Medicare.gov: When to Sign Up for Medicare: SEP rules, enrollment windows, and late enrollment penalty information.
Social Security Administration: Medicare Enrollment: where the employee submits their completed enrollment packet.

Special Cases & State Variations Situations that require extra attention when completing the form.+

Retirees vs. active employees: The key question on the employer form is whether coverage was based on current employment. For active employees, this is straightforward. For retirees on a retiree health plan, the coverage is typically not based on current employment, which may affect SEP eligibility. Confirm the basis of coverage before completing the form.
COBRA timing: If the employee is on COBRA when they transition to Medicare, COBRA is considered continuation of employer coverage, but it is not "based on current employment." This distinction matters for the form and for SEP eligibility. Employees on COBRA are generally not eligible for the employment-based SEP; they follow a different enrollment pathway.
Spouse or dependent coverage: If the request comes from a spouse or dependent who was covered under the employee's plan, the employer must confirm the coverage relationship accurately; the covered individual is the spouse or dependent, not a current employee.

Templates & Resources Direct CMS form links and an employer-section completion checklist.+

Direct links to the CMS forms and a quick-reference checklist for completing the employer section. Download the forms directly from CMS; do not use third-party versions, which may be outdated.

Forms to Download

Form CMS-L564: Request for Employment Information: the employer completes this form.
Form CMS-40B: Medicare Part B Enrollment Application: the employee completes this; both forms are submitted together.

Employer Section Completion Checklist

Work through this before signing. Every field must be accurate; errors require the employee to resubmit and can delay enrollment.

☐ Employee's full legal name matches their Medicare / Social Security records
☐ Employer's legal name and address entered correctly
☐ Group health plan name confirmed from enrollment records (not from memory)
☐ Group or policy number confirmed from enrollment records
☐ Coverage start date confirmed, pulled from HRIS or benefits system, not estimated
☐ Coverage end date confirmed, or "coverage still active" indicated if applicable
☐ "Coverage based on current employment" question answered correctly (yes for active employees; different answer for retirees or COBRA, see Special Cases)
☐ Form signed and dated by an authorized HR or benefits representative
☐ Copy saved to employee file before returning
☐ Form returned to employee with a note to submit alongside Form CMS-40B