Medicare · Supporting
Form CMS L564: how to document employer coverage for a Medicare Part B special enrollment
Last reviewed September 14, 20264 min readBy the Goodsurance editorial team Reviewed by the Goodsurance editorial team
Form CMS L564, titled "Request for Employment Information," is the document your employer fills out to confirm that you had group health plan coverage based on active employment. Social Security uses that confirmation to verify you qualify for a Part B Special Enrollment Period (SEP), which lets you sign up for Medicare Part B outside the standard Initial Enrollment Period (IEP) without a late-enrollment penalty.
What CMS L564 is
The form exists because Social Security has no direct way to see your employment history through a private employer. CMS L564 closes that gap. Without a completed form, Social Security cannot confirm your SEP eligibility, and your application may stall or be treated as if qualifying coverage never existed.
When you need it
CMS L564 applies when you delayed Part B because you or your spouse had employer-sponsored group health plan coverage based on active, current employment, and that coverage is now ending or has recently ended. It does not apply if you are enrolling through your IEP, which is the standard 7-month window centered on your 65th birthday.
According to Medicare.gov, the employment-based Part B SEP is 8 months, starting the day employment ends or the group health plan coverage ends, whichever comes first. If you submit a complete CMS L564 with your Part B application within that window, no late-enrollment penalty applies.
One critical point that catches many people off guard: COBRA and retiree coverage do not count as active employer coverage for SEP or penalty purposes. If you left a job and your only remaining coverage is COBRA, your 8-month SEP clock has already started from the day active employment or the original employer coverage ended. Waiting until COBRA expires does not extend the window.
How to fill out the two sections
CMS L564 is divided into two sections, and both must be complete before you submit.
Section A is for you, the Medicare applicant. You provide your name, Social Security number, Medicare number if you already have one, and the name of the employer whose coverage qualifies you for the SEP.
Section B is for your current or former employer. An authorized company representative must certify:
- The dates your group health plan coverage was in effect.
- Whether the coverage was based on your own employment or a family member's employment.
- The total number of employees at the company.
That employee count carries real weight. With 20 or more employees, the employer group plan is the primary payer and Medicare pays secondary. With fewer than 20 employees, Medicare is the primary payer and the coordination of benefits works differently. Social Security uses this detail to evaluate your coverage history accurately.
If your employer has closed or cannot complete Section B, contact Social Security before submitting. They can advise on substitute documentation, such as pay stubs, W-2 forms, or letters from a plan administrator, that may satisfy the verification requirement in place of the form.
Employer size and who pays first
Social Security uses the employee count from Section B to determine how your coverage history is evaluated.
How to submit CMS L564 with form CMS-40B
You must submit CMS L564 together with form CMS-40B, "Application for Enrollment in Medicare Part B (Medical Insurance)." Social Security needs both documents to process your enrollment. Submitting one without the other delays the review.
Your options for submission:
- In person at any Social Security Administration office.
- By mail to your local Social Security office.
- By fax, where accepted by the local office.
This process cannot be completed entirely online. Because CMS L564 requires an employer signature on Section B, it must be physically submitted. Both forms are available for download at Medicare.gov and SSA.gov.
If you are still actively employed and your coverage has not ended, you may ask your employer to complete Section B in advance so the paperwork is ready to go as soon as coverage ends.
What happens if you miss the 8-month window
Missing the SEP window means waiting for the General Enrollment Period, which runs January 1 through March 31 each year. More significantly, it means a permanent Part B late-enrollment penalty. According to Medicare.gov, the penalty adds 10% to your Part B premium for each full 12-month period you went without Part B and without other qualifying coverage. It does not expire.
In 2026, the standard monthly Part B premium is $202.90 per CMS. A single year of unqualified delay increases that base amount by 10%, and the penalty compounds with each additional year. Because the penalty attaches permanently, acting promptly within the 8-month SEP window is worth considerable attention.
If you have questions about whether CMS L564 applies to your situation, or if you need help thinking through your enrollment options, please contact us to discuss plan options.
Missed the window? 10% is added to your premium for each year of delay, permanently.
Common questions about IRMAA appeals
Quick answers, fast .
Tap any question to expand. Each links to a fuller standalone answer.
Does Medicare pay for hearing aids
Original Medicare does not cover hearing aids or fittings.
Some Medicare Advantage plans may include a hearing benefit, but what they cover varies by plan.
Does Medicare cover ambulance services?
Yes, in limited situations.
Medicare Part B covers emergency ambulance transportation when traveling any other way could endanger your health, taking you to the nearest appropriate hospital or facility. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. Air ambulance is covered only when ground transport cannot reach you or would take too long. Non-emergency ambulance trips, for example to dialysis, are covered only when a doctor provides a written order stating they are medically necessary. Medicare does not cover ambulance rides taken purely for convenience.
Does Medicare cover skilled nursing facility care?
Yes, on a short-term basis.
Medicare Part A covers skilled nursing facility (SNF) care after a qualifying inpatient hospital stay of at least 3 days, when you need daily skilled care like nursing or therapy. In 2026 you pay $0 for days 1 through 20 of each benefit period, $217 per day for days 21 through 100, and all costs after day 100. Coverage is for skilled care while you recover, not for long-term or custodial care (help with daily activities like bathing or dressing), which Medicare does not cover. Long-term nursing home care is generally paid through Medicaid or private funds.
