View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0025
ICR Reference No:
202104-0938-002
Status:
Historical Active
Previous ICR Reference No:
201712-0938-010
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CM-CPC
Title:
Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR 406.13 and 407.27 (CMS-1763)
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
03/15/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/13/2021
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2025
36 Months From Approved
03/31/2022
Responses
114,215
0
101,000
Time Burden (Hours)
19,074
0
16,833
Cost Burden (Dollars)
0
0
0
Abstract:
The CMS-1763 is used by beneficiaries to request voluntary termination from Premium Hospital (premium-HI) and/or Supplementary Medical Insurance (SMI).
Authorizing Statute(s):
Statute at Large:
18 Stat. 1838
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
86 FR 8362
02/05/2021
30-day Notice:
Federal Register Citation:
Citation Date:
86 FR 19267
04/13/2021
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance
CMS-1763
Request for Termination of Premium Hospital and/or Supplementary Medical Insurance
ICR Summary of Burden
Total Approved
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
114,215
101,000
0
0
13,215
0
Annual Time Burden (Hours)
19,074
16,833
0
0
2,241
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The hourly burden from the 2017 approved submission increased from 16,833 hours to 19,074 to hours, a change of 2,241 The change is due to an increase in submissions.
Annual Cost to Federal Government:
$755,253
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
Agency Contact:
Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov
Common Form ICR:
No
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:
04/13/2021
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