TN 1 (03-07)

HI 01194.045 New Initial Determination Notices (Notice Type 540)

A. Purpose/Use

SSA sends a new initial determination notice when we use information provided by a beneficiary about his income to make an IRMAA determination, rather than the MAGI data provided by the IRS. New initial determination notices have appeal rights. New initial determinations are based on one of the following circumstances:

  • A qualifying life-changing event which reduced MAGI since the year of the IRS data;

  • An amended tax return for the tax year that IRS provided;

  • Proof of correction of the IRS information SSA used;

  • A beneficiary’s copy of a filed tax return for 2 years prior to the premium year, when IRS provided return data for 3 years prior; or

  • A report by a beneficiary who filed a tax return with a filing status of married filing separately that he lived apart from his spouse at all times during the tax year.

We send a dismissal notice (see HI 01194.050, New Initial Determination Dismissals) rather than a new initial determination notice when the beneficiary’s information does not substantiate either the circumstance or a significant change in modified adjusted gross income, or he/she requests a new initial determination outside of the time periods provided for such requests and good cause for a late request is not found.

B. Sample – New Initial Determination, Title II beneficiary, Life-changing Event (Marriage and Change in Tax Filing Status).

This sample depicts a new initial determination notice that we send to beneficiaries who request use of a more recent tax year’s MAGI estimate due to a life-changing event of marriage, and a resulting change in tax filing status. In the third paragraph under the caption “How We Decided Your Income-Related Premium Amount,” we explain the basis for our new determination; usually, this section specifies the type of event reported. The exception is that when the life-changing event type is a work stoppage or reduction, the language is non-specific about the type of event.

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

On January 10, 2007, you asked for a new decision about your Medicare Part B income-related premium amount for 2007 based on your marriage and change in your tax filing status. You asked us to use information that you provided about your tax return for a more recent year. We are writing to tell you your income-related premium amount has been removed.

  • Your 2007 monthly Medicare Part B premium is: $93.50

    • $93.50 for the standard Medicare premium

This change will be effective January, 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 that you filed your Federal income tax with a filing status of Single and adjusted gross income of $85,780.00.

You reported your marriage and tax filing status. You said that your MAGI was $154,300.00 in 2006 and that your tax filing status was married, filing jointly. 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 The Information You Gave Us Changes

You estimated your MAGI for 2006. You should give us a copy of your Federal income tax return after you file your income tax return for that year. It is important that you let us know if the information you gave us about your income changes.

Please contact us at 1-800-772-1213 if your estimate of your MAGI changes or you file your tax return for 2006.

If You Have Other Information About Your Income

You provided us with new information about your MAGI for 2006. Under certain circumstances, we may use information about your MAGI for a more recent year. 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 2006, and your MAGI from your amended tax return is lower than the MAGI information you gave us.

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 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

C. New Initial Determination – Title II Beneficiary, Amended Tax Return

This is a sample of the notice that we send to a beneficiary when he provides a copy of his amended tax return for the same year as the IRS information we used. For example, IRS sends us information about Mr. Brady’s MAGI from his tax return for 2005. Mr. Brady later amends his 2005 tax return, and his MAGI is significantly lower on the amended return.

In this sample, the amended return results in a reduction in IRMAA from range 2 to range 1, due to an MAGI reduction of $500.00.

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

On August 15, 2007, you asked for a new decision about your Medicare Part B income-related premium amount for 2007 based on your amended tax return. We are writing to tell you your income-related premium amount will be $12.30.

  • Your 2007 monthly Medicare Part B premium is: $105.80

    • $93.50 for the standard Medicare premium, plus

    • $12.30 for the income-related premium amount.

This change will be effective January 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 that you filed your Federal income tax with a filing status of Single and adjusted gross income of $100,100.00.

You provided your amended tax return. You said that your MAGI was $99,600 in 2005 and that your tax filing status was 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 The Information You Gave Us Changes

You gave us a copy of your tax return for 2005. It is important that you let us know if the information you gave us about your income changes.

Please contact us at 1-800-772-1213 if you amend your tax return for 2006.

If You Have Other Information About Your Income

You provided us with new information about your MAGI for 2005. Under certain circumstances, we may use information about your MAGI for a more recent year. 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 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 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

D. Sample – New Initial Determination – Title II Beneficiary, Correction of IRS Information

This is a sample of the notice we send to a beneficiary who provides proof that IRS tax return information that we used to make an IRMAA determination is incorrect.

