TN 9 (02-15)

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

Citations:

20 CFR 418.1150;

20 CFR 418.1201 through 20 CFR 418.1270;

20 CFR 418.1301 through 20 CFR 418.1355

A. Definition of new initial determination

A new initial determination is a new decision made by SSA. It does not require the reopening or revising of a prior determination. Only the income-related monthly adjustment amount (IRMAA) process uses new initial determinations.

We make IRMAA determinations based on information the IRS provides electronically. If the beneficiary wants SSA to use a more recent year's tax return information or information that is more accurate to make his or her IRMAA determination(s), he or she can request a new initial determination.

NOTE: If the data received electronically from IRS does not indicate that a beneficiary owes an IRMAA, we cannot impose an IRMAA using beneficiary provided data.

B. Policy for requesting a new initial determination

Some circumstances allow us to use the modified adjusted gross income (MAGI) information the beneficiary provides, rather than the information we receive from IRS to make a new initial determination of the IRMAA. See the circumstances listed in HI 01120.001D in this section.

  1. If the beneficiary meets the criteria for a new initial determination, there is no need to appeal the prior determination. For an overview of the appeals process for IRMAA, see HI 01140.001.

  2. In order for us to make a new initial determination of IRMAA, the beneficiary:

    • must have a qualifying circumstance; and

    • must request, either verbally or in writing, that we use other tax information.

NOTE: A beneficiary can file an appeal and request a new initial determination at the same time, if filed within the appeals period.

A request for a new initial determination applies only to the beneficiary requesting it. If a beneficiary requests a new initial determination and provides information that could affect a spouse or ex-spouse, we do not extend its findings to the non-reporting spouse or ex-spouse. It is the responsibility of the affected beneficiary to contact us.

If a beneficiary has a representative payee, the beneficiary or the payee can request a new initial determination on the beneficiary's behalf.

C. Timeframes for requesting a new initial determination

The allowable timeframes to request a new initial determination differ depending on the type of information the beneficiary reports. The beneficiary must file a request for a new initial determination within the appropriate timeframes listed in HI 01120.005, HI 01120.045 through HI 01120.060. If we can establish good cause, a request filed outside of the allowable timeframes is acceptable. For instructions on developing good cause, see GN 03101.020.

A new initial determination is a new decision we make that does not require reopening or revising a prior initial determination during a specified period. Only the IRMAA process uses new initial determinations.

D. Circumstances for allowing a new initial determination

The following chart provides references on circumstances allowing new initial determinations:

Life Changing Event (LCE)

See HI 01120.005.

Amended Tax Return Filed with the IRS

See HI 01120.045.

Correction of IRS Information

See HI 01120.050.

Use of two-year-old tax return when we use IRS information from three years prior to the premium year

See HI 01120.055.

Report of a change in Living Arrangement when Tax Filing status is “Married Filing Separately”

See HI 01120.060.

E. Procedure for service representative (SR) or 800 number agent for new initial determination requests

The following chart provides guidance on how to resolve the beneficiary’s concerns for new initial determination requests:

Determine the Reason for the Contact—SR, 800-Number Agent, or Receptionist

If…

Then…

Why…

the beneficiary alleges a life changing event (LCE) that affects MAGI, the qualifying LCEs are:

  • Death of Spouse;

  • Marriage;

  • Divorce or annulment;

  • Work Reduction;

  • Work Stoppage;

  • Loss of income-producing property;

  • Loss of employer pension income; or

  • Receipt of an employer payment

800-Number Agents:

Set up an appointment with the servicing field office.

If the beneficiary does not want to go into the office and is only reporting a life-changing event, the SSA-44, Medicare Income-Related Monthly Adjustment Amount – Life Changing Event is available online at

Internet: http://www.ssa.gov/online/ssa-44.pdf

The SSA-44 is only for beneficiaries wishing to request a new initial determination, based on a valid LCE; use of the form is optional.

SRs:

  • Refer to or make an appointment with a claims representative (CR).

  • Advise the beneficiary that we need evidence of both the LCE and the more recent tax year's MAGI submitted, per HI 01120.005 through HI 01120.043.

NOTE: If the beneficiary has not filed a tax return for the most recent tax year, we need a statement from the beneficiary estimating the MAGI.

If the result of the LCE is a significant reduction of MAGI or a change in tax filing status that results in the use of a lower threshold table, the beneficiary can qualify for a new initial determination.

the beneficiary alleges amending the tax return for the tax year we use to establish IRMAA

800-Number Agents:

Set up an appointment with the servicing field office.

SRs:

  1. Refer to or make an appointment with a CR.

  2. Advise the beneficiary to provide:

    • the amended return, and

    • a letter from IRS acknowledging receipt of the amended tax return. If the beneficiary does not have a letter, he or she can get a transcript of the amended tax return from IRS.

The beneficiary may be eligible for a new initial determination. For the policy on using an amended tax return, see HI 01120.045A.1.

the beneficiary states that IRS made an error in the tax year we use to establish IRMAA

NOTE: If the beneficiary alleges error in tax-exempt interest income, see HI 01120.050F.

ask the beneficiary if he or she contacted IRS about the error:

  • If no, then provide the beneficiary with the number to IRS, 1-800-829-1040, to request a correction. Advise the beneficiary to recontact us after he or she receives a letter from IRS about the correction.

  • If yes and the beneficiary has proof from IRS about the correction:

800-Number Agents:

Set up an appointment with the servicing field office.

SRs:

Refer to or make an appointment with a CR.

NOTE: If the beneficiary already contacted IRS and lacks IRS documentation, advise the beneficiary that we need to see the documentation from IRS before we can fully process the request.

It is the beneficiary’s responsibility to contact IRS for a correction of IRS information. A beneficiary must provide us with documentation of an IRS correction before we can make a new initial determination.

we use three-year-old tax information to establish IRMAA and the beneficiary filed a tax return for two years before the premium year, or alleges he or she did not have to file a tax return for that tax year

800 Number Agents:

Set up an appointment with the servicing field office.

SRs:

Refer to or make an appointment with a CR.

Both 800 Number Agents and SRs:

If the beneficiary filed a tax return for the tax year two years before the premium year, advise the beneficiary that he or she must provide the signed two-year-old tax return or similar proof (such as a transcript), and submit the proof from IRS in order for us to complete his or her request.

NOTE: If a beneficiary alleges electronic filing, ask the beneficiary to print and sign a copy of the electronic return.

The beneficiary may be eligible for a new initial determination. For information on using old tax data, see HI 01120.055A.

the beneficiary states that the tax return for the tax year we use to establish IRMAA is based on the status of “Married Filing Separately”, but he or she did not live with his or her spouse at all during that tax year

800 Number Agents:

Set up an appointment with the servicing field office.

SRs:

Refer to or make an appointment with a CR.

Both 800 Number Agents and SRs:

Advise the beneficiary that he or she must provide a copy of IRS Form 1040, or attest under penalty of perjury that he or she did not live with his or her spouse at all during that tax year, and provide the last known address of the spouse. For acceptable documentation on IRS Form 1040, see HI 01120.060B.

The beneficiary may be eligible for a new initial determination. For information on married, filing separately when the beneficiary did not live with his or her spouse all year, see HI 01120.060.

F. Determining if a request is for a new initial determination or an appeal and how to handle the request

The field office processes most new initial determination and reconsideration requests. Occasionally, the PC may receive a request from a beneficiary directly or from the field office because a processing limitation occurred. The PC is responsible for processing all requests received. When a field office or PC receives a request for a new initial determination, take the following actions:

  1. Determine if any actions are currently pending;

  2. Determine if an action has been taken but a processing limitation has occurred,

    NOTE: If a processing limitation exists, the PC must process a manual action. The FO will not be able to process the request to completion. DO NOT make multiple inputs in POS if the first input does not process in 48 hours. Review the THIS Query for a possible T2R exception that will require PC manual action.

  3. Check and review the IRMAA Appeals Tracking System to determine if an appeal is pending;

  4. If an appeal is pending, review the information in the Appeals Tracking System to determine if the NEW INITIAL DETERMINATION request is for the same premium year as the appeal.

    1. If the premium year is the same, see HI 01120.001I, in this section, for processing instructions.

    2. If there is no appeal pending or there is a different premium year involved, process the request as explained in HI 01120.005 through HI 01120.060.

    NOTE: If a beneficiary has a representative payee, the beneficiary or the representative payee can request a new initial determination on the beneficiary's behalf.

    The following chart provides guidance for handling requests for new initial determinations:

    If…

    Then…

    Why…

    the beneficiary alleges a life-changing event causing a significant reduction in modified adjusted gross income (MAGI)

    • treat as a request for a new initial determination.

    • do not take a request for an appeal unless the beneficiary insists. (For information on appeals, see HI 01140.001).

