Form SSA-44 "Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event"

What Is Form SSA-44?

Form SSA-44, Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event is a form used to notify the Social Security Administration (SSA) about a change in income and request a reduction of the income-related monthly adjustment amount (IRMAA) of the Medicare premium because of a life-changing event.

The most recent version of this form was issued by the SSA on November 1, 2019. A fillable version of the form - also known as the SSA Form 44 - is available for download below.

Life-changing events include the following: marriage, divorce or annulment, the death of the spouse, work stoppage or reduction, loss of income-producing property, loss or reduction of pension income, and employer settlement payment.

Where Do I File Form SSA-44?

Form SSA-44 can be filed in a local SSA office and all supporting documentation can be presented in person. Alternatively, the form can be downloaded, filled out digitally, printed out, and mailed to the local SSA office with originals or certified copies of the supporting documentation.

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Form SSA-44 Instructions

Medicare Part B and Part D premiums partially depend on the individual's income. These standard parts are constant and the IRMAA is added if the individual's income exceeds a certain amount. The required income level depends on the individual's status when enrolling into Medicare and it changes later on. If the individual's income has increased, they will have to pay the IRMAA the difference. However, if a life-changing event has decreased their income, the individual should file the SSA form 44 to request a reduction of the IRMAA part of their premium. The individual can file an appeal within 60 days after the IRMAA determination notice was received.

Medicare Part B is the part of Medicare insurance that covers medical services and supplies necessary to treat and prevent illnesses. This includes ambulance services, outpatient care, durable medical equipment, and preventive services. To be considered eligible for the Medicare Plan B, the individual must be a U.S citizen or a permanent resident lawfully residing in the U.S for at least five years and be at least 65 years old. If the individual is eligible for premium-free Part A, they are also eligible for Part B. People receiving Social Security or Railroad Retirement Board disability benefits are automatically enrolled in Medicare Part B after two years of disability benefits, even if they are under the age 65. Individuals with amyotrophic lateral sclerosis or end-stage renal disease are eligible for Part B before age 65.

Medicare Part D is an optional part of Medicare insurance covering prescription drugs. The individual enrolled in Part D pays a part of the prescription drug price - a copay - instead of a full price. The insurance company pays the rest to the pharmacy. Anyone enrolled in the Medicare Part A and B are eligible for Part D. While Part B has a penalty for late enrollment, Part D is voluntary.

How to Fill out Form SSA-44?

  1. Enter your name and social security number (SSN) on the first page of the form;
  2. Step 1, Type of Life-Changing Event. Check the corresponding box indicating the type of your life-changing event. Provide the date when the event took place;
  3. Step 2, Reduction of Income. Enter the tax year when your income was reduced. Enter the current year, if your adjusted gross income is lower this year then the year before. If the life-changing event took place last year and your income is not expected to decrease this year, enter the last year. Provide an estimated or actual adjusted gross income for the year you entered. Enter the actual tax-exempt interest income for the entered year. Tax-exempt income is the income that is not subject to the federal income tax. The adjusted gross income and tax-exempt income can be found on the IRS Form 1040. Check the corresponding box, indicating your status for the entered tax year;
  4. Step 3, Modified Adjusted Gross Income. Check the corresponding box, indicating, whether your modified adjusted gross income (MAGI) is expected to be lower the year following the year entered in the previous step. If you do not expect it to be lower, check the corresponding box and skip this step. If you answered positively, provide the tax year after the year you entered in Step 2. Enter your estimated adjusted gross income and tax-exempt for that year. Check the corresponding box indicating your expected tax status for the next year;
  5. Step 4, Documentation. Attach a certified copy or original of documents proving your life-changing event and MAGI. A copy of a tax return or transcript from the Internal Revenue Service (IRS) can serve as a proof of the MAGI and the documents supporting the life-changing event depend on the event;
  6. Step 5, Signature. Provide your phone number and mailing address before signing the form.

What is Modified Adjusted Gross Income for SSA-44?

Modified Adjusted Gross Income (MAGI) is calculated based on the Adjusted Gross Income (AGI). The AGI is a subtraction of allowable deductions from the gross income. Then the certain income types are included or subtracted to calculate the MAGI. The IRS calculates it and provides the information to the SSA.

