The following list contains the sequencing of captions and paragraphs for IRMAA Initial
Determination Notices for Non-T2 beneficiaries. An “R” indicates a required paragraph,
while an “O” indicates an optional paragraph.
-
•
Introductory (no caption)
MIR003 R
MIR018 R
-
•
COPC01 – Other Information
MIR013 O
-
•
· MIRC04 – How We Decided Your Income-Related Premium Amount
MIR080 O
MIR081 O
MIR084 O
MIR030 O
MIR019 R
MIR020 R
MIR097 O
-
•
MIRC03 – If You Have Other Information About Your Income
MIR021 O
MIR027 O
MIR022 R
MIR026 O
MIR023 O
MIR024 R
MIR088 R
MIR025 O
-
•
ALSC19 – If You Disagree With This Decision
ALS162 R
-
•
REPC01 – If You Want Help With Your Appeal
REP031 R
-
•
REFC01 - If You Have Any Questions
REF093 O
REF103 O
REF104 O
REF106 O