The following list contains the sequencing of captions and paragraphs for Income-Related
Monthly Adjustment Amount (IRMAA) Annual Verification Predetermination Notices for
T2 beneficiaries. An “R” indicates a required paragraph, while an “O” indicates an
optional paragraph.
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•
Introductory (no caption)
MIR092 R
MIR094 R
MIR095 R
-
•
INFC01 – The Information We Have
MIR107 R
MIR002 R
MIR065 R
MIR006 O
MIR007 R
MIR017 O
MIR120 R
-
•
MIRC04 – How We Decided Your Income-Related Premium Amount
MIR102 O
Or MIR103 O
Or MIR115 & MIR116 O
MIR108 O
Or MIR109 O
MIR019 R
MIR020 R
NOTE: If MIR115 generates, MIR116 is required.
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•
MESC01 – What You Can Do
MIR110 R
-
•
REFC01 – If You Have Any Questions
REF103 O
REF104 O
REF106 O