This is a sample of the new initial determination notice that we will send to a beneficiary
when he asked us to use his retained copy of his tax return for the year 2 years prior
to the premium year to replace IRS information we used from 3 years prior. In this
example, for the premium year 2007, we made an initial determination using IRS information
from tax year 2004. The beneficiary provided us with a copy of his filed tax return
for 2005. In this sample, the effective date of the determination is April, 2007,
because the beneficiary was first entitled to Medicare and enrolled in Part B at that
time.
Social Security
Administration
Medicare
Part B Premium
Important Information
Return Address
Date
Claim Number: xxx-xx-xxxxA
Beneficiary Name
Beneficiary Address
On September 20, 2007, you asked for a new decision about your Medicare Part B income-related premium amount for 2007 based on new information about your income. You
asked us to use information that you provided
about your tax return for a more recent year. We are writing to tell you your income-related premium amount is $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 April, 2007.
Another Letter
You will get another letter explaining how this will affect your Social Security benefits.
How We Decided Your Income-Related Premium
Amount
To decide if your income is high enough that you must pay an income-related adjustment, we asked the Internal Revenue Service (IRS)
for information about your modified adjusted gross income (MAGI) from your income tax return for 2005. Because
the IRS did not have any information about that year, they gave
us information about your MAGI
from your tax return
for 2004. MAGI is the sum of your adjusted gross income plus certain amounts of income that are not taxable. For most
people, MAGI is the sum of adjusted gross income and tax-exempt interest income on
IRS form 1040.
IRS told us that you filed your Federal income tax with a filing status of Married, filing jointly
and adjusted gross income of $417,900.00.
You reported that you had filed your tax return
for the following year. You said that your MAGI was $378,500.00 in 2005 and that your tax filing status was
Married filing jointly. We used the following table to decide your income-related adjustment:
If your filing status
was:
|
And your MAGI was:
|
Then your income-related monthly adjustment
amount 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.
|
$ 12.30
$ 30.90
$ 49.40
$ 67.90
|
Married, filing separately (if you lived apart throughout the year, see below)
|
$ 80,000.01 - $ 120,000.00
More than $ 120,000.00
|
$ 49.40
$ 67.90
|
If The Information You Gave Us Changes
You gave us a copy of your tax return for 2005. It is important that you let us know if the information you gave us about your income changes.
Please contact us at 1-800-772-1213 if your estimate of your MAGI changes or you amend your tax return for 2005.
If You Have Other Information About Your Income
You provided us with new information about your MAGI for 2005. Under certain circumstances, we may use information about your MAGI for a more recent year. 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:
-
•
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 our spouse’s pension stops or is reduced due to termination of the pension plan.
-
•
You have an amended tax return for 2005, and your MAGI from your amended tax return is lower than the MAGI information you gave us.
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 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 also write or visit any Social Security office. The office that serves your area is located at:
Address of field office
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.
(Signature)
Regional Commissioner