TN 1 (03-07)

HI 01194.060 New Initial Determination Update Dismissal (Notice Type 570)

A. Purpose/Use

As explained in HI 01194.055, when we use MAGI information provided by a beneficiary to make a new initial determination of his IRMAA, the beneficiary is advised to provide updated information about that tax year. If updated information does not result in a change in IRMAA, we will update the MAGI information in the database, and send the beneficiary a dismissal letter. Dismissal notices do not contain appeal rights.

B. Sample – New Initial Determination Update Dismissal – Title II Beneficiary

This is a sample of the notice that we send to a beneficiary when his updated information does not result in a change in his IRMAA. Contrast this with the sample in HI 01194.045B. (the original new initial determination notice), and the sample in HI 01194.055, which shows the notice we would sent to the same beneficiary if his update results in a change in his IRMAA.

Social Security Administration

Medicare Part B Premium

Important Information

Return Address

Date

Claim Number: xxx-xx-xxxxA

Beneficiary Name

Beneficiary Address

This is about the new information that you provided about your income.

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 $159,890 and you filed your taxes with a tax filing status of Married, filing jointly.

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 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.

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

  • You amend your tax return for 2006.

  • 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 (1-800-633-4273, 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/0601194060
HI 01194.060 - New In