TN 2 (10-07)

HI 01194.110 IRMAA Annual Verification Overage Notice (Notice Type 610)

A. Purpose/Use

Annual Verification Overage notices are mailed when the annual IRS verification data exchange results in an IRMAA premium refund being due to the beneficiary for the current premium year. This notice includes appeal rights.

See HI 01130.005 for a description of the IRMAA Annual Verification process.

B. Sample - Annual Verification Overage Notice – Title 2 Beneficiary – IRS PY-1 MAGI is Lower than Beneficiary Estimate

This is a sample of the notice that will be sent to a Title 2 beneficiary when we originally used PY-2 MAGI; the beneficiary supplied a PY-1 estimate and during the annual verification data exchange IRS provides PY-1 MAGI lower than the PY-1 MAGI the beneficiary provided. We owe the beneficiary IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a lower premium. Because you paid a higher Part B premium amount than what was required, you are due a refund for the excess premiums you paid.

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium.

   

Another Letter

  

You will get another letter explaining how this will affect your Social Security benefits and any refund due to you.

   

The Information We Have

  

When we matched computer records with IRS, we learned that your 2006 MAGI was $94,042.00.

Based on the information we have, your 2007 monthly Medicare Part B premium will be:

  • $ 93.50 for the standard Medicare premium, plus

  • $ 12.30 for the income-related premium amount.

    • This change will be effective January through December 2007.

$105.80

  

How We Decided Your Income-Related Premium Amount

  

We used information that you gave us about your MAGI for 2006 to set your income-related premium amount for 2007. You told us your MAGI in 2006 was $104,366.00. You had an adjusted gross income of $94,000.00 plus tax exempt interest income of $10,366.00 and filed your taxes with a tax filing status of Single. We set your income-related amount at $30.90. We verified your information by asking the IRS about your 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. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

IRS told us your MAGI in 2006 was $94,042.00. In 2006, you had an adjusted gross income of $84,000.00 plus tax-exempt interest income of $10,042.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your 2007 income-related adjustment:

If your filing status was:

And your MAGI range was:

Then your income-related monthly adjustment 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 $400,000.00

$12.30

$30.90

$49.40

$67.90

  • Married, filing separately

$ 80,000.01 - $120,000.00

More than $120,000.00

$49.40

$67.90

  

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, 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 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

   

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20th Floor

                                                                               1234 Market Street

                                                                               Philadelphia, PA 19107

   

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.

   

                                                                               Regional Commissioner

C. Sample - Annual Verification Overage Notice – Title 2 Beneficiary – IRS Returns SSN

This is a sample of the notice that will be sent to a Title 2 beneficiary when we were temporarily using PY-3 MAGI and at verification we ask IRS for PY-2 MAGI. IRS returns an SSN which means IRS did not have tax return information showing MAGI over the threshold for PY-2. The IRMAA level is reduced to zero. We owe the beneficiary IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a lower premium. Because you paid a higher Part B premium amount than what was required, you are due a refund for the excess premiums you paid.

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium.

  

Another Letter

  

You will get another letter explaining how this will affect your Social Security benefits and any refund due to you.

  

The Information We Have

  

When we matched computer records with IRS, we learned that your 2005 MAGI was below the amount we use to set a Medicare Part B income-related amount.

Based on the information we have, your 2007 monthly Medicare Part B premium will be:

$ 93.50 for the standard Medicare premium.

This change will be effective January through December 2007.

$93.50

  

How We Decided Your Income-Related Premium Amount

  

We asked the IRS for information about your modified adjusted gross income (MAGI) from your income tax return for 2005 to determine if you must pay an income-related amount. Because IRS did not have any information about that year when we first asked, 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. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

Since we were temporarily using tax information from three years before 2007, we asked IRS for MAGI information for tax year 2005.

IRS Tax information for 2005 indicates that we should not have adjusted your Medicare Part B premium. Therefore, we will not charge you an income-related premium amount for 2007.

  

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 call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

   

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20th Floor

                                                                               1234 Market Street

                                                                               Philadelphia, PA 19107

  

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.

  

                                                                               Regional Commissioner

D. Sample - Annual Verification Overage Notice - Title 2 Beneficiary - IRS Returns SSN for PY-2- VSMI Reimposed – Previously Used Beneficiary Estimate

This is a sample of the notice that will be sent to a Title 2 beneficiary when we originally used PY-3 MAGI, the beneficiary provided PY-2 MAGI, and at verification we ask IRS for PY-2 MAGI. IRS returned an SSN which means IRS did not have tax return information showing MAGI over the threshold for PY-2. The IRMAA level is reduced to zero and variable SMI is reimposed. We owe the beneficiary IRMAA plus the difference between the standard Medicare Part B premium and his variable SMI premium.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a lower premium. Because you paid a higher Part B premium amount than what was required, you are due a refund for the excess premiums you paid. Your standard monthly premium also should have been lower, so that amount will be refunded to you as well.

