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 202504-0938-005

OMB: 0938-1441

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10831 Beneficiaries Form and Instruction	Modified
Form CMS-10831 Beneficiaries Form and Instruction	Modified
CMS-10831_Supporting Statement__clean v2.docx Supporting Statement A	2025-04-04
CMS-10831_Supporting Statement__clean v2.docx Supporting Statement A	2025-04-04
CMS 10831 - Non-Sub Change Request Memo - February 2025.docx Justification for No Material/Nonsubstantive Change	2025-04-04
CMS 10831 - Non-Sub Change Request Memo - February 2025.docx Justification for No Material/Nonsubstantive Change	2025-04-04

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
257780	Beneficiaries Form and Instruction	Modified