The following list contains the sequencing of captions and paragraphs for IRMAA Annual
Verification Reconsideration - Affirmation Notices for Non-T2 beneficiaries. An “R”
indicates a required paragraph, while an “O” indicates an optional paragraph.
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•
Introductory (no caption)
MIR099 R
MIR060 R
-
•
MIRC04 – How We Decided Your Income-Related Premium Amount
MIR080 O
MIR104 R
MIR019 R
MIR020 R
-
•
MIRC03 – If You Have Other Information About Your Income
MIR021 R
MIR024 R
MIR022 R
MIR088 R
MIR025 R
-
•
ALSC19 – If You Disagree With This Decision
ALS163 R
-
•
ALSC25 – If You Want Help With Your Hearing
REP032 R
-
•
REFC01 – If You Have Any Questions
REF093 (RRB) O
REF103 O
REF104 O
REF106 O