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This page is for informational purposes only. Please consult the Social Security Administration for help completing this form or for answers to your questions. We cannot assist you with IRMAA questions or concerns.

If you are a Medicare beneficiary that had a high income within the last couple of years, you may be penalized with a higher premium by Medicare. This penalty can affect your Part B premium and your prescription drug (Part D) premium. There is a process to appeal a Part B premium penalty.

The technical name for this penalty is the Income-Related Monthly Adjustment Amount, or IRMAA. A Request for Reconsideration is a petition that you can file with Social Security if you feel your premium amount is unwarranted or based on inaccurate information (more on that below).

Once you retire, your income is likely to drop. Yet, the IRMAA can cause you to pay may more even though at retirement your income is lower. The Request for Reconsideration could help lower your premium.

How Your Part B and Part D Premium is Calculated

Your Modified Adjusted Gross Income (MAGI) is calculated by adding your adjusted gross income plus any tax-exempt income. This could include items such as dividends, interest, capital gains, wages, rental income, or non-taxable Social Security benefits.

In order to determine this amount, Social Security will use the information from your most recent federal tax return. So the amount that they are basing your premium on could be your MAGI from 18-24 months ago.

Part B Monthly Premium

Most people pay the standard Part B premium amount ($185 in 2025). Social Security will tell you the exact amount you’ll pay for Part B in 2025. You pay the standard premium amount if you:

■ Enroll in Part B for the first time in 2025.
■ Do not receive Social Security benefits.
■ Directly billed for your Part B premiums.
■ Have Medicare and Medicaid, and Medicaid pays your premiums.

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard Part B premium and an income-related monthly adjustment amount.

Part D monthly premium

The chart above also shows your estimated drug plan monthly premium based on your income. If your income is above a certain limit, you’ll pay an income-related monthly adjustment amount (IRMAA) in addition to your plan premium.

If Social Security determines that you are in a bracket that will trigger a Part B or Part D premium penalty, you will receive a letter from them informing you of what your premium will be. They will also include an explanation of your Medicare Part B premium penalty. If you disagree with their assessment, you can then file a Request for Reconsideration.

Situations That May Qualify You For a Lower Part B Premium

You can call the SSA to request the reconsideration. The number is 1-800-772-1213.

Here are the situations that may cause a Part B premium penalty to be reversed:

1. Tax return inaccurate or out of date

• A beneficiary filed an amended tax return for the year SSA is using to make an IRMAA decision
• There was an error in the IRS data
• The IRS provided SSA with older data and the beneficiary wants to use newer information
• You had a major life-changing event that significantly reduced your income

2. A life-changing event that affects the beneficiary’s modified adjusted gross income:

• Death of spouse
• Marriage
• Divorce or annulment
• Work reduction
• Work stoppage
• Loss of income from income-producing property
• Loss or reduction of certain kinds of pension income

The most common of these is work reduction or work stoppage. If you were making $100,000 when you retired two years ago and your retirement income is now $40,000, you have a pretty good case for having your premium reduced.

How To Appeal a Part B Premium Penalty

When following the steps below, be sure to keep a record of all your correspondence. This is your Medicare Part B premium penalty you are trying to lower, so it puts money back in your pocket if you are successful. So, make sure you keep a copy of everything. The IRMAA also can affect your Part D premiums. If you are entitled to having your premium adjusted it is in your best interest to do so.

1. 1. Complete a request to SSA for reconsideration. Contact SSA to learn how to file this request. Here is a direct link to the form you will need (CLICK).
   2. Your premium amounts will be corrected if your reconsideration is successful. If your reconsideration is denied, you can appeal to the Administrative Law Judge (ALJ) within 60 days of the date on the reconsideration denial. Follow the directions on the denial to file an appeal with the ALJ. If you decide to appeal to the ALJ, you may want to contact a legal services organization or lawyer to help you with this or any further levels of appeal—but this is not required. You must submit any new evidence within 10 days of filing your appeal to the ALJ. Contact the ALJ to learn how to submit this. You can ask the ALJ for an extension if you are unable to submit new evidence within 10 days.
   3. If your ALJ appeal is successful, your premium amount will be corrected. If your appeal is denied, you can choose to appeal to the Medicare Appeals Council (MAC) within 60 days of the date on the ALJ denial.
   4. The Part B premium amount will be corrected if the MAC appeal is successful. If the MAC denies your appeal, you can choose to appeal to the federal judicial district has at least one courthouse, and most districts have more than one. Each state has at least one judicial district.

This page is for informational purposes only. Please consult the Social Security Administration for help completing this form or for answers to your questions. We cannot assist you with IRMAA questions or concerns.

For many years, it was easy to know when retirement, Social Security, and Medicare were going to be a reality in our lives. Age 65 was the defining marker for all of those, including Medicare enrollment. That one birthday used to mean that retirement (and hopefully a pension), better healthcare options through Medicare, and the beginning of Social Security benefits were available. That is no longer the case.

The Social Security Amendments of 1983 (H.R. 1900, Public Law 98-21) contained two provisions which may have an impact on when an individual decides to retire. For those born from 1943 through 1954, the age you can begin full SSI benefits in age 66. This means that turning 65 is no longer an automatic trigger for Medicare enrollment. Because of this change in retirement age, many seniors are unaware that they still need to enroll in Medicare at age 65, not 66. Not enrolling when you are first eligible could lead to lifelong penalties on your Medicare premium.

Seniors who are already receiving SSI payments when they turn 65 are not affected by enrollment issues. You will be automatically enrolled is you are receiving SSI benefits. If you postpone your Social Security benefits either because you are still working or want a higher payout by waiting to start, you will need to enroll yourself in Medicare at age 65.

Medicare Enrollment Period

If you are still covered by group coverage from a retiree plan, or your or your spouse’s plan, you might want to wait to enroll in Part B. However, you can sign up for free Part A (if you’re eligible) anytime during or after your Initial Enrollment Period starts. Your coverage start date will depend on when you sign up. If you have to buy Part A and/or Part B, you can only sign up during a valid enrollment period. The General Enrollment Period (GEP) runs from January 1 through March 31 of each year. Coverage for enrollments during GEP will begin July 1 of that year.

If you are not covered by a group or retiree plan, you must enroll in Medicare during your Initial Enrollment Period (IEP). That period is a seven-month period that begins three months before the month of your 65th birthday. It includes your birth month and ends three months after your birth month. You can enroll in Part A and Part B of Medicare at that time. Part A is free as long as you worked 40 quarter hours (or 10 years) during your lifetime. It covers hospital and most other inpatient services.

Part B requires a premium. It covers physician and outpatient services. Part C is the Medicare replacement plan known as Medicare Advantage. Part D is the prescription drug program, which you will also need to look into when you first enroll in Medicare. You can also get a Medicare supplement plan to cover the gaps in Medicare. These are also known as Medigap plans. If you are confused about the Parts and Plans of Medicare, be sure to check out our article and video that fully explains both by clicking here.

The Late Enrollment Penalty For Medicare Part B

If you do not enroll in Part B when first eligible, and you are not enrolled in a qualifying group or retiree plan, you will be penalized. For every year that you delay Medicare enrollment in Part B, you have a 10% surcharge added to your Part B premiums. The surcharge is permanent – you will pay it the rest of your life. So if you delay enrollment in Part B for two years, that would mean a 20% surcharge added to your Part B premium going forward.

As mentioned previously, you can delay Part B enrollment. You must be covered by an employer plan (yours or your spouse’s) or a retiree group plan. Once that coverage ends, you will be eligible for a Special Enrollment Period (SEP) to enroll in Part B. That SEP gives you up to eight months to sign up for Medicare without a penalty.

