The Department of Health and Human Services’ (DHHS) Administrative Law Judges (ALJs)
conduct all hearings in the Office of Medicare Hearings and Appeals (OMHA). The beneficiary
(or legal guardian or parent of a minor) who wishes to appeal an income-related monthly
adjustment amount (IRMAA) determination must complete the Form HA-501-U5 (Request
for Hearing by Administrative Law Judge).
NOTE: Changes in IRS law grants SSA authorization to disclose information that we receive
from IRS and that we use to make an IRMAA determination to OMHA ALJs and to the Medicare
Appeals Council (MAC). There is no longer any form other than an HA-501-U5 needed
for an appeal past the reconsideration level unless there is a representative involved
with the appeal. If a beneficiary has a representative for an IRMAA appeal higher
than the reconsideration level, DHHS requires an additional form:
DHHS requires Form CMS-1696 (Appointment of Representative) for all appeals when a
representative payee is involved. If a beneficiary or representative contacts SSA
to request Form CMS-1696, inform the caller they may request the form from the Medicare
toll-free number (1-800-633-4227), (TTY or TDD 1-877-486-2048), or downloaded and
printed from: CMS-1696.