TN 5 (02-15)

HI 01140.001 Overview of the Appeals Process for the Income-Related Monthly Adjustment Amount

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.

If a beneficiary….

then…

disagrees with the planned action as stated in the predetermination notice and alleges:

  • a life-changing event (LCE),

  • an amended tax return or corrected tax information for the tax year being used,

  • PY-2 (rather than PY-3) tax information, or

  • a tax filing status of married filing separately, living apart for the entire tax year stated in the predetermination notice;

  • Access the Online Retrieval System (ORS) to verify that the notice received is in fact a predetermination notice.

  • Inform the beneficiary that an appeal may not be the appropriate action at this time.

  • Advise the beneficiary that a new initial determination may be applicable. If the beneficiary agrees to file a request for a new initial determination, follow the instructions in HI 01120.001E.

disagrees with the planned action as stated in the predetermination notice and insists on filing an appeal;

  • Access the Online Retrieval System (ORS) to verify that the notice is in fact a predetermination notice.

  • Inform the beneficiary that an appeal may not be the appropriate action at this time.

  • Advise the beneficiary that a new initial determination may be applicable. If the beneficiary agrees to filing a request for a new initial determination, follow the instructions in HI 01120.001E.

  • If the beneficiary insists on filing an appeal, follow the instructions listed in HI 01140.001E in this section.

disagrees with the constitutional legality of charging IRMAA;

the beneficiary should file an appeal. For information on the IRMAA reconsideration process, see HI 01140.005C through HI 01140.005E.

disagrees with the information IRS provided to SSA;

inform the beneficiary he or she can file a request for a new initial determination if he or she has proof of the error, or if he or she filed an amended tax return for the tax year imposing IRMAA. For information on using corrected and amended tax returns, see HI 01120.045 and HI 01120.050.

  • If he or she has the required proof, process a request for a new initial determination, per HI 01120.001E, or

  • Advise the beneficiary to contact IRS at 1-800-829-1040, if he or she does not have the required proof.

Emphasize to the beneficiary that he or she is responsible for contacting SSA with proof of the IRS correction once he or she receives it and needs to provide a receipt or letter that the IRS accepted an amended return.

If the beneficiary still insists on filing an appeal, see HI 01140.001E in this section

wants SSA to use a more recent tax year based on an LCE or different tax information;

advise the beneficiary of his or her option to file a request for a new initial determination instead of filing an appeal. For information on new initial determinations regarding IRMAA, see HI 01120.001.

If after explaining the new initial determination process the beneficiary insists on filing an appeal, see HI 01140.001E in this section.

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.

If…

then…

a beneficiary states:

  • he or she does not agree with the decision or a proposed action,

  • no appeal is pending, and

  • he or she wants to file a reconsideration of his or her IRMAA determination;

N8NN Agents:

  • Do not refer the caller to the WSU.

  • Send Form SSA-561-U2 (Request for Reconsideration) with a courtesy return envelope addressed to the local servicing field office (FO). Inform the beneficiary of the proofs required and request that he or she submit the required proofs with the appeal request.

  • For evidence requirements for individuals appealing based on a life changing event, amended, corrected or more recent tax return information, or a living arrangement change with a tax filing status of married filing separately, see HI 01120.001 through HI 01120.060. If the beneficiary indicates he or she needs help completing the forms, schedule an appointment using the post-entitlement appointment calendar.

SRs and Public Contact Employees:

  • Refer the beneficiary to a Claims Representative (CR).

  • If the beneficiary is not able to take care of the action immediately, provide the beneficiary with Form SSA-561-U2 with a courtesy return envelope addressed to the field office. Inform the beneficiary of the proofs required and request him or her to submit the required proofs with the appeal request. When returned, a CR processes the completed form. If the beneficiary indicates he or she needs help completing the forms, schedule an appointment using the post-entitlement appointment calendar.

NOTE: Someone other than the person who made the original decision will process the reconsideration request.

a beneficiary states he or she does not agree with the decision made on his or her reconsideration regarding his or her IRMAA;

800 Number Agents:

Send the beneficiary Form HA-501-U5 (Request for Hearing by an Administrative Law Judge) and a courtesy return envelope addressed to:

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

If the beneficiary indicates that he or she needs help completing the form, schedule an appointment with the servicing FO using the post-entitlement appointment calendar.

SRs and Public Contact Employees:

  • Refer the beneficiary to a CR for completion of the HA-501-U5.

  • If the beneficiary is not able to take care of the action immediately, provide the beneficiary with Form HA-501-U5 and a courtesy return envelope addressed to:

    Southeastern Program Service Center
    P O Box 12247
    Birmingham, AL 35202
  • If the beneficiary indicates that he or she needs help completing the form, schedule an appointment with the servicing FO using the post-entitlement appointment calendar.

the beneficiary states he or she does not agree with the decision made on his or her hearing regarding his or her IRMAA;

Explain to the individual that SSA has no role in the review of DHHS ALJ decisions and he or she should follow the instructions in the ALJ's notice regarding further appeals. If the beneficiary states that he or she does not have his or her notice, advise the beneficiary to contact the Departmental Appeals Board (DAB) Medicare Operations Division (MOD) at (866 ) 365-8204 or (202) 565-0100.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0601140001
HI 01140.001 - Overview of the Appeals Process for the Income-Related Monthly Adjustment Amount - 02/04/2015
Batch run: 02/04/2015
Rev:02/04/2015