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

On April 10, 2007, you asked for a new decision about your Medicare Part B income-related premium amount for 2007 based on your proof of corrected IRS information. We are writing to tell you your income-related premium amount has been removed.

  • Your 2007 monthly Medicare Part B premium is: $102.90

    • $93.50 for the standard Medicare premium plus

    • $9.40 for your premium surcharge.

This change will be effective January, 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 that you filed your Federal income tax with a filing status of Single and adjusted gross income of $99,660.00.

You provided your proof of corrected IRS information. You said that your MAGI was $79,660 in 2005 and that your tax filing status was 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 The Information You Gave Us Changes

You gave us a copy of your tax return for 2005. It is important that you let us know if the information you gave us about your income changes.

Please contact us at 1-800-772-1213 if your estimate of your MAGI changes or you amend your tax return for 2005.

If You Have Other Information About Your Income

You provided us with new information about your MAGI for 2005. Under certain circumstances, we may use information about your MAGI for a more recent year. 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 you gave us.

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 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

E. Example – New Initial Determination – Title II Beneficiary Provides A Copy of His Tax Return From 2 Years Prior to the Premium Year

This is a sample of the new initial determination notice that we will send to a beneficiary when he asked us to use his retained copy of his tax return for the year 2 years prior to the premium year to replace IRS information we used from 3 years prior. In this example, for the premium year 2007, we made an initial determination using IRS information from tax year 2004. The beneficiary provided us with a copy of his filed tax return for 2005. In this sample, the effective date of the determination is April, 2007, because the beneficiary was first entitled to Medicare and enrolled in Part B at that time.

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

On September 20, 2007, you asked for a new decision about your Medicare Part B income-related premium amount for 2007 based on new information about your income. You asked us to use information that you provided about your tax return for a more recent year. We are writing to tell you your income-related premium amount is $49.40.

  • Your 2007 monthly Medicare Part B premium is: $142.90

    • $93.50 for the standard Medicare premium plus

    • $49.40 for the income-related premium amount.

This change will be effective April, 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, we asked the Internal Revenue Service (IRS) for information about your modified adjusted gross income (MAGI) from your income tax return for 2005. Because the IRS did not have any information about that year, they gave us information about your MAGI from your tax return for 2004. 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 that you filed your Federal income tax with a filing status of Married, filing jointly and adjusted gross income of $417,900.00.

You reported that you had filed your tax return for the following year. You said that your MAGI was $378,500.00 in 2005 and that your tax filing status was Married filing jointly. 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 The Information You Gave Us Changes

You gave us a copy of your tax return for 2005. It is important that you let us know if the information you gave us about your income changes.

Please contact us at 1-800-772-1213 if your estimate of your MAGI changes or you amend your tax return for 2005.

If You Have Other Information About Your Income

You provided us with new information about your MAGI for 2005. Under certain circumstances, we may use information about your MAGI for a more recent year. 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 you gave us.

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 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

F. Sample – New Initial Determination – Title II Beneficiary with Tax Filing Status of Married, Filing Separately Provides Proof That He Lived Apart From His Spouse

This is a sample of the new initial determination notice that we send to a beneficiary when we have used information from IRS to set his IRMAA, and the IRS reported that his tax filing status was married, filing separately. The law provides for beneficiaries with this tax filing status who lived apart from their spouse at all times during the year to have their IRMAA set using the adjustment that applies to single tax filers. See HI 01120.060 for an explanation of policy for new initial determinations based on a report of living arrangements.

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

On February 6, 2007, you asked for a new decision about your Medicare Part B income-related premium amount for 2007 based on the fact that you lived apart from your spouse in the tax year we used to make our decision. We are writing to tell you your income-related premium amount is $12.30.

  • Your 2007 monthly Medicare Part B premium is: $105.80

    • $93.50 for the standard Medicare premium plus

    • $12.30 for the income-related premium amount.

This change will be effective January, 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 that you filed your Federal income tax with a filing status of Married, filing separately and adjusted gross income of $82,750.00.

You told us that you lived apart from your spouse at all times during that tax year. You said that your MAGI was $82,750.00 in 2005 and that your tax filing status was Married filing separately. 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 The Information You Gave Us Changes

You gave us a copy of your tax return for 2005. It is important that you let us know if the information you gave us about your income changes.

Please contact us at 1-800-772-1213 if your estimate of your MAGI changes or you amend your tax return for 2005.

If You Have Other Information About Your Income

You provided us with new information about your MAGI for 2005. Under certain circumstances, we may use information about your MAGI for a more recent year. 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 you gave us.

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 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 q