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USSSARev. 12-2023

Official form guide

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

Requests a reduction in Medicare Part B and Part D premium surcharges (IRMAA) due to a qualifying life-changing event such as marriage, divorce, or reduced income.

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Form Overview

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

Requests a reduction in Medicare Part B and Part D premium surcharges (IRMAA) due to a qualifying life-changing event such as marriage, divorce, or reduced income.

A request for SSA to use more recent income information rather than the two-year-old tax return data normally used to set IRMAA.

Risk Radar

Scan points
  • 1Not providing documentation of the life-changing event — SSA requires evidence such as a death certificate or retirement letter.
  • 2Not submitting your estimated current year income — required to calculate the adjusted premium.
  • 3Confusing IRMAA reduction with general Medicare premium reduction — this form only applies to IRMAA surcharges.

Plain English

If your income dropped significantly due to a major life event (like retirement, job loss, or death of a spouse), use this form to ask SSA to lower your Medicare premium surcharge.

Submission Date

  • Filing date: File any time after experiencing a qualifying life-changing event that reduced your income.
  • Preparation window: collect IDs, supporting records, and signatures in advance.
  • Final review: verify names, dates, and required fields before submission.

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Glossary Terms

income

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Field map

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8 fields

Personal Info

3 items

Name

Your full name as it appears on Medicare.

Requiredtext
Medicare Beneficiary Identifier (MBI)

Your Medicare ID number from your Medicare card.

Requiredtext
Social Security Number

Your SSN.

Requiredssn

Life-Changing Event

2 items

Type of Life-Changing Event

Select the qualifying event (marriage, divorce, death of spouse, reduced work hours, loss of income from income-producing property, etc.).

Requiredselect
Date of Event

When the life-changing event occurred.

Requireddate

Income

1 items

Estimated Modified Adjusted Gross Income

Your estimated MAGI for the current year.

Requiredamount

Signature

2 items

Signature

Your signature.

Requiredsignature
Date

Date signed.

Requireddate

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Quick Facts

Medicare beneficiaries subject to Income-Related Monthly Adjustment Amount (IRMAA) surcharges who experienced a qualifying life-changing event.
A request for SSA to use more recent income information rather than the two-year-old tax return data normally used to set IRMAA.
File any time after experiencing a qualifying life-changing event that reduced your income.
Submit to your local Social Security office or by mail.
IRMAA surcharges are based on income from two years ago. This form allows you to use current income if it is substantially lower.
Complete the form, identify the qualifying life-changing event, provide your new estimated income, and attach supporting documentation.

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Copyright & Licensing - US Government Forms

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Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
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