    • follow the instructions on life changing events (LCE) in HI 01120.005 through HI 01120.043.

    We can use certain events to make a new determination without filing an appeal.

    NOTE: A beneficiary can file an appeal and request a new initial determination at the same time.

    the beneficiary alleges there is an amended tax return for the tax year that we use to determine the IRMAA

    • treat as a request for a new initial determination.

    • do not take a request for an appeal unless the beneficiary insists (For information on appeals, see HI 01140.001).

    • follow instructions on using amended income tax returns in HI 01120.045.

    We can use an amended tax return to make a new determination without filing an appeal.

    NOTE: A beneficiary can file an appeal and request a new initial determination at the same time.

    the beneficiary alleges there is corrected IRS information for the tax year that we use to determine the IRMAA

    • treat as a request for a new initial determination.

    • do not take a request for an appeal unless the beneficiary insists. (For information on appeals, see HI 01140.001).

    • follow instructions on using corrected IRS tax data in HI 01120.050.

    We can use corrected IRS tax information to make a new determination without filing an appeal.

    NOTE: A beneficiary can file an appeal and request a new initial determination at the same time.

    the beneficiary alleges there is a copy of a tax return from two years before the premium year and we use three-year-old information to set IRMAA or alleges he or she did not have to file taxes for that tax year

    • treat as a request for a new initial determination.

    • do not take a request for an appeal unless the beneficiary insists. (For information on appeals, see HI 01140.001).

    • follow instructions on using old tax data in HI 01120.055.

    We can use certain events to make a new determination without filing an appeal.

    NOTE: A beneficiary can file an appeal and request a new initial determination at the same time.

    the beneficiary alleges filing a tax return for the tax year we use to establish IRMAA as “Married Filing Separately” and did not live with his or her spouse at all during that tax year

    • treat as a request for a new initial determination.

    • do not take a request for an appeal unless the beneficiary insists. (For information on appeals, see HI 01140.001).

    • follow instruction on married, filing separately when the beneficiary did not live with his or her spouse all year in HI 01120.060.

    We can use certain events to make a new determination without filing an appeal.

    NOTE: A beneficiary can file an appeal and request a new initial determination at the same time.

G. Processing a request for a new initial determination when evidence is not readily available

All requests for a new initial determination require that the beneficiary provide evidence of a life-changing event (LCE) and more recent or accurate tax information. In some situations, the beneficiary can provide estimates of tax information pending the submission of evidence.

NOTE: If the PC receives a request directly from the beneficiary, or erroneously from the FO, the PC will process the request using the following instructions. Do not transfer the case to the FO.

If…

Then…

a beneficiary requests a new initial determination, but does not have evidence readily available

Access the IRMAA screens (See screen details in MSOM T2PE 008.001 through MSOM T2PE 008.019).

  1. On the IRMN screen:

    • Enter the beneficiary's own SSN.

    • In the “Select the Desired Option” field, select “1” Establish.

    • Input the Premium Year applying to the new initial determination.

    • In the “Select the Desired Function” field, select “1” Life Changing Event or “2” Tax Information.

    • Input the Tax Year the beneficiary requests we use to determine the IRMAA.

    • Press Enter.

      If the PYTY screen appears, there is data on file for the tax year requested and it displays under the “Highest Probative Value Data” Field. (For an explanation of Highest Probative see MSOM T2PE 008.019.)

    • If you select “1”, use the highest probative value, the system will process the determination using the data on file. Note: The data also propagates to the IRMA screen.

    • If you select “2” New Tax Data, the system will process the determination using the new information provided, as long as the value of the data is of higher value than the information on file. See MSOM T2PE 008.019.

    • Press Enter.

  2. On the IRLC screen (if an LCE is involved):

    • In the “Select Life Changing Event” field, select the appropriate Event “1” through “7”.

    • In the “Date of LCE” field, enter the date of the LCE that the beneficiary is claiming.

    • If we require proof of the LCE and a beneficiary statement is not sufficient and the proof is not available, use the allegation of the beneficiary. Show proof as “PENDING.”

    • In the “Remarks” field, document any information related to the LCE or leave blank.

    • Press Enter.

  3. On the IRMA screen:

    • Input the beneficiary's alleged adjusted gross income and tax-exempt income for the tax year the beneficiary is requesting to use. NOTE: If you select “1,” Use Highest Probative Data on the PYTY, the tax data propagates into this field and you cannot change it.

    • On the “Select Type” field, select the appropriate tax source, based on the information the beneficiary provides. See MSOM T2PE 008.005.

