TN 1 (03-07)

HI 01194.040 Initial Determination Notices (Notice Type 530)

A. Purpose/Use

An IRMAA initial determination notice is sent to those who do not contact SSA in the 20 days following the predetermination notice (HI 01194.030). It includes appeal rights, and states that beneficiaries will receive another notice about the impact the withholding will have on benefits (a title II notice, which will explain premium withholding, and changes in benefit amounts). Note that notices to Railroad Retirement Board (RRB) beneficiaries and Civil Service annuitants will not contain information about the total premium amount or withholding. Notices to these groups of beneficiaries will direct them to the agency responsible for premium withholding.

B. Sample Initial Determination Notice – Title II Beneficiary, No Contact with SSA Following Predetermination Notice

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date: June 24, 2006

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

In May, we told you a Medicare law requires some people to pay higher premiums for Medicare Part B (Medical Insurance) coverage based on their income. We also told you that, based on information about your income, you would have to pay an income-related premium.

  • Your 2007 monthly Medicare Part B premium is: $105.20

    • $93.50 for the standard Medicare plus

    • 9.40 for your premium surcharge, plus

    • 12.30 for the income-related premium minus

    • $10.00 for your Medicare Advantage premium reduction.

This change will be effective May, 2007.

Another Letter

You will get another letter explaining how this will affect your Social Security benefits.

How We Decided Your Income-Related Premium Amount

To decide if your income is high enough that you must pay an income-related adjustment, the Internal Revenue Service (IRS) gave us information about your modified adjusted gross income (MAGI) from your income tax return for 2005. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. For most people, MAGI is the sum of adjusted gross income and tax-exempt interest income on IRS form 1040.

IRS told us your MAGI in 2005 was $85,000. In 2005, you had an adjusted gross income of $82,000 plus tax exempt interest income of $3,000 and you filed your taxes with a tax filing status of Single. We used the following table to decide your income-related adjustment:

If your filing status was:

And your MAGI was:

Then your income-related monthly adjustment amount is:

Single, Head of household or Qualifying widow(er)

$ 80,000.01 - $ 100,000.00

$ 100,000.01 - $ 150,000.00

$ 150,000.01 - $ 200,000.00

More than $ 200,000.00

$ 12.30

$ 30.90

$ 49.40

$ 67.90

Married, filing jointly

$ 160,000.01 - $ 200,000.00

$ 200,000.01 - $ 300,000.00

$ 300,000.01 - $ 400,000.00

More than $400,000.

$ 12.30

$ 30.90

$ 49.40

$ 67.90

Married, filing separately (if you lived apart throughout the year, see below)

$ 80,000.01 - $ 120,000.00

More than $ 120,000.00

$ 49.40

$ 67.90

If You Have Other Information About Your Income

The law permits us to use other information about your MAGI under certain circumstances. If any of the situations in the list below apply or if they occur later this year, you should contact us and explain that you have new information about your Medicare Part B income-related premium. You can call us at 1-800-772-1213 (TTY 1-800-325-0778 for the hearing-impaired) or visit any Social Security office to discuss the following situations:

  • Your MAGI goes down at least one range in the table above and:

    • you marry, divorce, or become widowed; or

    • you or your spouse stop working or reduce your work hours; or

    • you or your spouse lose income from property due to a disaster or other event beyond your control; or

    • you or our spouse’s pension stops or is reduced due to termination of the pension plan.

  • You have an amended tax return for 2005, and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

You should contact us as soon as you know about any of the situations listed above. We will be able to tell you what kind of evidence you need to give us about the situation and your change in MAGI.

If you believe that the information IRS gave us is incorrect, contact the IRS to get IRS's copy of your tax return. You can call us if you have any questions.

If You Disagree With This Decision

If you disagree with this decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision which you believe are incorrect and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

If you do appeal our decision, you will continue to pay an income-related premium amount until we make a decision on your appeal. If we change our decision about your income-related premium amount, we will make retroactive corrections to any incorrect income-related premium amounts.

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter. We assume that you got this letter 5 days after the date on it 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 on line at http://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, lawyer, or someone else help you with your appeal. Your local Social Security office has a list of groups that can help you with your with your appeal.

If You Have Any Questions

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4273, TTY 1-877-486-2048).

