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)

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.

The latest form for 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) expires 2027-08-31 and can be found here.