To calculate the MAGI for Medicare Premium, the following should be added to the MAGI: received or acquired tax-exempt interest income, interest from U.S. Savings bonds used to pay for higher education tuition and fees, earned income of U.S citizens living abroad that were excluded from gross income and income from sources within Guam, American Samoa, the Northern Mariana Islands or Puerto Rico, not otherwise included in AGI.

The MAGI determines whether an individual must pay the IRMAA and its amount. The MAGI for the previous tax year can be found on the IRS Form 1040.

Where to Mail SSA-44?

The completed form with the supporting documentation should be mailed to a local SSA office. Form SSA-44 mailing address can be found on the SSA website.

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Download Form SSA-44 "Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event"

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Form SSA-44 (11-2019)
Page 1 of 8
Discontinue Prior Editions
OMB No. 0960-0784
Social Security Administration
Medicare Income-Related Monthly Adjustment Amount -
Life-Changing Event
If you had a major life-changing event and your income has gone down, you may use
this form to request a reduction in your income-related monthly adjustment amount.
See page 5 for detailed information and line-by-line instructions. If you prefer to
schedule an interview with your local Social Security office, call 1-800-772-1213
(TTY 1-800-325-0778).
Name
Social Security Number
You may use this form if you received a notice that your monthly Medicare Part B (medical
insurance) or prescription drug coverage premiums include an income-related monthly
adjustment amount (IRMAA) and you experienced a life-changing event that may reduce your
IRMAA. To decide your IRMAA, we asked the Internal Revenue Service (IRS) about your
adjusted gross income plus certain tax-exempt income which we call "modified adjusted gross
income" or MAGI from the Federal income tax return you filed for tax year 2018. If that was not
available, we asked for your tax return information for 2017. We took this information and used
the table below to decide your income-related monthly adjustment amount.
The table below shows the income-related monthly adjustment amounts for Medicare
premiums based on your tax filing status and income. If your MAGI was lower than $87,000.01
(or lower than $174,000.01 if you filed your taxes with the filing status of married, filing jointly)
in your most recent filed tax return, you do not have to pay any income-related monthly
adjustment amount. If you do not have to pay an income-related monthly adjustment amount,
you should not fill out this form even if you experienced a life-changing event.
Your prescription
Your Part B
drug coverage
If you filed your taxes as:
And your MAGI was:
monthly
monthly
adjustment is:
adjustment is:
-Single,
$ 87,000.01 - $109,000.00
$ 57.80
$ 12.20
-Head of household,
$144.60
$ 31.50
$109,000.01 - $136,000.00
-Qualifying widow(er) with dependent
$231.40
$ 50.70
$136,000.01 - $163,000.00
child, or
$163,000.01 - $500,000.00
$318.10
$ 70.00
-Married filing separately (and you did
$347.00
$ 76.40
More than $500,000.00
not live with your spouse in tax year)*
$174,000.01 - $218,000.00
$ 57.80
$ 12.20
$144.60
$ 31.50
$218,000.01 - $272,000.00
$231.40
$ 50.70
$272,000.01 - $326,000.00
-Married, filing jointly
$318.10
$ 70.00
$326,000.01 - $750,000.00
$347.00
$ 76.40
More than $750,000.00
-Married, filing separately (and you
$87,000.00 - $413,000.00
$318.10
$ 70.00
lived with your spouse during part of
More than $413,000.00
$ 76.40
$347.00
that tax year)*
* Let us know if your tax filing status for the tax year was Married, filing separately, but you lived apart
from your spouse at all times during that tax year.
Form SSA-44 (11-2019)
Page 1 of 8
Discontinue Prior Editions
OMB No. 0960-0784
Social Security Administration
Medicare Income-Related Monthly Adjustment Amount -
Life-Changing Event
If you had a major life-changing event and your income has gone down, you may use
this form to request a reduction in your income-related monthly adjustment amount.
See page 5 for detailed information and line-by-line instructions. If you prefer to
schedule an interview with your local Social Security office, call 1-800-772-1213
(TTY 1-800-325-0778).
Name
Social Security Number
You may use this form if you received a notice that your monthly Medicare Part B (medical
insurance) or prescription drug coverage premiums include an income-related monthly
adjustment amount (IRMAA) and you experienced a life-changing event that may reduce your
IRMAA. To decide your IRMAA, we asked the Internal Revenue Service (IRS) about your
adjusted gross income plus certain tax-exempt income which we call "modified adjusted gross
