TN 5 (02-15)

Citations:

20 CFR 418.1301 - 20 CFR 418.1355

A. Policy for requesting an appeal of an IRMAA determination

SSA uses information from the Internal Revenue Service (IRS) to make an initial determination regarding a beneficiary's Income-Related Monthly Adjustment Amount (IRMAA) based on Modified Adjusted Gross Income (MAGI) data and tax filing status for a specific year. SSA also uses information that the beneficiary provides to support or update a request for an appeal or a new initial determination.

Initially, when SSA makes an IRMAA determination, we send the beneficiary a notice. This notice informs the beneficiary of the determination and his or her appeal rights. This notice also provides information about what a beneficiary should do if he or she has other information about his or her income or if his or her circumstances have changed.

If a beneficiary has Medicare Part B or Medicare prescription drug coverage only and enrolls in the other program later in the same premium year, we apply the initial IRMAA determination to the other program. SSA sends a notice informing the beneficiary of the change in his or her benefit and of his or her appeal rights.

NOTE: A predetermination notice is not a notice of determination and does not contain appeal rights. It is a notice of planned action. A beneficiary who disagrees with the planned action may request a new initial determination under certain circumstances.

If the beneficiary insists on filing an appeal based on a predetermination notice, we must accept his or her appeal request.

See Also:

• HI 01101.010 Modified Adjusted Gross Income (MAGI)

• HI 01120.001 Overview of New Initial Determinations on the Income-Related Monthly Adjustment Amount (IRMAA) Using Beneficiary Provided Information

• HI 01140.001D in this section, Appeals processing procedures for service representatives (SR) and 800 number agents (N8NN)

• HI 01140.005 The Reconsideration Process for Income-Related Monthly Adjustment Amount (IRMAA)

B. When and who can file an appeal request

A beneficiary or the beneficiary’s representative can file a request for reconsideration within 60 days of receipt of an IRMAA determination notice. “Date Received” means 5 days after the date on the notice unless the individual shows that he or she did not receive it within the 5-day period. For information on when to request a reconsideration, see GN 03102.100C.

For requests received outside of the allowable timeframe, SSA or the Department of Health and Human Services (DHHS) (for appeals beyond the reconsideration) determines whether to establish good cause for late filing. For instructions on developing good cause, see GN 03101.020.

NOTE: A dismissal of a request for an appeal or a new initial determination is not a determination subject to further administrative or judicial review. A dismissal of a new initial determination request may be a basis for good cause for late filing of an appeal request. For the policy on the reconsideration process for IRMAA, see HI 01140.005A.

NOTE: If a beneficiary has a representative payee, the payee can request reconsideration on the beneficiary’s behalf. When a payee is involved, be sure to check the MBR to verify the person making the request is the correct representative payee for the beneficiary. 

Document the Remarks field on the IRMA (Tax Information) screen with a statement showing the representative payee's information as follows: representative payee name for beneficiary's name. 

The beneficiary, the legal guardian, the parent of a minor child who is a beneficiary, or the legal executor of the estate of the beneficiary may request an appeal beyond the reconsideration using the HA-501-U5 (Request for Hearing by Administrative Law Judge). For the policy on the hearing process for IRMAA, see HI 01140.010A.

See Also:

GN 03910.001 Representation of Claimants – Overview

C. Levels of IRMAA appeals and where they are processed

The four levels of IRMAA appeals:

1. A reconsideration which is processed by the Field Office (see GN 03102.175B.1.) or Processing Center (see note in GN 03102.175B.2.);

2. A Hearing before a Department of Health and Human Services (DHHS) Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals (OMHA) see GN 03101.150;

3. A review by the DHHS Medicare Appeals Council (MAC); and

4. Federal Court Action.

D. Appeals processing procedures for service representatives (SR) and 800 number agents (N8NN)

Appeal vs. New Initial Determination

When trying to determine the appropriate review process, remember that filing an appeal on an IRMAA determination is not always necessary. A beneficiary disagreeing with the IRMAA determination does not always mean there is a request for an appeal. For example, if a beneficiary disagrees with SSA using PY-3 (tax information from three years before the premium year) and requests that SSA use PY-2 based on information he or she provides, that request for change does not mean he or she is requesting an appeal. A new initial determination could provide the beneficiary with the desired result. If the beneficiary does not insist on filing an appeal and it appears that a new initial determination is appropriate, see HI 01120.001.

NOTE: A beneficiary can file an appeal of the IRMAA determination and file a request for a new initial determination at the same time. However, in most situations, a new initial determination can provide the beneficiary with the same results as an appeal (i.e., a change in the IRMAA), so an appeal is not necessary.

If a beneficiary is outside of the appeal period and presents information that may qualify him or her for a new initial determination, explain the new initial determination process and if the beneficiary agrees, refer to a CR to process a new initial determination, per HI 01120.001.

NOTE: A beneficiary can file an appeal of the IRMAA determination and file a request for a new initial determination at the same time. However, in most situations, a new initial determination can provide the beneficiary with the same results as an appeal (i.e., a change in the IRMAA), so an appeal is not necessary.

E. Process for SRs and N8NN agents or public contact employees to determine the level of appeal and the appropriate referral procedures

Review the IRMAA Appeals Tracking System at: http://irmaa.bi.ssa.gov and query the beneficiary’s SSN to determine if an appeal is pending. If an appeal is pending, advise the beneficiary of the status and if necessary, what actions he or she must take (contact DHHS, file next level of appeal if applicable). For appeals status information, see HI 01140.020.

If no appeal is pending, follow the chart to determine the proper level of appeal.