What is Medicare Advantage?

Medicare Advantage, also called Part C, is offered by private insurance companies approved by Medicare. It usually combines Part A, Part B, and often Part D prescription drug coverage.

What is the difference between Original Medicare and Medicare Advantage?

Original Medicare is run by the federal government and lets you use any provider that accepts Medicare. Medicare Advantage is offered by private insurers and often uses provider networks.

What is Medicare Supplement or Medigap?

Medicare Supplement, also called Medigap, works with Original Medicare to help reduce out-of-pocket costs. It can help cover certain copays, coinsurance, and deductibles.

Does Medigap include prescription drug coverage?

Medigap plans sold today do not include prescription drug coverage. Most people need a separate Medicare Part D plan for medications.

What is Medicare Part D?

Medicare Part D is prescription drug coverage offered by private insurance companies approved by Medicare. It helps cover medication costs based on the plan’s formulary.

When is the Medicare Annual Enrollment Period?

The Medicare Annual Enrollment Period usually runs from October 15 to December 7 each year. During this time, many people can review or change Medicare Advantage and Part D plans.

Can I switch Medicare Advantage plans later?

Yes, but timing matters. Most people can switch during Annual Enrollment, Medicare Advantage Open Enrollment, or a qualifying Special Enrollment Period.

What is the difference between HMO and PPO Medicare Advantage plans?

HMO plans usually require in-network care and may need referrals. PPO plans generally offer more provider flexibility but may cost more for out-of-network care.

Do Medicare Advantage plans require prior authorization?

Many Medicare Advantage plans require prior authorization for certain services. This can include imaging, surgeries, skilled nursing care, or other covered treatments.

Do Medicare Advantage plans have an out-of-pocket limit?

Yes, Medicare Advantage plans include an annual maximum out-of-pocket limit for covered medical services. Original Medicare does not include this protection by itself.

Why do Medicare plans change every year?

Plans may update premiums, copays, drug formularies, provider networks, and benefits each year. Reviewing your plan annually helps avoid unexpected changes.

How can I find a Medicare plan that includes my doctor?

You should check the plan’s provider network before enrolling. A local Medicare agent can help confirm whether your doctors and hospitals are included.

IRMAA is an income-related adjustment that can increase Medicare Part B and Part D premiums. It is based on your reported income from prior tax years.

What is a Special Enrollment Period?

A Special Enrollment Period allows certain Medicare changes outside normal enrollment windows. Qualifying events may include moving, losing coverage, or plan changes.

Why work with a local Medicare agent?

A local Medicare agent can help compare plan options, explain networks, and review coverage based on your area. This can make Medicare decisions easier to understand.

What Is a Medicare Excess Charge: Clear Explanation, Impact, and How to Avoid It

January 28, 2026

You can owe up to 15% more when a doctor does not accept Medicare assignment — that extra fee is called a Medicare Part B excess charge. If a provider doesn’t accept Medicare’s approved amount, you may have to pay the difference out of pocket, unless your Medigap plan covers it.

Knowing this helps you avoid surprise bills and plan for care costs. This article will explain how excess charges are calculated, which providers can bill them, and which states limit or ban them.

You’ll learn how Medigap can protect you, how to check whether a doctor accepts Medicare assignment, and practical steps to lower your chances of facing extra fees. If you want one-on-one help, The Modern Medicare Agency can guide you through your options.

Our licensed agents speak with you directly, match Medicare packages to your needs, and help avoid plans that add unnecessary costs — all without charging extra fees.

Understanding Medicare Excess Charges

Medicare excess charges are extra amounts some doctors can bill you beyond what Medicare pays. You need to know how they form, which services often carry them, and how to avoid surprise bills.

Definition of Medicare Excess Charges

A Medicare excess charge is the extra fee a provider can bill you when they do not accept Medicare assignment. Medicare sets an approved amount for each service.

If a doctor opts out of assignment, they can charge up to 15% more than that approved amount. You still pay your Part B deductible and coinsurance in addition to any excess charge.

Not all providers charge the full 15%; some add 5% or 10% instead. Medigap plans vary: some cover excess charges and some do not.

How Excess Charges Originate

Excess charges arise when a provider refuses Medicare assignment. Accepting assignment means the provider agrees to accept Medicare’s approved amount as full payment.

When providers decline, they can set their own fee above Medicare’s rate. Medicare notifies you of the approved amount on your Explanation of Benefits.

Providers must tell you if they won’t accept assignment for a visit. You can avoid excess charges by choosing providers who accept assignment or by selecting a Medigap plan that covers excess charges.

Services Commonly Subject to Excess Charges

Excess charges most often appear for office visits, outpatient procedures, and specialist consultations. Lab tests and imaging may also carry extra fees if the provider doesn’t accept assignment.

Emergency services billed by an out-of-network doctor can generate excess charges too. Before scheduling non-emergency services, ask the provider if they accept Medicare assignment and request a written estimate if you expect higher costs.

Why choose The Modern Medicare Agency? Our licensed agents are real people you can speak with one-on-one.

They match Medicare packages to your needs and help you find providers who accept assignment, all without extra fees that break the bank.

How Medicare Excess Charges Work

Medicare excess charges happen when a provider bills more than what Medicare approves. You need to know when providers can add a fee, how that fee is figured, and the legal cap on extra charges.

Role of Medicare Assignment

Medicare assignment is an agreement where a doctor accepts the Medicare-approved amount as full payment. If a provider accepts assignment, you pay only your Part B coinsurance or deductible and no extra charge from that provider.

If a provider does not accept assignment, they can bill you beyond Medicare’s approved amount. You still get reimbursed by Medicare for its share, but you must pay the difference between the provider’s charge and the Medicare-approved amount, plus your usual out-of-pocket share.

Your best protection is to confirm assignment before care. Ask the office whether they accept Medicare assignment and get it in writing when possible.

The Modern Medicare Agency can help you check provider assignment status and explain how it affects your costs.

Calculation of Excess Charges

Excess charges equal the provider’s billed amount minus the Medicare-approved amount. For example, if Medicare approves $100 for a service and the provider bills $110, the excess charge is $10.

Medicare pays its portion of the approved amount directly to you or the provider depending on assignment. You then owe the excess plus any coinsurance or deductible you already owe.

Keep receipts and Medicare statements to verify calculations. If you have a Medigap plan, certain plans cover excess charges.

Check your specific Medigap benefits or talk to an agent who can compare plans and tell you whether your plan will cover the difference.

Limits on Excess Charges

Federal rules cap Medicare Part B excess charges at 15% above the Medicare-approved amount. That means a provider cannot bill you more than 115% of the approved amount for most services.

Not all providers can charge excess fees. Providers who accept assignment cannot impose excess charges.

Also, Medicare Advantage plans generally use different cost rules and typically do not allow traditional excess charges. If a provider violates the cap or misrepresents assignment, report it to Medicare and consider contacting a licensed agent at The Modern Medicare Agency.

Our agents are real people you can speak to one-on-one, and they help you find Medicare packages that match your needs without charging extra fees that break the bank.

Providers and Acceptance of Medicare Assignment

Knowing whether a provider accepts Medicare assignment affects how much you pay and whether you risk extra charges. This section explains the difference between provider types and how your choice can change out-of-pocket costs.

Participating vs. Non-participating Providers

Participating providers sign an agreement with Medicare to accept the Medicare-approved amount as full payment. When a participating doctor bills Medicare directly, you only pay the Part B deductible and the coinsurance or copay that Medicare allows.

You will not face extra or “balance” bills beyond those amounts. Non-participating providers do not always accept the Medicare-approved amount.

They may accept assignment for certain services but can also bill above Medicare’s approved rate. That extra charge is called an excess charge and can be up to 15% over Medicare’s approved amount.

If you see a non-participating provider, ask in advance whether they accept assignment for the service you need so you know if an excess charge might apply.

How Provider Choice Affects Excess Charges

If you use a participating provider, you avoid excess charges entirely. That reduces your financial risk for covered services under Original Medicare.

Participating providers bill Medicare directly and follow Medicare’s payment rules. If you choose a non-participating provider, plan for possible extra costs.

Non-participating providers can charge up to 15% more than Medicare’s approved amount for Medicare-covered services. These excess charges are separate from your deductible and coinsurance.

Check provider status before an appointment. If you need help comparing plans or finding providers who accept assignment, contact The Modern Medicare Agency.

Our licensed agents speak with you one-on-one, match Medicare packages to your needs, and don’t add extra fees.

States With Restrictions on Excess Charges

Some states stop doctors from charging more than Medicare allows, while others add rules that protect you in specific ways. Know which states ban excess charges and what extra protections you might have so you aren’t surprised by out‑of‑pocket costs.

States That Prohibit Excess Charges

Eight states currently prohibit Medicare Part B excess charges. These states are Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont.

If you live in one of these states, non‑participating providers cannot bill you the extra 15% above the Medicare‑approved amount. If you move or travel, check billing practices in the state where you get care.

Even inside these states, confirm with your provider that they will not issue an excess charge and always ask whether they accept Medicare assignment before services.

State-specific Protections for Beneficiaries

Some states add rules beyond outright bans. Protections can include limits on surprise billing, tighter enforcement of billing laws, and clearer appeal rights if you get billed incorrectly.

These measures make it easier for you to contest improper charges and reduce unexpected costs. If you want help understanding how state rules affect your plan choices, contact The Modern Medicare Agency.

Our licensed agents are real people you can speak with one‑on‑one. They’ll review your needs, explain state rules that matter to you, and find Medicare plans without extra fees that break the bank.

Impact on Beneficiaries

You may face extra costs and new billing steps if a provider charges more than the Medicare-approved amount. Know what you might pay and what tasks fall to you when that happens.

Out-of-pocket Costs

If a provider does not accept Medicare assignment, they can charge up to 15% more than the Medicare-approved amount. That extra fee, called the excess charge, does not count toward your Medicare Part B deductible.

You still pay the standard Part B coinsurance or copay, then add the excess charge on top. Examples:

If Medicare pays $100, a non-assigned provider can bill you up to $115.
You would owe your coinsurance plus the excess charge, increasing your bill significantly for some services.

Medigap Plans F and G can cover excess charges in many cases. Plan F is not available to new Medicare enrollees since 2020, so check Plan G or other supplements.

The Modern Medicare Agency can help you compare plans and find one that limits your out-of-pocket exposure.

Billing Processes and Patient Responsibilities

When a provider does not accept assignment, they must tell you in writing before giving non-emergency services. You should receive an Advance Beneficiary Notice or a clear statement that the provider will charge excess amounts.

Review any written notice carefully before you agree to the service. You are responsible for:

Asking whether the provider accepts Medicare assignment.
Requesting a cost estimate in writing for non-emergency care.
Keeping copies of notices and bills to dispute errors.

If a bill seems wrong, contact the provider first. If that does not resolve it, call Medicare or get help from The Modern Medicare Agency.

Our licensed agents will talk with you 1 on 1, review statements, and help you understand whether charges are valid and which plan options reduce your risk.

Medigap and Coverage for Excess Charges

Medigap can fill gaps in Original Medicare by paying certain out-of-pocket costs that Medicare doesn’t cover. Some Medigap plans specifically handle Part B excess charges, and choosing the right one affects how much you pay when a provider charges above the Medicare-approved amount.

Medigap Plans That Cover Excess Charges

Only a few Medigap plans cover Part B excess charges. Plan G covers excess charges, and Plan F also does but is only available if you were eligible for Medicare before January 1, 2020.

If you have either plan, Medicare pays its share first, and then your Medigap policy can pay the amount the provider adds above the Medicare-approved fee (up to the legal 15% limit where allowed). Check if your state allows excess charges.

In states that ban them, this issue won’t apply. Also confirm whether your current or prospective doctors accept Medicare assignment; if they do, excess charges won’t occur.

Ask about excess-charge coverage when you shop for plans so you avoid surprise bills.

Selecting a Medigap Plan for Protection

Decide based on your health habits and provider network. If you visit doctors who don’t accept Medicare assignment, a plan that covers excess charges will protect you from those extra costs.

Compare premiums: plans that cover excess charges often cost more, so weigh the premium against how often you expect to face excess charges. Talk with a licensed agent to match a plan to your needs.

The Modern Medicare Agency offers real, licensed agents who speak with you one-on-one, review your provider list, and identify Medigap packages that fit your budget without hidden fees. That personal help can simplify choices and reduce the chance of unexpected bills.

Steps to Avoid Paying Medicare Excess Charges

You can prevent extra Part B fees by checking whether a provider accepts Medicare assignment and by getting a clear assignment agreement before care. Both steps take minutes but can save you up to 15% per visit.

Verifying Provider Participation

Call the provider’s office and ask directly if they accept Medicare assignment for the specific service you need. Confirm whether they bill Medicare directly and accept the Medicare-approved amount as full payment.

Check the provider’s participation for each visit. Some doctors accept assignment for some services but not others.

Ask for written confirmation or an email so you have proof if a charge appears later. If you live in Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or Vermont, state rules may already limit excess charges.

Still verify with the provider to avoid surprises. The Modern Medicare Agency can help you check providers.

Our licensed agents will call on your behalf and confirm assignment status so you don’t get unexpected bills.

Using Assignment in Advance

Ask the provider to sign an assignment agreement before treatment. Assignment means the provider agrees to accept the Medicare-approved amount as full payment for the service.

