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Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Download and Print the SSA-44

Request may not be processed if the form is incomplete or illegible.

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 2011.

If that was not available, we asked for your tax return information for 2010.

We took this information and used the table below to decide your income-related monthly adjustment amount.

And much more...