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium.

  

Another Letter

  

You will get another letter explaining how this will affect your Social Security benefits and any refund due to you.

  

The Information We Have

  

When we matched computer records with IRS, we learned that your 2005 MAGI was below the amount we use to set a Medicare Part B income-related amount.

Based on the information we have your 2007 monthly Medicare Part B premium will be:

  • $ 93.50 for the standard Medicare premium, minus

  • $10.00 for the reduction in your standard monthly premium.

    • This change will be effective January through December 2007.

$83.50

  

How We Decided Your Income-Related Premium Amount

  

We used information that you gave us about your MAGI for 2005 to set your income-related premium amount for 2007. You told us your MAGI in 2005 was $85,000.00. You had an adjusted gross income of $84,500.00 plus tax exempt interest income of $500.00 and filed your taxes with a tax filing status of Single. We set your income-related amount at $12.30. We verified your information by asking the IRS about your 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. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

IRS tax information for 2005 indicates that we should not have adjusted your Medicare Part B premium. Therefore, we will not charge you an income-related premium amount for 2007.

The standard premium amount of $93.50 will be reduced to $83.50 effective with January of this year. This reduction is being made because the increase in your premium as of January resulted in a decrease in your monthly Social Security payment. The law does not permit us to reduce the Part B premium when an income-related premium is being charged. However, since you are no longer being charged an income-related premium, we will reduce your Part B premium.

  

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 call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

   

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20th Floor

                                                                               1234 Market Street

                                                                               Philadelphia, PA 19107

  

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.

  

                                                                               Regional Commissioner

E. Sample - Annual Verification Overage Notice - Title 2 Beneficiary - IRS PY-2 MAGI Lower Than IRS PY-3 MAGI

This is a sample of the notice that will be sent to a Title 2 beneficiary when we were temporarily using PY-3 MAGI. During the annual verification data exchange we ask for PY-2 MAGI and IRS returns PY-2 MAGI lower than the PY-3 MAGI. We owe the beneficiary IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a lower premium. Because you paid a higher Part B premium amount than what was required, you are due a refund for the excess premiums you paid.

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium.

  

Another Letter

  

You will get another letter explaining how this will affect your Social Security benefits and any refund due to you.

  

The Information We Have

  

When we matched computer records with IRS, we learned that your 2005 MAGI was $94,042.00.

Based on the information we have, your 2007 monthly Medicare Part B premium will be:

  • $ 93.50 for the standard Medicare premium, plus

  • $ 12.30 for the income-related premium amount.

    • This change will be effective January through December 2007.

$105.80

  

How We Decided Your Income-Related Premium Amount

  

We asked the IRS for information about your modified adjusted gross income (MAGI) from your income tax return for 2005 to determine if you must pay an income-related amount. Because IRS did not have any information about that year when we first asked, 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. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

Tax information for 2005 has become available. IRS told us your MAGI in 2005 was $94,042.00. In 2005, you had an adjusted gross income of $93,000.00 plus tax-exempt interest income of $1,042.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your 2007 income-related adjustment:

If your filing status was:

And your MAGI range was:

Then your income-related monthly adjustment 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 $400,000.00

$12.30

$30.90

$49.40

$67.90

  • Married, filing separately

$ 80,000.01 - $120,000.00

More than $120,000.00

$49.40

$67.90

  

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, 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 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

  

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20th Floor

                                                                               1234 Market Street

                                                                               Philadelphia, PA 19107

  

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.

  

                                                                               Regional Commissioner

F. Sample - Annual Verification Overage Notice - Title 2 Beneficiary - IRS PY-2 Magi Lower Than Beneficiary Reported PY-2 MAGI

This is a sample of the notice that will be sent to a Title 2 beneficiary when we originally used PY-3 MAGI and the beneficiary provides PY-2 MAGI. During the annual verification data exchange, we request PY-2and IRS returns PY-2 MAGI lower than the beneficiary reported PY-2.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a lower premium. Because you paid a higher Part B premium amount than what was required, you are due a refund for the excess premiums you paid.

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium.

  

Another Letter

  

You will get another letter explaining how this will affect your Social Security benefits and any refund due to you.

  

The Information We Have

  

When we matched computer records with IRS, we learned that your 2005 MAGI was $94,042.00.

Based on the information we have, your 2007 monthly Medicare Part B premium will be:

  • $ 93.50 for the standard Medicare premium, plus

  • $ 12.30 for the income-related premium amount.

    • This change will be effective January through December 2007.

