Information Collection Request
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 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1441 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 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 | Repair queued |
| CMS-10831_LI NET ApplForm 2025v3 Crosswalk_508.pdf |
Supplementary Document | Uploaded 2024-08-06 | Repair queued |
 CMS-10831_Supporting Statement__a.docx |
Supporting Statement A | Uploaded 2024-08-06 | Repair queued |
IC Document Collections
| 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 |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-1441 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202309-0938-018 |
| Agency Tracking No | CM CPC |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |