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

OMB No. 0938-1441

Expires: 11/30/2024

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

• <LI NET sponsor name> gets this direct reimbursement request from you

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 <LI NET sponsor address>, fax to <LI NET sponsor fax number>, or email to <LI NET sponsor email address>.

<LI NET sponsor name> 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 <LI NET sponsor name> 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.

For help with this form

Call the LI NET help desk at <LI NET sponsor phone number>. TTY users can call <phone number/TTY>.

Go to <LI NET sponsor website>.

Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

En español: Llame a <LI NET sponsor name> al

<phone number/TTY> 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: Male Female		Phone number: ( )
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:

1. A copy of your Medicaid card

2. A copy of a letter from the State or Social Security Administration showing your low-income subsidy (LIS) or “Extra Help” status

3. 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

4. A copy of a document from your State that confirms your Medicaid status is active

5. A screen-print from your State’s Medicaid systems showing your Medicaid status

6. Proof from a pharmacy that they billed Medicaid and that Medicaid made a payment to it

7. 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	Black or African American
Asian:	Native Hawaiian and Pacific Islander:
Asian Indian	Guamanian or Chamorro
Chinese	Native Hawaiian
Filipino	Samoan
Japanese	Other Pacific Islander
Korean	White
Vietnamese	I choose not to answer.
Other Asian

What is your gender? Select one.

Woman	I use a different term: _______________
Man	I choose not to answer.
Non-binary

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 <LI NET sponsor name> at <LI NET sponsor phone number> if you need information in an accessible format other than what’s listed above. Our office hours are <LI NET sponsor’s days and hours of operation>. TTY users can call <TTY number>.

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: