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.
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Based on the information we have, your 2007 monthly Medicare Part B premium will be:
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$93.50 for the standard Medicare premium, minus
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•
$10.00 for the reduction in your standard monthly premium.
This change will be effective January through December 2007.
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$83.50
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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.
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You have 60 days to ask for an appeal.
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•
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.
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You must have good reason for waiting more than 60 days to ask for an appeal.
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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