We send a reconsideration affirmation notice to beneficiaries when we reconsider an initial determination of IRMAA, and find that our initial determination was correct (i.e., we “affirm” our initial determination). This situation may occur when a beneficiary insists on filing a reconsideration of our initial determination, when he does not have a qualifying circumstance for a new initial determination (see HI 01140.001D.). These notices contain appeal rights.

 

 

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 think our decision is correct. In this letter, we will explain the information we used, and tell you what you should do if you disagree with our decision.

 

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 $139,500.00. In 2005, you had an adjusted gross income of $134,500.00 plus tax-exempt interest income of $5,000.00 and you filed your taxes with a tax filing status of Single. We used the following table to decide your income-related adjustment:

 

 

 

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:

 

• •

  You have an amended tax return for 2005, and your MAGI from your amended tax return is lower than the MAGI information we received from IRS.

• •

  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 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.

• •

  You have 60 days to ask for a hearing.

• •

  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.

• •

  You must have good reason for waiting more than 60 days to ask for a hearing.

• •

  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 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