    • On the “Select Filing Status” field, enter the appropriate filing status for the beneficiary.

    • On the “Select Proof” field, select “1” Proven. If proof of the tax information is required and proof is not available, show proof as “PENDING.”

    • Press Enter.

Inform the beneficiary that you will dismiss the new initial determination if he or she does not provide the required evidence within 30 days.

 
  • If the beneficiary is unable to submit the documents immediately, or if he or she requests a formal notice of our request, send the DPS notice, “IRMAA Request For Information” informing the beneficiary of all documents needed and the timeframe in which to return them.

    NOTE: PCs send the AURORA exhibit notice E4008

  • Prepare a 15-day follow-up tickle or Processing Center Action Control System (PCACS) diary using TOEL1/TOEL2=MEDACT IRMAA.

after 15 days have passed from the date the beneficiary requested a new initial determination and you have not received the necessary evidence

  • Query the Master Beneficiary Record (MBR), Evidence (EVID), and IRMAA screens for any updated activity, as it is possible that another office received the required evidence and completed the IRMAA action.

  • If another office completed the action, cancel any outstanding tickles or PCACS diaries.

  • If there has been no update activity, contact the beneficiary to remind him or her of the time remaining and the evidence needed to process the new initial determination. If unable to contact the beneficiary by phone, send the DPS “IRMAA Request For Information” notice and include the closeout paragraph with the request for evidence.

  • Prepare another 15-day tickle or PCACS diary (or 90 days if the beneficiary requests additional time to provide proof).

after 30 days have passed from the date the beneficiary requests a new initial determination (or 90 days if the beneficiary requests additional time to provide proof) and you have not received the necessary evidence or the evidence submitted is insufficient

  • Query the MBR, EVID, and IRMAA screens for any updates, as it is possible that another SSA office received the required evidence and completed the IRMAA action.

  • Access the IRMAA screens to change the proof from “PENDING” to “NOT PROVEN.” (See screen details in MSOM T2PE 008.001 through MSOM T2PE 008.019).

  • Process the dismissal on the IRMAA Results (IRRE) screen. The system automatically sends the dismissal notice.

NOTE: If a beneficiary has not provided the required proof within the 30 days and he or she re-contacts us to request additional time to provide the proof, advise him or her that we may grant a 90-day extension. If you do not receive proof within the additional 90 days, process as a dismissal.

the beneficiary provides the requested proof

  • Query the MBR, EVID, and IRMAA screens for any updates, as it is possible that another SSA office received the required evidence and completed the IRMAA action.

  • Access the IRMAA screens to change the proof from “PENDING” to “PROVEN.” (See screen details in MSOM T2PE 008.001 through MSOM T2PE 008.019).

  • The IRRE Screen displays the current and recalculated IRMAA data. The “New Determination Results” field provides the new initial determination based on the information entered.

  • The IRMN Screen displays an alert to go to the EVID screen to document proofs submitted for the event reported. Pressing any “PF” key or the “Enter” key from the IRMN screen takes you to the Shared Processes Menu.

H. Procedure for recording evidence submitted for a new initial determination request

You must record all evidence submitted with a new initial determination request on the EVID screen of Shared Processes (Selection Number 4 on the SSA Main Menu). Pressing any PF key or the “Enter” key from the IRMN screen takes you to the Shared Processes Menu.

NOTE: If we receive an SSA-44 (Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event) to report an LCE, destroy the form once you document all the information from the form on the IRMAA screens and document all evidence received regarding the LCE on the EVID screen in Shared Processes. For instructions on how to complete the IRMAA screens and document the EVID screen, follow HI 01120.005 through HI 01120.043.

Once you record all information in the IRMAA system, and you properly document the EVID screens, you may destroy all SSA-795s (Statement of Claimant or other person), related to the IRMAA, containing information documented on the IRMAA screens and in the EVID screen in Shared Processes. This includes an SSA-795 providing an income estimate or stating the beneficiary did not have to file a tax return.

