Medicare for Nurses: IRMAA, Travel Nurse Income, and Hospital Coverage Coordination

Nursing careers produce complicated Medicare situations that most financial advisors aren't equipped to model. Travel nursing assignments in your early 60s can spike MAGI into IRMAA territory two years after the work is done. Overtime and shift differentials in final working years follow you into retirement via the two-year look-back. CRNAs and nurse practitioners earning $200,000+ face some of the highest IRMAA surcharges of any Medicare enrollee. And nurses who remain employed at large hospitals past 65 have special enrollment rules that trip up generalist advisors. Here is the full picture.

How nurse income types count for IRMAA

IRMAA MAGI equals your Adjusted Gross Income (Form 1040 Line 11) plus tax-exempt interest (Line 2a). Nursing compensation flows into MAGI through several channels depending on your employment arrangement.¹

Shift differentials and overtime in the two-year look-back

Hospital nursing is built around irregular pay. Night differentials, weekend premiums, float pool bonuses, charge nurse stipends, and mandatory overtime create earnings well above base salary in many years. For IRMAA purposes, all of this income counts toward MAGI in the year it is received — not the year it was earned.

The two-year look-back rule means SSA uses your 2024 income to set your 2026 Part B and D premiums, and your 2025 income to set your 2027 premiums. A nurse who works intensive overtime in the final two years before retirement — because of staffing shortages, extra vacation accrual, or simply financial planning — can inadvertently trigger IRMAA surcharges in the first one to two years of Medicare coverage, even though her current retirement income is well below the threshold.

The practical implication: if you know you will retire in a specific year, consider moderating optional overtime in the two prior years. Every dollar of W-2 income above the IRMAA threshold in year N costs you $1,148 to $6,936 in year N+2 Medicare premiums. Whether that tradeoff makes sense depends on your wage rate and marginal tax situation — but it should be a conscious decision, not a surprise two years later.

Travel nurse income and IRMAA: the delayed bill

Travel nursing has expanded dramatically, with experienced nurses routinely earning $130,000–$180,000/year from high-demand hospital systems — well above the $109,000 single-filer IRMAA threshold.² Many travel nurses plan to work intensively through their early 60s and retire at 65 when Medicare eligibility begins. The problem is timing.

A nurse who does travel assignments at ages 63 and 64 earns the income in 2023 and 2024. Those years' MAGI set Medicare premiums in 2025 and 2026 — which are the first two years she actually uses Medicare. She may not realize the connection at all until the first IRMAA determination letter arrives from SSA.

If the travel assignments produce MAGI above the IRMAA threshold specifically because of the temporary travel income — and her retirement income on its own would be below threshold — filing Form SSA-44 is worth examining. The qualifying life-changing event is retirement. However, SSA-44 asks for current-year estimated income, not the prior year. If retirement happened in the Medicare enrollment year and current income is materially lower, SSA can use that estimate instead of the two-year-old high-income tax return. See the full SSA-44 guide for when this works and when it doesn't.

CRNA and nurse practitioner IRMAA

Certified Registered Nurse Anesthetists (CRNAs) are among the highest-earning nurses, with a median wage of approximately $212,000/year according to BLS data.³ Nurse practitioners (NPs) in specialty practice can also earn $130,000–$180,000 or more. At these income levels, IRMAA planning is not optional.

For CRNAs or NPs still working past 63, the two-year look-back is almost always the dominant issue. A CRNA earning $250,000 in 2024 with $32,500 in 403(b) deferrals has MAGI of approximately $217,500 — just under the single-filer Tier 4 threshold of $205,001. Even modest investment income pushes her into Tier 4, which adds $6,355/year in Medicare surcharges.

At retirement, filing SSA-44 is critical. A CRNA going from $250,000 MAGI to $45,000 in retirement income saves potentially $5,000–$6,000/year in IRMAA while SSA catches up to the new income level over one to two years. Most hospital HR departments will not mention this. See IRMAA appeal guide for the SSA-44 process.

Hospital employer coverage at age 65: the Medicare coordination rules

Nurses employed at large hospitals — generally any facility with 20 or more employees — are subject to the large employer Medicare secondary payer (MSP) rules.⁴ This creates options that nurses working at smaller practices do not have.

If you are working past 65 at a large hospital:

• You can delay Medicare Part B enrollment without incurring the permanent 10%-per-year late enrollment penalty, as long as you remain actively enrolled in qualifying employer group health coverage.
• Medicare Part A (hospital coverage) is premium-free for most nurses at 65 and has no late enrollment penalty, so enrolling in Part A at 65 is usually harmless — unless you contribute to a Health Savings Account (see the HSA trap below).
• Once employment ends, you have an 8-month Special Enrollment Period (SEP) to enroll in Part B without penalty. Do not confuse this with COBRA: COBRA is not active employer coverage, and the SEP clock starts when employer coverage ends — not when COBRA ends.

