TN 4 (02-12)

HI 01194.005 Annual Benefit Rate Increase Notice for Title II Beneficiaries Affected by Income-Related Monthly Adjustment Amount (IRMAA)

A. Purpose or Use

When SSA determines that a title II beneficiary must pay an Income-Related Monthly Adjustment Amount (IRMAA), we send this notice instead of the standard annual cost-of-living (COLA) mailer. These notices contain the same information as the standard COLA notice plus additional information about IRMAA. Affected beneficiaries receive this notice the same time other title II beneficiaries receive their annual COLA letters (usually in late November of each year).

Notices to title II beneficiaries with Medicare Part B (medical insurance) list all of the components that make the total Part B premium. For beneficiaries with a Medicare prescription drug plan, the IRMAA-D information is the only Part D amount routinely displayed. If the beneficiary has the Part D premium withheld from the title II benefit, the notice will also include the amount of that premium.

This section contains a sample of a Title II IRMAA cost-of-living notice. This sample does not cover all possible options.

B. Sample Annual Income-Related Monthly Adjustment Amount (IRMAA) Notice for Title II Beneficiaries with a Cost of Living Adjustment (COLA)

Social Security Administration

Date: Month, day, year

Claim Number: xxx-xx-xxxxA

Beneficiary Name
Address
City State Zip

   

Social Security benefits will increase by x.x percent in 20xx because of a rise in the cost of living. The Social Security Act requires some people to pay higher premiums for their Medicare Part B (Medical Insurance) and their prescription drug coverage based on their income. Because of your income, your premiums will be increased. The information in this notice about your premium is for 20xx only.

If you currently do not have Medicare Part B or prescription drug coverage and enroll in 20xx, those premiums will also be increased based on your income.

How Much Social Security Will I Get?

  • Your new 20xx monthly benefit amount before deductions is: $x,xxx.xx

  • Your 20xx monthly deduction for the Medicare Part B Premium is: $xxx.xx

    • $xxx.xx for the standard Medicare premium, plus

    • $xx.xx for late filing surcharges for Medicare Part BP plus

    • $xxx.xx for the income-related monthly adjustment amount based on your 20xx

Your Medicare Premiums

If you are enrolled in Medicare Part B, your Medicare Part B premiums for 20xx include any surcharges for late enrollment or reenrollment, plus an income-related monthly adjustment amount. Your Medicare Part B premiums, including the income-related monthly adjustment amount, will be deducted from your Social Security benefits, if you have prescription drug coverage, your income-related monthly adjustment amount for that coverage will be deducted from your Social Security benefits regardless of how you ordinarily pay your prescription drug coverage premiums. If the prescription drug coverage income-related monthly adjustment amount is more than the benefit payment, we will not be able to deduct it. If this happens, you will get a separate bill from the Centers for Medicare & Medicaid Services.

Each year to decide if you must pay an income-related monthly adjustment amount, we use your Federal income tax information for the most recent tax year that is available. However, we do not use any information that is more than three years old. We ask the Internal Revenue Service (IRS) for your tax filing status, your adjusted gross income, and your tax-exempt interest income. We then add your adjusted gross income together with your tax-exempt interest income to get an amount that we call modified adjusted gross income (MAGI). We compare your MAGI with the income thresholds set by Medicare law.

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 premium for only one year.

How We Figured Your Income - Related Monthly Adjustment Amounts

The IRS told us that in 20xx you filed your taxes as Single. You had an adjusted gross income of $xx,xxx.xx plus $xx,xxx.xx in tax-exempt interest income. We added these amounts together to get your MAGI of $ xxx,xxx.xx.

We used the following table to decide income-related monthly adjustment amounts for the Medicare Part B premiums and prescription drug coverage premiums:

If you filed as:With MAGI of:Part B
IRMAA is:
Prescription
Drug Coverage
IRMAA is:
Single, Head of $85,000.01 - $107,000.00$xx.xx $xx.xx
household or$107,000-01 - $160,000.00$xxx.xx $xx.xx
Qualifying$160,000.01 - $214,000.00$xxx.xx $xx.xx
Widow(er)More than $214000.00$xxx.xx $xx.xx
    
Married, filing $170,000.01 - $214,000.00$xx.xx$xx.xx
jointly$214,000.01 - $320,000.00$xxx.xx$xx.xx
 $320,000.01 - $428,000.00$xxx.xx$xx.xx
 More than $423,000.00$xxx.xx$xx.xx
    
Married, filing$85,000,01 - $129,000.00 $xxx.xx $xx.xx
Separately
(if you lived apart
throughout 20xx, see
below about Some
Special Situations)
More than $129,000.00$xxx.xx $xx.xx

These income-related monthly adjustment amounts are effective for 20xx only. Next year when we receive updated information from the IRS, we will make a new decision about any income-related adjustment amounts.

Some Special Situations That May Apply To You

If your tax filing status was married, filing separately, and you lived apart from your spouse throughout the tax year we used, please call us about your living arrangement. It could lower your IRMAA. We will set up an appointment to discuss that information. You will need to bring a copy of the most recent income tax return you filed with IRS to the appointment.

If you have been paying a reduced Part B premium based on a small Social Security benefit, the increased premium amount will apply beginning with your January benefit.

If Your Income Has Gone Down

In some situations, we can make a new decision about your income-related monthly adjustment amounts. Contact us to request a new decision if your MAGI has gone down at least one range in the table above or has gone below the lowest amounts in the table since you filed your 20xx tax return, AND the decrease in MAGI was caused by any of the following life-changing events:

  • You married,

  • You divorced, or your marriage was annulled,

  • You became a widow or widower,

  • You or your spouse stopped working or reduced work hours,

  • You or your spouse lost income-producing property due to a disaster or other event beyond your control,

  • You or your spouse experienced a scheduled cessation, termination, or reorganization of an employer's pension plan, or

  • You or your spouse received a settlement from an employer or former employer because of the employer's closure, bankruptcy or reorganization.

We will use the new lower MAGI to see if we can make a new decision about your income related monthly adjustment amounts. We cannot make a new decision if your income has changed for a reason other than those listed above, such as receiving one-time income from capital gains.

You will need to submit proof of the event listed above that caused your income to go down (such as a death certificate, a letter from your pension fund administrator, or a letter from your employer about your retirement). If you filed an amended or corrected tax return for the year you want changed, you will also need to submit a copy of the tax return with proof it has been received by the IRS.

If your MAGI has gone down at any time during January through September, you will need to tell us before the end of that year so we can correct your income-related monthly adjustment amount in that year. However, if the event that makes your MAGI go down did not occur until October 1 or later in the year, we can correct your income-related monthly adjustment amount for that year if you tell us before the end of March of the following year.

If The Information We Used Is Incorrect

We based the income-related monthly adjustment amounts on information we received from the IRS. If you have proof that the information we received from the IRS was not correct, please contact us to ask for a new decision about your income-related Medicare premiums. If you filed an amended tax return for that year, you will need to show us a copy of your amended Federal income tax return. You also will need to show us a letter or transcript from the IRS acknowledging receipt of your amended return. If the IRS corrected their records of your tax information for the year we used, you will need to show us the letter you received from the IRS. If you do not have all this information, the IRS can help you get it.

If we have included an income-related monthly adjustment amount for your prescription drug coverage, and you do not have a prescription drug coverage, please contact the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). CMS is the only agency that can correct the information about your prescription drug coverage.

If You Disagree With Our Decision

If you disagree with our decision about your income-related monthly adjustment amounts, you have the right to:

  • request a new decision if your income has gone down due to any of the life-changing events listed above; or

  • request a new decision using more recent tax information if you have amended or corrected tax information for 20xx, or if we used tax information for 20xx; and/or

  • appeal this decision.

If you qualify for a new decision on your income-related monthly adjustment amount, we will make a new decision using your tax information. You will not need to file an appeal on this decision if we find that you qualify for a new decision. If we make a new decision, you will be able to file an appeal on the new decision.

If You Want To Appeal This Decision

If you disagree with this decision about your income-related monthly adjustment amounts, you have the right to appeal. We will review the decision we made to verify that a correct decision was made. A person who did not make the first decision will decide your case.

If you do appeal, we may start withholding your increased premiums before we make our decision on your appeal. If we change our decision about your income-related monthly adjustment amounts, we will correct the amounts and refund any incorrectly withheld premiums.

We based the income-related monthly adjustment amounts of your Medicare Part B and prescription drug coverage premiums on information we received from the IRS. If you request an appeal because you believe that the IRS information is incorrect, we will give you information on how you can contact the IRS to obtain evidence to support your request for a new decision. If you request an appeal because we included amounts for your prescription drug coverage and you do not participate in that program, you will need to contact the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). CMS is the only agency that can correct the information about your prescription drug coverage.

  • You have 60 days to ask for an appeal,

  • The 60 days start the day after you get this letter. We will assume you received this letter 5 days after the date of the letter, unless you show us that you did not get it within the 5-day period.

  • You must have good reason for waiting more than 60 days to ask for an appeal.

  • You may contact one of our offices to file your appeal. You may also request an appeal using a Form SSA-561-U2, called "Request for Reconsideration." You can find the form online at www.socialsecurity.gov/online/ssa-561.pdf, or you can call 1-800-772-1213 for help.

If You Want Help With Your Appeal

You can have a friend, representative or someone else help you with your appeal. You should let us know if someone will be helping you. If you pay a fee to someone for helping you, the fee cannot be automatically deducted from your monthly benefits. You are responsible for paying all legal fees.

Things To Remember For The Future

If you have children or grandchildren younger than age 19 who are not covered by health insurance, the Children's Health Insurance Program may help. To find out more, visit www.insurekidsnow.govor call, toll-free,

1-877-KIDS-NOW (1-877-543-7669). The number connects you to your State's program.

The Eldercare Locator is a free public service of the U.S. Administration on Aging. By calling 1-800-677-1116, or visiting www.eldercare.gov, you can connect with a specialist in your area who can explain programs that give financial, employment, legal, and caregiving help to seniors.

Be aware of scams through the mail, Internet, telephone, or in person. You should be careful when someone asks for personal information, including your Social security number.

For More Information Or To Contact Us

We invite you to visit our website at www.socialsecurity.govon the Internet to find general information about Social Security. If you have questions about your income-related monthly adjustment amounts, please visit www.medicare.gov. You can also call us at 1-80O-772-12I3 and speak to a representative from 7 a.m. until 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. Our lines are busiest early in the week and early in the month, so if your business can wait, it is best to call at other times. If you are deaf or hard of hearing, you may call our TTY number. 1-800-325-0775. If you are inside the United States, you also can visit your local office. If you are outside the United States, you can contact any U.S. embassy or consulate office, or the Veterans Affairs Regional Office in Manila. Please have your full nine-digit Social Security claim number available when you call or visit and include it on any letter you may send to the Social Security Administration.

SOCIAL SECURITY
550 FOREST AVE
SUITE 150
PORTLAND ME 04101

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

Signature

Regional Commissioner

C. Sample Annual Income-Related Monthly Adjustment Amount (IRMAA) Notice for Title II Beneficiaries – with no Cost–of-Living Adjustment (COLA)

Social Security Administration

Date: Month, day, year

Claim Number: xxx-xx-xxxxA

Beneficiary Name
Address
City State Zip

Your Social Security benefits are protected against inflation. By law, they increase when there is a rise in the cost-of-living. The government measures changes in the cost of living through the Department of Labor's Consumer Price Index (CPI). The CPI has not risen since the last cost-of-living adjustment was determined in 20xx. As a result, your benefits will not increase in 20xx.

The Social Security Act requires some people to pay higher premiums for their Medicare Part B (Medical Insurance) and their prescription drug coverage based on their income. Because of your income, your premiums will be increased. The information in this notice about your premiums is for 20xx

only.

If you currently do not have Medicare Part B or prescription drug coverage and enroll in 20xx, those premiums will also be increased based on your income.

How Much Social Security Will I Get?

  • Your new 20xx monthly benefit amount before deductions is: $x,xxx.xx

  • Your 20xx monthly deduction for the Medicare Part B Premium is: $xxx.xx

    • $xxx.xx for the standard Medicare premium, plus

    • $xx.xx for late filing surcharges for Medicare Part BP plus

    • $xxx.xx for the income-related monthly adjustment amount based on your 20xx

Your Medicare Premiums

If you are enrolled in Medicare Part B, your Medicare Part B premiums for 20xx include any surcharges for late enrollment or reenrollment, plus an income-related monthly adjustment amount. Your Medicare Part B premiums, including the income-related monthly adjustment amount, will be deducted from your Social Security benefits, if you have prescription drug coverage, your income-related monthly adjustment amount for that coverage will be deducted from your Social Security benefits regardless of how you ordinarily pay your prescription drug coverage premiums. If the prescription drug coverage income-related monthly adjustment amount is more than the benefit payment, we will not be able to deduct it. If this happens, you will get a separate bill from the Centers for Medicare & Medicaid Services.

