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How to prepare CMS-L564

Obtain the CMS-L564 on the internet
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About CMS-L564

For purposes of this form you are considered to have a job when you are employed full-time or by your own independent means, and you have a relationship with the payer other than a common-law partner. This means you can have a relationship with an employer and have a job without meeting the strict requirements of working as a dependent on someone else's Medicaid or Medicare program. The IRS has an example of this in its “Questions and Answers About Medicaid and Dependent Care” published in the June 2023 tax software bulletin. People who have more than two employers may apply for the Special Enrollment Period in the first year of a marriage or relationship. Form CMS-L564 can be used for married people who are covered by a marriage or relationship plan of less than two years or by a common-law relationship, but only if the person filing this form does not have Medicaid or Medicare benefits, and he or she is covered by the group plan prior to the filing of his return for that year. The IRS issued Notice 2016-12 on August 25, 2016, which clarified that people with Medicaid and Medicare and are applying for the Special Enrollment Period must follow all the rules when applying from their prior group plan. If you have the same group plan as your prior plan, and you have had a change in your employment status, you no longer need to file Form CMS-L564 and can apply for the Special Enrollment Period as if you were not covered by that plan. The Special Enrollment Period does not apply to people who are exempt because they are not required to file an Income Tax Return or who are already enrolled in Medicaid or Medicare at the time the Form CMS-564 is submitted. Note: If one of your employers has a group plan that you are no longer on, you can be treated as being still employed part-time on that other plan. However, if you take your coverage elsewhere before you take the Special Enrollment Period, you are still required to file Form CMS-L564 to remain a member of your group plan or your prior plan and are not eligible to receive employer premium tax credits or cost-sharing subsidies. Additional Questions for Certain Groups of Beneficiaries To understand what to do to ensure that you qualify for the Special Enrollment Period and take advantage of the benefits for which you qualify, we have prepared questions and answers for certain groups of beneficiaries that are not referred to in the CMS-L564 instructions.

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