CMS-10831 Application to Enroll in the Limited Income Newly Eligib

OMB No. 0938-TBD
Expires: [MM/DD/YYYY]

APPLICATION FORM TO ENROLL IN THE LIMITED INCOME NEWLY ELIGIBLE
TRANSITION (LI NET) PROGRAM

What is LI NET?

LI NET is a Medicare program that gives temporary
drug coverage for people with Medicare who
qualify for Extra Help and have no prescription
drug coverage.
Fill out this form to enroll in LI NET
• Complete Section 1 and include one of
the documents from the list of
acceptable supporting documentation.
• Send the information either by mail to , fax to , or email to .

When should I use this form?

Use this form if you haven’t enrolled through any of
these ways:
• Automatic enrollment by CMS
• Point of sale enrollment
• Direct reimbursement request

What do I need to complete this form?
•
•
•

Your Medicare Number (the number on your
red, white, and blue Medicare card)
Your permanent address and phone number
One of the documents from the list of acceptable
supporting documentation

What happens next?

After we process your , you’ll get a welcome letter
with information and instructions.

For help with this form

Call the LI NET help desk at . TTY users can call .
Go to .
Or, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048.
En español: Llame a al
o a Medicare gratis al
1-800-633-4227 y oprima el 2 para asistencia en
español y un representante estará disponible para
asistirle.

If you’re experiencing homelessness
•

If you want to enroll in LINET but don’t have a
permanent residence, you can list a Post Office
Box, an address of a shelter or clinic, or the
address where you get mail (like your Social
Security checks) as your permanent residence
address.

PRA Disclosure Statement
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare sponsors to track beneficiary enrollment, improve care, and for the payment of Medicare
benefits. Sections 1860D-1 of the Social Security Act and 42 CFR §§ 423.30 and 423.32 authorize the collection of this information. CMS may use, disclose, and exchange enrollment
data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response
to this form is voluntary. However, failure to respond may affect enrollment in the plan. Under the Privacy Act of 1974, any personally identifying information obtained will be kept
private to the extent of the law.
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 0938-TBD. The time required to complete this information is estimated to average 15 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note
that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please see “For help with this form” on this page to send your
completed form to the LI NET sponsor.

Section 1

FIRST name:
LAST name:
Birth date: (MM/DD/YYYY)
Sex:
(
/
/
)
Male
Female
Permanent Residence street address (Don’t enter a PO Box):
City:

County (optional):

Phone number:
(
)

Middle initial (optional):

State:

Mailing address, if different from your permanent address (PO Box allowed):
Street address:
City:
State:
Your Medicare information:
Medicare Number:
____-___-____
Information submitted by:
Self
Caregiver/Patient Advocate
Other

ZIP code:
ZIP code:

Name (if other than person with Medicare):
Phone number:

Provide one of these documents from the list of acceptable supporting documentation:
(A)
A copy of your Medicaid card
(B)
A copy of a letter from the state or Social Security Administration showing your low-income subsidy
status
(C)
The date you called your state Medicaid agency to verify your Medicaid coverage, the name and phone
number of the state staff person who verified the Medicaid period, and the Medicaid eligibility dates
confirmed on the call
(D)
A copy of a document from your state that confirms your Medicaid status is active
(E)
A screen-print from your state’s Medicaid systems showing your Medicaid status
(F)
Proof from a pharmacy that they billed Medicaid and that Medicaid made a payment to it

Section 2 (Optional)

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.
Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
I choose not to answer.
What’s your race? Select all that apply.
American Indian or Alaska Native
Chinese
Japanese
Other Asian
Vietnamese
I choose not to answer.

Asian Indian
Filipino
Korean
Other Pacific Islander
White

Black or African American
Guamanian or Chamorro
Native Hawaiian
Samoan

Select a language below if you want us to send you information in a language other than English.
[LI NET sponsor to insert the languages required in its service area.]
Select one if you want us to send you information in an accessible format.
Braille
Large print
Audio CD
Please contact at if you need information in an
accessible format other than what’s listed above. Our office hours are . TTY users can call .
Do you work?

Yes

No

Does your spouse work?

Yes

No

List your Primary Care Physician (PCP), clinic, or health center:
I want to get the following materials via email. Select one or more.
[LI NET sponsor may list those types or categories of materials that are available for electronic delivery]
E-mail address: