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| section_id ▼ | title_number | title_name | chapter | subchapter | part_number | part_name | subpart | subpart_name | section_number | section_heading | agency | authority | source_citation | amendment_citations | full_text |
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| 20:20:2.0.1.1.10.2.468.1 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1001 What is this subpart about? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 78 FR 57259, Sept. 18, 2013; 83 FR 55628, Nov. 7, 2018] | This subpart relates to section 1839(i) of the Social Security Act (the Act), as amended. Section 1839(i) establishes an income-related monthly adjustment to the Medicare Part B premium. Beneficiaries enrolled in Medicare Part B who have modified adjusted gross income over a threshold amount established in the statute will pay an income-related monthly adjustment amount in addition to the Medicare Part B standard monthly premium and any applicable premium increases as described in 42 CFR 408.20. The regulations in this subpart explain how we decide whether you are required to pay an income-related monthly adjustment amount, and if you are, the amount of your adjustment. The rules are divided into the following groups of sections: (a) Sections 418.1001 through 418.1010 contain the introduction, a statement of the general purpose of the income-related monthly adjustment amount, general provisions that apply to the income-related monthly adjustment amount, and definitions of terms that we use in this subpart. (b) Sections 418.1101 through 418.1150 describe what information about your modified adjusted gross income we will use to determine if you are required to pay an income-related monthly adjustment amount. In these sections, we also describe how the income-related monthly adjustment amount will affect your total Medicare Part B premium. (c) Sections 418.1201 through 418.1270 contain an explanation of the standards that you must meet for us to grant your request to use modified adjusted gross income information that you provide for a more recent tax year rather than the information described in paragraph (b) of this section. These sections explain when we may consider such a request, and the evidence that you will be required to provide. These sections also explain when income-related monthly adjustment amount determinations based on information you provide will be effective, and how long they will remain in effect. Additionally, these sections describe how retroactive adjustments of the income-related monthly … | ||||
| 20:20:2.0.1.1.10.2.468.2 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1005 Purpose and administration. | SSA | (a) The purpose of the income-related monthly adjustment amount is to reduce the Federal subsidy of the Medicare Part B program for beneficiaries with modified adjusted gross income above an established threshold. These beneficiaries will pay a greater share of actual program costs. Medicare Part B premiums paid by beneficiaries cover approximately 25 percent of total Medicare Part B program costs and the remaining 75 percent of program costs are subsidized by the Federal Government's contributions to the Federal Supplementary Medical Insurance Trust Fund. The reduction in the Medicare Part B premium subsidy results in an increase in the total amount that affected beneficiaries pay for Medicare Part B coverage. A beneficiary with modified adjusted gross income above the threshold amount will pay: (1) The Medicare Part B standard monthly premium; plus (2) Any applicable increase in the standard monthly premium for late enrollment or reenrollment; plus (3) An income-related monthly adjustment amount. (b) The Centers for Medicare & Medicaid Services (CMS) in the Department of Health and Human Services (HHS) publishes the Medicare Part B standard monthly premium each year. CMS also establishes rules for entitlement to a nonstandard premium, as well as premium penalties for late enrollment or reenrollment (42 CFR 408.20 through 408.27). (c) We use information that we get from IRS to determine if beneficiaries who are enrolled in Medicare Part B are required to pay an income-related monthly adjustment amount. We also change income-related monthly adjustment amount determinations using information provided by a beneficiary under certain circumstances. In addition, we notify beneficiaries when the social security benefit amounts they receive will change based on our income-related monthly adjustment amount determination. | |||||
| 20:20:2.0.1.1.10.2.468.3 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1010 Definitions. | SSA | (a) Terms relating to the Act and regulations. For the purposes of this subpart: (1) Administrator means the Administrator of the Centers for Medicare & Medicaid Services (CMS) in HHS. (2) CMS means the Centers for Medicare & Medicaid Services in HHS. (3) Commissioner means the Commissioner of Social Security. (4) HHS means the Department of Health and Human Services which oversees the Centers for Medicare & Medicaid Services, the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (MAC). (5) IRS means the Internal Revenue Service in the Department of the Treasury. (6) MAC means the Medicare Appeals Council in HHS. (7) OMHA means the Office of Medicare Hearings and Appeals in HHS. (8) Section means a section of the regulations in this part unless the context indicates otherwise. (9) The Act means the Social Security Act, as amended. (10) Title means a title of the Act. (11) We, our, or us means the Social Security Administration (SSA). (b) Miscellaneous. For the purposes of this subpart: (1) Amended tax return means a Federal income tax return for which an amended tax return using the required IRS form(s) has been filed by an individual or couple and accepted by IRS. (2) Effective year means the calendar year for which we make an income-related monthly adjustment amount determination. (3) Federal premium subsidy is the portion of the full cost of providing Medicare Part B coverage that is paid by the Federal Government through transfers into the Federal Supplementary Medical Insurance Trust Fund. (4) Income-related monthly adjustment amount is an additional amount of premium that you will pay for Medicare Part B coverage if you have income above the threshold. The amount of your income-related monthly adjustment amount is based on your modified adjusted gross income. (5) Medicare Part B standard monthly premium means the monthly Medicare Part B premium amount which is set annually by CMS, according to regulations in 42 CFR 408.20 t… | |||||
| 20:20:2.0.1.1.10.2.469.10 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1130 [Reserved] | SSA | ||||||
| 20:20:2.0.1.1.10.2.469.11 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1135 What modified adjusted gross income information will we use to determine your income-related monthly adjustment amount? | SSA | (a) In general, we will use your modified adjusted gross income provided by IRS for the tax year 2 years prior to the effective year of the income-related monthly adjustment amount determination. Modified adjusted gross income is based on information you provide to IRS when you file your Federal income tax return. (b) We will use your modified adjusted gross income for the tax year 3 years prior to the effective year of the income-related monthly adjustment amount determination when IRS does not provide the information specified in paragraph (a) of this section. If IRS can provide modified adjusted gross income for the tax year 3 years prior to the income-related monthly adjustment amount effective year, we will temporarily use that information to determine your income-related monthly adjustment amount and make adjustments as described in § 418.1110(b) to all affected income-related monthly adjustment amounts when information for the year specified in paragraph (a) of this section is provided by IRS. (c) When we have used the information in paragraph (b) of this section, you may provide us with evidence of your modified adjusted gross income for the year in paragraph (a) of this section. You must provide a retained copy of your signed Federal income tax return for that year, if available. If you filed a return for that year, but did not retain a copy, you must request a transcript or a copy of your return from IRS and provide it to us. When we use this evidence, we will later confirm this information with IRS records. (d) When you meet the conditions specified in § 418.1150 because you have amended your Federal income tax return, or when you believe we have used information provided by IRS which is incorrect, as described in § 418.1335, we will use information that you provide directly to us regarding your modified adjusted gross income. (e) We may use information that you give us about your modified adjusted gross income for a more recent tax year than those discussed in paragraphs (a) or (b) of this section… | |||||
| 20:20:2.0.1.1.10.2.469.12 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1140 What will happen if the modified adjusted gross income information from IRS is different from the modified adjusted gross income information we used to determine your income-related monthly adjustment amount? | SSA | In general, we will use modified adjusted gross income information from IRS to determine your income-related monthly adjustment. We will make retroactive adjustments to your income-related monthly adjustment amount as described in paragraphs (a), (b), and (d) of this section. (a) When we have used modified adjusted gross income from the tax year 3 years prior to the effective year as described in § 418.1135(b), and IRS provides modified adjusted gross income information from the tax year 2 years prior to the effective year, we will use the new information to make an initial determination for the effective year. We will make retroactive adjustments back to January 1 of the effective year, or the first month you were enrolled or reenrolled in Medicare Part B if later than January. (b) When we have used the modified adjusted gross income information that you provided for the tax year 2 years prior to the effective year and the modified adjusted gross income information we receive from IRS for that same year is different from the information you provided, we will use the modified adjusted gross income information provided to us by IRS to make a new initial determination. We will make retroactive adjustments back to January 1 of the effective year, or the first month you were enrolled or reenrolled in Medicare Part B if later than January. (c) When we have used information from your amended Federal tax return that you provide, as explained in § 418.1150, or you provide proof that the information IRS provided to us is incorrect as described in § 418.1335, we will not make any adjustments to your income-related monthly adjustment amount for the effective year or years based on IRS information we receive later from IRS. (d) When we use modified adjusted gross income information that you provided due to a qualifying life-changing event and we receive different information from IRS, we will use the IRS information to make retroactive corrections to all months in the effective year(s) during which you were enrolled in M… | |||||
| 20:20:2.0.1.1.10.2.469.13 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1145 How do we determine your income-related monthly adjustment amount if IRS does not provide information about your modified adjusted gross income? | SSA | In general, if we do not receive any information for you from IRS showing that you had modified adjusted gross income above the threshold in the tax year we request, we will not make an income-related monthly adjustment amount determination. | |||||
| 20:20:2.0.1.1.10.2.469.14 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1150 When will we use your amended tax return filed with IRS? | SSA | You may provide your amended tax return for a tax year we used within 3 calendar years following the close of the tax year for which you filed the amended tax return. You must provide us with your retained copy of your amended U.S. Individual Income Tax Return on the required IRS form and a copy of the IRS letter confirming the amended tax return was filed or a transcript from IRS if they did not send a letter. If you cannot provide your retained copy of the amended tax return, you must obtain a copy of the return from IRS. We will then make any necessary retroactive corrections as defined in § 418.1110(c) to your income-related monthly adjustment amount. | |||||
| 20:20:2.0.1.1.10.2.469.4 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1101 What is the income-related monthly adjustment amount? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 78 FR 57259, Sept. 18, 2013] | (a) The income-related monthly adjustment amount is an amount that you will pay in addition to the Medicare Part B standard monthly premium plus any applicable increase in that premium as described in 42 CFR 408.22 for your Medicare Part B coverage when your modified adjusted gross income is above the threshold described in § 418.1105. (b) Your income-related monthly adjustment amount is based on your applicable modified adjusted gross income as described in § 418.1115 and your tax filing status. (c) We will determine your income-related monthly adjustment amount using the method described in § 418.1120. | ||||
| 20:20:2.0.1.1.10.2.469.5 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1105 What is the threshold? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 78 FR 57259, Sept. 18, 2013] | (a) The threshold is a level of modified adjusted gross income above which the beneficiary will have to pay the income-related monthly adjustment amount. (b) From January 1, 2011 through December 31, 2019, the modified adjusted gross income threshold is $170,000 for individuals with a Federal income tax filing status of married filing jointly. The threshold is $85,000 for individuals with any other filing status. (c) Starting on January 1, 2020, the threshold amounts will resume adjustment for inflation as required by section 1839(i)(5) of the Act. In each year thereafter, CMS will set all modified adjusted gross income threshold amounts for the following year by increasing the preceding year's threshold amounts by any percentage increase in the Consumer Price Index rounded to the nearest $1,000. CMS will publish the amounts in the Federal Register in September of each year. Published threshold amounts will be effective January 1 of the next calendar year, for the full calendar year. | ||||
| 20:20:2.0.1.1.10.2.469.6 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1110 What is the effective date of our initial determination about your income-related monthly adjustment amount? | SSA | (a) Generally, an income-related monthly adjustment amount will be effective for all months that you are enrolled in Medicare Part B during the year for which we determine you must pay an income-related monthly adjustment amount. We will follow the rules in 42 CFR part 408, subpart C, regarding premium collections to withhold your income-related monthly adjustment amount from a benefit payment or to determine if you will be billed directly. (b) When we have used modified adjusted gross income information from IRS for the tax year 3 years prior to the effective year to determine your income-related monthly adjustment amount and modified adjusted gross income information for the tax year 2 years prior later becomes available from IRS, we will review the new information to determine if we should revise our initial determination. If we revise our initial determination, the effective date of the new initial determination will be January 1 of the effective year, or the first month you were enrolled or re-enrolled in Medicare Part B if later than January. (c) When we use your amended tax return, as described in § 418.1150, the effective date will be January 1 of the year(s) that is affected, or the first month in that year that you were enrolled or reenrolled in Medicare Part B if later than January. (d) When we use evidence that you provide which proves that the IRS modified adjusted gross income information we used is incorrect, as described in § 418.1335, the effective date will be January of the year(s) that is affected or the first month in that year that you were enrolled or reenrolled in Medicare Part B if later than January. (e) When we use information from a more recent tax year that you provide due to a major life-changing event, as described in § 418.1201, the effective date is described in § 418.1230. | |||||
| 20:20:2.0.1.1.10.2.469.7 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1115 What are the modified adjusted gross income ranges? | SSA | [78 FR 57259, Sept. 18, 2013, as amended at 83 FR 55628, Nov. 7, 2018] | (a) We list the modified adjusted gross income ranges for the calendar years 2011 through and including 2017, 2018, and for years beginning in 2019 for each Federal tax filing category in paragraphs (b), (c) and (d) of this section. We will use your modified adjusted gross income amount together with your tax filing status to determine the amount of your income-related monthly adjustment for these calendar years. (b) The modified adjusted gross income ranges for individuals with a Federal tax filing status of single, head of household, qualifying widow(er) with dependent child, and married filing separately when the individual has lived apart from his/her spouse for the entire tax year for the year we use to make our income-related monthly adjustment amount determination are as follows. (1) For calendar years 2011 through and including 2017— (i) Greater than $85,000 but less than or equal to $107,000; (ii) Greater than $107,000 but less than or equal to $160,000; (iii) Greater than $160,000 but less than or equal to $214,000; and (iv) Greater than $214,000. (2) For calendar year 2018— (i) Greater than $85,000 but less than or equal to $107,000; (ii) Greater than $107,000 but less than or equal to $133,500; (iii) Greater than $133,500 but less than or equal to $160,000; and (iv) Greater than $160,000 (3) For calendar years beginning with 2019— (i) Greater than $85,000 but less than or equal to $107,000; (ii) Greater than $107,000 but less than or equal to $133,500; (iii) Greater than $133,500 but less than or equal to $160,000; (iv) Greater than $160,000 but less than $500,000; and (v) Greater than or equal to $500,000. (c) The modified adjusted gross income ranges for individuals who are married and filed a joint tax return for the tax year we use to make the income-related monthly adjustment amount determination are as follows. (1) For calendar years 2011 through and including 2017— (i) Greater than $170,000 but less than or equal to $214,000; (ii) Greater than $214,000 but less than or equa… | ||||
| 20:20:2.0.1.1.10.2.469.8 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1120 How do we determine your income-related monthly adjustment amount? | SSA | [78 FR 57259, Sept. 18, 2013, as amended at 83 FR 55628, Nov. 7, 2018] | (a) We will determine your income-related monthly adjustment amount by using your tax filing status and modified adjusted gross income. (b) Tables of applicable percentage. The tables in paragraphs (b)(1) through (b)(3) of this section contain the modified adjusted gross income ranges for calendar years 2011 through and including 2017, 2018, and beginning in 2019 in the column on the left in each table. The middle column in each table shows the percentage of the unsubsidized Medicare Part B premium that will be paid by individuals with modified adjusted gross income that falls within each of the ranges. The column on the right in each table shows the percentage of the Medicare Part B premium that will be subsidized by contributions from the Federal Government. We use your tax filing status and your modified adjusted gross income for the tax year to determine which income-related monthly adjustment amount to apply to you. The dollar amount of income-related monthly adjustment for each range will be set annually for each year after 2019 as described in paragraph (c) of this section. The modified adjusted gross income ranges will be adjusted annually after 2019 as described in § 418.1115(e). (1) General tables of applicable percentages. If, for the tax year, we use your filing status for your Federal income taxes for the tax year is single; head of household; qualifying widow(er) with dependent child; or married filing separately and you lived apart from your spouse for the entire tax year, we will use the general tables of applicable percentages. When your modified adjusted gross income for the year we use is in the range listed in the left column in the following tables, then the Federal Government's Part B premium subsidy of 75 percent is reduced to the percentage listed in the right column. You will pay an amount based on the percentage listed in the center column. (2) Tables of applicable percentages for joint returns. If, for the tax year, we use your Federal tax filing status is married filing jointl… | ||||
| 20:20:2.0.1.1.10.2.469.9 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1125 How will the income-related monthly adjustment amount affect your total Medicare Part B premium? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 78 FR 57260, Sept. 18, 2013] | (a) If you must pay an income-related monthly adjustment amount, your total Medicare Part B premium will be the sum of: (1) The Medicare Part B standard monthly premium, determined using the rules in 42 CFR 408.20; plus (2) Any applicable increase in the Medicare Part B standard monthly premium as described in 42 CFR 408.22; plus (3) Your income-related monthly adjustment amount. (b) The nonstandard Medicare Part B premium amount described in 42 CFR 408.20 does not apply to individuals who must pay an income-related monthly adjustment amount. Such individuals must pay the full Medicare Part B standard monthly premium plus any applicable penalties for late enrollment or reenrollment plus the income-related adjustment. | ||||
| 20:20:2.0.1.1.10.2.470.15 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1201 When will we determine your income-related monthly adjustment amount based on the modified adjusted gross income information that you provide for a more recent tax year? | SSA | We will use a more recent tax year than the years described in § 418.1135(a) or (b) to reduce or eliminate your income-related monthly adjustment amount when all of the following occur: (a) You experience a major life-changing event as defined in § 418.1205; and (b) That major life-changing event results in a significant reduction in your modified adjusted gross income for the year which you request we use and the next year, if applicable. For purposes of this section, a significant reduction in your modified adjusted gross income is one that results in the decrease or elimination of your income-related monthly adjustment amount; and (c) You request that we use a more recent tax year's modified adjusted gross income; and (d) You provide evidence as described in §§ 418.1255 and 418.1265. | |||||
| 20:20:2.0.1.1.10.2.470.16 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1205 What is a major life-changing event? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 75 FR 41086, July 15, 2010] | For the purposes of this subpart, we will consider the following to be major life-changing events: (a) Your spouse dies; (b) You marry; (c) Your marriage ends through divorce or annulment; (d) You or your spouse stop working or reduce the hours you work; (e) You or your spouse experiences a loss of income-producing property, provided the loss is not at the direction of you or your spouse (e.g., due to the sale or transfer of the property) and is not a result of the ordinary risk of investment. Examples of the type of property loss include, but are not limited to: Loss of real property within a Presidentially or Gubernatorially-declared disaster area, destruction of livestock or crops by natural disaster or disease, loss from real property due to arson, or loss of investment property as a result of fraud or theft due to a criminal act by a third party; (f) You or your spouse experiences a scheduled cessation, termination, or reorganization of an employer's pension plan; (g) You or your spouse receives a settlement from an employer or former employer because of the employer's closure, bankruptcy, or reorganization. | ||||
| 20:20:2.0.1.1.10.2.470.17 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1210 What is not a major life-changing event? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 75 FR 41086, July 15, 2010] | We will not consider events other than those described in § 418.1205 to be major life-changing events. Certain types of events are not considered major life-changing events for the purposes of this subpart, such as: (a) Events that affect your expenses, but not your income; or (b) Events that result in the loss of dividend income because of the ordinary risk of investment. | ||||
| 20:20:2.0.1.1.10.2.470.18 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1215 What is a significant reduction in your income? | SSA | For purposes of this subpart, we will consider a reduction in your income to be significant if your modified adjusted gross income decreases; and (a) The decrease reduces the percentage of the income-related monthly adjustment amount you must pay according to the Table of Applicable Percentages in § 418.1120; or (b) The decrease reduces your modified adjusted gross income to an amount below the threshold described in § 418.1105 and eliminates any income-related monthly adjustment amount you must pay. | |||||
| 20:20:2.0.1.1.10.2.470.19 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1220 What is not a significant reduction in your income? | SSA | For purposes of this subpart, we will not consider a reduction in your income to be significant unless the reduction affects the amount of income-related monthly adjustment you must pay. | |||||
| 20:20:2.0.1.1.10.2.470.20 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1225 Which more recent tax year will we use? | SSA | We will consider evidence of your modified adjusted gross income that you provide for a tax year that is more recent than the year described in § 418.1135 (a) or (b) when you meet all of the requirements described in § 418.1201. We will always ask you for your retained copy of your filed Federal income tax return for the more recent year you request that we use and will use that information to make an initial determination. If you have not filed your Federal income tax return for the more recent year you request that we use, you must provide us with evidence that is equivalent to a copy of a filed Federal income tax return. Evidence that is equivalent to a copy of a filed Federal income tax return is defined in § 418.1265(c). | |||||
| 20:20:2.0.1.1.10.2.470.21 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1230 What is the effective date of an income-related monthly adjustment amount initial determination that is based on a more recent tax year? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 75 FR 41086, July 15, 2010; 78 FR 57260, Sept. 28, 2013] | (a) Subject to paragraph (b) of this section, when your modified adjusted gross income for the more recent tax year is significantly reduced as a result of a major life-changing event, our initial determination is generally effective on January 1 of the year in which you make your request. If your first month of enrollment or reenrollment in Medicare Part B is after January of the year for which you make your request, our initial determination is effective on the first day of your Medicare Part B enrollment or reenrollment. (b) We will make a determination about your income-related monthly adjustment amount for the year preceding the year that you make your request in the limited circumstances explained in § 418.1310(a)(4). When we make a determination for the preceding year, our initial determination is generally effective on January 1 of that year. If your first month of enrollment or reenrollment in Medicare Part B is after January of that year, our initial determination is effective on the first day of your Medicare Part B enrollment or reenrollment. (c) Our initial determination will be effective January 1 of the year following the year you make your request, when your modified adjusted gross income will not be significantly reduced as a result of one or more of the events described in § 418.1205(a) through (g) until the year following the year you make your request. | ||||
| 20:20:2.0.1.1.10.2.470.22 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1235 When will we stop using your more recent tax year's modified adjusted gross income to determine your income-related monthly adjustment amount? | SSA | We will use your more recent tax year's modified adjusted gross income to determine your income-related monthly adjustment amount effective with the month and year described in § 418.1230 and for each year thereafter until one of the following occurs: (a) We receive your modified adjusted gross income from IRS for the more recent tax year we used or a later tax year; (b) Your more recent tax year modified adjusted gross income that we used is for a tax year more than 3 years prior to the income-related monthly adjustment amount effective year; (c) You request we use a more recent tax year based on another major life-changing event as described in § 418.1201; or (d) You notify us of a change in your modified adjusted gross income for the more recent tax year we used as described in § 418.1240. | |||||
| 20:20:2.0.1.1.10.2.470.23 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1240 Should you notify us if the information you gave us about your modified adjusted gross income for the more recent tax year changes? | SSA | If you know that the information you provided to us about the more recent tax year that we used has changed, you should tell us so that we can determine if your income-related monthly adjustment amount should be eliminated or adjusted. We will accept new modified adjusted gross income information at any time after your request until the end of the calendar year following the more recent tax year(s) that we used. For us to make a new initial determination using your new modified adjusted gross income information, you must provide evidence as described in § 418.1265 to support the reduction or increase in your modified adjusted gross income. If you amend your Federal income tax return for the more recent tax year we used, we will use the rules in § 418.1150. | |||||
| 20:20:2.0.1.1.10.2.470.24 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1245 What will happen if you notify us that your modified adjusted gross income for the more recent tax year changes? | SSA | (a) If you notify us that your modified adjusted gross income for the more recent tax year has changed from what is in our records, we may make a new initial determination for each effective year involved. To make a new initial determination(s) we will take into account: (1) The new modified adjusted gross income information for the more recent tax year you provide; and (2) Any modified adjusted gross income information from IRS, as described in § 418.1135, that we have available for each effective year; and (3) Any modified adjusted gross income information from you, as described in § 418.1135, that we have available for each effective year. (b) For each new initial determination that results in a change in your income-related monthly adjustment amount, we will make retroactive adjustments that will apply to all enrolled months of the effective year. (c) We will continue to use a new initial determination described in paragraph (a) of this section to determine additional yearly income-related monthly adjustment amount(s) until an event described in § 418.1235 occurs. (d) We will make a new determination about your income-related monthly adjustment amount when we receive modified adjusted gross income for the effective year from IRS, as described in § 418.1140(d). | |||||
| 20:20:2.0.1.1.10.2.470.25 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1250 What evidence will you need to support your request that we use a more recent tax year? | SSA | When you request that we use a more recent tax year to determine your income-related monthly adjustment amount, we will ask for evidence of the major life-changing event and how the event significantly reduced your modified adjusted gross income as described in §§ 418.1255 and 418.1265. Unless we have information in our records that raises a doubt about the evidence, additional evidence documenting the major life-changing event(s) will not be needed. | |||||
| 20:20:2.0.1.1.10.2.470.26 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1255 What kind of major life-changing event evidence will you need to support your request for us to use a more recent tax year? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 75 FR 41086, July 15, 2010] | (a) If your spouse died and we do not have evidence of the death in our records, we will require proof of death as described in § 404.720(b) or (c) or § 404.721 of this chapter. (b) If you marry and we do not have evidence of the marriage in our records, we will require proof of marriage as described in §§ 404.725 through 404.727 of this chapter. (c) If your marriage ends and we do not have evidence that the marriage has ended in our records, we will require proof that the marriage has ended as described in § 404.728(b) or (c) of this chapter. (d) If you or your spouse stop working or reduce your work hours, we will require evidence documenting the change in work activity. Examples of acceptable documentation include, but are not limited to, documents we can corroborate such as a signed statement from your employer, proof of the transfer of your business, or your signed statement under penalty of perjury, describing your work separation or a reduction in hours. (e) If you or your spouse experiences a loss of income-producing property, we will require evidence documenting the loss. Examples of acceptable evidence include, but are not limited to, insurance claims or an insurance adjuster's statement. If the claim of loss is due to criminal fraud or theft by a third party, we will also require proof of conviction for the fraud or theft, such as a court document. (f) If you or your spouse experiences a scheduled cessation, termination, or reorganization of an employer's pension plan, we will require evidence documenting the change in or loss of the pension. An example of acceptable evidence includes, but is not limited to, a statement from your pension fund administrator explaining the reduction or termination of your benefits. (g) If you or your spouse receives a settlement from an employer or former employer because of the employer's closure, bankruptcy, or reorganization, we will require evidence documenting the settlement and the reason(s) for the settlement. An example of acceptable evidence includes, but … | ||||
| 20:20:2.0.1.1.10.2.470.27 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1260 What major life-changing event evidence will we not accept? | SSA | (a) We will not accept evidence of death that fails to meet the requirements in §§ 404.720 through 404.721 of this chapter. (b) We will not accept evidence of marriage that fails to meet the requirements in §§ 404.725 through 404.727 of this chapter. (c) We will not accept evidence that your marriage has ended if the evidence fails to meet the requirements in § 404.728 of this chapter. (d) We will not accept documents supporting loss of income from income-producing property, or failure of or loss from a defined benefit pension plan unless the documents are original documents or copies from the original source. (e) We will not accept evidence of work reduction or work stoppage that cannot be substantiated. | |||||
| 20:20:2.0.1.1.10.2.470.28 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1265 What kind of significant modified adjusted gross income reduction evidence will you need to support your request? | SSA | [71 FR 62931, Oct. 27, 2006, as amended at 75 FR 41087, July 15, 2010] | (a) You must provide evidence that one or more of the major life-changing events described in § 418.1205 resulted in a significant reduction in your modified adjusted gross income for the tax year you request we use. (b) The preferred evidence is your retained copy of your filed Federal income tax return, your retained copy of your amended tax return with an IRS letter of receipt of the amended tax return, your copy of proof of a correction of the IRS information we used or a copy of your return or amended or proof of a correction of tax return information that you obtain from IRS for the more recent tax year you request we use. (c) When a copy of your filed Federal income tax return is not available for the more recent tax year in which your modified adjusted gross income was significantly reduced, we will accept equivalent evidence. Equivalent evidence is the appropriate proof(s) in paragraphs (c)(1), (2) and (3) of this section, plus your signed statement under penalty of perjury that the information you provide is true and correct. When the major life-changing event changes your tax filing status, or the income-related monthly adjustment amount determination could be affected by your tax filing status, you will also be required to sign a statement regarding your intended income tax filing status for the tax year you request we use. (1) If you experience one or more of the events described in § 418.1205(a), (b), or (c), you must provide evidence as to how the event(s) significantly reduced your modified adjusted gross income. Examples of the type of evidence include, but are not limited to, evidence of your spouse's modified adjusted gross income and/or your modified adjusted gross income for the tax year we use. (2) If you experience one or more of the events described in § 418.1205(d), (e), (f), or (g), you must provide evidence of how the event(s) significantly reduced your modified adjusted gross income, such as a statement explaining any modified adjusted gross income changes for the tax year we used … | ||||
| 20:20:2.0.1.1.10.2.470.29 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1270 What modified adjusted gross income evidence will we not accept? | SSA | We will not accept a correction or amendment of your income tax return without a letter from IRS acknowledging the change. We will also not accept illegible or unsigned copies of income tax returns or attestations or other statements of income unless they are provided under penalty of perjury. | |||||
| 20:20:2.0.1.1.10.2.471.30 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1301 What is an initial determination regarding your income-related monthly adjustment amount? | SSA | An initial determination is the determination we make about your income-related monthly adjustment amount that is subject to administrative review. For the purposes of administering the income-related monthly adjustment amount, initial determinations include but are not limited to determinations about: (a) The amount of your income-related monthly adjustment amount based on information provided by IRS; and (b) Any change in your income-related monthly adjustment amount based on one of the circumstances listed in § 418.1310(a)(1) through (a)(4). | |||||
| 20:20:2.0.1.1.10.2.471.31 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1305 What is not an initial determination regarding your income-related monthly adjustment amount? | SSA | Administrative actions that are not initial determinations may be reviewed by us, but they are not subject to the administrative review process as provided by §§ 418.1320 through 418.1325 and §§ 418.1340 through 418.1355, and they are not subject to judicial review. These actions include, but are not limited to, our dismissal of a request for reconsideration as described in § 418.1330 and our dismissal of a request for a new initial determination as described in § 418.1310(d). | |||||
| 20:20:2.0.1.1.10.2.471.32 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1310 When may you request that we make a new initial determination? | SSA | (a) You may request that we make a new initial determination in the following circumstances: (1) You provide a copy of your filed Federal income tax return for the tax year 2 years prior to the effective year when IRS has provided information for the tax year 3 years prior to the effective year. You may request a new initial determination beginning with the date you receive a notice from us regarding your income-related monthly adjustment amount until the end of the effective year, with one exception. If you receive the notice during the last 3 months of a calendar year, you may request a new initial determination beginning with the date you receive the notice until March 31 of the following year. We will follow the rules and procedures in §§ 418.1110(b) and 418.1140(b) to make a new initial determination and any necessary retroactive adjustments back to January 1 of the effective year, or the first month you were enrolled in Medicare Part B in the effective year if later than January. (2) You provide a copy of an amended tax return filed with IRS, as defined in § 418.1010(b)(1). We will use your amended tax return for the same tax year as the year used to determine your income-related monthly adjustment amount. You must request the new initial determination within the timeframe described in § 418.1150. (3) You provide proof that the tax return information about your modified adjusted gross income or tax filing status IRS gave us is incorrect. We will use proof that you obtain from IRS of a correction of your tax return information for the same tax year instead of the information that was provided to us by IRS, as explained in § 418.1335(a). You may request a new initial determination at any time after you receive a notice from us regarding your income-related monthly adjustment amount if you have such proof. We will use the rules and procedures in § 418.1335. (4) You have a major life-changing event. You may request a new initial determination based on a major life-changing event when you meet all the requir… | |||||
| 20:20:2.0.1.1.10.2.471.33 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1315 How will we notify you and what information will we provide about our initial determination? | SSA | (a) We will mail a written notice of all initial determinations to you. The notice of the initial determination will state the important facts and give the reasons for our conclusions. Generally, we will not send a notice if your income-related monthly adjustment amount stops because of your death. (b) The written notice that we send will tell you: (1) What our initial determination is; (2) What modified adjusted gross income information we used to make our determination; (3) The reason for our determination; (4) The effect of the initial determination; and (5) Your right to a reconsideration or a new initial determination. | |||||
| 20:20:2.0.1.1.10.2.471.34 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1320 What is the effect of an initial determination? | SSA | An initial determination is binding unless you request a reconsideration within the time period described in §§ 404.909 and 404.911 of this chapter or we revise the initial determination or issue a new initial determination. | |||||
| 20:20:2.0.1.1.10.2.471.35 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1322 How will a Medicare prescription drug coverage income-related monthly adjustment amount determination for the effective year affect your Medicare Part B? | SSA | [75 FR 75890, Dec. 7, 2010] | If we make an income-related monthly adjustment amount determination for you for the effective year under subpart C of this part (Medicare Prescription Drug Coverage Income-Related Monthly Adjustment Amount), we will apply that income-related monthly adjustment amount determination under this subpart to determine your Part D income-related monthly adjustment amount for the same effective year. Therefore, if you become enrolled in Medicare Part B in the effective year after we make an income-related monthly adjustment amount determination about your Medicare prescription drug coverage, the income-related monthly adjustment amount determination for your Medicare prescription drug coverage will also be used to determine your Medicare Part B income-related monthly adjustment amount. Any change in your net benefit due will be accompanied by a letter explaining the change in your net benefit and your right to appeal the change. | ||||
| 20:20:2.0.1.1.10.2.471.36 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1325 When may you request a reconsideration? | SSA | If you are dissatisfied with our initial determination about your income-related monthly adjustment amount, you may request that we reconsider it. In addition, a person who shows that his or her rights may be adversely affected by the initial determination may request a reconsideration. We may accept requests for reconsideration that are filed by electronic or other means that we determine to be appropriate. Subject to the provisions of this section and § 418.1330, when you request a reconsideration, we will use the rules in §§ 404.907 through 404.922 of this chapter. | |||||
| 20:20:2.0.1.1.10.2.471.37 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1330 Can you request a reconsideration when you believe that the IRS information we used is incorrect? | SSA | If you request a reconsideration solely because you believe that the information that IRS gave us is incorrect, we will dismiss your request for a reconsideration and notify you to obtain proof of a correction from IRS and request a new initial determination (§ 418.1335). Our dismissal of your request for reconsideration is not an initial determination subject to further administrative or judicial review. | |||||
| 20:20:2.0.1.1.10.2.471.38 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1335 What should you do if our initial determination is based on modified adjusted gross income information you believe to be incorrect? | SSA | If you believe that IRS or you provided incorrect modified adjusted gross income information to us that we used to determine your income-related monthly adjustment amount, you can request information from us on how to contact IRS regarding the information we used. (a) If IRS determines that the information it provided is not correct, IRS will provide you with documentation of the error, such as a copy of your Federal income tax return. If you would like us to use the revised or corrected information to determine your income-related monthly adjustment amount, you will need to request that we use that information and provide us with the IRS documentation confirming the error. We will make any necessary retroactive corrections as described in § 418.1110(d) to your income-related monthly adjustment amount. (b) If you provided information to us about your modified adjusted gross income that we used to determine your income-related monthly adjustment amount, and that information is not correct, you may provide revised or corrected information. We will use the revised or corrected information if it reduces or eliminates your income-related monthly adjustment amount. We will make any necessary retroactive corrections as described in § 418.1110 to your income-related monthly adjustment amount. If you are providing corrected information about a more recent tax year's modified adjusted gross income that we used due to your major life-changing event, as described in § 418.1240, we will use the rules in § 418.1245 to determine how it will affect your income-related monthly adjustment amount. | |||||
| 20:20:2.0.1.1.10.2.471.39 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1340 What are the rules for our administrative review process? | SSA | To the extent that they are not inconsistent with the rules in this subpart for making initial determinations and reconsidered determinations, we will use the same rules for the administrative review process that we use for determinations and decisions about your rights regarding non-medical issues under title II of the Act, as described in subpart J of part 404 of this chapter. We will accept oral requests as well as the written requests required in subpart J of part 404 of this chapter for requesting administrative review of our determination. If you are dissatisfied with our reconsidered determination, you may request review in accordance with § 418.1350 for this subpart. A request for a new initial determination, described in § 418.1310, is not the same as a request for reconsideration or further administrative review. | |||||
| 20:20:2.0.1.1.10.2.471.40 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1345 Is reopening of an initial or reconsidered determination made by us ever appropriate? | SSA | We may reopen an initial or reconsidered determination made by us when the conditions for reopening are met as described in § 404.988 of this chapter. We will use the rules in §§ 404.987 through 404.991a of this chapter when we reopen determinations made by us. | |||||
| 20:20:2.0.1.1.10.2.471.41 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1350 What are the rules for review of a reconsidered determination or an administrative law judge decision? | SSA | [78 FR 57260, Sept. 18, 2013] | You may request a hearing before an OMHA administrative law judge consistent with HHS' regulations at 42 CFR part 405. You may seek further review of the administrative law judge's decision by requesting MAC review and judicial review in accordance with HHS' regulations. | ||||
| 20:20:2.0.1.1.10.2.471.42 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | B | Subpart B—Medicare Part B Income-Related Monthly Adjustment Amount | § 418.1355 What are the rules for reopening a decision by an administrative law judge of the Office of Medicare Hearings and Appeals (OMHA) or by the Medicare Appeals Council (MAC)? | SSA | The rules in 42 CFR 405.980 through 405.986 govern reopenings of decisions by an administrative law judge of the OMHA and decisions by the MAC. A decision by an administrative law judge of the OMHA may be reopened by the administrative law judge or by the MAC. A decision by the MAC may be reopened only by the MAC. | |||||
| 20:20:2.0.1.1.10.3.472.1 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2001 What is this subpart about? | SSA | This subpart implements sections 1860D-13(a)(7) and 1860D-13(c)(4) of the Social Security Act (the Act), as added by section 3308 of the Affordable Care Act (Pub. L. 111-148). Section 3308(a) establishes an income-related monthly adjustment to Medicare prescription drug coverage premiums. Persons enrolled in Medicare prescription drug plans, Medicare Advantage plans with prescription drug coverage, Programs of All-Inclusive Care for the Elderly plans, and cost plans offering prescription drug coverage who have modified adjusted gross income over a threshold amount established in the statute will pay an income-related monthly adjustment amount in addition to their Medicare prescription drug coverage plan's monthly premium and any applicable premium increases as described in 42 CFR 423.286. The regulations in this subpart explain how we determine whether you are required to pay an income-related monthly adjustment amount, and if you are, the amount of your adjustment. We have divided the rules into the following groups of sections: (a) Sections 418.2001 through 418.2010 contain the introduction, a statement of the general purpose of the income-related monthly adjustment amount, general provisions that apply to the income-related monthly adjustment amount, and definitions of terms that we use in this subpart. (b) Sections 418.2101 through 418.2150 describe what information about your modified adjusted gross income we will use to determine if you are required to pay an income-related monthly adjustment amount. In these sections, we also describe how the income-related monthly adjustment amount will affect your total Medicare prescription drug coverage premium. (c) Sections 418.2201 through 418.2270 contain an explanation of the standards that you must meet for us to grant your request to use modified adjusted gross income information that you provide for a more recent tax year rather than the information described in paragraph (b) of this section. These sections explain when we may consider such a request, and the… | |||||
| 20:20:2.0.1.1.10.3.472.2 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2005 Purpose and administration. | SSA | (a) The purpose of the income-related monthly adjustment amount is for beneficiaries who have modified adjusted gross income above an established threshold to reimburse the Federal Government for a portion of the Federal subsidy of the Medicare prescription drug coverage. Persons who have modified adjusted gross income above the thresholds described in § 418.2105 will pay an income-related monthly adjustment amount in addition to the premium for their prescription drug coverage. The income-related monthly adjustment amount due will be determined based on the base beneficiary premium amount that represents 25.5 percent of the cost of the basic Medicare prescription drug coverage. The application of an income-related monthly adjustment amount results in an increase in the total amount that those who are affected pay for Medicare prescription drug coverage plans. A person who has modified adjusted gross income above the threshold amount will pay: (1) The Medicare prescription drug coverage plan monthly premium; plus (2) Any applicable increase for late enrollment or reenrollment; (3) An income-related monthly adjustment amount; and (b) The Centers for Medicare & Medicaid Services in the Department of Health and Human Services establishes rules for eligibility for Medicare prescription drug coverage and enrollment in Medicare prescription drug coverage plans, as well as premium penalties for late enrollment or reenrollment (42 CFR 423.30 through 423.56). (c) We use information from CMS about enrollment in Medicare prescription drug coverage plans to determine the records that we must send to the IRS. (d) We use information that we get from the IRS to determine if persons enrolled in Medicare prescription drug coverage plans are required to pay an income-related monthly adjustment amount. We also change income-related monthly adjustment amount determinations using information you provide under certain circumstances. In addition, we notify beneficiaries when the social security benefit amounts they receive will c… | |||||
| 20:20:2.0.1.1.10.3.472.3 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2010 Definitions. | SSA | (a) Terms relating to the Act and regulations. For the purposes of this subpart: (1) Administrator means the Administrator of CMS in HHS. (2) ALJ means administrative law judge. (3) CMS means the Centers for Medicare & Medicaid Services in HHS. (4) Commissioner means the Commissioner of Social Security. (5) HHS means the Department of Health and Human Services, which oversees the Centers for Medicare & Medicaid Services (CMS), the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council (MAC) (6) IRS means the Internal Revenue Service in the Department of the Treasury. (7) MAC means the Medicare Appeals Council in HHS. (8) Medicare Prescription Drug Coverage Plan means a Medicare prescription drug plan, a Medicare Advantage plan with prescription drug coverage, a Program for All-inclusive Care for the Elderly plan offering qualified prescription drug coverage, or a cost plan offering qualified prescription drug coverage. (9) OMHA means the Office of Medicare Hearings and Appeals in HHS. (10) Section means a section of the regulations in this part unless the context indicates otherwise. (11) The Act means the Social Security Act, as amended. (12) Title means a title of the Act. (13) We, our, or us means the Social Security Administration (SSA). (b) Miscellaneous. For the purposes of this subpart: (1) Amended tax return means a Federal income tax return for which an individual or couple has filed an amended tax return that has been accepted by the IRS. (2) Effective year means the calendar year for which we make an income-related monthly adjustment amount determination. (3) Federal premium subsidy is the portion of the cost of providing Medicare prescription drug coverage that is paid by the Federal Government. The Federal Government pays this amount to Medicare Prescription Drug coverage Plans from payments made into the Medicare Prescription Drug Account in the Federal Supplementary Medical Insurance Trust Fund. (4) Income-related mon… | |||||
| 20:20:2.0.1.1.10.3.473.10 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2125 How will the income-related monthly adjustment amount affect your total Medicare prescription drug coverage premium? | SSA | (a) If you must pay an income-related monthly adjustment amount, your total Medicare prescription drug coverage premium will be the sum of: (1) Your prescription drug coverage monthly premium, as determined by your plan; plus (2) Any applicable increase in the prescription drug coverage monthly premium as described in 42 CFR 423.286; plus (3) Your income-related monthly adjustment amount. (b) Regardless of the method you use to pay your Medicare prescription drug coverage premiums to your Medicare prescription drug coverage plan, you will pay any income-related monthly adjustment amount you owe using the method described in 418.2112. | |||||
| 20:20:2.0.1.1.10.3.473.11 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2135 What modified adjusted gross income information will we use to determine your income-related monthly adjustment amount? | SSA | We will follow the rules in § 418.1135, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.473.12 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2140 What will happen if the modified adjusted gross income information from the IRS is different from the modified adjusted gross income information we used to determine your income-related monthly adjustment amount? | SSA | We will follow the rules in § 418.1140, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.473.13 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2145 How do we determine your income-related monthly adjustment amount if the IRS does not provide information about your modified adjusted gross income? | SSA | We will follow the rules in § 418.1145, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.473.14 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2150 When will we use your amended tax return filed with the IRS? | SSA | We will follow the rules in § 418.1150, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.473.4 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2101 What is the income-related monthly adjustment amount? | SSA | (a) The income-related monthly adjustment amount is an amount that you will pay in addition to the Medicare prescription drug coverage plan monthly premium, plus any applicable increase in that premium as described in 42 CFR 423.286, for your Medicare prescription drug coverage plan when your modified adjusted gross income is above the threshold described in § 418.2105. (b) Your income-related monthly adjustment amount is based on your applicable modified adjusted gross income as described in § 418.2115 and your tax filing status. (c) We will determine your income-related monthly adjustment amount using the method described in § 418.2120. | |||||
| 20:20:2.0.1.1.10.3.473.5 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2105 What is the threshold? | SSA | (a) The threshold is a level of modified adjusted gross income above which you will have to pay the income-related monthly adjustment amount. (b) For calendar years 2011 through and including 2019, the modified adjusted gross income threshold is $85,000 for individuals with a Federal income tax filing status of single, married filing separately, head of household, and qualifying widow(er) with dependent child. The threshold is $170,000 for individuals with a Federal income tax filing status of married filing jointly. (c) Starting at the end of calendar year 2019 and for each calendar year thereafter, CMS will set the threshold amounts for the following year. CMS will publish the threshold amounts annually in the Federal Register. Published threshold amounts will be effective January 1 of the next calendar year, and remain unchanged for the full calendar year. | |||||
| 20:20:2.0.1.1.10.3.473.6 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2110 What is the effective date of our initial determination about your income-related monthly adjustment amount? | SSA | (a) Generally, an income-related monthly adjustment amount determination will be effective for all months that you are enrolled in a prescription drug coverage plan during the year for which we determine you must pay an income-related monthly adjustment amount. (b) When we have used modified adjusted gross income information from the IRS for the tax year 3 years prior to the effective year to determine your income-related monthly adjustment amount, and modified adjusted gross income information for the tax year 2 years prior later becomes available from the IRS, we will review the new information to determine if we should revise our initial determination concerning the income-related monthly adjustment amount. If we revise our initial determination, the effective date of the new initial determination will be January 1 of the effective year, or the first month your enrollment or re-enrollment in a Medicare prescription drug coverage plan became effective if later than January. (c) When we use your amended tax return, as described in § 418.2150, the effective date will be January 1 of the year(s) that is affected, or the first month in that year that your enrollment or re-enrollment in a Medicare prescription drug coverage plan became effective if later than January. (d) When we use evidence that you provide to proves the IRS modified adjusted gross income information we used was incorrect, as described in § 418.2335, the effective date will be January of the year(s) that is affected or the first month in that year that your enrollment or re-enrollment in a Medicare prescription drug coverage plan became effective if later than January. (e) When we use information from a more recent tax year that you provide due to a major life-changing event, as described in § 418.2201, the effective date is described in § 418.2230. | |||||
| 20:20:2.0.1.1.10.3.473.7 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2112 Paying your income-related monthly adjustment amount. | SSA | (a) We will deduct the income-related monthly adjustment amount from your Social Security benefits if they are sufficient to cover the amount owed. If the amount of your Social Security benefits is not sufficient to pay the full amount of your income-related monthly adjustment amount, CMS will bill you for the full amount owed. (b) If you do not receive Social Security or Railroad Retirement Board benefits, but you receive benefits from the Office of Personnel Management, the Office of Personnel Management will deduct the income-related monthly adjustment amount from your benefits if they are sufficient to cover the amount owed. If the amount of your Office of Personnel Management benefits is not sufficient to pay the full amount of your income-related monthly adjustment amount, CMS will bill you for the full amount owed. (c) If you do not receive Social Security, Railroad Retirement Board, or Office of Personnel Management benefits, CMS will bill you for your income-related monthly adjustment amount. | |||||
| 20:20:2.0.1.1.10.3.473.8 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2115 What are the modified adjusted gross income ranges? | SSA | [75 FR 75891, Dec. 7, 2010, as amended at 55630, Nov. 7, 2018] | (a) We list the modified adjusted gross income ranges for the calendar years 2011 through and including 2017, 2018, and beginning in 2019 for each Federal tax filing category in paragraphs (b), (c) and (d) of this section. We will use your modified adjusted gross income amount together with your tax filing status to determine the amount of your income-related monthly adjustment for these calendar years. (b) The modified adjusted gross income ranges for individuals with a Federal tax filing status of single, head of household, qualifying widow(er) with dependent child, and married filing separately when the individual has lived apart from his/her spouse for the entire tax year for the year we use to make our income-related monthly adjustment amount determination are as follows: (1) For calendar years 2011 through and including 2017— (i) Greater than $85,000 but less than or equal to $107,000; (ii) Greater than $107,000 but less than or equal to $160,000; (iii) Greater than $160,000 but less than or equal to $214,000; and (iv) Greater than $214,000. (2) For calendar year 2018— (i) Greater than $85,000 but less than $107,000; (ii) Greater than $107,000 but less than $133,500; (iii) Greater than $133,500 but less than $160,000; and (iv) Greater than $160,000. (3) For calendar years beginning in 2019— (i) Greater than $85,000 but less than or equal to $107,000; (ii) Greater than $107,000 but less than or equal to $133,500; (iii) Greater than $133,500 but less than or equal to $160,000; (iv) Greater than $160,000 but less than $500,000; and (v) Greater than or equal to $500,000. (c) The modified adjusted gross income ranges for individuals who are married and filed a joint tax return for the tax year we use to make the income-related monthly adjustment amount determination are as follows. (1) For calendar years 2011 through 2017— (i) Greater than $170,000 but less than or equal to $214,000; (ii) Greater than $214,000 but less than or equal to $320,000; (iii) Greater than $320,000 but less than or … | ||||
| 20:20:2.0.1.1.10.3.473.9 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2120 How do we determine your income-related monthly adjustment amount? | SSA | [75 FR 75891, Dec. 7, 2010, as amended at 55631, Nov. 3, 2018] | (a) We will determine your income-related monthly adjustment amount by using your tax filing status and modified adjusted gross income. (b) Tables of applicable percentage. The tables in paragraphs (b)(1) through (b)(3) of this section contain the modified adjusted gross income ranges for calendar years 2011 through and including 2017, 2018, and 2019, and the corresponding percentage of the cost of basic Medicare prescription drug coverage that individuals with modified adjusted gross incomes that fall within each of the ranges will pay. The monthly dollar amounts will be determined by CMS using the formula in section 1860D-13(a)(7)(B) of the Act. Based on your tax filing status for the tax year we use to make a determination about your income-related monthly adjustment amount, we will determine which table is applicable to you. We will use your modified adjusted gross income to determine which income-related monthly adjustment amount to apply to you. The dollar amounts used for each of the ranges of income-related monthly adjustment will be set annually after 2019 as described in paragraph (c) of this section. The modified adjusted gross income ranges will be adjusted annually after 2019 as described in § 418.2115(e). (1) General tables of applicable percentages. If your filing status for your Federal income taxes for the tax year we use is single; head of household; qualifying widow(er) with dependent child; or married filing separately and you lived apart from your spouse for the entire tax year, we will use the general tables of applicable percentages. When your modified adjusted gross income for the year we use is in the range listed in the left column in the following tables, you will pay an amount based on the percentage listed in the right column, which represents a percentage of the cost of basic Medicare prescription drug coverage. (2) Tables of applicable percentages for joint returns. If your Federal tax filing status is married filing jointly for the tax year we use and your modified adjuste… | ||||
| 20:20:2.0.1.1.10.3.474.15 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2201 When will we determine your income-related monthly adjustment amount based on the modified adjusted gross income information that you provide for a more recent tax year? | SSA | We will follow the rules in § 418.1201, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.16 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2205 What is a major life-changing event? | SSA | We will follow the rules in § 418.1205, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.17 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2210 What is not a major life-changing event? | SSA | We will follow the rules in § 418.1210, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.18 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2215 What is a significant reduction in your income? | SSA | We will follow the rules in § 418.1215, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.19 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2220 What is not a significant reduction in your income? | SSA | We will follow the rules in § 418.1220, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.20 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2225 Which more recent tax year will we use? | SSA | We will follow the rules in § 418.1225, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.21 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2230 What is the effective date of an income-related monthly adjustment amount initial determination based on a more recent tax year? | SSA | We will follow the rules in § 418.1230, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.22 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2235 When will we stop using your more recent tax year's modified adjusted gross income to determine your income-related monthly adjustment amount? | SSA | We will follow the rules in § 418.1235, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.23 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2240 Should you notify us if the information you gave us about your modified adjusted gross income for the more recent tax year changes? | SSA | We will follow the rules in § 418.1240, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.24 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2245 What will happen if you notify us that your modified adjusted gross income for the more recent tax year changes? | SSA | (a) If you notify us that your modified adjusted gross income for the more recent tax year has changed from what is in our records, we may make a new initial determination for each effective year involved. To make a new initial determination(s) we will take into account: (1) The new modified adjusted gross income information for the more recent tax year you provide; and (2) Any modified adjusted gross income information from the IRS, as described in § 418.2135, that we have available for each effective year; and (3) Any modified adjusted gross income information from you, as described in § 418.2135, that we have available for each effective year. (b) For each new initial determination that results in a change in your income-related monthly adjustment amount, we will make retroactive corrections that will apply to all enrolled months of the effective year. (c) We will continue to use a new initial determination described in paragraph (a) of this section to determine additional yearly income-related monthly adjustment amount(s) until an event described in § 418.2235 occurs. (d) We will make a new determination about your income-related monthly adjustment amount when we receive modified adjusted gross income for the effective year from the IRS, as described in § 418.1140(d). | |||||
