Beneficiaries

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)

OMB: 0938-1441

IC ID: 257780

Information Collection (IC) Details

View Information Collection (IC)

Beneficiaries
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program Application to Enroll in the LI NET Program (CMS-4201-F version 5).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program Direct Reimbursement Request for the LI NET Program (CMS-4201-F version 5).pdf Yes Yes Fillable Fileable

Health Health Care Services

 

36,982 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 36,982 0 36,982 0 0 0
Annual IC Time Burden (Hours) 9,246 0 9,246 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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