TN 2 (10-07)

HI 01194.115 IRMAA Annual Verification Correction Notice (Notice Type 630)

A. Purpose/Use

Annual Verification Correction notices are mailed when beneficiaries do not contact SSA within 20 days from the date of the Predetermination notice to protest the MAGI that IRS provided. It includes appeal rights and states that there will be another notice about the impact on benefits. OPM annuitants will receive a similar notice which does not promise any separate notification, although OPM has indicated that they will send notification of withholding. Affected RRB beneficiaries will be told that they will receive a letter from the Railroad Retirement Board about how to pay the past-due income-related premium amount. CMS will be responsible for notifying Medicare-only beneficiaries who are direct-billed for their premiums.

B. Sample -Annual Verification Correction Notice – RRB Beneficiary – IRS PY-2 MAGI Higher than Previously Used Beneficiary Estimate or Beneficiary supplied PY2

This is a sample of the notice that will be sent to an RRB 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, during the annual verification data exchange, IRS provides PY-2 MAGI that is higher than the previously used beneficiary estimate or beneficiary supplied PY-2 MAGI. The beneficiary owes IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 25, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

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 amount than what was required, you owe an additional amount for your Medicare Part B premiums.

In February 2007, at your request, we used information you provided about your modified adjusted gross income (MAGI) for 2006. Based on your information, we set your income-related premium amount at $30.90 a month for 2007.

We have received your MAGI information for 2006 from the Internal Revenue Service (IRS). Based on that information, your income-related premium amount should have been $49.40 a month for 2007.

  

Other Information

  

You will receive a letter from the Railroad Retirement Board about how you will pay the past-due income-related premium amount you owe.

  

How We Decided Your Income-Related Premium Amount

  

IRS told us your MAGI in 2006 was $196,000.00. In 2006, you had an adjusted gross income of $152,000.00 plus tax-exempt income of $44,000.00 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 payment of your Medicare premiums or about how this change affects benefits you may be receiving, please contact your nearest Railroad Retirement Board office. You can find the telephone number of the RRB office serving your area by calling 1-800-808-0772 or by visiting www.rrb.gov on the Internet.

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

                                                                               2315 Second Avenue North

                                                                               Fort 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 the office.

  

                                                                               Regional Commissioner

C. Sample - Annual Verification Correction Notice – Title 2 Beneficiary – IRS PY2 MAGI Higher Than Previously Used Beneficiary Estimate or Beneficiary Supplied PY-2

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, during the annual verification data exchange, IRS provides PY-2 MAGI that is higher than the previously used beneficiary estimate or beneficiary supplied PY-2 MAGI. The beneficiary owes us IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 25, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

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 amount than what was required, you owe an additional amount for your Medicare Part B premiums.

In February 2007, at your request, we used information you provided about your modified adjusted gross income (MAGI) for 2005. Based on your information, we set your income-related premium amount at $30.90 a month for 2007.

We have received your MAGI information for 2005 from the Internal Revenue Service (IRS). Based on that information, your income-related premium amount should have been $49.40 a month for 2007.

  

Another Letter

  

You will receive another letter about how you will pay any past-due income-related premium amount.

  

How We Decided Your Income-Related Premium Amount

  

IRS told us your MAGI in 2005 was $196,000.00. In 2005, you had an adjusted gross income of $152,000.00 plus tax-exempt income of $44,000.00 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, 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

                                                                               2315 Second Avenue North

                                                                               Fort 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 the office.

  

                                                                               Regional Commissioner

D. Sample - Annual Verification Correction Notice - RRB Beneficiary – IRS PY2 MAGI Higher Than Previously Used PY-3 MAGI

This is a sample of the notice that will be sent to an RRB 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, during the annual verification data exchange, IRS provides PY-2 MAGI that is higher than the temporarily used PY-3 MAGI. The beneficiary owes us IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 25, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

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.

In 2007, because the Internal Revenue Service (IRS) did not have any information for 2005, they gave us information about your modified adjusted gross income (MAGI) from your tax return for 2004. Based on that information, we set your income-related premium amount at $30.90 a month for 2007.

We have received your MAGI information for 2005 from IRS. Based on that information, your income-related premium amount should have been $49.40 a month for 2007.

  

Other Information

You will receive a letter from the Railroad Retirement Board about how you will pay the past-due income-related premium amount you owe.

  

How We Decided Your Income-Related Premium Amount

  

IRS told us your MAGI in 2005 was $196,000.00. In 2005, you had an adjusted gross income of $152,000.00 plus tax-exempt income of $44,000.00 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 payment of your Medicare premiums or about how this change affects benefits you may be receiving, please contact your nearest Railroad Retirement Board office. You can find the telephone number of the RRB office serving your area by calling 1-800-808-0772 or by visiting www.rrb.gov on the Internet.

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

                                                                               2315 Second Avenue North

                                                                               Fort 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 the office.

  

                                                                               Regional Commissioner

E. Sample - Annual Verification Correction Notice – Title 2 Beneficiary – IRS PY2 MAGI Higher Than Previously Used PY-3 MAGI

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, during the annual verification data exchange, IRS provides PY-2 MAGI that is higher than the temporarily used PY-3 MAGI. The beneficiary owes IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 25, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

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.

In 2007, because the Internal Revenue Service (IRS) did not have any information for 2005, they gave us information about your modified adjusted gross income (MAGI) from your tax return for 2004. Based on that information, we set your income-related premium amount at $30.90 a month for 2007.

We have received your MAGI information for 2005 from IRS. Based on that information, your income-related premium amount should have been $49.40 a month for 2007.

  

Another Letter

  

You will receive another letter about how you will pay any past-due income-related premium amount

  

How We Decided Your Income-Related Premium Amount

  

IRS told us your MAGI in 2005 was $196,000.00. In 2005, you had an adjusted gross income of $152,000.00 plus tax-exempt income of $44,000.00 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, 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

                                                                               2315 Second Avenue North

                                                                               Fort 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 the office.

  

                                                                               Regional Commissioner

F. Sample - Annual Verification Correction Notice - Title 2 Beneficiary – IRS PY-1 MAGI Exceeds Beneficiary PY-1 Estimate or Beneficiary Supplied PY-1 MAGI

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

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 25, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

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.

  

Another Letter

  

You will receive another letter about how you will pay any past-due income-related premium amount.

  

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 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, 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: