Get SSA-44 2020-2023
Form SSA-44 12-2017 Discontinue Prior Editions Social Security Administration Page 1 of 8 OMB No. 0960-0784 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 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 2016. If that was not available we asked for your tax return information for 2015. 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 85 000. 01 or lower than 170 000. 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 you should not fill out this form even if you experienced a life-changing event. Your prescription drug coverage monthly adjustment is If you filed your taxes as And your MAGI was Your Part B -Single -Head of household -Qualifying widow er with dependent child or -Married filing separately and you did not live with your spouse in tax year 85 000. 01 - 107 000. 00 107 000. 01 - 133 500. 00 133 500. 01 - 160 000. 00 More than 160 000 53. 50 133. 90 214. 30 294. 60 13. 00 33. 60 54. 20 74. 80 170 000. 01 - 214 000. 00 214 000. 01 - 267 000. 00 267 000. 01 - 320 000. 00 lived with your spouse during part of 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. 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 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 37 of IRS form 1040 and tax-exempt interest income as used on line 8b of IRS form 1040 and your tax filing status.
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