Form SSA-44 (12-2021)
Discontinue Prior Editions
Social Security Administration
Medicare Income-Related Monthly Adjustment Amount -
Life-Changing Event
Page 1 of 8
OMB No. 0960-0784
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 2020. If that was not
available, we asked for your tax return information for 2019. 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 $91,000.01
(or lower than $182,000.01 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.
If you filed your taxes as: And your MAGI was:
Your Part B
monthly
adjustment is:
Your prescription
drug coverage
monthly
adjustment is:
-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)*
$ 91,000.01 - $114,000.00
$114,000.01 - $142,000.00
$142,000.01 - $170,000.00
$170,000.01 - $499,999.99
More than $499,999.99
$ 68.00
$170.10
$272.20
$408.20
$ 12.40
$ 32.10
$ 51.70
$ 77.90
-Married, filing jointly
$182,000.01 - $228,000.00
$228,000.01 - $284,000.00
$284,000.01 - $340,000.00
$340,000.01 - $749,999.99
More than $750,000.00
$ 68.00
$170.10
$272.20
$408.20
$ 12.40
$ 32.10
$ 51.70
$ 77.90
-Married, filing separately (and you
lived with your spouse during part of
that tax year)*
$91,000.01 - $408,999.99
More than $409,000.00
$374.20
$408.20
$ 71.30
$ 77.90
* 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.
$ 71.30$374.20
$ 71.30$374.20