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A W-4 is for adjusting your income tax withholding, not for making estimated tax payments. (Those are done with Form 1040-ES.) I'm pretty the IRS is saying you can adjust your income tax withholding to account for this additional tax.

From the website:

Will I need to make estimated tax payments for Additional Medicare Tax?

If you anticipate that you will owe Additional Medicare Tax but will not satisfy the liability through Additional Medicare Tax withholding and did not request additional income tax withholding using Form W-4, you may need to make estimated tax payments. You should consider your estimated total tax liability in light of your wages, other compensation, and self-employment income, and the applicable threshold for your filing status when determining whether estimated tax payments are necessary.

I'm not sure how additional Federal Income Tax withholding helps with the Medicare Tax unless there is a provision to apply any overage to the Medicare tax -which will probably mean another form.

And your forgot the other side of the coin. Take that married couple, but only one is working and making $220k. That spouse will have the medicare surtax withheld, but the couple won't be subject to the tax. I'm sure the overwithholding will be handled just like additional income tax withholding on the tax return.

I did not forget it actually...this situation was addressed in the FAQ's...
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