TN 2 (08-08)

HI 01190.040 Sequencing for Income-Related Monthly Adjustment Amount (IRMAA) New Initial Determination Dismissal Notices

A. Sequencing for IRMAA new initial determination dismissal notices for T2 beneficiaries

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

  • Introductory (no caption)

    MIR070                  R

  • MIRC10 – About Your Request For A New Decision

    MIR071                  O

    MIR073                  O

    MIR072                  O

    MIR086                  O

  • MIRC03If You Have Other Information About Your Income

    MIR074                  O

    MIR052                  R

    MIR082                  R

  • · REFC01 – If You Have Any Questions

    REF103                  O

    REF104                  O

    REF106                 O

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

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

  • Introductory (no caption)

    MIR070                     R

  • MIRC10 – About Your Request For A New Decision

    MIR071                     O

    MIR073                     O

    MIR072                     O

    MIR086                     O

  • MIRC03If You Have Other Information About Your Income

    MIR074                     O

    MIR052                     R

    MIR082                     R

  • REFC01 – If You Have Any Questions

    REF093                     O

    REF103                     O

    REF104                     O

    REF106                     O


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