Each year to decide if you must pay an income-related monthly adjustment amount, we use your Federal income tax information for the most recent tax year that is available. However, we do not use any information that is more than three years old. We ask the Internal Revenue Service (IRS) for your tax filing status, your adjusted gross income, and your tax-exempt interest income. We then add your adjusted gross income together with your tax-exempt interest income to get an amount that we call modified adjusted gross income (MAGI). We compare your MAGI with the income thresholds set by Medicare law.

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 premium for only one year.

How We Figured Your Income Related Monthly Adjustment Amounts

The IRS told us that in 20xx you filed your taxes as Single. You had an adjusted gross income of $xx,xxx.xx plus $xx,xxx.xx in tax-exempt interest income. We added these amounts together to get your MAGI of $ xxx,xxx.xx.

We used the following table to decide income-related monthly adjustment amounts for the Medicare Part B premiums and prescription drug coverage premiums:

If you filed as:With MAGI of:Part B
IRMAA is:
Prescription
Drug Coverage
IRMAA is:
Single, Head of $85,000.01 - $107,000.00$xx.xx $xx.xx
household or$107,000-01 - $160,000.00$xxx.xx $xx.xx
Qualifying$160,000.01 - $214,000.00$xxx.xx $xx.xx
Widow(er)More than $214000.00$xxx.xx $xx.xx
    
Married, filing $170,000.01 - $214,000.00$xx.xx$xx.xx
jointly$214,000.01 - $320,000.00$xxx.xx$xx.xx
 $320,000.01 - $428,000.00$xxx.xx$xx.xx
 More than $423,000.00$xxx.xx$xx.xx
    
Married, filing$85,000,01 - $129,000.00 $xxx.xx $xx.xx
Separately
(if you lived apart
throughout 20xx, see
below about Some
Special Situations)
More than $129,000.00$xxx.xx $xx.xx

These income-related monthly adjustment amounts are effective for 20xx only. Next year when we receive updated information from the IRS, we will make a new decision about any income-related adjustment amounts.

Some Special Situations That May Apply To You

If your tax filing status was married, filing separately, and you lived apart from your spouse throughout the tax year we used, please call us about your living arrangement. It could lower your IRMAA. We will set up an appointment to discuss that information. You will need to bring a copy of the most recent income tax return you filed with IRS to the appointment.

If you have been paying a reduced Part B premium based on a small Social Security benefit, the increased premium amount will apply beginning with your January benefit.

If Your Income Has Gone Down

In some situations, we can make a new decision about your income-related monthly adjustment amounts. Contact us to request a new decision if your MAGI has gone down at least one range in the table above or has gone below the lowest amounts in the table since you filed your 20xx tax return, AND the decrease in MAGI was caused by any of the following life-changing events:

  • You married,

  • You divorced, or your marriage was annulled,

  • You became a widow or widower,

  • You or your spouse stopped working or reduced work hours,

  • You or your spouse lost income-producing property due to a disaster or other event beyond your control,

  • You or your spouse experienced a scheduled cessation, termination, or reorganization of an employer's pension plan, or

  • You or your spouse received a settlement from an employer or former employer because of the employer's closure, bankruptcy or reorganization.

We will use the new lower MAGI to see if we can make a new decision about your income related monthly adjustment amounts. We cannot make a new decision if your income has changed for a reason other than those listed above, such as receiving one-time income from capital gains.

You will need to submit proof of the event listed above that caused your income to go down (such as a death certificate, a letter from your pension fund administrator, or a letter from your employer about your retirement). If you filed an amended or corrected tax return for the year you want changed, you will also need to submit a copy of the tax return with proof it has been received by the IRS.

If your MAGI has gone down at any time during January through September, you will need to tell us before the end of that year so we can correct your income-related monthly adjustment amount in that year. However, if the event that makes your MAGI go down did not occur until October 1 or later in the year, we can correct your income-related monthly adjustment amount for that year if you tell us before the end of March of the following year.

If The Information We Used Is Incorrect

We based the income-related monthly adjustment amounts on information we received from the IRS. If you have proof that the information we received from the IRS was not correct, please contact us to ask for a new decision about your income-related Medicare premiums. If you filed an amended tax return for that year, you will need to show us a copy of your amended Federal income tax return. You also will need to show us a letter or transcript from the IRS acknowledging receipt of your amended return. If the IRS corrected their records of your tax information for the year we used, you will need to show us the letter you received from the IRS. If you do not have all this information, the IRS can help you get it.

