Effective Dates: 8/29/2023 - Present

Identification Number:
NL 00701 TN 23
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Form Notices
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part NL – Notices, Letters and Paragraphs

Chapter 007 – Letters and Paragraphs for Title II, Title XVI, and Title XVIII

Subchapter 01 – Form Notices

Transmittal No. 23, 08/29/2023

Audience

PSC: BA, CA, CCRE, CS, DE, DS, ICDS, IES, ILPDS, IPDS, ISRA, NPR, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, BTE, CC, CCRE, CDT, CR, CTE, EIE, FDE, PETL, RECONE, RECONR, RECOVR;
OCO-ODO: BET, BTE, CCE, CST, CT, CTE, CTE TE, DE, DEC, DS, DSE, PAS, PCS, PETE, PETL, RCOVTA, RECONE, RECOVR;
FO/TSC: CS, CS TII, CSR, FR, OA, OS, RR, TA;

Originating Component

CMS

Effective Date

Upon Receipt

Background

The CMS-L457 and CMS-L458 have been archived.  Language regarding how an individual can cancel a termination request has been added to theCMS-1763.  Further, technicians should advise individuals that if they want to cancel their request for termination, they should contact SSA prior to the date of coverage stoppage.

Summary of Changes

NL 00701.005 Usage Chart for HI/SMI Form Notices

This section will be archived.

NL 00701.117 Form CMS-L457 — Acknowledgement of Request for Medicare Part B Termination

This section will be archived.

NL 00701.120 Form CMS-L458 — Acknowledgement of Request for Premium Hospital Insurance Termination

This section will be archived.

NL 00701 TN 23 - Form Notices - 8/29/2023