One important note about ending group coverage. If you opt for COBRA, you will not be exempted from needing to enroll in Part B. The 8-month SEP runs concurrently with COBRA. It is based on termination of group coverage, not termination of COBRA. So you need to enroll in Part B when your group coverage ends, not when COBRA ends. Otherwise, you will have the late enrollment surcharge applied to all future Part B premiums. That penalty applies ONLY to your Part B premium and does not affect Medicare supplement premiums.

To enroll in Medicare past age 65, you will need to call Medicare. Their number is 1-800-MEDICARE (1-800-633-4227). TIP: call them late at night or really early in the morning. Their service is available 24 hours a day. You can also visit the website at http://medicare.gov.

Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act (H.R. 5772 and S. 3236)

As of the writing of this article, there is legislation in both houses of Congress to address this confusing enrollment process. In late August 2016, 73 state and national organizations that represent seniors, health insurers, unions, people with disabilities, and health care providers sent a letter to the lead sponsors of the legislation in both the House and Senate expressing their support for these bills.

“The basic rules underpinning the Part B enrollment system were developed more than 50 years ago, when Medicare was first established. Through bipartisan, low-cost reforms, the BENES Act shields people with Medicare from steep premium penalties, fills needless gaps in coverage and expands avenues for relief among those who mistakenly delay or decline Part B.”   -From the coalition

The coalition also pointed out that over 750,000 Medicare beneficiaries were paying a lifetime penalty in 2014. These penalties were a result of not enrolling in Part B within the Initial Enrollment Period. The coalition also pointed out that the average penalty being paid was 30%.

In addition to this, Congressional leaders also received comments from eight past administrators of the Centers for Medicare & Medicaid Services (CMS) expressing their support. CMS is the agency that administers the Medicare program. These administrators were from both Republican and Democrat administrations. Their letter stated:

“The decoupling of eligibility ages for Medicare and full Social Security benefits, revisions to Medicare Secondary Payor law, and the growing number of Americans working past the age of 65 have, together, substantially complicated the decision-making process for eligible individuals and couples in deciding when and how to enroll in Medicare.”

Because of a shortened Congressional session and the fact that this is a Presidential election year, some believe the standalone bill has little chance of passage. However, once new Medicare premiums and Social Security benefits are announced for next year, this bill could attach itself to legislation addressing those issues. In 2015, Congress passed legislation addressing a very large Part B premium increase. If they were to do so again this year, this new bill could be lumped in with it.  This would give it a much better chance of passage.

If you are still confused about Medicare enrollment periods and how this can affect you, please give us a call or write to us. The phone number is 888-228-6119. It is at the top of the page. You can use the request form on the right side of the page to send your questions, as well.

The advice on this website is informational. Please consult with us before making a purchasing decision to determine what is best for your individual situation. You can contact Keith Murray at 888-228-6119 or keith@expertmedicare.com.

Keith Murray is an independent agent and the owner of Integrity Senior Solutions Inc. He has over 25 years of experience working with Seniors to meet their insurance and financial needs.

The Senior Medicare Patrol (SMP) consists of volunteers who donate their time and energy to teach others about fraud in Medicare and Medicaid. These volunteers are well-versed on how to detect, prevent, and report fraud. The Senior Medicare Patrol believes that this will help to protect our citizens’ health and health benefits, as well as strengthen the Medicare and Medicaid programs.

According to the Senior Medicare Patrol website, they focus their work in three areas:

1. Conduct Outreach and Education. SMPs give presentations to groups, exhibit at events, and work one-on-one with Medicare beneficiaries. Since 1997 more than 30 million people have been reached during community education events, more than 6.5 million beneficiaries have been educated and served, and more than 46,000 volunteers have been active.
2. Engage Volunteers. Protecting older persons’ health, finances, and medical identity while saving precious Medicare dollars is a cause that attracts civic-minded Americans. The SMP program engages over 5,200 volunteers nationally who collectively contribute more than 155,000 hours each year.
3. Receive Beneficiary Complaints. When Medicare beneficiaries, caregivers, and family members bring their complaints to the SMP, the SMP makes a determination about whether or not fraud, errors, or abuse is suspected. When fraud or abuse is suspected, they make referrals to the appropriate state and federal agencies for further investigation.