The HSA trap for nurses with employer HSA plans. Many large hospital systems offer High-Deductible Health Plans (HDHPs) paired with employer-contributed HSAs. Enrolling in any part of Medicare — including Part A — makes you ineligible for HSA contributions starting the first day of the enrollment month.⁵ Worse, Medicare Part A enrollment is retroactive up to six months (or back to age 65, whichever is shorter). If you apply for Social Security benefits, Medicare Part A enrollment is automatic and also retroactive. A nurse who enrolls in Social Security at 65 while still contributing to an employer HSA may inadvertently create taxable excess contributions for the retroactive period. The penalty is income tax plus 6% excise tax on each year the excess remains. See Medicare and HSA enrollment guide for the full rules.

Nurse pension plans and IRMAA stacking

Defined benefit pensions are less common in nursing than they were a generation ago — most large hospital systems converted to 403(b) defined contribution plans in the 1990s and 2000s. However, nurses who spent careers at Kaiser Permanente, specific union hospital systems (under SEIU, NYSNA, or CNA bargaining agreements), VA medical centers, or state and county public hospitals may have meaningful DB pension income in retirement.

Pension income is 100% taxable ordinary income and flows dollar-for-dollar into IRMAA MAGI. A nurse with a $28,000/year hospital pension, $18,000/year in Social Security (85% taxable = $15,300), and $35,000/year in 403(b) withdrawals has estimated MAGI of $78,300 — below the Tier 1 threshold. But if her spouse has similar income and they file jointly, their combined MAGI of $156,600 approaches the $218,000 MFJ Tier 1 boundary at retirement, and will cross it when RMDs begin.

The trajectory matters as much as the current number. Required minimum distributions from traditional 403(b) and IRA accounts begin at age 73 and grow with account balances over time. A nurse who retires at 65 with modest MAGI may see premiums climb into IRMAA territory by her mid-70s without any lifestyle change — simply because RMDs compound upward. Projecting the 10–15-year premium trajectory is the central job of Medicare planning for nurses with substantial retirement savings.

WEP and GPO repeal: impact for nurses in government positions

On January 5, 2025, Congress repealed both the Windfall Elimination Provision (WEP) and the Government Pension Offset (GPO) via the Social Security Fairness Act, effective retroactive to January 2024.⁶ This affects nurses who:

• Worked for state or county public hospitals in non-Social-Security-covered positions AND also worked Social-Security-covered jobs at some point in their career
• Are surviving spouses of such workers
• Were employed at VA medical centers (federal, SS-covered under FERS) while also having some non-covered government pension from a prior state employer

For most hospital nurses at large nonprofit or private hospital systems, WEP/GPO was not a factor because those jobs were SS-covered. The repeal's largest impact falls on government-employed nurses — public health nurses at county departments, state psychiatric hospital nurses, or county hospital ICU nurses in states like California, Ohio, and Illinois that had non-SS-covered government health positions.

If the WEP/GPO repeal increased your Social Security benefit, that increase — and the retroactive lump-sum SSA sent — counts toward IRMAA MAGI in the year received. A $15,000 retroactive payment received in 2025 flows into 2025 AGI and affects 2027 Medicare premiums. This is a one-time hit, not a permanent change to your bracket, but it is worth knowing about.

IRMAA calculator for nurses

Estimate your 2026 Medicare IRMAA surcharge based on your nursing income sources. Enter the income year you want to model — typically 2024 income for 2026 premiums, or your estimated current retirement income to assess SSA-44 eligibility.

5 strategies to reduce IRMAA for nurses

1. Maximize pre-tax 403(b) and catch-up contributions before retirement. The 2026 403(b) elective deferral limit is $24,500/year. Nurses ages 50–59 and 64+ can contribute an additional $8,000 catch-up (total $32,500). Nurses ages 60–63 get a SECURE 2.0 "super catch-up" of $11,250 (total $35,750).⁷ Every pre-tax dollar contributed reduces MAGI in the contribution year — which becomes the base for IRMAA two years later. A charge nurse earning $140,000 who contributes $35,750 to her traditional 403(b) at age 62 reduces that year's MAGI to approximately $104,000, staying just under the Tier 1 threshold.

2. File Form SSA-44 at retirement. If you retired and your current income is materially lower than the two-year-old tax return SSA used to set your Medicare premiums, file SSA-44. Retirement is a qualifying life-changing event. SSA will use your estimated current-year income if it is lower, and premiums are adjusted for subsequent years automatically. The savings can be $1,148–$6,355/year per person. See IRMAA appeal guide for the exact process and documentation needed.

3. Use qualified charitable distributions (QCDs) once you reach 70½. If you have rolled a 403(b) or 457(b) over to a traditional IRA (governmental 457(b) plans can be rolled to IRA; non-governmental 457(b) plans cannot), you can make QCDs directly from the IRA to qualifying charities. QCDs exclude up to $111,000/year per person from AGI entirely — not just as a deduction, but as a full bypass of MAGI.⁸ A nurse with $115,000 MAGI at Tier 1 who donates $10,000 to her hospital's foundation via QCD drops to $105,000 and eliminates $1,148/year in IRMAA surcharges. See 7 IRMAA reduction strategies.

