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.
Part B Premium
Claim Number: xxx-xx-xxxxA
This is about the new information that you provided about your income.
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.