Annual Verification Predetermination notices are mailed when the annual IRS data exchange to verify a beneficiary estimate, to verify beneficiary provided tax data, or to obtain PY-2 when we have been temporarily using PY-3 indicate that a beneficiary owes IRMAA premiums for the current premium year. The notice does not contain appeal rights but will invite beneficiaries to contact SSA within 10 days if the information is incorrect.

 

See HI 01130.005 for a description of the IRMAA Annual Verification process.

 

This is a sample of the notice that will be sent to a Title 2 beneficiary who supplied a copy of their PY-2 tax return and later, IRS returns a higher MAGI at the time of the annual verification data exchange.

   

Social Security Administration

Medicare Part B Premium

Notice of Planned Action

   

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

   

Beneficiary Name

Beneficiary Address

   

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a higher premium.

 

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

 

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium. We also will tell you what you should do if you have other information about your income.

 

If you do not contact us within 10 days from the date of this letter, we will assume the information in this letter is correct and use it to increase your Medicare Part B premium. We will send another letter at that time. It will explain how much you owe in Medicare Part B premiums and how to appeal our decision.

   

The Information We Have

   

When we matched computer records with IRS, we learned that your 2005 MAGI was $204,042.00.

 

 

How We Decided Your Income-Related Premium Amount

   

We used information that you gave us about your MAGI for 2005 to set your income-related premium amount for 2007. You told us your MAGI in 2005 was $194,042.00. You had an adjusted gross income of $184,000.00 plus tax exempt interest income of $10,042.00 and filed your taxes with a tax filing status of Single. We set your income-related amount at $49.40. We verified your information by asking the IRS about your MAGI from your income tax return for 2005. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

 

IRS told us your MAGI in 2005 was $204,042.00. In 2005, you had an adjusted gross income of $194,000.00 plus tax-exempt interest income of $10,042.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your 2007 income-related adjustment:

 

 

What You Can Do

   

We will not use this information from IRS to change your Medicare Part B Premium until we give you an opportunity to review it. Certain circumstances could change our plan to increase your premium. Please let us know right away if:

• •

  you believe that the information IRS gave us is incorrect, or

• •

  you have an amended tax return for 2005 and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

 

For proof of an IRS correction you need to provide either a letter from IRS acknowledging the correction or a transcript from IRS with new information and a copy of the filed tax return for the tax year the error occurred.

 

For proof of an amended tax return you need to provide a copy of the amended tax return and a receipt letter from IRS or a transcript from IRS if they have not sent you a receipt letter. If you cannot provide your copy of the amended tax return, you will need to get a copy of the amended tax return from IRS.

  

If You Have Any Questions

  

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).

 

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

   

                                                                                          SOCIAL SECURITY

                                                                                          Suite 2000, 20^th Floor

                                                                                          1234 Market Street

                                                                                           Philadelphia, PA 19107

  

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

  

                                                                                          Regional Commissioner

 

This is a sample of the notice that will be sent to an RRB beneficiary who provided their copy of PY-2 tax return. IRS returns a higher MAGI at the time of the annual verification data exchange. The beneficiary owes IRMAA.

   

Social Security Administration

Medicare Part B Premium

Notice of Planned Action

   

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

   

Beneficiary Name

Beneficiary Address

   

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a higher premium.

   

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

 

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium. We also will tell you what you should do if you have other information about your income.

 

If you do not contact us within 10 days from the date of this letter, we will assume the information in this letter is correct and use it to increase your Medicare Part B premium. We will send another letter at that time. It will explain how much you owe in Medicare Part B premiums and how to appeal our decision.

   

The Information We Have

   

When we matched computer records with IRS, we learned that your 2005 MAGI was $204,042.00.

 

You will pay $67.90 for the income-related amount of your monthly Medicare Part B premium. We plan to make this change effective 2007.

   

How We Decided Your Income-Related Premium Amount

   

We used information that you gave us about your MAGI for 2005 to set your income-related premium amount for 2007. You told us your MAGI in 2005 was $194,042.00. You had an adjusted gross income of $184,000.00 plus tax exempt interest income of $10,042.00 and filed your taxes with a tax filing status of Single. We set your income-related amount at $49.40. We verified your information by asking the IRS about your MAGI from your income tax return for 2005. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

 

IRS told us your MAGI in 2005 was $204,042.00. In 2005, you had an adjusted gross income of $194,000.00 plus tax-exempt interest income of $10,042.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your 2007 income-related adjustment:

 

 

What You Can Do

   

We will not use this information from IRS to change your Medicare Part B Premium until we give you an opportunity to review it. Certain circumstances could change our plan to increase your premium. Please let us know right away if:

• •

  you believe that the information IRS gave us is incorrect, or

• •

  you have an amended tax return for 2005 and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

For proof of an IRS correction you need to provide either a letter from IRS acknowledging the correction or a transcript from IRS with new information and a copy of the filed tax return for the tax year the error occurred.

