Crosswalk: Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage

Revisions to Form CMS 1763 (OMB 0938-0025) Request for Termination of Premium Hospital Insurance and/or Supplemental Medical Insurance

The form was updated to include instructions and to provide clarity. There were no statutory or regulatory changes. The form changes did not affect the burden.

Changes

Question	Updated Form	Original Form	Reason for Change	Burden Effect
N/A	Form Title on Page 1 and Page 2 Request for Termination of Premium Part A, Part B or Part B Immunosuppressive Drug Coverage	Form Title Page 1 Request for Termination of Premium Hospital Insurance and/or Supplemental Medical Insurance	Updated to reflect the new uses of the form, to include Part B Immunosuppressive Drug Coverage under proposed rule 4199-P.	N/A
Instructions Page Who can use this application? When do you use this application? What information do you need to complete this application? What are the consequences of disenrollment? What happens next? How do I get help with this application? Reminders What if you want to re-enroll in Medicare?	Page 1	N/A	An instructions page was created to provide applicants with additional information about the forms intended audience, when the form should be used, what information is needed to complete the form, and what the next steps are. The instructions page also outlines the consequences of disenrolling to help beneficiaries make informed decisions about whether to disenroll.	N/A
This is a request for termination of: Hospital Insurance Medical Insurance Part B Immunosuppressive Drug Coverage	Page 2	Page 1 included Hospital Insurance and Medical Insurance. Part B Immunosuppressive Drug Coverage is newly added.	The Part B Immunosuppressive drug coverage was adopted into law under Section 402 of the Consolidated Appropriations Act, 2021. Individuals who are enrolled have an opportunity to disenroll at any time. This disenrollment opportunity was added to the current disenrollment form under proposed rule 4199-P.	Burden increased by 77 respondents yearly.