Crosswalk

Crosswalk for Changes to CMS Form Request for Employment Information (CMS-L564/CMS-R-297)
Changes made prior to the 60-day notice
Section on Current CMS-L564
(CMS-R-297) (04/10)

Type of Change

Rationale for Change

n/a

Add: coversheet

Explains the purpose of the form
for proper use by beneficiaries
seeking to enroll in Part B using
the statutory SEP

Section A

Remove: From Social Security
Administration and Telephone
Number

Beneficiaries will fill out Section
A. A SSA representative is not
needed as the form now includes
instructions to assist the
applicants and employers with
completing the form

Section A

Remove: Note from SSA to
employer

This form no longer requires this
information

Section B

Add: Additional questions and
reformat form

To properly determine eligibility
for individuals with GHP
coverage, with hours bank
arrangements or for disabled
individuals with large GHP
coverage

n/a

Add: Instructions for completion
of form

To provide explanation for each
data element requested on the
form for accurate completion by
the applicant and the employer

Changes made prior to the 30-day notice
CMS did not receive any public comments during the 60-day comment period. Changes were made due
to internal review and consultation with the Social Security Administration.
Section on Current CMS-L564
(CMS-R-297) (04/10)

Type of Change

Rationale for Change

Section B

Add: End date of coverage for a
disabled individual who had
coverage in a large group health
plan (LGHP)

To properly determine Special
enrollment period eligibility for
disabled individuals with LGHP
coverage