This is a sample of the notice that will be sent to a Title 2 beneficiary who did
not contact SSA within 20 days from the date of the Predetermination notice to protest
the MAGI that IRS provided. In this sample, we originally used PY-2 to set the current
year premium. The beneficiary then reported a life-changing event and asked us to
use a more recent tax year, in this case PY-1, to determine his IRMAA. We processed
that request thereby lowering his IRMAA level. During the annual verification data
exchange, IRS provides PY-1 MAGI that is higher than the beneficiary PY-1 estimate
and higher than IRS PY-2 MAGI. Therefore, the beneficiary’s IRMAA level is determined
by using PY-2. The beneficiary owes IRMAA.
Social Security Administration
Part B Premium
November 25, 2007
We are writing to tell you that we have made a decision about your Medicare Part B
income-related premium amount for 2007. Because you paid a lower Part B premium than
what was required, you owe an additional amount for your Medicare Part B premiums.
According to the law, we set your 2007 premium based on your modified adjusted gross
income (MAGI) from 2005. The Internal Revenue Service (IRS) told us your MAGI in 2005
was $136,000.00. You had an adjusted gross income of $130,000.00 plus tax-exempt interest
income of $6,000.00 and you filed your taxes with a tax filing status of Single. We
charged you an income-related premium amount of $30.90. In February 2007, you reported
a life changing event that reduced your 2006 MAGI. In such circumstances, at your
request, we can use a more recent tax year return if it significantly lowers your
MAGI. Therefore, we used the information you provided for 2006 to change your 2007
income-related premium amount to $12.30 a month.
When we verified the information that you gave us about your 2006 MAGI with IRS, we
discovered that your 2006 MAGI is not significantly less than your 2005 MAGI. IRS
reported that your 2006 MAGI was $151,000.00. You had an adjusted gross income of
$150,000.00 plus tax-exempt interest income of $1,000.00 and you filed your taxes
with a tax filing status of Single. Therefore, we will not use your 2006 MAGI to determine
your 2007 income-related premium amount. We will use your 2005 MAGI information to
determine your 2007 income-related premium amount. Based on your 2005 MAGI, your 2007
income-related premium amount will be $30.90.
You will receive another letter about how you will pay any past-due income-related
How We Decided Your Income-Related Premium Amount
IRS told us your MAGI in 2005 was $136,000.00. In 2005, you had an adjusted gross
income of $130,000.00 plus tax-exempt income of $6,000.00 and you filed your taxes
with a tax filing status of Single. We used the following table to decide your 2007
If your filing status was:
And your MAGI range was:
Then your income-related monthly
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
$160,000.01 - $200,000.00
$200,000.01 - $300,000.00
$300,000.01 - $400,000.00
More than $400,000.00
Married, filing separately
$ 80,000.01 - $120,000.00
More than $120,000.00
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,
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:
Second Avenue North
Dodge, IA 50501-9918
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