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
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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, plus
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•
$ 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:
|
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•
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
|
|
|
$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
|
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•
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.
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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
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