 

For proof of an amended tax return you need to provide a copy of the amended tax return and a receipt letter from IRS or a transcript from IRS if they have not sent you a receipt letter. If you cannot provide your copy of the amended tax return, you will need to get a copy of the amended tax return from IRS.

   

If You Have Any Questions

   

If you have questions about payment of your Medicare premiums or about how this change affects benefits you may be receiving, please contact your nearest Railroad Retirement Board office. You can find the telephone number of the RRB office serving your area by calling 1-800-808-0772 or by visiting www.rrb.gov on the Internet.

 

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).

 

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

   

                                                                                        SOCIAL SECURITY

                                                                                        Suite 2000, 20^th Floor

                                                                                        1234 Market Street

                                                                                        Philadelphia, PA 19107

  

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

  

                                                                                        Regional Commissioner

This is a sample of the notice that will be sent to a Title 2 beneficiary when we are currently using the beneficiary’s estimate and during the annual verification data exchange, IRS supplies MAGI which is higher than the beneficiary estimate. The beneficiary owes IRMAA.

  

Social Security Administration

Medicare Part B Premium

Notice of Planned Action

  

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a higher premium.

 

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

 

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium. We also will tell you what you should do if you have other information about your income.

 

If you do not contact us within 10 days from the date of this letter, we will assume the information in this letter is correct and use it to increase your Medicare Part B premium. We will send another letter at that time. It will explain how much you owe in Medicare Part B premiums and how to appeal our decision.

  

The Information We Have

  

When we matched computer records with the IRS, we learned that your 2006 MAGI was $132,022.00.

 

 

How We Decided Your Income-Related Premium Amount

  

We used information that you gave us about your MAGI for 2006 to set your income-related premium amount for 2007. You told us your MAGI in 2006 was $94,022.00. You had an adjusted gross income of $84,000.00 plus tax exempt interest income of $10,022.00 and filed your taxes with a tax filing status of Single. We set your income-related amount at $12.30. We verified your information by asking the IRS about your MAGI from your income tax return for 2006. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

 

IRS told us your MAGI in 2006 was $132,022.00. In 2006, you had an adjusted gross income of $93,000.00 plus tax-exempt interest income of $39,022.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your 2007 income-related adjustment:

 

 

What You Can Do

  

We will not use this information from IRS to change your Medicare Part B Premium until we give you an opportunity to review it. Certain circumstances could change our plan to increase your premium. Please let us know right away if:

• •

  you believe that the information IRS gave us is incorrect, or

• •

  you have an amended tax return for 2006 and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

 

For proof of an IRS correction you need to provide either a letter from IRS acknowledging the correction or a transcript from IRS with new information and a copy of the filed tax return for the tax year the error occurred.

 

For proof of an amended tax return you need to provide a copy of the amended tax return and a receipt letter from IRS or a transcript from IRS if they have not sent you a receipt letter. If you cannot provide your copy of the amended tax return, you will need to get a copy of the amended tax return from IRS.

  

If You Have Any Questions

  

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).

 

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

  

                                                                                             SOCIAL SECURITY

                                                                                             Suite 2000, 20^th Floor

                                                                                             1234 Market Street

                                                                                             Philadelphia, PA 19107

  

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

  

                                                                                           Regional Commissioner

  

This is a sample of the notice that will be sent to a Title 2 beneficiary when we are currently using PY-3 MAGI and during the annual verification data exchange, IRS supplies PY-2 MAGI which is higher than the PY-3 MAGI. The beneficiary owes IRMAA.

  

Social Security Administration

Medicare Part B Premium

Notice of Planned Action

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a higher premium.

 

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

 

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium. We also will tell you what you should do if you have other information about your income.

 

If you do not contact us within 10 days from the date of this letter, we will assume the information in this letter is correct and use it to increase your Medicare Part B premium. We will send another letter at that time. It will explain how much you owe in Medicare Part B premiums and how to appeal our decision.

  

The Information We Have

  

When we matched computer records with the IRS, we learned that your 2005 MAGI was $204,042.00.

