TN 2 (08-08)

HI 01190.060 Sequencing for Income-Related Monthly Adjustment Amount (IRMAA) Reconsideration Affirmation Notices

A. Sequencing for IRMAA reconsideration affirmation notices for T2 beneficiaries

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

  • Introductory (no caption)

    MIR087                    R

    MIR060                    R

  • MIRC04 – How We Decided Your Income-Related Premium Amount

    MIR080                   O

    MIR081                   O

    MIR084                   O

    MIR030                   O

    MIR019                   R

    MIR020                   R

  • MIRC03 – If You Have Other Information About Your Income

    MIR021                   R

    MIR024                   O

    MIR022                   R

    MIR088                   R

    MIR025                   R

  • ALSC19 – If You Disagree With This Decision

    ALS163                     R

  • ALSC25 – If You Want Help With Your Hearing

    REP032                     R

  • REFC01 – If You Have Any Questions

    REF103                     O

    REF104                     O

    REF106                     O

B. Sequencing for IRMAA reconsideration affirmation notices for non-T2 beneficiaries

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

  • Introductory (no caption)

    MIR087                   R

    MIR060                   R

  • MIRC04 – How We Decided Your Income-Related Premium Amount

    MIR080                   O

    MIR081                   O

    MIR084                   O

    MIR030                   O

    MIR019                   R

    MIR020                   R

  • MIRC03 – If You Have Other In