TN 27 (11-14)

A. Policy and procedure for obtaining evidence from the employer, group health plan (GHP) or large group health plan (LGHP)

For a special enrollment period (SEP) or premium surcharge rollback, we require evidence of GHP and LGHP coverage based on current employment status. Use the information in this subsection to obtain such evidence.

1. Form CMS-L564 (Request for Employment Information)

The Form CMS-L564 has two sections. The applicant completes Section A and the employer, the GHP or LGHP completes Section B of the form. The information provided in Section B is the evidence of GHP or LGHP coverage. To view the Form CMS-L564, see HI 00805.340.

Offer the beneficiary the option to have the Form CMS-L564 mailed to them or to visit Medicare.gov to get the form by clicking on the tab “Forms, Help & Resources” and selecting “Forms”. This tab is located on the top of the screen at the far right. (Medicare.gov/forms-help-and-resources/forms/medicare-forms.html). This is where the beneficiary can find the form. On Form CMS-L564, the beneficiary completes Section A and submits it to the employer, GHP or LGHP to complete Section B.

If the beneficiary wants to have the form mailed to him or her, provide a field office (FO) return envelope in the mailing. The form may also be mailed directly to the employer or GHP. If the FO is assisting the beneficiary with completing the form, only complete Section A and send the form to the employer or GHP to complete Section B.

Explain to the beneficiary that he or she should mail or take the completed form to their local FO for processing.

2. Telephone contact with the employer, GHP or LGHP

Document the information regarding GHP or LGHP coverage based on current employment status on Form SSA-5002 (Report of Contact).

3. Certification from an employer’s records by an authorized field office (FO) employee (e.g., a claims representative)

When information provided in the Form CMS-L564 or written notification from the employer, GHP or LGHP, is incomplete or appears to be erroneous, a FO may obtain the missing information or verify the validity of the information regarding GHP or LGHP coverage based on current employment status from an employer’s records. The FO is certifying the received information so that we can adjudicate the request. Document the certification in the individual’s record by:

• faxing the certification into the electronic repository, or

• preparing a SSA-5002 annotating the information and faxing it into the electronic repository.  

4. Written notification from the employer, GHP, or LGHP

A FO can accept a letter, fax, or email from the employer, GHP, or LGHP as evidence of GHP or LGHP coverage.

NOTE: A letter of Creditable Coverage (for the purposes of Medicare Part D) is not proof of GHP coverage for SEP or premium surcharge rollback purposes.

The written notification must be signed by (or come from) the company’s or GHP’s official, and include:

• the official’s title;

• the official’s phone number and/or other contact information; and

• the date.

B. Policy when the employer, GHP, or LGHP cannot provide evidence

When the employer, GHP or LGHP cannot provide all evidence of GHP or LGHP coverage based on current employment status, the applicant may submit other documents that reflect employment, GHP or LGHP coverage (in addition to or in lieu of the evidence listed in HI 00805.295A of this section). Acceptable documents include but are not limited to:

• income tax returns that show health insurance premiums paid;

• W-2s reflecting pre-tax medical contributions;

• pay stubs that reflect health insurance premium deductions;

• health insurance cards with a policy effective date;

• explanations of benefits paid by the GHP or LGHP; and

• statements or receipts that reflect payment of health insurance premiums.

C. Policy for GHP coverage

The evidence may be in any form as long as all of the following are present:

• there is no question that the evidence is from the employer or the GHP, except in cases where the employer, GHP, or LGHP cannot provide such evidence;

• the evidence indicates (or can be determined) when the beneficiary had GHP coverage based on current employment status; and

• the evidence indicates (or can be determined), where applicable, the end date of the GHP coverage based on current employment status.

The evidence does not need to indicate how large the employer is or if the GHP is primary to Medicare.

D. Policy for LGHP coverage

The same requirements, in HI 00805.295C, apply to the disabled beneficiary covered under an LGHP, except that the evidence must show that the beneficiary currently has or had coverage under an LGHP based on current employment status.

NOTE: We only require confirmation that the health plan is an LGHP for family members other than the worker or his or her spouse, or for beneficiaries whose first month of supplementary medical insurance (SMI) eligibility is prior to July 1990. For information on verifying that the GHP is an LGHP, see HI 00805.295F of this section.

E. Policy for countries with national health plans

Consider health plans in countries that have national health plans (also called Universal Healthcare) to meet the definition of a GHP for purposes of the SEP and premium surcharge rollback. 

A beneficiary (or a spouse) requesting an SEP or premium surcharge rollback who worked in a country with a national health plan must provide evidence of employment and evidence of coverage under the national health plan.

Evidence of employment includes statements from the employer, income tax returns, pay statements, or any other verification of employment. Evidence of coverage under the national health plan may be in any form as long as it is from an official source (e.g., statement from the employer or the plan, income tax returns) and clearly reflects that the beneficiary has or had coverage under the national health plan.

NOTE: Some countries’ national health plans cover only citizens of that country.

F. Procedure for verifying that the GHP meets the definition of LGHP

Ask the employer the question, “How many employees did you have on at least 50 percent of your business days during the last calendar year?” by:

• modifying Form CMS-L564 to add the question; or

• contacting the employer while adjudicating the SEP request as outlined in HI 00805.295A in this section.

If the response is that the employer had at least 100 employees, then the GHP is an LGHP.

When it is common knowledge (or the FO has established a precedent) that the GHP meets the definition of LGHP, prepare a Form SSA-5002 to document that the GHP is an LGHP.

If there is a question as to whether the GHP meets the definition of LGHP, the written notification from the employer or the LGHP is acceptable. This may be in the form of a letter, fax, or email. The company’s or GHP’s official must sign or provide the written notification. However, if there is any question as to the accuracy of the statement, develop to ensure that the GHP meets the definition of LGHP in HI 00805.266A.

G. Procedure when there is a question about whether a beneficiary is an “employee”

Beneficiaries applying for an SEP or premium surcharge rollback must have GHP or LHP coverage based on current employment as outlined in HI 00805.295A. Beneficiaries may also request to voluntarily terminate SMI based on the belief that Medicare is the secondary payer of benefits. If a question arises as to whether a beneficiary is an employee, take the following actions:

• accept the claimant’s request for SMI enrollment, voluntary termination, or premium surcharge rollback;

• document the file with the information on employment status received from the claimant and the employer; and

• refer the issue to the SSA Regional Office (RO) for a decision on the beneficiary’s status before taking any other action.

NOTE: The regional office (RO) consults with the Medicare Secondary Payer (MSP) Coordinator in the Centers for Medicare and Medicaid Services Regional Office (CMS RO) to resolve the secondary payer issue and thus help the claimant make an informed decision. For a list of MSP Coordinators, see HI 00805.345.

H. Procedure when a beneficiary has more than one employer

When a beneficiary who is requesting an SEP or premium surcharge rollback has more than one employer and coverage under more than one GHP or LGHP, the requirements apply to each employer per HI 00805.295C or HI 00805.295D in this section. You must obtain evidence of GHP or LGHP coverage based on current employment status from each employer.

I. References

• HI 00805.266 Description of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions

• HI 00805.320 Equitable Relief for Disabled Individuals Covered Under a GHP/LGHP

• HI 00805.340 Exhibit of Form CMS-L564 (Request For Employment Information)

• HI 00805.345 CMS Regional Office MSP Coordinators