Track Change: Direct Reimbursement Request for the Limited Income Newly Eligible Transition (LI NET) Program

OMB No. 0938-1441
Expires: 11/30/2027

DIRECT REIMBURSEMENT REQUEST FOR THE LIMITED INCOME NEWLY
ELIGIBLE TRANSITION (LI NET) PROGRAM
What is the Limited Income Newly
Eligible Transition (LI NET) program?

LI NET is a Medicare program that gives temporary
prescription drug coverage for people with
Medicare who qualify for low-income subsidy
(LIS) or “Extra Help” and have no prescription
drug coverage.

Ways people get enrolled into the LI NET
program:
•

•
•
•

Automatic enrollment by the Centers for
Medicare and Medicaid Services (CMS)
Point-of-sale enrollment at a pharmacy
LI NET application form
gets this
direct reimbursement request from
you

For help with this form
Call the LI NET help desk at . TTY users can call .
Go to .

When should I use this form?

Use this form if you’re eligible for a low-income
subsidy and are submitting receipts to request
reimbursement for prescription drugs that you paid
for out of pocket.

What do I need to complete this form?
•
•
•

Your Medicare Number (the number on your
red, white, and blue Medicare card)
Your permanent address* and phone number
Receipt(s)

What happens next?

Send the information either by mail to , fax to , or email to .

has 14 calendar days to reply
whether your request is eligible or not for
reimbursement, including the reason for denying the
request (if applicable).
If grants your request, it will:
• Send you your reimbursement check no later
than 30 days after it determines your claim is
eligible for reimbursement
• Retroactively enroll you into the LI NET
program.

Or, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048.
En español: Llame a al
o a Medicare gratis al
1-800-633-4227 y oprima el 8 para asistencia en
español y un representante estará disponible para
asistirle.

If you’re experiencing homelessness
•

*If you want to get reimbursed and enroll in
LI NET but don’t have a permanent
residence, you can list a Post Office Box, an
address of a shelter or clinic, or the address
where you get mail (like your Social Security
checks) as your permanent residence
address.

PRA Disclosure Statement
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare sponsors to track beneficiary enrollment, improve care, and for the payment of Medicare
benefits. Sections 1860D-1 of the Social Security Act and 42 CFR §§ 423.30 and 423.32 authorize the collection of this information. CMS may use, disclose, and exchange enrollment
data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response
to this form is voluntary. However, failure to respond may affect enrollment in the plan. Under the Privacy Act of 1974, any personally identifying information obtained will be kept
private to the extent of the law.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1441. The time required to complete this information is estimated to average 15 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note
that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please see “For help with this form” on this page to send your
completed form to the LI NET sponsor.

Section 1

FIRST name:
LAST name:
Middle initial (optional):
Birth date: (MM/DD/YYYY)
Sex:
Phone number:
Male
Female (
(
/
/
)
)
Permanent Residence street address (Don’t enter a P.O. Box. Note: For individuals experiencing homelessness, a
P.O. Box may be considered your permanent residence address.):
City:
County (optional):
State:
ZIP code:
Mailing address, if different from your permanent address (P.O. Box allowed):
Street address:
City:
State:
ZIP code:
Your Medicare information:
Medicare Number:
____-___-____
Information submitted by:
Self
Caregiver/Patient Advocate
Other
Name (if other than person with Medicare):
Phone number: (

)
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.
• 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:

Provide copy of receipt(s), pharmacy printout, or proof of payment for reimbursement for eligible claims
paid out of pocket.
You have the option to provide one of these documents with your application to support verification of
eligibility. This documentation may include:
(A) A copy of your Medicaid card
(B) A copy of a letter from the State or Social Security Administration showing your low-income subsidy (LIS)
or “Extra Help” status
(C) The date you called your State Medicaid agency to verify your Medicaid coverage, the name and phone
number of the State staff person who verified the Medicaid period, and the Medicaid eligibility dates
confirmed on the call
(D)
(E)

A copy of a document from your State that confirms your Medicaid status is active
A screen-print from your State’s Medicaid systems showing your Medicaid status

(F)
(G)

Proof from a pharmacy that they billed Medicaid and that Medicaid made a payment to it
Documentation of enrollment in other benefits such as Supplemental Security Income (SSI)

Section 2 (Optional)

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.
Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
I choose not to answer.
What’s your race? Select all that apply.
American Indian or Alaska Native
Asian:
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
What is your gender? Select one.
Woman
Man
Non-binary

Black or African American
Native Hawaiian and Pacific Islander:
Guamanian or Chamorro
Native Hawaiian
Samoan
Other Pacific Islander
White
I choose not to answer.
I use a different term: _______________
I choose not to answer.

Which of the following best represents how you think of yourself? Select one.
Lesbian or gay
I use a different term: _______________
Straight, that is, not gay or lesbian
I don’t know.
Bisexual
I choose not to answer.
Select a language below if you want us to send you information in a language other than English.
[LI NET sponsor to insert the languages required in its service area.]
Select one if you want us to send you information in an accessible format.
Braille
Large print
Audio CD
Data CD
Please contact at if you need information in an
accessible format other than what’s listed above. Our office hours are . TTY users can call .
I want to get the following materials via email. Select one or more.
[LI NET sponsor may list those types or categories of materials that are available for electronic delivery]
E-mail address: