Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID) and Request to Cancel Medicare Part B (Medical Insurance) (CMS-1763)

Forms and Documents

Document Name	Status
Form CMS-1763 Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage Form and Instruction	Modified
CMS-1763 Crosswalk of Changes.pdf Supplementary Document	2025-08-05
CMS-1763_Supporting Statement_A.docx Supporting Statement A	2025-08-05

IC Document Collections

IC ID	Document Title	Status
43649	Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0025	ICR Reference No: 202508-0938-004
Status: Received in OIRA	Previous ICR Reference No: 202210-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Termination of Medicare Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (Part B-ID) and Request to Cancel Medicare Part B (Medical Insurance) (CMS-1763)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/05/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	197,518	0
Time Burden (Hours)	33,578	0
Cost Burden (Dollars)	0	0

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Abstract: Sections 1818(c)(5), 1818A(c)(2)(B) and 1838(b)(1) of the Act and corresponding regulations at 42 CFR 406.28(a) and 407.27(c) require that a Medicare enrollee wishing to voluntarily terminate Part B and/or premium Part A coverage file a written request with CMS or SSA. The statute and regulations also specify when coverage ends based upon the date the request for termination is filed. Under sections 1838(b) and (h)(4) of the Act individuals are not required to enroll or remain enrolled in the Part B for immunosuppressive drugs (Part B-ID) benefit program. Individuals enrolled in the Part B-ID benefit can terminate their enrollment by filing notice that they no longer wish to participate in the Part B-ID benefit program. The CMS-1763 and 1763A are the forms used by individuals who wish to terminate their Medicare premium Part A, Part B or Part B-ID or cancel their Medicare Part B. This is necessary due to how SSA defines termination and cancellation. To terminate means that coverage has already begun, to cancel means that coverage has not yet started. Only one version of the form will apply to each case that is processed. Furthermore, it would improve our data by distinguishing between individuals who terminated their Medicare coverage after it began, and those who canceled their coverage before it started, potentially influencing future policy decisions.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1838
   PL: Pub.L. 116 - 120 402 Name of Law: Consolidated Appropriations Act of 2021
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 321	01/03/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 37515	08/05/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage	CMS-1763A, CMS-1763	Request for Termination of Premium Part A, Part B or Part B Immunosuppressive Drug Coverage ,   Request to Cancel Medicare Part B (Medical Insurance)

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	197,518	0	0	83,226	0	114,292
Annual Time Burden (Hours)	33,578	0	0	14,491	0	19,087
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The hourly burden from the 2022 approved submission increased from 19,087 hours to 33,578,380 hours -- a change of 14,491. The change is due to a marginal increase in terminations from the 2022 submission to the 2024

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Annual Cost to Federal Government: $1,469,549

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/05/2025

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