Direct Reimbursement Request Crosswalk

CMS-10831 DIRECT REIMBURSEMENT REQUEST FOR THE LIMITED INCOME NEWLY ELIGIBLE TRANSITION (LI NET) PROGRAM
CROSSWALK

LINET (i.e., one word)

Page 1,
LI NET (i.e., LI NET)
last bullet

IMPORTANT: Read and sign below
• I must keep Hospital (Part A) or
Medical (Part B) to stay in the LI NET
program.
• By joining the LI NET program, I
acknowledge that LI NET will share
my information with Medicare, who
may use it to track my enrollment, to
make payments, and for other
purposes allowed by Federal law that
authorize the collection of this
information (see PRA Disclosure
Statement above). Your response to
this form is voluntary. However,
failure to respond may affect
enrollment in the plan.
• The information on this enrollment
form is correct to the best of my
knowledge.

Rev

To correct typographical error to
maintain consistency throughout
document

Add 42 CFR 423.32 require individuals
completing the enrollment form to
acknowledge certain disclosure and
exchange of information statements.

Page 1, last bullet

Page 2, Section 1

• I understand that my signature (or
the signature of the person legally
authorized to act on my behalf) on
this application means that I have
read and understand the contents of
this application. If signed by an
authorized representative (as
described above), this signature
certifies that:
1) This person is authorized under
State law to complete this
enrollment, and
2) Documentation of this authority is
available upon request by Medicare.
Signature: __________
Today’s date: __________
If you’re the authorized representative,
sign above and fill out these fields:
Name: __________
Address: __________
Phone number: __________
Relationship to enrollee: __________
What is your gender? Select one.
• Woman
• Man
• Non-binary
• I use a different term: [free text]
• I choose not to answer.

Add CMS is prioritizing the integration of SOGI Page 3, Section 2
questions into enrollment forms.
(Optional)
Collecting data about the LGBTQI+
population will allow CMS to better
identify and address the community’s
needs in terms of health care access,
outreach, and protections against
discrimination.

Which of the following best represents
how you think of yourself? Select one.
• Lesbian or gay
• Straight, that is, not gay or
lesbian
• Bisexual
• I use a different term: [free text]
• I don’t know.
• I choose not to answer.

Add CMS is prioritizing the integration of SOGI Page 3, Section 2
questions into enrollment forms.
(Optional)
Collecting data about the LGBTQI+
population will allow CMS to better
identify and address the community’s
needs in terms of health care access,
outreach, and protections against
discrimination.

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.