| 20:20:2.0.1.1.10.3.474.25 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2250 What evidence will you need to support your request that we use a more recent tax year? | SSA | We will follow the rules in § 418.1250, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.26 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2255 What kind of evidence of a major life-changing event will you need to support your request for us to use a more recent tax year? | SSA | We will follow the rules in § 418.1255, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.27 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2260 What major life-changing event evidence will we not accept? | SSA | We will follow the rules in § 418.1260, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.28 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2265 What kind of evidence of a significant modified adjusted gross income reduction will you need to support your request? | SSA | We will follow the rules in § 418.1265, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.474.29 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2270 What modified adjusted gross income evidence will we not accept? | SSA | We will follow the rules in § 418.1270, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.30 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2301 What is an initial determination regarding your income-related monthly adjustment amount? | SSA | We will follow the rules in § 418.1301, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.31 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2305 What is not an initial determination regarding your income-related monthly adjustment amount? | SSA | We will follow the rules in § 418.1305, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.32 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2310 When may you request that we make a new initial determination? | SSA | We will follow the rules in § 418.1310, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.33 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2315 How will we notify you and what information will we provide about our initial determination? | SSA | We will follow the rules in § 418.1315, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.34 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2320 What is the effect of an initial determination? | SSA | We will follow the rules in § 418.1320, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.35 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2322 How will a Medicare Part B income-related monthly adjustment amount determination for the effective year affect your Medicare prescription drug coverage? | SSA | If we make an income-related monthly adjustment amount determination for you for the effective year under subpart B of this part (Medicare Part B Income-Related Monthly Adjustment Amount), we will apply that income-related monthly adjustment amount determination under this subpart to determine your Part D income-related monthly adjustment amount for the same effective year. Therefore, if you obtain Medicare prescription drug coverage in the effective year after we make an income-related monthly adjustment amount determination about your Medicare Part B, the income-related monthly adjustment amount determination we made for your Medicare Part B will also apply to your Medicare prescription drug coverage. Any change in your net benefit due will be accompanied by a letter explaining the change in your net benefit and your right to appeal the change. | |||||
| 20:20:2.0.1.1.10.3.475.36 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2325 When may you request a reconsideration? | SSA | We will follow the rules in § 418.1325, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.37 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2330 Can you request a reconsideration when you believe that the IRS information we used is incorrect? | SSA | If you request a reconsideration solely because you believe that the information that the IRS gave us is incorrect, we will dismiss your request for a reconsideration and notify you to obtain proof of a correction from the IRS and request a new initial determination (§ 418.2335). Our dismissal of your request for reconsideration is not an initial determination subject to further administrative or judicial review. | |||||
| 20:20:2.0.1.1.10.3.475.38 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2332 Can you request a reconsideration when you believe that the CMS information we used is incorrect? | SSA | If you request a reconsideration solely because you believe that the information that CMS gave us about your participation in a Medicare prescription drug coverage plan is incorrect, we will dismiss your request for a reconsideration and notify you that you must contact CMS to get your records corrected. Our dismissal of your request for reconsideration is not an initial determination subject to further administrative or judicial review. | |||||
| 20:20:2.0.1.1.10.3.475.39 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2335 What should you do if we base our initial determination on modified adjusted gross income information you believe to be incorrect? | SSA | We will follow the rules in § 418.1335, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.40 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2340 What are the rules for our administrative review process? | SSA | We will follow the rules in § 418.1340, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.41 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2345 Is reopening of an initial or reconsidered determination made by us ever appropriate? | SSA | We will follow the rules in § 418.1345, except that any references in that section to regulations in subpart B of this part shall be treated as references to the corresponding regulation in this subpart. | |||||
| 20:20:2.0.1.1.10.3.475.42 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2350 What are the rules for review of a reconsidered determination or an ALJ decision? | SSA | You may request a hearing before an OMHA administrative law judge consistent with HHS' regulations at 42 CFR part 423. You may seek further review of the administrative law judge's decision by requesting MAC review and judicial review in accordance with HHS' regulations. | |||||
| 20:20:2.0.1.1.10.3.475.43 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | C | Subpart C—Income-Related Monthly Adjustments to Medicare Prescription Drug Coverage Premiums | § 418.2355 What are the rules for reopening a decision by an ALJ of the Office of Medicare Hearings and Appeals (OMHA) or by the Medicare Appeals Council (MAC)? | SSA | The rules in 42 CFR 423.1980 through 423.1986 govern reopenings of decisions by an administrative law judge of the OMHA and decisions by the MAC. A decision by an administrative law judge of the OMHA may be reopened by the administrative law judge or the MAC. A decision by the MAC may be reopened only by the MAC. | |||||
| 20:20:2.0.1.1.10.4.476.1 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3001 What is this subpart about? | SSA | This subpart D relates to sections 1860D-1 through 1860D-24 of title XVIII of the Social Security Act (the Act) as added by section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173). Sections 1860D-1 through 1860D-24 established Part D of title XVIII of the Act to create a Medicare program known as the Voluntary Prescription Drug Benefit Program. Section 1860D-14, codified into the Act by section 101, includes a provision for subsidies of prescription drug premiums and of Part D cost-sharing requirements for Medicare beneficiaries whose income and resources do not exceed certain levels. The regulations in this subpart explain how we decide whether you are eligible for a Part D premium subsidy as defined in 42 CFR 423.780 and cost-sharing subsidy as defined in 42 CFR 423.782. The rules are divided into the following groups of sections according to subject content: (a) Sections 418.3001 through 418.3010 contain the introduction, a statement of the general purpose underlying the subsidy program for the Voluntary Prescription Drug Benefit Program under Medicare Part D, general provisions that apply to the subsidy program, a description of how we administer the program, and definitions of terms that we use in this subpart. (b) Sections 418.3101 through 418.3125 contain the general requirements that you must meet in order to be eligible for a subsidy. These sections set forth the subsidy eligibility requirements of being a Medicare beneficiary, of having income and resources below certain levels, and of filing an application. These sections also explain when we will redetermine your eligibility for a subsidy and the period covered by a redetermination. (c) Sections 418.3201 through 418.3230 contain the rules that relate to the filing of subsidy applications. (d) Sections 418.3301 through 418.3350 contain the rules that explain how we consider your income (and your spouse's income, if applicable) and define what income we count when we decide whether you are eligible… | |||||
| 20:20:2.0.1.1.10.4.476.2 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3005 Purpose and administration of the program. | SSA | The purpose of the subsidy program is to offer help with the costs of prescription drug coverage for individuals who meet certain income and resources requirements under the law as explained in this subpart. The Centers for Medicare & Medicaid Services (CMS) in the Department of Health and Human Services has responsibility for administration of the Medicare program, including the new Medicare Part D Voluntary Prescription Drug Benefit Program. We notify Medicare beneficiaries who appear to have limited income, based on our records, about the availability of the subsidy if they are not already eligible for this help, and take applications for and determine the eligibility of individuals for a subsidy. | |||||
| 20:20:2.0.1.1.10.4.476.3 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3010 Definitions. | SSA | (a) Terms relating to the Act and regulations. (1) CMS means the Centers for Medicare & Medicaid Services in the Department of Health and Human Services. (2) Commissioner means the Commissioner of Social Security. (3) Section means a section of the regulations in part 418 of this chapter unless the context indicates otherwise. (4) The Act means the Social Security Act, as amended. (5) Title means a title of the Act. (6) We , our or us means the Social Security Administration (SSA). (b) Miscellaneous. (1) Claimant means the person who files an application for himself or herself or the person on whose behalf an application is filed. (2) Date you receive a notice means 5 calendar days after the date on the notice, unless you show us you did not receive it within the 5-day period. (3) Decision means the decision we make after a hearing. (4) Determination means the initial determination that we make as defined in § 418.3605. (5) Family size , for purposes of this subpart, means family size as defined in 42 CFR 423.772. (6) Federal poverty line , for purposes of this subpart, has the same meaning as Federal poverty line in 42 CFR 423.772. (7) Full-benefit dual eligible individual for purposes of this subpart, has the same meaning as full-benefit dual eligible individual in 42 CFR 423.772. (8) Medicare beneficiary means an individual who is entitled to or enrolled in Medicare Part A (Hospital Insurance) or enrolled in Part B (Supplementary Medical Insurance) or both under title XVIII of the Act. (9) Periods of limitations ending on Federal non-workdays Title XVIII of the Act and regulations in this subpart require you to take certain actions within specified time periods or you may lose your right to a portion of or your entire subsidy. If any such period ends on a Saturday, Sunday, Federal legal holiday, or any other day all or part of which is declared to be a nonworkday for Federal employees by statute or Executive Order, you will have until the next Federal workday to… | |||||
| 20:20:2.0.1.1.10.4.477.10 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3125 What are redeterminations? | SSA | (a) Redeterminations defined. A redetermination is a periodic review of your eligibility to make sure that you are still eligible for a subsidy and if so, to determine whether you should continue to receive a full or partial subsidy. This review deals with evaluating your income and resources (and those of your spouse, who lives with you) and will not affect past months of eligibility. It will be used to determine your future subsidy eligibility and whether you should receive a full or partial subsidy for future months. We will redetermine your eligibility if we made the initial determination of your eligibility or if you are deemed eligible because you receive SSI benefits. Rules regarding redeterminations of initial eligibility determinations made by a State are described in 42 CFR 423.774. (b) When we make redeterminations. (1) We will redetermine your subsidy eligibility within one year after we determine that you are eligible for the subsidy. (2) After the first redetermination, we will redetermine your subsidy eligibility at intervals determined by the Commissioner. The length of time between redeterminations varies depending on the likelihood that your situation may change in a way that affects your eligibility and whether you should receive a full or partial subsidy. (3) We may also redetermine your eligibility and whether you should receive a full or partial subsidy when you tell us of a change in your circumstances described in § 418.3120. (4) We may redetermine your eligibility when we receive information from you or from data exchanges with Federal and State agencies that may affect whether you should receive a full or partial subsidy or your eligibility for the subsidy. (5) We will also redetermine eligibility on a random sample of cases for quality assurance purposes. For each collection of sample cases, all factors affecting eligibility and/or whether you should receive a full or partial subsidy may be verified by contact with primary repositories of information relevant to each individual… | |||||