The Senior Medicare Patrol volunteers are seniors and professionals such as doctors, nurses, investigators, independent insurance agents, law enforcement personnel, attorneys, and teachers.

In 2011, there were more than 5,600 active volunteers in the Senior Medicare Patrol. Some of their accomplishments include:

• Referring more than 800 complaints for investigation
• Educating and empowering over 11,000 groups and more than 4.3 million Medicare recipients
• Holding more than 66,000 one-on-one consultations

Since 1997, Senior Medicare Patrol projects have trained more than 30,000 volunteers and received more than 300,000 complaints for investigation. From those efforts, they have amassed more than $106 million in funds recovered by Medicare and Medicaid, as well as individuals receiving benefits.

Medical Identity Theft

One of the most impacted areas of fraud is identity. Over 250,000 Medicare beneficiaries have had their Medicare claim number stolen or misused. This is known as Medical Identity Theft. Medicare numbers are linked to a Social Security number of someone of either themselves or a spouse who qualified for benefits. They cannot be changed. Once someone’s Medicare ID number has been compromised, their future benefits could be at risk.

Impact On Your Health

Receiving care from someone posing as a healthcare provider could be dangerous at best. These fraudulent providers will not provide quality care and their care could actually be harmful. If receive legitimate care from a physician after receiving care from a fraudulent provider, your new physician may treat you based on previous medical records that are inaccurate.

Additionally, since Medicare has limitations on some of their benefits, you could actually be denied the care that you need. They may think you have already received care that you did not and therefore limit your benefits based on false information.

Impact on Personal Finances

Fraud in Medicare and Medicaid costs all of us. They cost taxpayers unnecessary extra expenses. Fraud also causes higher co-pays and deductibles because Medicare bases those numbers on how much it pays out each year. If it is paying for fraudulent claims, that affects everyone using their services.

You could also find yourself stuck with bills that you don’t really owe. If a provider that should have billed Medicare instead bills the patient for the full cost, that causes an issue.

Lastly, as mentioned above, your Medicare claim number is tied to your or your spouse’s Social Security Number. Once a thief has that they can open credit and bank accounts in your name. Those numbers are of great value to thieves.

The Cost of Fraud

The Medicare program loses billions of dollars each year due to fraud, errors, and abuse. These are our tax dollars. In 2014, the National Health Care Anti-Fraud Association estimated these losses at $60 billion annually, though the exact figure is impossible to know. The most commonly cited range for all health care fraud estimates is 3 to 10 percent of annual health care expenditures. 2012 Medicare expenditures were nearly $600 billion and are expected to rise as the baby boomer population ages.

What Can You Do?

Make sure that you read over any notices you receive from Medicare. A Medicare Summary Notice is sent to those on original Medicare with a Medicare Supplement plan. Those on Medicare Advantage plans and Part D drug plans will receive an Explanation of Benefits (EOB). Check them carefully. If you don’t understand the information on there, have your Medicare agent help you.

These two types of notices will tell you:

• What the health care provider billed for
• The amount approved by Medicare for payment
• How much Medicare paid
• What the beneficiary may be billed for

Detect Potential Fraud, Errors, or Abuse

• Review your Medicare statements when you receive them. Be sure you actually received all of the services listed on the statement.
• Keep a written record of your healthcare visits including what services and tests were provided.
• Compare your written record to what is on the statement. If they don’t match up, contact your provider or insurance company to discuss discrepancies.
• You can see your most recent statements at the MyMedicare.gov website. You can also track your claims for up to three years and see if your provider has been paid on their site. Registration and use of this feature is free.

Conclusion

So you can see that the work of Senior Medicare Patrol is very important. We all owe those volunteers a huge pat on the back for their patriotic service to all of us in helping attack fraud and waste. If you would like to volunteer for this service, you can click here to contact your local office.