income" or MAGI from the Federal income tax return you filed for tax year 2018. If that was not
available, we asked for your tax return information for 2017. We took this information and used
the table below to decide your income-related monthly adjustment amount.
The table below shows the income-related monthly adjustment amounts for Medicare
premiums based on your tax filing status and income. If your MAGI was lower than $87,000.01
(or lower than $174,000.01 if you filed your taxes with the filing status of married, filing jointly)
in your most recent filed tax return, you do not have to pay any income-related monthly
adjustment amount. If you do not have to pay an income-related monthly adjustment amount,
you should not fill out this form even if you experienced a life-changing event.
Your prescription
Your Part B
drug coverage
If you filed your taxes as:
And your MAGI was:
monthly
monthly
adjustment is:
adjustment is:
-Single,
$ 87,000.01 - $109,000.00
$ 57.80
$ 12.20
-Head of household,
$144.60
$ 31.50
$109,000.01 - $136,000.00
-Qualifying widow(er) with dependent
$231.40
$ 50.70
$136,000.01 - $163,000.00
child, or
$163,000.01 - $500,000.00
$318.10
$ 70.00
-Married filing separately (and you did
$347.00
$ 76.40
More than $500,000.00
not live with your spouse in tax year)*
$174,000.01 - $218,000.00
$ 57.80
$ 12.20
$144.60
$ 31.50
$218,000.01 - $272,000.00
$231.40
$ 50.70
$272,000.01 - $326,000.00
-Married, filing jointly
$318.10
$ 70.00
$326,000.01 - $750,000.00
$347.00
$ 76.40
More than $750,000.00
-Married, filing separately (and you
$87,000.00 - $413,000.00
$318.10
$ 70.00
lived with your spouse during part of
More than $413,000.00
$ 76.40
$347.00
that tax year)*
* Let us know if your tax filing status for the tax year was Married, filing separately, but you lived apart
from your spouse at all times during that tax year.
Form SSA-44 (11-2019)
Page 2 of 8
STEP 1: Type of Life-Changing Event
Check ONE life-changing event and fill in the date that the event occurred (mm/dd/yyyy). If
you had more than one life-changing event, please call Social Security at 1-800-772-1213
(TTY 1-800-325-0778).
Marriage
Work Reduction
Divorce/Annulment
Loss of Income-Producing Property
Death of Your Spouse
Loss of Pension Income
Work Stoppage
Employer Settlement Payment
Date of life-changing event:
mm/dd/yyyy
STEP 2: Reduction in Income
Fill in the tax year in which your income was reduced by the life-changing event (see
instructions on page 6), the amount of your adjusted gross income (AGI, as used on line 7 of
IRS form 1040) and tax-exempt interest income (as used on line 2a of IRS form 1040), and
your tax filing status.
Tax Year
Adjusted Gross Income
Tax-Exempt Interest
2 0 __ __
$ __ __ __ __ __ __ . __ __
$ __ __ __ __ __ __ . __ __
Tax Filing Status for this Tax Year (choose ONE ):
Qualifying Widow(er)
Single
Head of Household
with Dependent Child
Married, Filing Jointly
Married, Filing Separately
STEP 3: Modified Adjusted Gross Income
Will your modified adjusted gross income be lower next year than the year in Step 2?
No - Skip to STEP 4
Yes - Complete the blocks below for next year
Tax Year
Estimated Adjusted Gross Income
Estimated Tax-Exempt Interest
2 0 __ __
$ __ __ __ __ __ __. __ __
$ __ __ __ __ __ __. __ __
Expected Tax Filing Status for this Tax Year (choose ONE ):
Qualifying Widow(er)
Single
Head of Household
with Dependent Child
Married, Filing Jointly
Married, Filing Separately
Form SSA-44 (11-2019)
Page 3 of 8
STEP 4: Documentation
Provide evidence of your modified adjusted gross income (MAGI) and your life-changing event.
You can either:
1. Attach the required evidence and we will mail your original documents or certified copies
back to you;
OR
2. Show your original documents or certified copies of evidence of your life-changing event
and modified adjusted gross income to an SSA employee.
Note: You must sign in Step 5 and attach all required evidence. Make sure that you provide
your current address and a phone number so that we can contact you if we have any
questions about your request.
STEP 5: Signature
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS
FORM.
I understand that the Social Security Administration (SSA) will check my statements with
records from the Internal Revenue Service to make sure the determination is correct.
I declare under penalty of perjury that I have examined the information on this form and it
is true and correct to the best of my knowledge.
I understand that signing this form does not constitute a request for SSA to use more
recent tax year information unless it is accompanied by:
• Evidence that I have had the life-changing event indicated on this form;
• A copy of my Federal tax return; or
• Other evidence of the more recent tax year's modified adjusted gross income.
Phone Number
Signature
Apartment Number
Mailing Address
City
State
ZIP Code
Form SSA-44 (11-2019)
Page 4 of 8
