TN 2 (10-07)

HI 01194.120 IRMAA Annual Verification Determination Notice (Notice Type 640)

A. Purpose/Use

Annual Verification Determination notices are mailed when beneficiaries contact SSA within 20 days from the date of the Predetermination notice with proof of IRS corrected data or an amended tax return or documentation of an obvious IRS transcription error in tax-exempt interest income which SSA accepts and processes. It includes appeal rights and states that there will be another notice about the impact on benefits.

B. Sample - Annual Verification Determination Notice – RRB Beneficiary – Beneficiary Supplies Amended Return for PY-2 After Receiving Predetermination Notice – Results in an Overage

This is a sample of the notice that will be sent to an RRB beneficiary who supplies an amended return after receiving a Predetermination notice. In this sample, acceptance and processing of the amended return results in an overage. The beneficiary is owed IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 14, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007.

Because you paid a higher Part B premium amount than what was required, you are due a refund for the excess premiums paid.

On November 12, 2007, you asked us to change our plan to increase your Medicare Part B income-related premium amount for 2007 and you provided your amended tax return for 2005. We are writing to tell you your income-related premium amount will be $30.90.

You will pay $30.90 for the income-related amount of your monthly Medicare Part B premium. This change will be effective January through December 2007.

  

Other Information

  

You will receive a letter from the Railroad Retirement Board about the refund of the excess premiums you paid.

  

How We Decided Your Income-Related Premium Amount

  

IRS told us your MAGI in 2005 was $196,002.00. You had an adjusted gross income of $152,000.00 plus tax-exempt interest income of $44,000.00 and you filed your taxes with a tax filing status of Single. We planned to set your income-related premium amount at $49.40 for 2007.

However, you then provided your amended tax return. You showed that your MAGI was $146,000.00 in 2005 and that your tax filing status was 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 Determination Notice – Title 2 Beneficiary – Beneficiary Supplies Amended Return for PY-2 After Receiving Predetermination Notice – Results in an Arrearage

This is a sample of the notice that will be sent to a Title 2 beneficiary who supplies an amended return after receiving a Predetermination notice. In this sample, acceptance and processing of the amended return results in an arrearage. The beneficiary owes IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 14, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007. Because you paid a lower Medicare Part B premium amount than what was required, you owe an additional amount for your Medicare Part B premiums.

On November 12, 2007, you asked us to change our plan to increase your Medicare Part B income-related premium amount for 2007 and you provided your amended tax return for 2005. We are writing to tell you your income-related premium amount will be $49.40.

Your 2007 monthly Medicare Part B premium is: $142.90

  • $93.50 for the standard Medicare premium, plus

  • $49.40 for the income-related premium amount.

This change will be effective January through December 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 $146,000.00. You had an adjusted gross income of $142,000.00 plus tax-exempt interest income of $4,000.00 and you filed your taxes with a tax filing status of Single. We planned to set your income-related premium amount at $30.90 for 2007.

However, you then provided your amended tax return. You showed that your MAGI was $156,000.00 in 2005 and that your tax filing status was 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 Determination Notice – Title 2 Beneficiary – Beneficiary Supplies Proof of IRS Correction After Receiving Predetermination Notice – Changes SSA’s Planned Action But Does Not Result In A Change To The MBR

This is a sample of the notice that will be sent to a Title 2 beneficiary who supplies proof of IRS corrected data within 20 days from the date of the Predetermination notice. In this sample, acceptance and processing of the IRS corrected data results in neither an arrearage nor an overage because the change that we notified the beneficiary of in the Predetermination notice has not yet taken effect and the proof that the beneficiary supplied supports the current premium year IRMAA.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 14, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007.

On November 12, 2007, you asked us to change our plan to increase your Medicare Part B income-related premium amount for 2007 and you provided your proof of corrected Internal Revenue Service (IRS) information. We are writing to tell you your income-related premium amount will be $12.30.

Your 2007 monthly Medicare Part B premium is: $105.80

  • $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.

  

How We Decided Your Income-Related Premium Amount

  

In February 2007, at your request, we used information you provided about your MAGI for 2006. You said your 2006 MAGI was $99,845.00. You said you had an adjusted gross income of $98,000.00 plus tax exempt interest income of $1,845.00 and you filed your taxes with a tax filing status of Single. Based on your information, we set your income-related premium amount at $12.30 for 2007.

IRS told us your MAGI in 2006 was $146,000.00. You had an adjusted gross income of $142,000.00 plus tax-exempt interest income of $4,000.00 and you filed your taxes with a tax filing status of Single. We planned to set your income-related premium amount at $30.90 for 2007.

However, you then provided your proof of corrected IRS information. You showed that your MAGI was $99,845.00 in 2006 and that your tax filing status was 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

E. Sample - Annual Verification Determination Notice – T2 Beneficiary – Beneficiary Supplies Proof of IRS Correction After Receiving Predetermination Notice – Changes SSA’s Planned Action But Does Not Result In A Change To The MBR – VSMI Involved

This is a sample of the notice that will be sent to a Title 2 beneficiary who supplies proof of IRS corrected data after receiving within 20 days from the date of the Predetermination notice. In this sample, acceptance and processing of the IRS corrected data results in neither an arrearage nor an overage because the change that we notified the beneficiary of in the Predetermination notice has not yet taken effect and the proof that the beneficiary supplied supports the current premium year IRMAA level. Variable SMI is involved.

  

Social Security Administration

Medicare Part B Premium

Important Information

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: November 14, 2007

                                                                                             Claim Number: xxx-xx-xxxxA

  

Beneficiary Name

Beneficiary Address

  

This letter is about your Medicare Part B (Medical Insurance) premiums for 2007.

On November 12, 2007, you asked us to change our plan to increase your Medicare Part B income-related premium amount for 2007 and you provided your proof of corrected Internal Revenue Service (IRS) information. We are writing to tell you your income-related premium amount will be $0.00.

Your 2007 monthly Medicare Part B premium is: $83.50

  • $93.50 for the standard Medicare premium, minus

  • $10.00 for the reduction in your standard monthly premium, plus

  • $ 0.00 for the income-related premium amount.

This change will be effective January through December 2007.

  

How We Decided Your Income-Related Premium Amount

  

In February 2007, at your request, we used information you provided about your MAGI for 2006. You said your 2006 MAGI was $51,845.00. You said you had an adjusted gross income of $50,000.00 plus tax exempt interest income of $1,845.00 and you filed your taxes with a tax filing status of Single. Based on your information, we set your income-related premium amount at $0.00 for 2007.

IRS told us your MAGI in 2006 was $146,000.00. You had an adjusted gross income of $142,000.00 plus tax-exempt interest income of $4,000.00 and you filed your taxes with a tax filing status of Single. We planned to set your income-related premium amount at $30.90 for 2007.

However, you then provided your proof of corrected IRS information. You showed that your MAGI was $75,000.00 in 2006 and that your tax filing status was 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

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

                                                                               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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601194120
HI 01194.120 - IRMAA Annual Verification Determination Notice (Not