This is a sample of a notice that we send to a beneficiary who updates his MAGI estimate
associated with a request for a new initial determination due to a major life-changing
event. See HI
01194.045B for a sample of the new initial determination notice that was sent to the individual
who later updates his MAGI estimate and receives the notice below.
Note that new initial determination updates are also sent to beneficiaries who update
other types of new initial determination MAGI reports. Some of the language in the
notice will change, depending on the circumstances.
Part B Premium
Claim Number: xxx-xx-xxxxA
On February 20,
2008, you asked for a new decision about your Medicare Part B income-related premium amount for 2007 based on new information about your income. We are writing to tell you your income-related premium amount will be $12.30.
Your 2007 monthly Medicare Part B premium should have been: $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.
You will get another letter explaining how this will affect your Social Security benefits.
How We Decided Your Income-Related Premium Amount
On January 10, 2007 you gave us information about your modified adjusted gross income (MAGI) that we used to determine the income-related
adjustment to your Medicare Part B premium. On March 20, 2007, you updated your information. You gave
us a copy of your tax return for 2006. You said your modified adjusted gross income was $161,080.00 and you filed your taxes with a tax filing status of 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
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.
Married, filing separately (if you lived apart throughout the year, see below)
$ 80,000.01 - $ 120,000.00
More than $ 120,000.00
If The Information You Gave Us Changes
You gave us a copy of your
tax return for 2006. 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 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:
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
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.