There is a particular unfairness that catches American retirees after a successful move to Spain. They have already accepted that Medicare does not cover routine care in Spain. They have bought the Spanish private policy required for the non-lucrative visa. Some are also planning, later, to use the convenio especial once they have enough residence history.
Then a US notice arrives saying their Medicare premium is higher because of income. That extra amount is IRMAA: the income-related monthly adjustment amount. It does not ask whether Medicare is useful where you live. It asks only whether you are enrolled in Part B or Medicare drug coverage, and what your modified adjusted gross income looked like on the IRS return Social Security is using.
This page is not an argument for keeping or dropping Medicare. That decision belongs with your US Medicare adviser, tax adviser and financial planner. Our role is narrower: when we build a Spain move around a visa calendar, Spanish private insurance, first-year tax residence and retirement-income timing, IRMAA is one more delayed cost line that needs to be visible before the move is already done.
On this page
What IRMAA is The 2026 lookback: 2024 MAGI Why Spain does not switch it off The moves that create a delayed surcharge SSA-44 and life-changing events The Part B decision from Spain How to plan before the visa year Frequently asked questions
"For retirees, healthcare planning is a sequence. Spanish private insurance solves the visa. The convenio especial may solve the long term. Medicare is a separate US decision. IRMAA matters because a tax move you make before Spain can raise a premium after you are already here."
— Lola Jurado · Immigration lawyer, Ilustre Colegio de Abogados de Málaga (nº 10907)
What IRMAA is
IRMAA is not a Spanish tax, not a Spanish insurance premium and not a visa requirement. It is an additional US Medicare premium charged to higher-income beneficiaries. Social Security describes it as the income-related monthly adjustment amount. It can apply to Medicare Part B and to Medicare prescription drug coverage, commonly called Part D. It does not apply to premium-free Part A.
The key word is additional. For Part B, most people pay the standard monthly premium. In 2026, Medicare.gov lists the standard Part B premium as $202.90. If your income crosses the IRMAA threshold, you pay that standard premium plus an extra monthly amount. If you have Part D coverage, you can also pay a Part D IRMAA on top of your drug plan premium.
Social Security usually deducts the amount from your monthly Social Security payment. If the deduction is bigger than the payment, or if you do not receive monthly Social Security, another federal agency may bill you. That matters for expats because a person living in Spain can still be in the US billing system even when the underlying Medicare coverage has limited practical value abroad.
The 2026 lookback: 2024 MAGI
IRMAA is delayed by design. For 2026 premiums, Social Security generally looks at your modified adjusted gross income from your 2024 IRS tax return. In 2026, the threshold starts above $109,000 for an individual return and above $218,000 for a joint return. Married filing separately has its own compressed table.
That two-year lookback is the part that turns ordinary pre-move planning into a surprise. A retiree may sell a US home in 2024, do a Roth conversion in 2024, realise a large brokerage gain in 2024, move to Spain in 2025 and only see the Medicare premium increase in 2026. By then the Spanish lease is signed, the private insurance is running and the retiree may feel the premium is coming from nowhere. It is not. It is coming from the old return.
Why Spain does not switch it off
Medicare's foreign-coverage rule and IRMAA's income rule answer different questions. Medicare generally does not pay for care outside the United States, which is why a US retiree needs Spanish private insurance for the visa and a Spanish healthcare plan for real life. But IRMAA is attached to enrollment and income. It does not ask whether a doctor in Marbella can bill Medicare.
This creates a neat but uncomfortable split. Spain requires you to carry a compliant Spanish private policy for the non-lucrative visa. Later, Spain may let you access public healthcare through the convenio especial if you qualify. Neither fact removes a US premium surcharge if you keep Medicare Part B or Part D and your income is high enough. You can be paying for a Spanish policy, paying into Spanish public care later, and still paying a higher US Medicare premium for coverage you preserve mainly for US returns, a future move back, or risk management.
That does not make keeping Medicare irrational. It just means the cost must be modelled honestly. For a snowbird or someone with serious US medical relationships, Part B may still be worth keeping. For someone making a permanent move with no likely US return, the premium, IRMAA and late-enrollment consequences need a deliberate US-side decision.
The moves that create a delayed surcharge
The visa itself does not create IRMAA. The triggers are usually tax events that lift MAGI. The most common ones we see around a Spain move are:
- Roth conversions. A conversion may be excellent long-term US planning, but it can raise MAGI for IRMAA. Read this alongside our Roth IRA and Spain guide.
- Large capital gains. Selling a portfolio position, business interest or second home before the move can be tax-efficient compared with Spanish residence-year taxation, but the US Medicare premium lookback can still catch it later.
- Required minimum distributions. RMDs can lift MAGI even when they are ordinary retirement income rather than investment income. Our RMD page covers the Spain timing layer.
