Navigating Medicare can feel overwhelming, especially if you didn’t sign up for Part B when you first became eligible. The good news? Medicare provides options to help kupuna and families in Hawai‘i avoid gaps in coverage or costly penalties. Two critical forms—the CMS-40B and CMS-L564—play a big role in this process.
The CMS-40B is the official application form for Medicare Part B (medical insurance).
Individuals eligible for Medicare (usually age 65 or older) who did not enroll in Part B when first eligible.
People who initially declined Part B coverage but later decided they need it.
Anyone who missed their enrollment window and now qualifies through the General Enrollment Period or a Special Enrollment Period.
The CMS-40B allows Medicare beneficiaries to apply for Part B after their initial enrollment period. It is most often used during the General Enrollment Period (January 1 – March 31) or in special circumstances, such as when other health coverage ends.
When completing CMS-40B, you’ll need to provide:
Personal details (full name, address, date of birth, Social Security number)
Reason for applying for Part B after the initial eligibility period
Employment status (if applicable)
🔗 Access the form here: CMS-40B Application for Medicare Part B
The CMS-L564, or Request for Employment Information, is the companion form to CMS-40B.
This form is used by individuals who delayed enrolling in Part B because they were covered under group health insurance through their employer or a spouse’s employer.
CMS-L564 serves as proof of creditable coverage—confirmation that you had employer-sponsored insurance and did not need to sign up for Medicare Part B right away. This proof helps you avoid late enrollment penalties when you eventually apply for Part B.
The CMS-L564 must be filled out and signed by your employer or health insurer. It includes:
Employment history or group health insurance details
Dates of coverage under the employer’s plan
Confirmation that you had valid insurance while eligible for Medicare
🔗 Access the form here: CMS-L564 Request for Employment Information
The CMS-40B and CMS-L564 are often submitted side by side:
For example, if you delayed enrolling in Medicare Part B because you had health insurance through your employer, you would complete CMS-40B to apply and have your employer complete CMS-L564 to verify your past coverage.
Healthcare access is essential for our kupuna and families. Missing Medicare deadlines without the right forms can lead to coverage gaps or costly late penalties. By understanding and using CMS-40B and CMS-L564, Hawai‘i residents can ensure they remain connected to the care they need—whether that’s doctor visits, lab tests, or outpatient services.
For those on neighbor islands or in rural communities, where access to care can already be challenging, having these forms completed on time can make all the difference.
If you or a loved one are unsure about how or when to use CMS-40B and CMS-L564, the Hawai‘i State Health Insurance Assistance Program (SHIP) is here for you. We provide free, unbiased counseling to Medicare beneficiaries, their families, and caregivers.
Our team can:
📞 Contact Hawai‘i SHIP today for free guidance and peace of mind.
🌺 Key Takeaway: CMS-40B gets you enrolled in Medicare Part B, and CMS-L564 proves you had employer coverage—together, they keep your health coverage seamless and penalty-free.
