Request for Termination of Premium-Hospital and or Supplementary Medical Insurance and Supporting Regulations in 42 CFR 406.13 and 407.27 (CMS-1763)

Forms and Documents

Document Name	Status
Form CMS-1763 Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance Form and Instruction	Modified
CMS-1763 OMB 00938-0025 Crosswalk Changes.xlsx Supplementary Document	2018-01-24
CMS-1763 - Supporting Statement A rev OSORA PRA (OIRA Passback) CLEAN.docx Supporting Statement A	2018-05-14

IC Document Collections

IC ID	Document Title	Status
43649	Request for Termination of Premium-Hospital and/or Supplementary Medical Insurance Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0025	ICR Reference No: 201712-0938-010
Status: Active	Previous ICR Reference No: 201309-0938-023
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: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/23/2018
	Date Received in OIRA: 01/25/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved
Responses	101,000	0	0
Time Burden (Hours)	16,833	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS-1763 is used by beneficiaries to request voluntary termination from Premium Hospital (premium-HI) and/or Supplementary Medical Insurance (SMI).

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Authorizing Statute(s): Statute at Large: 18 Stat. 1838 Name of Statute: null
  

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:
	82 FR 14517	04/30/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 31609	07/07/2017
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-Hospital and/or Supplementary Medical Insurance	CMS-1763	Request for Termination of Premium Hospital and/or Supplementary Medical Insurance

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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	101,000	0	0	0	87,000	14,000
Annual Time Burden (Hours)	16,833	0	0	0	11,000	5,833
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 increase is a result of improved methods to approximate the number of annual responses using the CMS Medicare Beneficiary Database (MBD). The MBD provides more accurate data than was previously used in 2013. The enrollment data for the 12-month period of January through December 2016 was used to determine the annual number of responses. Based on this more reliable data source, the total number of respondents increased from 14,000 to 101,000 (an increase of 87,000). Additionally, the per response time estimate was reduced from 25 minutes to 10 minutes, based on updated processes and efficiencies at SSA to assist individuals. The form’s PRA Disclosure Statement was updated to match this per response time estimate. Beginning in April 2018, the term “Medicare Claim Number” will be replaced with the term “Medicare number” in response to the MACRA act. The form CMS 1763 has been updated to reflect this change. The change does not have an effect on the burden, as the requirements of the form remain the same.

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Annual Cost to Federal Government: $665,338

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? Uncollected

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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: 01/25/2018

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