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)

ICR 202408-0938-003

OMB: 0938-1441

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10831 Beneficiaries Form and Instruction	Modified
CMS-10831_LI NET DirectReimbReq 2025v3 Crosswalk_508.pdf Supplementary Document	2024-08-06
CMS-10831_LI NET ApplForm 2025v3 Crosswalk_508.pdf Supplementary Document	2024-08-06
CMS-10831_Supporting Statement__a.docx Supporting Statement A	2024-08-06

IC Document Collections

IC ID	Document Title	Status
257782	Sponsor (Report to CMS)	Unchanged
257781	Pharmacists (Fax the Documentation to the LI NET Sponsor)	Unchanged
257780	Beneficiaries Form and Instruction	Modified