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:
202210-0938-007
Status:
Historical Active
Previous ICR Reference No:
202207-0938-002
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CM-CPC
Title:
Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
12/14/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/04/2022
Terms of Clearance:
Prior to the re-submission of the information collection Request for Termination of Premium Part A, Part B, or Part B Immunosuppressive Drug Coverage (CMS-1763) (0938-0025), and in conjunction with Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID) (0938-1428), the agency will evaluate its beneficiaries' experience and ability to terminate Part B immunosuppressive drug coverage benefits. The evaluation will inform and be integrated in the agency’s next extension or revision of this information collection.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2024
36 Months From Approved
03/31/2025
Responses
114,292
0
114,215
Time Burden (Hours)
19,087
0
19,074
Cost Burden (Dollars)
0
0
0
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. Form CMS-1763 collects the information necessary to process Medicare enrollment terminations.
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:
PL: Pub.L. 116 - 120 402 Name of Law: Consolidated Appropriations Act of 2021
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
0938-AU85
Final or interim final rulemaking
87 FR 66454
11/03/2022
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
87 FR 25090
04/27/2022
30-day Notice:
Federal Register Citation:
Citation Date:
87 FR 66454
11/03/2022
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 Part A, Part B, or Part B Immunosuppressive Drug Coverage
CMS-1763
Request for Termination of Premium Part A, Part B or Part B Immunosuppressive Drug Coverage
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
114,292
114,215
77
0
0
0
Annual Time Burden (Hours)
19,087
19,074
13
0
0
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 burden changed due to an increase in the number of respondents which increased by 77 respondents, with the expansion of the use of the form. The expansion allows individuals to use the form to disenroll from Part B for immunosuppressive drugs. Based on voluntary terminations of the Part B-ID benefit only, we expect an added annual burden of 13 hours (77 requests to terminate the Part B-ID benefit x 0.167 hr) at a cost of $364 (13 hr x $28.01/hr) per year.
Annual Cost to Federal Government:
$780,043
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:
Mitch Bryman 410 786-5258 Mitch.Bryman@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:
11/04/2022
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