Does Medicare cover physical therapy?
Yes.
Medicare Part B covers outpatient physical therapy that is medically necessary to treat your condition. You pay 20% of the Medicare-approved amount after the yearly Part B deductible ($283 in 2026). There is no longer a hard dollar cap on therapy, but once your physical and speech therapy together pass $2,480 in 2026, your therapist must add a note (called a KX modifier) confirming you still need care. Claims above $3,000 may be reviewed for medical necessity. Part A covers physical therapy you receive as a hospital inpatient or in a skilled nursing facility. A doctor or therapist must set up and regularly review your plan of care.
Does Medicare cover mental health services?
Yes.
Medicare covers mental health care across its parts in 2026. Part B covers outpatient services like therapy, counseling, and visits with psychiatrists, psychologists, and clinical social workers, and since 2024 it also covers marriage and family therapists and mental health counselors. You pay 20% of the Medicare-approved amount after the $283 deductible, and one depression screening each year is free. Part A covers inpatient mental health care, with a lifetime limit of 190 days in a freestanding psychiatric hospital. Part D covers most mental health medications. Many of these services are also available by telehealth, and Medicare Advantage plans cover at least the same benefits.
Does Medicare cover chiropractic care?
Partly.
Medicare Part B covers one specific chiropractic service: manual manipulation of the spine to correct a subluxation (when one or more bones of the spine are out of position) that a doctor confirms is medically necessary. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. Medicare does not cover other services a chiropractor might offer, such as X-rays, massage therapy, acupuncture, or routine wellness visits, so you would pay the full cost for those. Some Medicare Advantage plans include extra chiropractic or wellness benefits beyond this.
Does Medicare cover home health care?
Yes, when you qualify.
Medicare Parts A and B cover home health care if a doctor certifies that you are homebound (leaving home takes a major effort) and need part-time skilled care, such as skilled nursing, physical therapy, occupational therapy, or speech therapy. A Medicare-certified home health agency must provide the care under a plan your doctor reviews. You pay $0 for covered home health visits in 2026, and 20% for any durable medical equipment. Medicare does not cover 24-hour home care, meal delivery, or homemaker services like cleaning when that is the only care you need.
Does Medicare cover vision care?
Mostly no for routine care.
In 2026, Original Medicare does not cover routine eye exams for glasses or contact lenses, and it does not pay for the glasses or contacts themselves. It does cover some medical eye care: yearly glaucoma screenings for people at high risk, diabetic retinopathy exams, treatment for eye diseases, and cataract surgery (including one pair of standard glasses or contacts afterward). For those covered services you pay 20% after the $283 Part B deductible. Many Medicare Advantage plans add a routine vision benefit covering eye exams and an allowance for glasses.
Does Medicare cover hearing aids?
Original Medicare does not cover hearing aids or the exams used to fit them.
Some Medicare Advantage plans include a hearing benefit, but coverage varies by plan.
Does Medicare cover diabetes supplies and testing?
Yes.
In 2026 Medicare covers most diabetes care across two parts. Part B (outpatient care and equipment) covers blood sugar monitors, test strips, lancets, and continuous glucose monitors (CGMs) as durable medical equipment, plus diabetes screenings and a self-management training program. You pay 20% of the Medicare-approved amount after the $283 Part B deductible. Part D (drug coverage) covers insulin and related supplies like syringes, and in 2026 your insulin is capped at $35 for a month's supply. If you have a Medicare Advantage plan, it covers at least the same diabetes benefits, sometimes with added extras.
Does Medicare cover durable medical equipment?
Yes.
Medicare Part B covers durable medical equipment (DME): reusable medical gear your doctor prescribes for use at home, such as wheelchairs, walkers, hospital beds, oxygen equipment, CPAP machines, and blood sugar monitors. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026, and Medicare pays the other 80%. To be covered, the item must be ordered by a Medicare-enrolled doctor and supplied by a Medicare-enrolled supplier, and some items are rented rather than bought. Equipment meant mainly for use outside the home, or only for comfort or convenience, is not covered.
Which is better, Medigap or Medicare Advantage?
Neither is better for everyone; they suit different needs.
Medigap (also called Medicare Supplement, a private policy that pairs with Original Medicare) lets you see any doctor nationwide who accepts Medicare with no network and very predictable out-of-pocket costs, but you pay a monthly Medigap premium and add a separate Part D drug plan. Medicare Advantage (Part C, your Medicare benefits through a private plan) often has a lower or $0 plan premium, bundles drug coverage and extras like dental and vision, and caps your yearly out-of-pocket costs, but uses provider networks and may require prior approval. People who travel, want maximum doctor freedom, and prefer steady costs often lean Medigap; people who want low premiums, extras, and a network they are comfortable with often lean Medicare Advantage. With both, you still pay the Part B premium ($202.90 per month in 2026). To find out which fits your situation, reach out to a licensed Goodsurance advisor at 1-888-301-8091 (TTY 711), Mon to Fri 8 am to 5 pm PT.