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)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10831 Beneficiaries Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib Application to Enroll in the LI NET Program (2023 version 6).pdf Form and Instruction
CMS-10831 Application to Enroll in the Limited Income Newly Eligib Application to Enroll in the LI NET Program (2023 version 6).pdf Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program (2023 version 6).pdf Form and Instruction
CMS-10831 Direct Reimbursement Request for the Limited Income Newl Direct Reimbursement Request for the LI NET Program (2023 version 6).pdf Form and Instruction
Application to Enroll in the LI NET Program (2023 version 6) Track Change.pdf Track Change: Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program IC Document
Application to Enroll in the LI NET Program (2023 version 6) Track Change.pdf Track Change: Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program IC Document
Direct Reimbursement Request for the LI NET Program (2023 version 6) Track Change.pdf Track Change: Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program IC Document
Direct Reimbursement Request for the LI NET Program (2023 version 6) Track Change.pdf Track Change: Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program IC Document

Information Collection (IC) Details

IC Title:	Beneficiaries	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

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 (2023 version 6).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 (2023 version 6).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36,982	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	36,982	36,982
Annual IC Time Burden (Hours)	9,246	9,246
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change: Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program	Application to Enroll in the LI NET Program (2023 version 6) Track Change.pdf	09/27/2023
Track Change: Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program	Direct Reimbursement Request for the LI NET Program (2023 version 6) Track Change.pdf	09/27/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.