This is a sample of the notice that we send to a title II beneficiary who reported
a life-changing event or new tax information at the time that he/she filed a claim
for benefits or Medicare-only. In this sample, the beneficiary also has a reduction
in his total Medicare Part B premium due to a Medicare Advantage reduction (SM 03040.335).
Social Security
Administration
Medicare
Part B Premium
Important Information
Return Address
Date
Claim Number: xxx-xx-xxxxA
Beneficiary Name
Beneficiary Address
A Medicare law requires that some people, based on their income, pay higher premiums
for their Medicare Part B (Medical Insurance) coverage. We received information about
your income from the Internal Revenue Service (IRS) that shows you must pay a higher premium.
You reported other information to us, which we will use to decide if you must pay a higher premium. If you want to report any changes in the information you
gave us, you need to contact us.
Based on the information we have, your 2007 monthly Medicare
Part B premium will be: $115.40
-
–
$93.50 for the standard Medicare premium plus
-
–
$30.90 for the income-related premium minus
-
–
$9.00 for your Medicare Advantage premium reduction.
This change will be effective March, 2007.
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 your MAGI in 2005 was $340,800.00. In 2005, you had an adjusted gross income of $340,800.00 and you filed your taxes with a tax filing status of Married, filing jointly. We used the following table to decide your income-related adjustment:
You reported an unanticipated loss of pension income. You said that your MAGI will
be $220,000.00 in 2007 and that your tax filing status will be 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 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:
-
•
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 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 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