The following list contains the sequencing of captions and paragraphs for Income-Related
Monthly Adjustment Amount (IRMAA) Annual Verification Determination Notices for T2
beneficiaries. An “R” indicates a required paragraph, while an “O” indicates an optional
paragraph.
-
•
Introductory (no caption)
MIR100 O
Or MIR099 O
MIR098 R
MIR004 R
MIR065 R
MIR016 O
MIR006 O
MIR007 R
MIR017 O
MIR008 R
-
•
MIRC02 – Another Letter
MIR011 O
MIR012 O
-
•
MIRC04 – How We Decided Your Income-Related Premium Amount
MIR111 O
MIR113 R
MIR112 R
MIR119 R
MIR020 R
MIR114 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
REF103 O
REF104 O
REF106 O