If we have included an income-related monthly adjustment amount for your prescription drug coverage, and you do not have a prescription drug coverage, please contact the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). CMS is the only agency that can correct the information about your prescription drug coverage.

If You Disagree With Our Decision

If you disagree with our decision about your income-related monthly adjustment amounts, you have the right to:

  • request a new decision if your income has gone down due to any of the life-changing events listed above; or

  • request a new decision using more recent tax information if you have amended or corrected tax information for 20xx, or if we used tax information for 20xx; and/or

  • appeal this decision.

If you qualify for a new decision on your income-related monthly adjustment amount, we will make a new decision using your tax information. You will not need to file an appeal on this decision if we find that you qualify for a new decision. If we make a new decision, you will be able to file an appeal on the new decision.

If You Want To Appeal This Decision

If you disagree with this decision about your income-related monthly adjustment amounts, you have the right to appeal. We will review the decision we made to verify that a correct decision was made. A person who did not make the first decision will decide your case.

If you do appeal, we may start withholding your increased premiums before we make our decision on your appeal. If we change our decision about your income-related monthly adjustment amounts, we will correct the amounts and refund any incorrectly withheld premiums.

We based the income-related monthly adjustment amounts of your Medicare Part B and prescription drug coverage premiums on information we received from the IRS. If you request an appeal because you believe that the IRS information is incorrect, we will give you information on how you can contact the IRS to obtain evidence to support your request for a new decision. If you request an appeal because we included amounts for your prescription drug coverage and you do not participate in that program, you will need to contact the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). CMS is the only agency that can correct the information about your prescription drug coverage.

  • You have 60 days to ask for an appeal,

  • The 60 days start the day after you get this letter. We will assume you received this letter 5 days after the date of the letter, unless you show us that you did not get it within the 5-day period.

  • You must have good reason for waiting more than 60 days to ask for an appeal.

  • You may contact one of our offices to file your appeal. You may also request an appeal using a Form SSA-561-U2, called "Request for Reconsideration." You can find the form online at www.socialsecurity.gov/online/ssa-561.pdf, or you can call 1-800-772-1213 for help.

If You Want Help With Your Appeal

You can have a friend, representative or someone else help you with your appeal. You should let us know if someone will be helping you. If you pay a fee to someone for helping you, the fee cannot be automatically deducted from your monthly benefits. You are responsible for paying all legal fees.

Things To Remember For The Future

If you have children or grandchildren younger than age 19 who are not covered by health insurance, the Children's Health Insurance Program may help. To find out more, visit www.insurekidsnow.gov or call, toll-free,

1-877-KIDS-NOW (1-877-543-7669). The number connects you to your State's program.

The Eldercare Locator is a free public service of the U.S. Administration on Aging. By calling 1-800-677-1116, or visiting www.eldercare.gov, you can connect with a specialist in your area who can explain programs that give financial, employment, legal, and caregiving help to seniors.

Be aware of scams through the mail, Internet, telephone, or in person. You should be careful when someone asks for personal information, including your Social security number.

For More Information Or To Contact Us

We invite you to visit our website at www.socialsecurity.govon the Internet to find general information about Social Security. If you have questions about your income-related monthly adjustment amounts, please visit www.medicare.gov. You can also call us at 1-80O-772-12I3 and speak to a representative from 7 a.m. until 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. Our lines are busiest early in the week and early in the month, so if your business can wait, it is best to call at other times. If you are deaf or hard of hearing, you may call our TTY number. 1-800-325-0775. If you are inside the United States, you also can visit your local office. If you are outside the United States, you can contact any U.S. embassy or consulate office, or the Veterans Affairs Regional Office in Manila. Please have your full nine-digit Social Security claim number available when you call or visit and include it on any letter you may send to the Social Security Administration.

SOCIAL SECURITY
550 FOREST AVE
SUITE 150
PORTLAND ME 04101

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

Signature

Regional Commissioner


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601194005
HI 01194.005 - Annual Benefit Rate Increase Notice for Title II Beneficiaries Affected by Income-Related Monthly Adjustment Amount (IRMAA) - 02/22/2012
Batch run: 02/22/2012
Rev:02/22/2012