Table of Contents
The CMS-1763 Exp form is an essential document used in the Medicare system, primarily for those seeking to appeal the termination of their Medicare coverage. This form plays a crucial role in ensuring that beneficiaries can formally request a reconsideration of their eligibility status. By completing the CMS-1763 Exp, individuals can provide necessary information regarding their circumstances, which may support their case for continued coverage. The form requires specific details, including personal identification information and the reason for the appeal, allowing Medicare officials to review the case thoroughly. Understanding the nuances of this form is vital for beneficiaries who wish to navigate the complexities of the Medicare appeals process effectively. Clarity and accuracy in filling out the CMS-1763 Exp can significantly impact the outcome of an appeal, making it a critical tool for those facing coverage challenges.
Document Specifics
| Fact Name | Details |
|---|---|
| Purpose | The CMS-1763 Exp form is used to request a termination of Medicare Part B coverage. |
| Eligibility | Individuals who no longer want Medicare Part B can submit this form. |
| Submission Method | The form can be submitted online, by mail, or in person at a local Social Security office. |
| Processing Time | Typically, it takes about 30 days to process the request after submission. |
| Effective Date | The termination of coverage is effective the first day of the month after the form is processed. |
| State-Specific Requirements | Some states may have additional requirements based on local laws governing health insurance. |
| Impact on Benefits | Terminating Medicare Part B may affect eligibility for other health programs and benefits. |
| Re-enrollment | Individuals can re-enroll in Medicare Part B during the General Enrollment Period, but penalties may apply. |
| Contact Information | For questions, individuals can contact the Social Security Administration or visit their website. |
Similar forms
The CMS-1763 Exp form is a crucial document used in the Medicare system, specifically for disenrollment from Medicare Advantage plans or Medicare prescription drug coverage. It shares similarities with several other forms that serve related purposes. Here are four documents that are comparable to the CMS-1763 Exp form:
- CMS-40B Form: This form is used for individuals who want to enroll in Medicare Part B. Like the CMS-1763, it requires personal information and is essential for managing Medicare coverage.
- The Texas Real Estate Purchase Agreement is an important document similar to the CMS-1763 Exp form, providing clarity and direction in transactions, allowing buyers and sellers in Texas to effectively navigate their agreements as detailed at https://fillable-forms.com/.
- CMS-10106 Form: This document is utilized for applying for Extra Help with Medicare prescription drug costs. Similar to the CMS-1763, it addresses financial aspects of Medicare and requires detailed income information.
- CMS-855I Form: This is an application for Medicare enrollment as a provider. Both the CMS-855I and CMS-1763 involve enrollment processes, ensuring that individuals or entities are properly registered in the Medicare system.
- CMS-1763 Form: While this may seem redundant, it’s important to note that the original CMS-1763 is used for voluntary disenrollment from Medicare, focusing on different aspects of enrollment and coverage status.
Each of these forms plays a vital role in the management of Medicare benefits, ensuring that individuals can navigate their healthcare options effectively.
CMS-1763 Exp Example
DEPARTMENT OF HEALTH AND HUMAN SERVICES |
Form Approved |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
OMB No. |
|
Expires: 04/24 |
REQUEST FOR TERMINATION OF PREMIUM PART A, PART B, OR
PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
WHO CAN USE THIS FORM?
People with Medicare premium Part A or B who would like to terminate their hospital or medical insurance coverage.
WHEN DO YOU USE THIS APPLICATION?
Use this form:
•If you have premium Part A or Part B, but wish to no longer be enrolled.
•If you have Part B, but recently
•If you have Part B, but are now covered under a spouse’s
WHAT HAPPENS NEXT?
Send your completed and signed application to your local Social Security office. If you have questions, call Social Security at
HOW DO YOU GET HELP WITH THIS
APPLICATION?
•Phone: Call Social Security at
•En español: Llame a SSA gratis al
•In person: Your local Social Security office. For an office near you check www.ssa.gov.
WHAT INFORMATION DO YOU NEED TO COMPLETE THIS APPLICATION?
•Your Medicare number
•Your current address and phone number
•A witness and their current address and phone number, if you signed the form with “X”
•Date you are requesting to end your premium Part A or Part B
WHAT ARE THE CONSEQUENCES OF
DISENROLLMENT?
•If you disenroll from Part B, it may result in gaps in your coverage, and you may incur a late enrollment penalty of 10% for each full
•You must have Part B while enrolled in premium Part A. If you disenroll from Part B, your premium Part A will also terminate.
REMINDERS
If you’ve already received your Medicare card, you’ll need to return it to the SSA office or mail it back.