$105.80

  

How We Decided Your Income-Related Premium Amount

  

We used information that you gave us about your MAGI for 2005 to set your income-related premium amount for 2007. You told us your MAGI in 2005 was $104,366.00. You had an adjusted gross income of $94,000.00 plus tax exempt interest income of $10,366.00 and filed your taxes with a tax filing status of Single. We set your income-related amount at $30.90. We verified your information by asking the IRS about your 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. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

IRS told us your MAGI in 2005 was $94,042.00. In 2005, you had an adjusted gross income of $84,000.00 plus tax-exempt interest income of $10,042.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your 2007 income-related adjustment:

If your filing status was:

And your MAGI range was:

Then your income-related monthly adjustment 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 $400,000.00

$12.30

$30.90

$49.40

$67.90

  • Married, filing separately

$ 80,000.01 - $120,000.00

More than $120,000.00

$49.40

$67.90

  

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, 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 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

  

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20th Floor

                                                                               1234 Market Street

                                                                               Philadelphia, PA 19107

  

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.

  

                                                                               Regional Commissioner

G. Sample - Annual Verification Overage Notice - Title 2 Beneficiary - IRS Returns SSN - VSMI Reimposed – Previously Used Beneficiary Supplied PY-1

This is a sample of the notice that will be sent to a Title 2 beneficiary when we originally used PY-2 MAGI, the beneficiary provided PY-1 MAGI, we asked IRS for PY-1 MAGI during the annual verification data exchange, and IRS returned an SSN which means IRS did not have tax return information showing MAGI over the threshold for PY-1. The IRMAA level is reduced to zero and variable SMI is reimposed. We owe the beneficiary IRMAA plus the difference in the standard Part B premium and the beneficiary’s variable SMI premium.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: October 31, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. We received information about your income from the Internal Revenue Service (IRS) that shows you must pay a lower premium. Because you paid a higher Part B premium amount than what was required, you are due a refund for the excess premiums you paid. Your standard monthly premium also should have been lower, so you are due a refund of that amount as well.

Generally, we use two year old tax information from the IRS to determine if you must pay an income-related premium amount which is added to the standard Medicare premium. We ask IRS to verify your modified adjusted gross income (MAGI) if we used three year old tax information instead of two year old tax information or tax information you gave us to decide your Medicare Part B income-related premium amount. We compare your MAGI with the income thresholds set by law to make any necessary corrections to your income-related premium amount.

In this letter, we will tell you what information we received from IRS about your income and how it will affect your Medicare Part B premium.

  

Another Letter

  

You will get another letter explaining how this will affect your Social Security benefits and any refund due to you.

  

The Information We Have

  

When we matched computer records with IRS, we learned that your 2006 MAGI was below the amount we use to set a Medicare Part B income-related amount.

Based on the information we have, your 2007 monthly Medicare Part B premium will be:

  • $93.50 for the standard Medicare premium, minus

  • $10.00 for the reduction in your standard monthly premium.

This change will be effective January through December 2007.

$83.50

  

How We Decided Your Income-Related Premium Amount

  

We used information that you gave us about your MAGI for 2006 to set your income-related premium amount for 2007. You told us your MAGI in 2006 was $84,000.00. You had an adjusted gross income of $83,000.00 plus tax exempt interest income of $1,000.00 and filed your taxes with a tax filing status of Single. We set your income-related amount at $12.30. We verified your information by asking the IRS about your 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. Your adjusted gross income is from line 37 of the IRS Form-1040 and your tax exempt interest income is from line 8b of your IRS Form-1040. MAGI may include one-time only income, such as capital gains, the sale of property, withdrawals from an Individual Retirement Account (IRA) or conversion from a traditional IRA to a Roth IRA. One-time income will affect your Medicare Part B premium for only one year.

IRS tax information for 2006 indicates that we should not have adjusted your Medicare Part B premium. Therefore, we will not charge you an income-related premium amount for 2007.

The standard premium amount of $93.50 will be reduced to $83.50 effective with January of this year. This reduction is being made because the increase in your premium as of January resulted in a decrease in your monthly Social Security payment. The law does not permit us to reduce the Part B premium when an income-related premium is being charged. However, since you are no longer being charged an income-related premium we will reduce your Part B premium.

  

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 call your local Social Security office at 1-515-576-5185. You can also write or visit any Social Security office. The office that serves your area is located at:

  

                                                                               SOCIAL SECURITY

                                                                               Suite 2000, 20th Floor

                                                                               1234 Market Street

                                                                               Philadelphia, PA 19107

  

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.

  

                                                                               Regional Commissioner


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601194110
HI 01194.110 - IRMAA Annual Verification Overage Notice (Notice Type 610) - 10/29/2007
Batch run: 01/27/2009
Rev:10/29/2007