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Many retirees spend years carefully planning for taxes, Social Security, investment withdrawals, and healthcare costs. Yet one retirement expense often catches people completely by surprise. It is called IRMAA, which stands for Income Related Monthly Adjustment Amount. Most retirees simply know it as the Medicare surcharge. The frustrating part is that many people do not discover IRMAA until after the damage has already been done. A large Roth conversion, a substantial capital gain, the sale of a property, or a large IRA withdrawal can trigger higher Medicare premiums years later.