WHAT IF YOU WANT TO
If you do not qualify for a special enrollment period (SEP), you will need to wait until the general enrollment period (GEP), which is every year from
If you would like to
CMS
•If you qualify for an SEP based on employer group health plan coverage, you’ll need to complete the CMS L564.
•If you qualify for an SEP based on another circumstance you’ll need to complete form CMS 10797.
•The forms will need to be provided to SSA per the instructions on each individual form.
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit
Form
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
REQUEST FOR TERMINATION OF PREMIUM PART A, PART B,
OR PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
The completion of this form is needed to document your voluntary request for termination of Medicare coverage as permitted under the Code of Federal Regulations. Section 1838(b) and 1818A(c)(2)(B) of the Social Security Act require filing of notice advising the Administration when termination of Medicare coverage is requested. While you are not required to give your reasons for requesting termination, the information given will be used to document your understanding of the effects of your request.
DO NOT WRITE IN THIS SPACE
NAME OF ENROLLEE (Please Print)
MEDICARE NUMBER
NAME OF PERSON, IF OTHER THAN ENROLLEE, WHO IS EXECUTING THIS REQUEST.
THIS IS A REQUEST FOR TERMINATION OF |
DATE PART A |
DATE PART B |
DATE PBID |
HOSPITAL INSURANCE |
WILL END |
WILL END |
WILL END |
MEDICAL INSURANCE |
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PART B IMMUNOSUPPRESSIVE DRUG COVERAGE |
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I request termination of my enrollment under the above sections of title XVIII of the Social Security Act, as amended, for the reason(s) stated below:
I UNDERSTAND THAT IF I AM REQUIRED TO PAY FOR MY HOSPITAL INSURANCE, THE TERMINATION OF MY PART B COVERAGE WILL ALSO END MY PART A COVERAGE.
If this request has been signed by mark (X), two witnesses who know the applicant must sign below, giving their full addresses.
1. NAME OF WITNESS
SIGNATURE (Write in Ink)
SIGN
HERE
ADDRESS (Number and Street, City, State and Zip Code)
MAILING ADDRESS (Number and Street)
2. NAME OF WITNESS
CITY, STATE, ZIP CODE
ADDRESS (Number and Street, City, State and Zip Code)
DATE (Month, Day and Year)
TELEPHONE NUMBER
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
Form
Understanding CMS-1763 Exp
What is the CMS-1763 Exp form?
The CMS-1763 Exp form is a document used by individuals to request an extension of their Medicare coverage. This form is typically filled out by beneficiaries who need additional time to complete their enrollment or who are facing special circumstances that affect their coverage.
Who should fill out the CMS-1763 Exp form?
This form is intended for Medicare beneficiaries who are seeking an extension for their coverage. If you have missed a deadline for enrollment or have specific reasons that require more time, you should consider filling out this form.
How do I obtain the CMS-1763 Exp form?
You can obtain the CMS-1763 Exp form from the official Medicare website or by contacting your local Social Security office. Many healthcare providers may also have copies available for their patients.
What information do I need to provide on the form?
When filling out the CMS-1763 Exp form, you will need to provide personal information such as your name, Medicare number, and contact details. Additionally, you should explain your reasons for requesting an extension and include any relevant documentation that supports your request.
Where do I send the completed CMS-1763 Exp form?
The completed form should be sent to the address specified in the instructions that accompany the form. Typically, this will be the local Social Security office or the Medicare administrative office handling your case.
How long does it take to process the CMS-1763 Exp form?
Processing times can vary, but it usually takes several weeks to receive a response after submitting the form. It is advisable to submit your request as early as possible to avoid any gaps in your Medicare coverage.
What happens if my request for an extension is denied?
If your request for an extension is denied, you will receive a notification explaining the reason for the denial. You may have the option to appeal the decision, and the instructions for doing so will be included in the notification.
Can I get help with filling out the CMS-1763 Exp form?
Yes, assistance is available for those who need help completing the form. You can reach out to Medicare representatives, local advocacy groups, or even family members who are familiar with the process. It’s important to ensure that the form is filled out correctly to avoid delays.
Is there a deadline for submitting the CMS-1763 Exp form?
Yes, there is typically a deadline for submitting the CMS-1763 Exp form. This deadline can vary based on your specific situation. It is crucial to check the instructions provided with the form to ensure you submit it on time.
Dos and Don'ts
When filling out the CMS-1763 Exp form, it is important to follow certain guidelines to ensure accuracy and efficiency. Here is a list of things you should and shouldn't do:
- Do read the instructions carefully before starting.
- Do provide accurate and complete information.
- Do double-check your entries for errors.
- Do sign and date the form where required.
- Don't leave any required fields blank.
- Don't use correction fluid or tape on the form.
- Don't submit the form without reviewing it first.
- Don't forget to keep a copy for your records.
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