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)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10831 Direct Reimbursement Request for the Limited Inon (LI NET) Program ()come Newly Eligible Transition(Vietnamese)	Form and Instruction	Modified	Available
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Vietnamese)	Form and Instruction	Modified	Available
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Spanish)	Form and Instruction	Modified	Available
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Spanish)	Form and Instruction	Modified	Available
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Korean))	Form and Instruction	Modified	Available
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Korean))	Form and Instruction	Modified	Available
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Chinese)	Form and Instruction	Modified	Available
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Chinese))	Form and Instruction	Modified	Available
Form CMS-10831 Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (English))	Form and Instruction	Modified	Available
Form CMS-10831 Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (English)	Form and Instruction	Modified	Repair queued
Form CMS-10831 Beneficiaries	Form and Instruction	Modified	Repair queued
CMS-10831_LI NET DirectReimbReq 2025v3 Crosswalk_508.pdf	Supplementary Document	Uploaded 2024-08-06	Available
CMS-10831_LI NET DirectReimbReq 2025v3 Crosswalk_508.pdf	Supplementary Document	Uploaded 2024-08-06	Repair queued
CMS-10831_LI NET ApplForm 2025v3 Crosswalk_508.pdf	Supplementary Document	Uploaded 2024-08-06	Repair queued
CMS-10831_LI NET ApplForm 2025v3 Crosswalk_508.pdf	Supplementary Document	Uploaded 2024-08-06	Repair queued
CMS-10831_Supporting Statement__a-111424Clean.docx	Supporting Statement A	Uploaded 2024-11-14	Repair queued
CMS-10831_Supporting Statement__a.docx	Supporting Statement A	Uploaded 2024-08-06	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
257782	Sponsor (Report to CMS)		Unchanged
257781	Pharmacists (Fax the Documentation to the LI NET Sponsor)		Unchanged
257780	Beneficiaries	Form and Instruction	Modified	Direct Reimbursement Request for the Limited Inon (LI NET) Program ()come Newly Eligible Transition(Vietnamese)
257780	Beneficiaries	Form and Instruction	Modified	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Vietnamese)
257780	Beneficiaries	Form and Instruction	Modified	Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Spanish)
257780	Beneficiaries	Form and Instruction	Modified	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Spanish)
257780	Beneficiaries	Form and Instruction	Modified	Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Korean))
257780	Beneficiaries	Form and Instruction	Modified	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Korean))
257780	Beneficiaries	Form and Instruction	Modified	Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Chinese)
257780	Beneficiaries	Form and Instruction	Modified	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Chinese))
257780	Beneficiaries	Form and Instruction	Modified	Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (English))
257780	Beneficiaries	Form and Instruction	Modified	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (English)
257780	Beneficiaries	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1441	ICR Reference No: 202408-0938-003
Status: Historical Active	Previous ICR Reference No: 202309-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: CM CPC
Title: 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)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/15/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/06/2024
Terms of Clearance: Approved consistent with the understanding that the agency will update the race/ethnicity question in this information collection to be in compliance with the updated SPD 15 (effective as of March 28, 2024) by December 2026.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	36 Months From Approved	11/30/2024
Responses	110,686	0	110,686
Time Burden (Hours)	11,701	0	11,701
Cost Burden (Dollars)	0	0	0

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Abstract: Section 118 of the Consolidated Appropriations Act, 2021 (CAA) (Public Law 116-260) enacted on December 27, 2020, amended Section 1860D-14 of the Social Security Act (the Act) (42 U.S.C. 1395w-114) and authorized CMS to make transitional coverage and retroactive Medicare Part D coverage for certain low-income beneficiaries, called the Limited Income Newly Eligible Transition (LI NET) program a permanent part of the Part D program. The LI NET program under this statute must begin no later than January 1, 2024.

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Authorizing Statute(s): PL: Pub.L. 116 - 260 118 Name of Law: Consolidated Appropriations Act, 2021 (CAA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 25879	04/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 63953	08/06/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Beneficiaries	CMS-10831, CMS-10831, CMS-10831, CMS-10831, CMS-10831, CMS-10831, CMS-10831, CMS-10831, CMS-10831, CMS-10831	Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (English) ,   Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (English)) ,   Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Chinese)) ,   Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Chinese) ,   Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Korean)) ,   Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Korean)) ,   Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Spanish) ,   Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program (Spanish) ,   Application to Enroll in the Limited Income Newly Eligible Transition (LI NET) Program (Vietnamese) ,   Direct Reimbursement Request for the Limited Inon (LI NET) Program ()come Newly Eligible Transition(Vietnamese)
Pharmacists (Fax the Documentation to the LI NET Sponsor)
Sponsor (Report to CMS)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	110,686	110,686	0	0	0	0
Annual Time Burden (Hours)	11,701	11,701	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $11,304

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/06/2024

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