Transitional Coverage and Retroactive Medicare Part D Coverage for Certain Low-Income Beneficiaries through the Limited Income Newly Eligible Transition (LI NET) Program (CMS-10831)

ICR 202301-0938-003

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1441 can be found here:

Forms and Documents

Document Name	Status
Form CMS-10831 Beneficiaries Form and Instruction	New
CMS-10831_Supporting Statement A (CMS-4201-P version 6).docx Supporting Statement A	2023-01-09

IC Document Collections

IC ID	Document Title	Status
257782	Sponsor (Report to CMS)	New
257781	Pharmacists (Fax the Documentation to the LI NET Sponsor)	New
257780	Beneficiaries Form and Instruction	New

ICR Details