| 20:20:2.0.1.1.10.4.477.4 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3101 How do you become eligible for a subsidy? | SSA | Unless you are deemed eligible as explained in § 418.3105 and 42 CFR 423.773(c), you are eligible for a Medicare Part D prescription drug subsidy if you meet all of the following requirements: (a) You are entitled to or enrolled in Medicare Part A (Hospital Insurance) or enrolled in Medicare Part B (Supplementary Medical Insurance) or both under title XVIII of the Act. (b) You are enrolled in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage. We can also determine your eligibility for a subsidy before you enroll in one of the above programs. However, as explained in § 418.3225(b), if we determine that you would be eligible for a subsidy before you have enrolled in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage, you must enroll in one of these plans to actually receive a subsidy. (c) You reside in the United States as defined in § 418.3010. (d) You (and your spouse, if applicable) meet the income requirements as explained in §§ 418.3301 through 418.3350 and 42 CFR 423.773. (e) You (and your spouse, if applicable) meet the resources requirements as explained in §§ 418.3401 through 418.3425 and 42 CFR 423.773. (f) You or your personal representative file an application for a subsidy as explained in §§ 418.3201 through 418.3230. | |||||
| 20:20:2.0.1.1.10.4.477.5 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3105 Who does not need to file an application for a subsidy? | SSA | Regulations in 42 CFR 423.773(c) explain who is deemed eligible and does not need to file an application for a subsidy to be eligible for this assistance. Full-benefit dual eligible beneficiaries are in this category. If beneficiaries have deemed eligibility status because they receive Medicaid coverage, are enrolled in a Medicare Savings Program within their State, or receive SSI and have Medicare, then their subsidy is effective with the first month they have deemed eligibility status. | |||||
| 20:20:2.0.1.1.10.4.477.6 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3110 What happens when you apply for a subsidy? | SSA | (a) When you or your personal representative apply for a subsidy, we will ask for information that we need to determine if you meet all the requirements for a subsidy. You must give us complete information. If, based on the information you present to us, you do not meet all the requirements for eligibility listed in § 418.3101, or if one of the events listed in § 418.3115 exists, or you fail to submit information we request, we will deny your claim. (b) If you meet all the requirements for eligibility listed in § 418.3101, or you meet all the requirements except for enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage, we will send you a notice telling you the following: (1) You are eligible for a full or partial subsidy for a period not to exceed 1 year; (2) What information we used to make this determination including how we calculated your income and resources; (3) What you may do if your circumstances change as described in § 418.3120; and (4) Your appeal rights. (c) If you are not already enrolled with a Medicare prescription drug plan or a Medicare Advantage plan with prescription drug coverage, you must enroll in order to receive your subsidy. (d) If you do not meet all the requirements for eligibility listed in § 418.3101 or if § 418.3115 applies to you except for enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage as described in § 418.3225, we will send you a notice telling you the following: (1) You are not eligible for a subsidy; (2) The information we used to make this determination including how we calculated your income or resources; (3) You may reapply if your situation changes; and (4) Your appeal rights. | |||||
| 20:20:2.0.1.1.10.4.477.7 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3115 What events will make you ineligible for a subsidy? | SSA | Generally, even if you meet the other requirements in §§ 418.3101 through 418.3125, we will deny your claim or you will lose your subsidy if any of the following apply to you: (a) You lose entitlement to or are not enrolled in Medicare Part A and are not enrolled in Medicare Part B. (b) You do not enroll or lose your enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage. (c) You do not give us information we need to determine your eligibility and if eligible, whether you should receive a full or partial subsidy; or you do not give us information we need to determine whether you continue to be eligible for a subsidy and if eligible, whether you should receive a full or partial subsidy. (d) You knowingly give us false or misleading information. | |||||
| 20:20:2.0.1.1.10.4.477.8 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3120 What happens if your circumstances change after we determine you are eligible for a subsidy? | SSA | [70 FR 77675, Dec. 30, 2005, as amended at 75 FR 81845, Dec. 29, 2010] | (a) After we determine that you are eligible for a subsidy, your subsidy eligibility could change if: (1) You marry. (2) You and your spouse, who lives with you, divorce. (3) Subject to the provisions of paragraph (b)(4) of this section, your spouse, who lives with you, dies. (4) You and your spouse separate ( i.e. , you or your spouse move out of the household and you are no longer living with your spouse) unless the separation is a temporary absence as described in § 404.347 of this chapter. (5) You and your spouse resume living together after having been separated. (6) You and your spouse, who lives with you, have your marriage annulled. (7) You (or your spouse, who lives with you, if applicable) expect your estimated annual income to increase or decrease in the next calendar year. (8) You (or your spouse, who lives with you, if applicable) expect your resources to increase or decrease in the next calendar year. (9) Your family size as defined in 42 CFR 423.772 has changed or will change (other than a change resulting from one of the events in paragraphs (a)(1) through (6) of this section). (10) You become eligible for one of the programs listed in 42 CFR 423.773(c). (b)(1) When you report one of the events listed in paragraphs (a)(1) through (a)(6) of this section, or we receive such a report from another source (e.g., a data exchange of reports of death), we will send you a redetermination form upon receipt of the report. You must return the completed form within 90 days of the date of the form. (2) When you report one of the events listed in paragraphs (a)(7) through (a)(9) of this section or we receive such a report from another source (e.g., a data exchange involving income records), we will send you a redetermination form between August and December to evaluate the change. You must return the completed form to us within 30 days of the date of the form. (3) If we increase, decrease, or terminate your subsidy as a result of the redetermination, we will send you a notice telling you: (i) Wheth… | ||||
| 20:20:2.0.1.1.10.4.477.9 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3123 When is a change in your subsidy effective? | SSA | [70 FR 77675, Dec. 30, 2005, as amended at 75 FR 81845, Dec. 29, 2010] | (a) If we redetermine your subsidy as described in § 418.3120(b)(1), any change in your subsidy will be effective the month following the month of your report. (b) If we redetermine your subsidy as described in § 418.3120(b)(2), any change in your subsidy will be effective in January of the next year. (c) If you do not return the redetermination form described in § 418.3120(b)(1), we will terminate your subsidy effective with the month following the expiration of the 90-day period described in § 418.3120(b)(1). (d) If you do not return the redetermination forms described in § 418.3120(b)(2), we will terminate your subsidy effective in January of the next year. (e) Special rule for widows and widowers. If your spouse who lives with you dies and the changes in your income or resources resulting from your spouse's death would decrease or eliminate your subsidy, we will defer your next redetermination for 1 year from the month following the month we are notified of the death of your spouse, unless we receive a report of another event specified in 418.3120(a) that would affect your eligibility for a subsidy. | ||||
| 20:20:2.0.1.1.10.4.478.11 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3201 Must you file an application to become eligible for a subsidy? | SSA | Unless you are a person covered by § 418.3105, in addition to meeting other requirements, you or your personal representative must file an application to become eligible for a subsidy. If you believe you may be eligible for a subsidy, you should file an application. Filing a subsidy application does not commit you to participate in the Part D program. Filing an application will: (a) Permit us to make a formal determination on your eligibility for the subsidy and whether you should receive a full or partial subsidy; (b) Assure that you can receive the subsidy for any months that you are eligible and are enrolled in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage; and (c) Give you the right to appeal if you disagree with our determination. | |||||
| 20:20:2.0.1.1.10.4.478.12 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3205 What makes an application a claim for a subsidy? | SSA | We will consider your application a claim for the subsidy if: (a) You, or someone acting on your behalf as described in § 418.3215, complete an application on a form prescribed by us; (b) You, or someone acting on your behalf as described in § 418.3215, file the application with us pursuant to § 418.3220; and (c) You are alive on the first day of the month in which the application is filed. | |||||
| 20:20:2.0.1.1.10.4.478.13 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3210 What is a prescribed application for a subsidy? | SSA | If you choose to apply with SSA, you must file for the subsidy on an application prescribed by us. A prescribed application may include a printed form, an application our employees complete on computer screens, or an application available online on our Internet Web site ( www.socialsecurity.gov ). See § 418.3220 for places where an application for the subsidy may be filed and when it is considered filed. | |||||
| 20:20:2.0.1.1.10.4.478.14 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3215 Who may file your application for a subsidy? | SSA | You or your personal representative (as defined in 42 CFR 423.772) may complete and file your subsidy application. | |||||
| 20:20:2.0.1.1.10.4.478.15 | 20 | Employees' Benefits | III | 418 | PART 418—MEDICARE SUBSIDIES | D | Subpart D—Medicare Part D Subsidies | § 418.3220 When is your application considered filed? | SSA | (a) General rule. We consider an application for a subsidy as described in § 418.3210 to be filed with us on the day it is received by either one of our employees at one of our offices or by one of our employees who is authorized to receive it at a place other than one of our offices or it is considered filed on the day it is submitted electronically through our Internet Web site. If a State Medicaid agency forwards to us a subsidy application that you gave to it, we will consider the date you submitted that application to the State Medicaid agency as the filing date. (See 42 CFR 423.774 for applications filed with a State Medicaid agency.) (b) Exceptions. (1) When we receive an application that is mailed, we will assume that we received it 5 days earlier (unless you can show us that you did not receive it within the 5 days) and use the earlier date as the application filing date if it would result in another month of subsidy eligibility. (2) We may consider an application to be filed on the date a written or oral inquiry about your subsidy eligibility is made, or the date we receive a partially completed Internet subsidy application from our Internet Web site where the requirements set forth in § 418.3230 are met. |
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