 

 

How We Decided Your Income-Related Premium Amount

  

We asked the IRS for information about your modified adjusted gross income (MAGI) from your income tax return for 2005 to determine if you must pay an income-related amount. Because IRS did not have any information about that year when we first asked, they gave us information about your MAGI from your tax return for 2004. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

 

Tax information for 2005 has become available. IRS told us your MAGI in 2005 was $204,042.00. In 2005, you had an adjusted gross income of $194,000.00 plus tax-exempt interest income of $10,042.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your 2007 income-related adjustment:

 

 

What You Can Do

 

We will not use this information from IRS to change your Medicare Part B Premium until we give you an opportunity to review it. Certain circumstances could change our plan to increase your premium. Please let us know right away if:

• •

  you believe that the information IRS gave us is incorrect, or

• •

  you have an amended tax return for 2005 and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

 

For proof of an IRS correction, you need to provide either a letter from IRS acknowledging the correction or a transcript from IRS with new information and a copy of the filed tax return for the tax year the error occurred.

 

For proof of an amended tax return we will require a copy of the amended tax return and a receipt letter from IRS or a transcript from IRS if they have not sent you a receipt letter. If you cannot provide your copy of the amended tax return, you will need to get a copy of the amended tax return from IRS.

 

If You Have Any Questions

 

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).

 

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

  

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20^th Floor

                                                                               1234 Market Street

                                                                                Philadelphia, PA 19107

  

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

  

                                                                                Regional Commissioner

 

This is a sample of the notice that will be sent to a Title 2 beneficiary when we are currently using a beneficiary estimate or beneficiary supplied copy of a tax return for PY-1 to determine IRMAA when we previously used PY-3 MAGI. During the verification data exchange, IRS supplies PY-2 MAGI and PY-1 MAGI. The verified PY-1 MAGI exceeds PY-2 MAGI. Since use of a more recent tax year, PY-1, does not result in a significant reduction in IRMAA, we will use PY-2 to determine IRMAA for the Premium Year being verified.

  

Social Security Administration

Medicare Part B Premium

Notice of Planned Action

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a higher premium.

 

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

 

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium. We also will tell you what you should do if you have other information about your income.

 

If you do not contact us within 10 days from the date of this letter, we will assume the information in this letter is correct and use it to increase your Medicare Part B premium. We will send another letter at that time. It will explain how much you owe in Medicare Part B premiums and how to appeal our decision.

 

The Information We Have

 

When we matched computer records with the IRS, we learned that your 2006 MAGI was $151,000.00.

 

How We Decided Your Income-Related Premium Amount

 

According to the law, we set your 2007 premium based on your modified adjusted gross income (MAGI) from 2005. The Internal Revenue Service (IRS) told us your MAGI in 2005 was $136,000.00. You had an adjusted gross income of $130,000.00 plus tax-exempt interest income of $6,000.00 and you filed your taxes with a tax filing status of Single. We charged you an income-related premium amount of $30.90. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

 

In February 2007, you reported a life changing event that reduced your 2006 MAGI. In such circumstances, at your request, we can use a more recent tax year return if it significantly lowers your MAGI. Therefore, we used the information you provided for 2006 to change your 2007 income-related premium amount to $12.30 a month.

 

When we verified the information that you gave us about your 2006 MAGI with IRS, we discovered that your 2006 MAGI is not significantly less than your 2005 MAGI. IRS reported that your 2006 MAGI was $151,000.00. You had an adjusted gross income of $150,000.00 plus tax-exempt interest income of $1,000.00 and you filed your taxes with a tax filing status of Single. Therefore, we will not use your 2006 MAGI to determine your 2007 income-related premium amount. We will use your 2005 MAGI information to determine your 2007 income-related premium amount. Based on your 2005 MAGI, your 2007 income-related premium amount will be $30.90. We used the following table to decide your 2007 income-related adjustment:

 

 

What You Can Do

 

We will not use this information from IRS to change your Medicare Part B Premium until we give you an opportunity to review it. Certain circumstances could change our plan to increase your premium. Please let us know right away if:

• •

  you believe that the information IRS gave us is incorrect, or

• •

  you have an amended tax return for 2006 and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

 

For proof of an IRS correction you need to provide either a letter from IRS acknowledging the correction or a transcript from IRS with new information and a copy of the filed tax return for the tax year the error occurred.

 

For proof of an amended tax return you need to provide a copy of the amended tax return and a receipt letter from IRS or a transcript from IRS if they have not sent you a receipt letter. If you cannot provide your copy of the amended tax return, you will need to get a copy of the amended tax return from IRS.

 

If You Have Any Questions

 

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).

 

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

   

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20^th Floor

                                                                               1234 Market Street

                                                                               Philadelphia, PA 19107

   

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

   

                                                                               Regional Commissioner