4. Calibrate 403(b) withdrawals around IRMAA bracket cliffs. If your pension and SS put you at $95,000 MAGI (single filer), you have a $14,000 buffer before the $109,000 Tier 1 threshold. Drawing more than $14,000 from a traditional 403(b) in that year crosses you into IRMAA. Instead, consider drawing the $14,000 from traditional accounts and supplementing with Roth 403(b) or taxable accounts (where qualified dividends may be taxed at 0% federally and don't affect the IRMAA cliff in the same discrete way). See IRA and 401(k) withdrawal IRMAA guide.

5. Model the RMD runway before it begins. Traditional 403(b) and IRA balances subject to required minimum distributions starting at age 73 will mechanically add income each year at a growing rate. For a nurse with $400,000 in a traditional 403(b) who retires at 65, that account grows for eight years before RMDs begin. A financial advisor can model whether Roth conversions in the pre-RMD window (ages 65–72) reduce the lifetime IRMAA burden — by paying taxes at a lower rate now and permanently removing those funds from future MAGI. See RMDs and Medicare premiums for the projection framework.

What a Medicare specialist models that is hard to DIY

For nurses, the most common planning gap is not knowing what IRMAA tier you will land in your first Medicare year until the SSA determination letter arrives — six to eighteen months after the income year that set the premium. By then, the income has already been earned.

The actionable window is the two to three years before Medicare enrollment: maximizing pre-tax deferrals, calibrating travel assignments or overtime, timing any final large income events, and setting up the SSA-44 filing at retirement. A fee-only advisor familiar with Medicare planning can walk through your specific income sources, run the two-year look-back calendar, and quantify the strategies above in the context of your situation — before the income is earned.

Sources

1. SSA POMS HI 01101.020 — IRMAA Sliding Scale Tables: 2026 IRMAA bracket thresholds and Part B/D monthly surcharge amounts. Single-filer Tier 1 threshold $109,000; MFJ Tier 1 threshold $218,000. MAGI for IRMAA = AGI + tax-exempt interest. Standard Part B premium $202.90/month per CMS Nov 2025 fact sheet. Verified June 2026.
2. BLS Occupational Employment and Wage Statistics — Registered Nurses (SOC 29-1141): median annual wage approximately $81,220 for all RNs; experienced nurses in specialty units and charge roles earn substantially more. Travel nursing agency placements in high-demand hospital markets command significant total compensation premiums above staff rates. Verified June 2026.
3. BLS — Nurse Anesthetists (SOC 29-1151): median annual wage $212,650 as of the most recent BLS Occupational Employment and Wage Statistics survey. CRNAs in private practice or independent contracting arrangements often exceed this median. Verified June 2026.
4. CMS — Medicare Secondary Payer (MSP) Rules: for employers with 20 or more employees, group health plan is primary to Medicare for active employees age 65 and over; Medicare is secondary. Active employees may delay Part B without late enrollment penalty while employer coverage is in place; SEP begins when active employment or employer coverage ends, whichever comes first. 8-month SEP per 42 CFR 406.21. Verified June 2026.
5. IRS Publication 969 — Health Savings Accounts and Other Tax-Favored Health Plans: IRC §223(b)(7) — enrollment in Medicare (any part) disqualifies an individual from making HSA contributions. Part A enrollment may be retroactive up to 6 months from application date (but not before age 65). Excess HSA contributions are subject to income tax plus 6% excise tax. Verified June 2026.
6. SSA.gov — Social Security Fairness Act: H.R. 82 signed January 5, 2025, repealing WEP and GPO retroactive to January 2024. SSA began issuing retroactive lump-sum payments and adjusting monthly benefits in February 2025. Retroactive payments are Social Security benefits and are taxable income (85% of SS benefit rule applies) in the year received. Verified June 2026.
7. IRS — 403(b) Contribution Limits 2026: elective deferral limit $24,500; age 50–59 and 64+ catch-up $8,000 (total $32,500); ages 60–63 SECURE 2.0 super catch-up $11,250 (total $35,750) per IRS Rev. Proc. 2025-67. Roth 403(b) contributions do not reduce current-year MAGI. Verified June 2026.
8. IRS — Qualified Charitable Distributions (QCDs): IRC §408(d)(8) permits QCDs from IRAs only; 403(b) and 457(b) plans must be rolled to an IRA first (governmental 457(b) eligible; non-governmental 457(b) not eligible for IRA rollover per IRC §457(b)(10)). 2026 QCD annual limit $111,000 per person per IRS Notice 2025-67. QCD amount excluded from AGI and MAGI. Verified June 2026.

Values verified as of June 2026. IRMAA brackets per SSA POMS HI 01101.020. 403(b) limits per IRS Rev. Proc. 2025-67. QCD limit per IRS Notice 2025-67. Consult a licensed advisor for guidance specific to your situation.