TN 2 (08-08)

HI 01190.030 Sequencing for Income-Related Monthly Adjustment Amount (IRMAA) Initial Determination Notices

A. Sequencing for IRMAA initial determination notices for T2 beneficiaries

The following list contains the sequencing of captions and paragraphs for IRMAA Initial Determination Notices for T2 beneficiaries. An “R” indicates a required paragraph, while an “O” indicates an optional paragraph.

  • Introductory (no caption)

    MIR003                       R

    MIR004                       R

    MIR065                       R

    MIR016                       O

    MIR006                       O

    MIR007                       R

    MIR017                       O

    MIR008                       R

  • MIRC02 – Another Letter

    MIR010                       R

  • 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

    REPO31                     R

  • REFC01 – If You Have Any Questions

    REF103                     O

    REF104                     O

    REF106                     O

B. Sequencing for IRMAA initial determination notices for non-T2 beneficiaries

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

  • MIRC03If 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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601190030
HI 01190.030 - Sequencing for Income-Related Monthly Adjustment Amount (IRMAA) Initial Determination Notices - 08/13/2008
Batch run: 01/27/2009
Rev:08/13/2008