Social Security
Administration
Medicare
Part B Premium
Important Information
Return Address
Date
Claim Number: xxx-xx-xxxxA
Beneficiary Name
Beneficiary Address
On March 1, 2007, we told you that we had decided that you would have to pay an income-related premium amount of $30.90 a month for 2007. On March 17, 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 agree that we did not figure the income-related
amount of your Medicare Part B premium correctly. In this letter, we will explain the information we used, and tell you what you should
do if you disagree with our decision.
Your 2007 monthly Medicare Part B premium should have been: $102.90
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$93.50 for the standard Medicare premium plus
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–
$9.40 for your
premium surcharge.
This change will be effective January, 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, 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. 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 Single and adjusted gross income of $85,780.00.
You reported new information
about your income. You said that your MAGI was
$68,300.00 in 2006 and that your tax filing status was Single. We used the following table to decide your income-related adjustment:
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If your filing status was:
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And your MAGI was:
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Then your income-related monthly adjustment amount is:
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Single, Head of household or Qualifying widow(er)
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$ 80,000.01 - $ 100,000.00
$ 100,000.01 - $ 150,000.00
$ 150,000.01 - $ 200,000.00
More than $ 200,000.00
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$ 12.30
$ 30.90
$ 49.40
$ 67.90
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Married, filing jointly
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$ 160,000.01 - $ 200,000.00
$ 200,000.01 - $ 300,000.00
$ 300,000.01 - $ 400,000.00
More than $400,000.
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$ 12.30
$ 30.90
$ 49.40
$ 67.90
|
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Married, filing separately (if you lived apart throughout the year, see below)
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$ 80,000.01 - $ 120,000.00
More than $ 120,000.00
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$ 49.40
$ 67.90
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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:
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•
You have an amended tax return for 2006, and your MAGI from your amended tax return is lower than the MAGI information you gave us.
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•
Your MAGI goes down at least one range in the table above and:
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you marry,
divorce, or become widowed; or
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you or your spouse stop working or reduce your work hours; or
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you or your spouse lose income from property due to a disaster or other event beyond your control; or
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you or our 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 2005 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 Department of Health and Human Services of the U.S. Government.
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.
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•
You have 60 days to ask for a hearing.
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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.
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You must have good reason for waiting more than 60 days to ask for a hearing.
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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 2005 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 complete
and 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 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