TN 1 (03-07)

HI 01194.050 New Initial Determination Dismissal Notices (Notice Type 550)

A. Purpose/Use

We send a notice that we a have dismissed a beneficiary’s request for a new initial determination when the beneficiary:

  • makes his request outside of the time period established for such requests;

  • requests a new initial determination based on a non-qualifying life-changing event;

  • has not experienced a significant reduction in MAGI (i.e., the new MAGI amount he reports does not change his IRMAA); or

  • requests a new initial determination when he files a new claim and the IRS does not report above-threshold MAGI.

Dismissal notices do not contain appeal rights.

B. Sample – New Initial Determination Dismissal – Title II Beneficiary, Request Outside of Time Period for Request, No Good Cause

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date: November 24, 2006

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

This is about your request for a new decision about your Medicare Part B premium increase.

About Your Request For A New Decision

You asked for a review too late. We sent you a letter about the income-related amount of your Medicare Part B premium. That letter explained that you could appeal our decision or request a new decision about your income-related amount after one of the specified events reduced your income any time during the year. If the event happened in the last three months of the year, you could have until the end of March of the next year to ask for a new decision because the event occurred so late in the year. We require a good reason to extend the period you may appeal or request a new decision if an event occurred that caused your income to go down. You did not give us a good reason why you could not contact us in time.

If You Have Other Information About Your Income

We make new decisions when your modified adjusted gross income (MAGI) goes down enough to reduce your income-related premium amount 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.

Contact us at 1-800-772-1213 (TTY 1-800-325-0778) if:

  • You amend your tax return for 2005.

  • You experience a qualifying life-changing event from the list above.

If You Have Any Questions

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 – New Initial Determination Dismissal – Title II Beneficiary, Non-Qualifying Life-Changing Event

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date: November 24, 2006

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

This is about your request for a new decision about your Medicare Part B premium increase.

About Your Request For A New Decision

We cannot make a new decision in your case because you did not have a qualifying life changing event. We make new decisions when your modified adjusted gross income (MAGI) goes down enough to reduce your income-related premium amount and

  • you marry, divorce, or become widowed, or

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

If You Have Other Information About Your Income

Contact us at 1-800-772-1213 (TTY 1-800-325-0778) if:

  • You amend your tax return for 2005.

  • You experience a qualifying life-changing event from the list above.

If You Have Any Questions

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227, 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 Dismissal – Title II Beneficiary, MAGI Not Significantly Reduced

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date: November 24, 2006

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

This is about your request for a new decision about your Medicare Part B premium increase.

About Your Request For A New Decision

We cannot make a new decision in your case because your modified adjusted gross income (MAGI) did not change enough to make a difference in your income-related premium amount.

If You Have Other Information About Your Income

We make new decisions when your modified adjusted gross income (MAGI) goes down enough to reduce your income-related premium amount 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.

Contact us at 1-800-772-1213 (TTY 1-800-325-0778) if:

  • You amend your tax return for 2005.

  • You experience a qualifying life-changing event from the list above.

If You Have Any Questions

If you have questions about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227, 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. Sample - New Initial Determination Dismissal – Title II Beneficiary Reports Tax Information at Time of Filing Claim, No IRS Information Received

Example of a situation when this notice would be sent: Mr. Jones files a claim for Medicare benefits at age 65. He knows that we will be requesting IRS information, and he believes it will show that he has MAGI above the threshold. He reports his partial work stoppage and reduction of his MAGI to a below-threshold amount. We hold his information for use after the IRS data exchange; however, the IRS does not return any MAGI information about Mr. Jones. We dismiss his request for a new initial determination and he will not pay IRMAA.

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date: November 24, 2006

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

This is about your request for a new initial determination about your Medicare Part B income-related premium amount for 2008. You provided us information about your income to use in considering your request for a new initial determination.

About Your Request for a New Decision

We cannot make a new initial determination in your case because the Internal Revenue Service did not report to us that your modified adjusted gross income in your most recent filed income tax return was higher than the income-related premium threshold for a Medicare Part B income-related premium. Because of the IRS information we received, we will not charge you an income-related adjustment to your Medicare Part B premium. Since we can not determine whether the information you provided shows a lower income than the amount in the IRS records, we must dismiss your request.

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 call your local Social Security office at 1-555-332-0545. You can also write or visit any Social Security office. The office that serves your area is located at:

SOCIAL SECURITY
2315 Second Avenue North
Fort Dodge, IA 50501-9918

If you do 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