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pdfOMB No. 0938-TBD
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DIRECT REIMBURSEMENT REQUEST FOR 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.
Ways people get enrolled into the LI NET
program:
• Automatic enrollment
• Point-of-sale enrollment
• LI NET application form
•
gets this direct
reimbursement request from you
For help with this form
Call the LI NET help desk at . TTY users can call .
When should I use this form?
Use this form if you’re eligible for a low-income
subsidy and are submitting receipts to request
reimbursement for prescription drugs that you paid
for out of pocket.
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
Receipt(s)
What happens next?
has 14 calendar days to reply
whether your request is eligible or not for
reimbursement, including the reason for denying the
request (if applicable).
If grants your request, it will:
• Send you your reimbursement no later than 30
days after it determines your claim is eligible
for reimbursement
• Retroactively enroll you into the LI NET
program.
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
•
Send the information either by mail to , fax to , or email to .
If you want to get reimbursed and 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:
Phone number:
(
)
County (optional):
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
Name (if other than person with Medicare):
Phone number:
Provide receipt(s) for reimbursement for claims paid out of pocket.
ZIP code:
ZIP code:
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:
File Type | application/pdf |
File Title | 2023 Model PDP Individual Enrollment Request Form 0938-1378 |
Author | DEME UMO |
File Modified | 2022-12-07 |
File Created | 2022-12-07 |