CMS Form L457 is a document used by the Centers for Medicare and Medicaid Services (CMS) to collect information about state health programs. The form is used to determine whether a state program meets certain requirements that are set by CMS. Completed forms are reviewed by CMS officials, who then make a determination about whether or not the state program qualifies for funding. The completion of Form L457 is mandatory for all states wishing to receive funding for their health programs from CMS. Failure to submit the completed form may result in a loss of funding for the affected state program.
| Question | Answer |
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| Form Name | Form Cms L457 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | l457, CMS-L457, cms l457, ESRD |
U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES |
OMB Approval Not Required |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
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Acknowledgment of Request
for Medicare Part B Termination
From: Department of Health and Human Services |
Date: |
Centers for Medicare & Medicaid Services |
Claim Number: |
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You recently asked us to stop your Medicare Part B (medical insurance) protection. On the basis of your request, this coverage will end on (mm/dd/yyyy). You are responsible for all premiums due through the end of that month. If you are currently billed for your medical insurance premiums, you should continue to promptly pay all premiums due. A late payment could cause your insurance to stop earlier than you wish.
If you change your mind and decide you want to keep your Part B insurance, you can do so by completing the form below. Take it or mail it to any Social Security office before the date your coverage will stop, and your protection will continue without interruption.
The decision to keep or drop this protection is one that only you can make. However, to assist you with making this important decision, we urge you to carefully consider the following information.
What does Medicare Part B cover? Medicare Part B helps cover your doctor’s services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health services. Part B helps pay for these covered services and supplies when they are medically necessary.
How else can I protect myself against medical expenses if I drop Medicare Part B? You may not be able to get the same amount of protection that you now have with Medicare Part B. If you are considering the purchase of private insurance, you should discuss this with your insurance representative before you drop Part B. If your income is very low, you may qualify for Medicaid which helps pay for medical and health care costs, including the Part B premium, for those who are eligible. Contact your State medical assistance office for more information.
Can I keep Medicare Part A (hospital insurance) if I drop Medicare Part B? You can keep your Medicare Part A if you are entitled to
(Over)
I would like to keep my Medicare Part B insurance coverage.
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DESTROY PRIOR EDITIONS |
Can I keep Medicare prescription drug coverage if I drop Medicare Part B? You can keep your Medicare prescription drug coverage if you are entitled to
Can I keep TRICARE coverage if I drop Medicare Part B? If you have Medicare Part A, you must also have Part B to keep your TRICARE coverage. However, if you are an active duty service member, or the spouse or dependent child of an active duty service member, the following applies to you:
•You don’t have to keep Part B to retain your TRICARE coverage as long as the service member is on active duty.
•You can get Part B during a special enrollment period if you have Medicare because you are age 65 or older or you are disabled.
•If you have Medicare because of End Stage Renal Disease (ESRD), you can only get Part B again during the general enrollment period and you may have to pay a higher premium.
Can I join a Medicare Advantage plan if I drop Medicare Part B? You must have both Medicare Part A and Part B to join a Medicare Advantage plan. If you are already in a Medicare Advantage plan and you drop Part B, your coverage in the plan will end.
How can I get Medicare Part B again if I decide I want it? You can get Part B again by signing up during January, February or March of any year for coverage which begins the following July. But your monthly premium may be higher than if you had not dropped the insurance. The cost of Part B will go up 10% for each
Do I have special
•Anytime you or your spouse (or family member if you are disabled) are working and still covered under the group health plan, or
•During the eight months following the month when the group health plan coverage ends or when the employment
ends, whichever happens first.
NOTE: If you have COBRA coverage, you must enroll in Medicare Part B during the eight months following the month when the group health plan coverage ends or when the employment ends, whichever happens first.
What if I am serving as a volunteer outside of the United States?
United States, you may be eligible for a special enrollment period if you:
•Perform volunteer service outside of the United States through a program sponsored by a
•Have health insurance that provides coverage while you are outside of the United States.
You may
•You are no longer serving as a volunteer outside of the United States; or
•You do not have health insurance that provides coverage outside of the United States, or
•The sponsoring organization is no longer tax exempt.
NOTE: You are not eligible for this special enrollment period if you are under age 65 and purchasing Medicare Part A because you are disabled.
Where can I get more information? If you have any questions or need more information, contact any Social Security office. You may also call Social Security’s