If…

Then…

the evidence submitted is for:

  • Death;

  • Marriage; or

  • Divorce or annulment

follow instructions in GN 00301.286 through GN 00301.300 and MSOM EVID 001.003.

the evidence submitted is for proof of work reduction

see HI 01120.025.

the evidence submitted is for proof of work stoppage

see HI 01120.030.

the evidence submitted is for proof of loss of income-producing property

see HI 01120.035.

the evidence submitted is for proof of loss of employer pension income

see HI 01120.040.

the evidence submitted is for proof of an employer settlement payment

see HI 01120.043.

the beneficiary claims to have an amended tax return for the tax year that SSA is using to determine the IRMAA

see HI 01120.045.

he beneficiary claims to have corrected IRS information for the tax year that SSA is using to determine the IRMAA

see HI 01120.050.

the beneficiary claims to have a copy of a tax return from two years before the premium year or alleges he or she was not required to file a tax return for the tax year two years before the premium year and we used three-year-old information to set IRMAA

see HI 01120.055.

the beneficiary alleges having filed a tax return for the tax year SSA is using to establish his or her IRMAA, as “Married Filing Separately” and did not live with his or her spouse at all during that tax year

see HI 01120.060.

I. Processing a new initial determination when an appeal is pending

If an appeal is pending and you receive a new initial determination request for the same premium year, you must evaluate all the information received and determine if the information will or will not change the current IRMAA determination. To evaluate the MAGI information, use the IRMAA calculator in MSOM T2PE 008.013.

NOTE: If an appeal is pending with the Department of Health and Human Services (DHHS), you should immediately review the new initial determination request when you receive it. If you are not able to review the new initial determination request the same day you receive it, send an MDW to the Southeastern Program Service Center (SEPSC), FO C34 with “IRMAA HEAR” as the issue. Document the Remarks with the fact that you received a new initial determination request and an appeal is currently pending with DHHS for the same Premium Year.

If…

Then…

you receive a new initial determination request, with supporting evidence and a reconsideration is pending in the same or another SSA office, for the same premium year

  • do not process the new initial determination request.

  • inform the beneficiary that we will send the new information he or she provides to the office that currently has the appeal pending for the same premium year.

  • document the EVID screens in Shared Processes with any information the beneficiary provided for the new initial determination.

  • attach a route slip to the evidence stating “New Initial Determination Request, Recon Pending Same PY. Associate with IRMAA reconsideration filed mm/dd/yy” and forward to the appropriate office.

  • send an e-mail to the mailbox of the office with the pending appeal and advise that you received a new initial determination request and mailed it on mm/dd/yy. Include the name and SSN of the beneficiary.

  • if the appeal is pending in the same office, provide the new and material evidence to the technician with the pending reconsideration determination.

the new initial determination request does not change the current IRMAA determination and the Department of Health and Human Services' Office of Medicare Hearings and Appeals (OMHA) has an appeal pending

  • process the new initial determination as a dismissal as described in HI 01120.005 through HI 01120.060.

  • send an MDW to SEPSC (FO C34).

  • show the ISSUE as “IRMAA HEAR.”

  • document the REMARKS with a statement that you received and dismissed a new initial determination request for the same premium year as the current pending appeal, and give a reason for the dismissal.

  • record the evidence submitted on the EVID screen in Shared Processes. (For instructions on completing evidence screens, see GN 00301.286 through GN 00301.300 and MSOM EVID 001.003.)

the new initial determination request results in a change of the current IRMAA determination and the pending appeal is OMHA jurisdiction

  • do not process the request.

  • send an MDW to SEPSC FO C34.

  • show the ISSUE as “IRMAA HEAR.”

  • document the REMARKS with a statement that you received a new initial determination request. Advise that the new information changes the IRMAA determination and an appeal is pending with OMHA.

  • annotate that you are sending the new initial determination request to SEPSC.

  • send the new initial determination request to:

    Southeastern Program Service Center
    P.O. Box 12247
    Birmingham, AL 35202.

The new initial determination request will not change the current IRMAA determination and the pending appeal is Medicare Appeals Council (MAC) jurisdiction.

  • process a dismissal for the new initial determination as described in HI 01120.005 through HI 01120.060.

  • send an MDW to SEPSC FO C34.

  • show the ISSUE as “IRMAA MAC.”

  • document the REMARKS with a statement that you received and dismissed a new initial determination request for the same premium year as the current pending appeal, and give a reason for the dismissal.

  • record the evidence submitted on the EVID screen in Shared Processes (For instructions on completing evidence screens, see GN 00301.286 through GN 00301.300 and MSOM EVID 001.003).

The new initial determination request will result in a change of the current IRMAA determination and the pending appeal is MAC jurisdiction.

  • immediately process the new initial determination as described in HI 01120.005 through HI 01120.060.

  • send an MDW to SEPSC FO C34.

  • show the ISSUE as “IRMAA MAC”.

  • document the REMARKS with a statement that you received and processed a new initia