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. SSA corrects the agency’s IRMAA determination by removing
IRMAA and reimposing variable SMI.
Social Security Administration
Medicare
Part B Premium
Notice of Reconsideration
SOCIAL
SECURITY
Address
Date:
January 11, 2008
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 January 4, 2008, 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: $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 Medicare monthly premium, plus
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$0.00 for the income-related premium amount.
This change will be effective January through December 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. 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. In 2005, 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.
However, you then provided your proof of corrected IRS information. You showed that
your MAGI was $75,900.00 in 2005 and that your tax filing status was Married, filing
jointly. We used the following table to decide your 2007 income-related adjustment:
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If your filing status was:
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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 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 we received from IRS.
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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 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 US 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.
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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 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 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