TN 2 (10-07)

HI 01194.125 IRMAA Annual Verification Reconsideration Affirmation Notice (Notice Type 690)

A. Purpose/Use

Annual Verification Reconsideration notices are mailed when beneficiaries request SSA to reconsider their decision after receipt of a Predetermination notice, Overage notice, Correction notice or Determination notice. Reconsideration Affirmation notices uphold the agency’s IRMAA determination and include appeal rights.

B. Sample - Annual Verification Reconsideration Affirmation Notice

This is a sample of the notice that will be sent to beneficiaries who request reconsideration after receiving a Correction notice. In this sample the beneficiary provides proof of corrected IRS information however, the corrected IRS information did not result in a change to the income-related adjustment amount. SSA upholds the agency’s IRMAA determination.

  

Social Security Administration

Medicare Part B Premium

Notice of Reconsideration

                                                                                             SOCIAL SECURITY

                                                                                             Address

                                                                                             Date: December 7, 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 26, 2007, we told you that we had decided that you would have to pay an income-related premium amount of $49.40 a month for 2007. On December 1, 2007, you asked us to take another look at our decision about your income-related premium amount. Someone who did not make the first decision reviewed your case, including any new facts we received. After reviewing all the information carefully, we believe our decision is correct. In this letter, we will explain the information we used, and tell you what you should do if you disagree with our decision.

  

How We Decided Your Income-Related Premium Amount

  

To decide if your income is high enough that you must pay an income-related adjustment, the Internal Revenue Service (IRS) gave us information about your modified adjusted gross income (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. Adjusted gross income is from line 37 of the IRS Form-1040 and tax exempt interest income is from line 8b of 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 told us your MAGI in 2005 was $385,900.00. You had an adjusted gross income of $357,000.00 plus tax-exempt interest income of $28,900.00 and you filed your taxes with a tax filing status of Married, filing jointly.

You provided your proof of corrected IRS information. You showed that your MAGI was $335,900.00 in 2005 and that your tax filing status was Married, filing jointly. This does not result in a change to your income-related adjustment amount. 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 Have Other Information About Your Income

  

The law permits us to use other information about your MAGI under certain circumstances. If any of the situations in the list below apply or if they occur later this year, you should contact us and explain that you have new information about your Medicare Part B income-related premium. You can call us at 1-800-772-1213 (TTY 1-800-325-0778 for the hearing-impaired) or visit any Social Security office to discuss the following situations:

  • You have an amended tax return for 2005 and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

  • Your MAGI goes down at least one range in the table above and:

    • You marry, divorce, or become widowed; or

    • You or your spouse stop working or reduce your work hours; or

    • You or your spouse lose income from property due to a disaster or other event beyond your control; or

    • You or your spouse’s pension stops or is reduced due to termination of the pension plan.

You should contact us as soon as you know about any of the situations listed above. We will be able to tell you what kind of evidence you need to give us about the situation and your change in MAGI.

If you believe that the information IRS gave us is incorrect, contact the IRS to get IRS's copy of your tax return. You can call us if you have any questions.

  

If You Disagree With This Decision

  

If you disagree with this decision, you have the right to request a hearing.  A person who has not seen your case before will look at it.  That person is an Administrative Law Judge (ALJ) from the U.S. Department of Health and Human Services.  The ALJ will review your case again and look at any new facts you have before deciding your case.

 

If you do appeal our decision, you will have to pay an income-related premium amount until the ALJ makes a decision on your appeal.  If the ALJ changes 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 a hearing.

  • The 60 days start the day after you receive 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 a hearing.

  • You have to ask for a hearing in writing.  We will ask you to sign a form HA-501-U5, called “Request for Hearing by Administrative Law Judge” and an authorization for us to release information about your tax return to the Department of Health and Human Services, form 8821.  You can find these forms online at www.socialsecurity.gov, at an SSA field office or by calling us at 1-800-772-1213 to request the forms. If you are deaf or hard of hearing, you can call our TTY number, 1-800-325-0778.  If you download these forms, you should sign them and mail them to: Social Security Administration, Southeastern Program Service Center, P.O. Box 12247, Birmingham, AL 35202.  

The ALJ will mail you a letter at least 20 days before the hearing to tell you the date, time and place. The letter will explain the law in your case and tell you what has to be decided.  Since the ALJ will review all the facts in your case, it is important that you give us any new facts as soon as you can.

 

The hearing is your chance to tell the ALJ why you disagree with the decision in your case.  You can give the ALJ new evidence and bring people to testify for you.

  

If You Want Help With Your Hearing

  

You can have a friend, lawyer, or someone else help you. Your local Social Security office has a list of groups that can help you.

  

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 2ND AVE NORTH

                                                                               FORT DODGE, IA 50501

  

If you do call or visit an office, please have this letter with you. It will help us to answ