The following list contains the sequencing of captions and paragraphs for Income-Related
Monthly Adjustment Amount (IRMAA) Annual Verification Overage notices for T2 beneficiaries.
An “R” indicates a required paragraph, while an “O” indicates an optional paragraph.
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•
Introductory (no caption)
MIR093 R
MIR094 R
-
•
Caption MIRC02 – Another Letter
MIR012 O
-
•
Caption INFC01 – The Information We Have
MIR107 R
MIR002 R
MIR065 R
MIR016 O
MIR006 O
MIR007 R
MIR017 o
MIR008 R
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•
Caption MIRCO4 – How We Decided Your Income-Related Premium Amount
MIR102 O
Or MIR103 O
MIR106 O
MIR105 O
MIR108 O
Or MIR109 O
MIR019 O
MIR020 O
MIR114 O
-
•
Caption ALSC19 – If You Disagree With This Decision
ALS162 R
-
•
Caption REPC01 – If You Want Help With Your Appeal
REP031 R
-
•
Caption REFC01 – If You Have Any Questions
REF103 O
REF104 O
REF106 O