THE PRIVACY ACT
We are required by sections 1839(i) and 1860D-13 of the Social Security Act to ask you to give
us the information on this form. This information is needed to determine if you qualify for a
reduction in your monthly Medicare Part B and/or prescription drug coverage income-related
monthly adjustment amount (IRMAA). In order for us to determine if you qualify, we need to
evaluate information that you provide to us about your modified adjusted gross income.
Although the responses are voluntary, if you do not provide the requested information we will
not be able to consider a reduction in your IRMAA.
We rarely use the information you supply for any purpose other than for determining a potential
reduction in IRMAA. However, the law sometimes requires us to give out the facts on this form
without your consent. We may release this information to another Federal, State, or local
government agency to assist us in determining your eligibility for a reduction in your IRMAA, if
Federal law requires that we do so, or to do the research and audits needed to administer or
improve our efforts for the Medicare program.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local government
agencies. We will also compare the information you give us to your tax return records
maintained by the IRS. The law allows us to do this even if you do not agree to it. Information
from these matching programs can be used to establish or verify a person’s eligibility for
Federally funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Systems of Records Notice 60-0321 (Medicare Database File). The
Notice, additional information about this form, and any other information regarding our systems
and programs, are available on-line at
www.socialsecurity.gov
or at your local Social
Security office.
- This information collection meets the requirements of
Paperwork Reduction Act Statement
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do
not need to answer these questions unless we display a valid Office of Management and
Budget control number. We estimate that it will take about 45 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
Form SSA-44 (11-2019)
Page 5 of 8
INSTRUCTIONS FOR COMPLETING FORM SSA-44
Medicare Income-Related Monthly Adjustment Amount
Life-Changing Event--Request for Use of More Recent Tax Year Information
You do not have to complete this form in order to ask that we use your information about your
modified adjusted gross income for a more recent tax year. If you prefer, you may call
1-800-772-1213 and speak to a representative from 7 a.m. until 7 p.m. on business days to
request an appointment at one of our field offices. If you are hearing-impaired, you may call
our TTY number, 1-800-325-0778.
Identifying Information
Print your full name and your own Social Security Number as they appear on your Social
Security card. Your Social Security Number may be different from the number on your
Medicare card.
STEP 1
You should choose only one life-changing event on the list. If you experienced more than one
life-changing event, please call your local Social Security office at 1-800-772-1213 (TTY
1-800-325-0778). Fill in the date that the life-changing event occurred. The life-changing event
date must be in the same year or an earlier year than the tax year you ask us to use to decide
your income-related premium adjustment. For example, if we used your 2016 tax information to
determine your income-related monthly adjustment amount for 2018, you can request that we
use your 2017 tax information instead if you experienced a reduction in your income in 2017
due to a life-changing event that occurred in 2017 or an earlier year.
Life-Changing Event
Use this category if...
Marriage
You entered into a legal marriage.
Your legal marriage ended, and you will not file a joint return
Divorce/Annulment
with your spouse for the year.
Death of Your Spouse
Your spouse died.
You or your spouse stopped working or reduced the hours
Work Stoppage or Reduction
that you work.
You or your spouse experienced a loss of income-producing
property that was not at your direction (e.g., not due to the
sale or transfer of the property). This includes loss of real
Loss of Income-Producing
property in a Presidentially or Gubernatorially-declared
Property
disaster area, destruction of livestock or crops due to natural
disaster or disease, or loss of property due to arson, or loss
of investment property due to fraud or theft.
You or your spouse experienced a scheduled cessation,
Loss of Pension Income
termination, or reorganization of an employer's pension plan.
You or your spouse receive a settlement from an employer
Employer Settlement Payment
or former employer because of the employer's bankruptcy or
reorganization.

Browse Form SSA-44 by Year

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