15 49.0138 8.38624 1 0 4000 1 https://blog.pdffiller.com 300 true
СMS-1763

CMS 1763 Form: termination of premium hospital and/or supplementary medical insurance

Having decided to terminate your Medicare insurance, you should make sure you know how the process works and protect yourself from consequences. Today, we are providing you with our review of the CMS 1763 Form to help you understand it better.  

Having decided to terminate your Medicare insurance, you should make sure you know how the process works. We provide our review of the CMS 1763 Form to help you.

What is Form CMS 1763 for?

The CMS 1763 Request form is the only way to terminate Medicare Plan A and Plan B. Considering the seriousness of this decision, filling out the form is not the only step required. More often than not, before submitting the completed CMS-1763, the claimant will be invited to an interview with a Social Security representative. The interview can take place in person or over the phone. The claimant will need to explain the reason for terminating their plan, and the Social Security representative will, in turn, explain the procedure and results of canceling the current insurance coverage. During the interview, it’s recommended that the time is taken to ask as many questions as possible.

A typical situation for completing the request is when someone or their spouse has found a job that will cover their insurance. It is crucial that you as the claimant or spouse of a claimant make sure that the primary insurance is covered under your employer’s insurance plan. In general, a small employer (20 employees or less) offers secondary insurance. In this case, Medicare remains primary and you would receive almost no coverage from other insurance. Beware, your employer can’t force you to choose Medicare instead of a group health plan. It is illegal, you have the option to switch plans, but no one can make you do it. 

Who needs a CMS 1763 Form?

The Request for Termination of Premium Hospital and/or Supplementary Medical Insurance, CMS -1763, is a standard US Department of Health and Human Services form, used by the Medicare enrollee who wishes to terminate their Premium Hospital (premium Part A) and Supplementary Medical Insurance (Part B). This action is provisioned by the 1818A Section of the Social Security Act. 

Anyone who has Medicare can submit Form CMS 1763 and opt out of insurance. Medicare isn’t mandatory. But if you don’t have another primary health coverage, you might get hit with a penalty. 

As a reminder, Medicare is the federal social insurance program. US citizens aged 65 and older, people with disabilities of any age, and those who suffer from end-stage renal disease and amyotrophic lateral sclerosis, who are eligible for Social Security Disability Insurance benefits (SSDI) should enroll and use it. Make sure, whether you think you need this insurance program or not, answer these questions and figure it out.

But enrolling in Medicare means you cannot contribute to the Health Savings Account (HSA). Typically, as long as you continue to work and have health coverage under an employee plan you don’t need to sign up for Medicare Part B. 

Note: if you have to buy Medicare Part A or Part B, and you decline to purchase for some reason, you may have to pay a penalty. So, carefully consider all the reasons for terminating first. Then contact the Social Security Administration (SSA) at 1-800-772-1213 or your local office.

 Is Form CMS 1763 accompanied by other forms?

Filing the Request for Termination of Premium Hospital and/or Supplementary Medical Insurance does not require any supplementary documentation. So, all you need to do is complete the one-page CMS 1763 and speak with a Social Security representative. 

widget-banner

Your digital workflow at its best!

Start your 30-day Free Trial of PDFfiller’s fillable form
builder, PDF editor & e-signature solution.

When is Form CMS 1763 due?

The application for Medicare insurance has specific dates for retired Americans: the application must be filed three months before the applicant’s 65th birthday. The termination of hospital or medical insurance is not strictly regulated and can be done when considered necessary by the insured person. The termination should be expected at the end of the month that the request is filed. But money received from Social Security has to be returned in order to terminate the insurance. 

After termination, you and your spouse can always return to Medicare. For example, if you lose your insurance, you can enroll again within 8 months and won’t be given the late penalty. Please keep in mind, Medicare does not recognize domestic relationships. So even if you have coverage from a spouse’s insurance, you still need to enroll in Medicare by 65. After your spouse’s insurance stops working, you won’t be able to use the free enrollment period and will have to pay the fine.

How to fill out Form CMS 1763?

Form CMS-1763 is a single-page document consisting of several items:

  • Enrollee Name
  • Medicare Claim Number
  • Name of the Person Executing the Request (if appropriate)
  • Determination of the coverage requiring termination. If you want to opt-out of both coverages, check them. 
  • End Date of the Insurance
  • Reasons for the termination request. 
  • Signature
  • Address
  • Phone Number
  • Date

If an applicant signs the form by marking ‘x’ in the field, then the form must be signed by two witnesses. They should provide their names and mailing addresses. Witnesses have to know you to testify that the form was filed voluntarily. They can be your friends, relatives, or neighbors.

Where should Form CMS-1763 be sent?

The CMS 1763 form must be completed during or after an interview with a representative from the Social Security Administration. Having filled it out completely, the applicant should submit it to the applicant’s local SSA office

Although Form CMS 1763 is not available for online submission, you can find it in pdfFiller’s library, fill out and easily print it out from your account. We will help complete each field and take you through it step by step.

PDFfiller Blog | Weekly tips

651fsl2, applicable, certify, CFR, corrective, dot cdl medical card certificate forms printable, dotfill form medicine, embodies, examiner certificate, exempt, exemption, how to medical examiner certificate, intracity, medical examiner certificate, SPE
Previous Post
The Medical Examiner Certificate & Better Road Safety
425 report, current fillable standard form 425 federal financial report, federal financial report, form 425, form 425 federal financial report, form financial report, form sf 425, sf 425, sf 425 fillable, sf 425 form, sf 425 report, sf425, standard form 425, standard form 425 federal financial report, standard form 425 fillable
Next Post
SF 425 Form: Reporting the Status of Federal Grants