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

Address of field office

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

(Signature)

Regional Commissioner

C. Sample Initial Determination Notice – Title II Beneficiary, IRS Reported Filing Status of Married, Filing Separately, Late Filing Penalty Applies

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

In June, we told you a Medicare law requires some people to pay higher premiums for Medicare Part B (Medical Insurance) coverage based on their income. We also told you that, based on information about your income, you would have to pay an income-related premium.

  • Your 2007 monthly Medicare Part B premium is: $152.30

    • $93.50 for the standard Medicare plus

    • $9.40 for your premium surcharge, plus

    • $49.40 for the income-related premium.

This change will be effective June, 2008.

Another Letter

You will get another letter explaining how this will affect your Social Security benefits.

How We Decided Your Income-Related Premium Amount

To decide if your income is high enough that you must pay an income-related adjustment, the Internal Revenue Service (IRS) gave us information about your modified adjusted gross income (MAGI) from your income tax return for 2005. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. For most people, MAGI is the sum of adjusted gross income and tax-exempt interest income on IRS form 1040.

IRS told us your MAGI in 2005 was $87,250. In 2005, you had an adjusted gross income of $82,250 plus tax-exempt interest income of $5,000 and you filed your taxes with a tax filing status of Married, filing separately. You should contact us, as described below, if you lived apart from your spouse at all times during 2005. We used the following table to decide your income-related adjustment:

If your filing status was:

And your MAGI was:

Then your income-related monthly adjustment amount is:

Single, Head of household or Qualifying widow(er)

$ 80,000.01 - $ 100,000.00

$ 100,000.01 - $ 150,000.00

$ 150,000.01 - $ 200,000.00

More than $ 200,000.00

$ 12.30

$ 30.90

$ 49.40

$ 67.90

Married, filing jointly

$ 160,000.01 - $ 200,000.00

$ 200,000.01 - $ 300,000.00

$ 300,000.01 - $ 400,000.00

More than $400,000.

$ 12.30

$ 30.90

$ 49.40

$ 67.90

Married, filing separately (if you lived apart throughout the year, see below)

$ 80,000.01 - $ 120,000.00

More than $ 120,000.00

$ 49.40

$ 67.90

If You Have Other Information About Your Income

The law permits us to use other information about your MAGI under certain circumstances. If any of the situations in the list below apply or if they occur later this year, you should contact us and explain that you have new information about your Medicare Part B income-related premium. You can call us at 1-800-772-1213 (TTY 1-800-325-0778 for the hearing-impaired) or visit any Social Security office to discuss the following situations:

  • Your MAGI goes down at least one range in the table above and:

    • you marry, divorce, or become widowed; or

    • you or your spouse stop working or reduce your work hours; or

    • you or your spouse lose income from property due to a disaster or other event beyond your control; or

    • you or our spouse’s pension stops or is reduced due to termination of the pension plan.

  • You lived apart from your spouse at all times during 2005. The IRS reported that your tax filing status was married, filing separately in 2005, but they did not provide any information about your living arrangements. If you lived apart from your spouse at all times during 2005, we may be able to lower your income-related premium amount.

  • You have an amended tax return for 2005, and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

You should contact us as soon as you know about any of the situations listed above. We will be able to tell you what kind of evidence you need to give us about the situation and your change in MAGI.

If you believe that the information IRS gave us is incorrect, contact the IRS to get IRS's copy of your tax return. You can call us if you have any questions.

If You Disagree With This Decision

If you disagree with this decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision which you believe are incorrect and will look at any new facts you have. We may also review those parts which you believe are correct and may make them unfavorable or less favorable to you.

If you do appeal our decision, you will continue to pay an income-related premium amount until we make a decision on your appeal. If we change our decision about your income-related premium amount, we will make retroactive corrections to any incorrect income-related premium amounts.

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter. We assume that you got this letter 5 days after the date on it 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 on line at http://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, lawyer, or someone else help you with your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If You Have Any Questions

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4273, TTY 1-877-486-2048).

If you have questions about your Medicare Part B premium, please visit www.medicare.gov on the Internet. For general information, you can visit our website at www.socialsecurity.gov. You also can call us at 1-800-772-1213 and speak to a representative from 7 a.m. to 7 p.m. on business days. If you have a touch-tone phone, recorded information and services are available 24 hours a day. We can answer most questions over the phone. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

Address of field office

If you call or visit an office, please have this letter with you. It will help us to answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

(Signature)

Regional Commissioner


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601194040
HI 01194.040 - Initial Determination Notices (Notice Type 530) - 03/14/2007
Batch run: 01/27/2009
Rev:03/14/2007