- Qualified Opportunity Fund inclusions. Deferred gains that become taxable can hit the year you least want them to; see the QOF guide.
- Social Security plus portfolio income. Social Security itself is not the same thing as IRMAA, but taxable benefits are part of the MAGI picture. The income mix also matters for the visa file, as explained in Social Security plus investment income.
This is the same planning discipline as the 3.8% net investment income tax, but with a different mechanism. NIIT charges a tax on investment income above a threshold. IRMAA raises a healthcare premium after a lookback year. Both can be produced by the same event, and both are easy to miss if the only calendar you are watching is the visa appointment calendar.
SSA-44 and life-changing events
IRMAA is not always final. Social Security's Form SSA-44 exists for people whose income has fallen because of a life-changing event. The form lists events such as marriage, divorce or annulment, death of a spouse, work stoppage, work reduction, loss of income-producing property, loss of pension income and employer settlement payment. If one of those events applies and your household income has gone down, you can ask Social Security to use a more recent estimate instead of the older tax return.
The useful expat point is also the limit: moving to Spain is not, by itself, the life-changing event. Retiring before the move may be. A reduction in work may be. Loss of pension income may be. Selling your home, changing tax residence or deciding that Medicare is not useful in Spain does not automatically fit the form. If you are relying on SSA-44, the evidence should be built around the listed event and the reduced income, not around the relocation story.
The Part B decision from Spain
Dropping Part B simply to avoid IRMAA can be a bad answer. It may remove one premium, but it can create late-enrollment penalties and a gap if you move back to the United States or spend meaningful time there. Keeping Part B can also be a bad answer if the retiree treats the premium as a habit rather than a decision and then pays for years of coverage that does not solve any realistic risk.
The right analysis starts with facts. How often will you return to the US? Do you have a US doctor or treatment relationship you intend to preserve? Could you move back? Will you maintain Part D? Are you eligible for any other US coverage? What Spanish private policy will you carry for the visa? When might the convenio especial become available in your autonomous community? These are not legal questions in isolation; they are healthcare, tax and residence planning questions that need to be read together.
How to plan before the visa year
IRMAA belongs in the first-year budget because it is one of the costs that can arrive after the move from a decision made before the move. A careful plan usually does four things.
- Pull the old return. Identify the MAGI year that will drive the premium year. For 2026, start with 2024.
- Identify spikes before they happen. Roth conversions, business sales, QOF inclusions, RMD bunching and home sales should be modelled not just for US and Spanish tax, but also for Medicare premiums.
- Decide on Medicare deliberately. Treat Part B and Part D as a US coverage decision, not as a leftover payroll habit.
- Coordinate the Spain healthcare sequence. Visa private insurance first; real Spanish care plan next; possible convenio especial later. IRMAA sits outside that Spanish sequence but still affects cash flow.
Our immigration work cannot decide whether you should keep Medicare. What it can do is stop the visa move from being planned in a vacuum. If the date you become Spanish tax resident, the date you sell an asset, the date you retire and the Medicare premium year all point to different calendars, someone has to lay them on the same table before the paperwork starts.
Frequently asked questions
Does IRMAA still apply if I live in Spain?
Yes, if you are enrolled in Medicare Part B or Medicare prescription drug coverage and your MAGI is above the applicable threshold. IRMAA is tied to Medicare enrollment and US tax return income, not to where you receive medical care.
What income year is used for 2026 IRMAA?
For 2026 premiums, Social Security generally uses MAGI from the 2024 IRS tax return. That is why a pre-move Roth conversion, home sale or large capital gain can raise Medicare premiums after you are already living in Spain.
Can Form SSA-44 reduce IRMAA after I retire abroad?
Possibly. SSA-44 can be used after certain life-changing events, including work stoppage, work reduction, marriage, divorce, death of a spouse, loss of income-producing property, loss of pension income and employer settlement payment, if the event reduces household income. Moving to Spain itself is not the event.
Does IRMAA apply to Part A?
No. IRMAA applies to Medicare Part B and Medicare prescription drug coverage, often called Part D. It does not apply to premium-free Part A.
Should I drop Medicare Part B to avoid IRMAA?
Not on IRMAA alone. The decision depends on how often you return to the United States, whether you may move back, late-enrollment penalties, coverage gaps and your Spanish healthcare plan. IRMAA is one cost line in that decision, not the whole answer.
Sources reviewed July 2026: Social Security Administration guidance on Medicare premiums for higher-income beneficiaries and Form SSA-44; Medicare.gov 2026 Medicare Costs and Medicare & You materials; CMS 2026 Medicare Parts A and B premiums and deductibles fact sheet; SSA POMS IRMAA sliding-scale tables and calculation guidance. General information only, not legal, tax, financial, Medicare or insurance advice. Confirm current premiums, thresholds and appeal options with Social Security, Medicare and your own US advisers before relying on them.