To use this SEP you should call the Social Security Administration at 1-800-772-1213 and request two forms: the Part B enrollment request form (CMS 40B) and the request for employment information form (CMS L564). You’ll complete the Medicare enrollment application and give the request for employment information form to the employer to fill out. You want to request additional copies of form L564 from Social Security if you’ve been covered through more than one job-based plan since you qualified for Medicare.
If an employer is unable to fill out the form, Social Security may accept the following items as evidence you had job-based coverage:
Income tax forms showing you paid health insurance premiums;
W-2s or pay stubs showing pre-tax medical insurance premiums withheld;
health insurance cards with a policy effective date;
explanations of benefits; or
statements or receipts showing you paid health insurance premiums.
You should write down what you talk about with Social Security, and keep copies of the enrollment forms you submit in case you need to follow up. If your enrollment request is denied, you’ll have the chance to appeal.
People 65 and older only qualify for this SEP if they have coverage through their own or their spouse’s job, but disabled individuals can also qualify because they’re covered by a non-spouse family member’s plan.
You can delay your Part B effective date up to three months if you enroll while you still have employer-sponsored coverage or within one month after that coverage ends. Otherwise, your Part B coverage will begin the month after you enroll.