Get the assignment in writing and keep a copy. If a provider later tries to bill you more, your documentation helps resolve disputes with Medicare or the provider’s billing office.

If a provider refuses assignment, consider switching to a different doctor who does accept it. Your agent at The Modern Medicare Agency can quickly find nearby providers who accept assignment and match your plan.

Recent Changes and Trends

Medicare excess charges and related rules have seen targeted state and federal shifts. These changes affect when providers can bill above Medicare’s approved amount and which plans can protect you from those extra fees.

Policy Updates Impacting Excess Charges

Several states now limit or ban Part B excess charges. If you live in Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, or Vermont, providers cannot bill you the extra 15% above Medicare’s approved amount in most cases.

That law directly lowers your out-of-pocket risk when you see non‑assignment providers. At the federal level, regulators have focused on clearer billing notices and claim processing rules so beneficiaries get correct error-free statements.

You should check your state rules first, then confirm with any provider whether they accept Medicare assignment. If you have a Medigap Plan F or G, verify whether your plan still covers excess charges and whether you remain eligible.

Outlook for Future Legislation

Lawmakers have discussed expanding protections against excess charges in additional states and at the federal level. Proposals aim to require clearer patient disclosures when providers don’t accept assignment and to explore limits on how often providers can bill excess amounts.

These efforts could reduce surprise bills for outpatient services. You should watch state legislatures and Congress for bills that affect your rights.

If new protections pass in your state, you may no longer face the 15% surcharge from non‑assignment providers. For personal guidance on how upcoming changes may affect your plan choices, contact The Modern Medicare Agency.

Our licensed agents are real people you can speak to one‑on‑one. They will match Medicare packages to your needs without extra fees that break the bank.

Common Misconceptions About Medicare Excess Charges

Medicare excess charges only apply when a provider does not accept Medicare assignment and can be up to 15% above the Medicare-approved amount. You can avoid them by choosing providers who accept assignment or by using certain Medigap plans that cover excess charges.

Overestimating Frequency of Excess Charges

Many people think excess charges happen at most visits, but they are actually limited to situations where a provider does not accept Medicare assignment. Most primary care doctors and large health systems accept assignment, so you will rarely see excess charges there.

Specialists and small private practices are more likely to decline assignment. You should check a provider’s status before an appointment.

Ask directly, “Do you accept Medicare assignment?” or use Medicare’s online tools. If you have Medigap Plan F or G (subject to eligibility), those plans can help cover excess charges, reducing your out-of-pocket risk.

Beliefs About Universal Charges Across States

Some believe excess charges vary by state rule, but federal law caps them at 15% above the Medicare-approved amount for providers who don’t accept assignment.

States cannot raise that federal cap, though a provider in any state may choose not to accept assignment and charge up to that limit.

You still face local differences in how often providers refuse assignment.

Rural areas and specialty clinics can show higher rates of non-assignment.

What Is Medicare Part B and What Does It Actually Cover?

The complete guide to Medicare’s medical insurance — every service it covers, exactly what it costs in 2026, how it works with group insurance and VA benefits, and the excess charges most people have never heard of until they get a surprise bill.

The Short Answer

Medicare Part B is medical insurance — it covers doctor visits, outpatient care, preventive services, durable medical equipment, and more. Unlike Part A, Part B is not premium-free for anyone: everyone pays a monthly premium (202.90in2026formostpeople),anannualdeductible(283), and 20% coinsurance on most covered services, with no yearly cap on that 20% under Original Medicare alone. Whether you need to enroll at 65, and whether delaying is safe, depends heavily on your employment status and your employer’s size — getting this wrong is one of the most consequential and permanent mistakes in all of Medicare.

Key Takeaways

Part B is never premium-free — everyone pays a monthly premium, and higher earners pay significantly more through IRMAA.
The 20% coinsurance under Original Medicare alone has no yearly cap — this is the single biggest financial risk in Medicare, and it’s the reason Medigap and Medicare Advantage exist.
Whether you can safely delay Part B without a penalty depends on your employer’s size: 20+ employees generally allows delay; fewer than 20 generally does not.
Missing your enrollment window triggers a permanent 10% penalty for every 12-month period you went without coverage.
Veterans can and generally should enroll in Part B even with VA benefits, since Medicare and VA coverage don’t coordinate — each only pays for care received within its own system.
“Excess charges” from non-participating providers can add up to 15% on top of what Medicare approves, and only some Medigap plans protect you from them.

What Part B Actually Covers

While Part A handles hospital room and board, Part B is the half of Original Medicare that covers medical care and most services delivered outside a hospital admission — doctor visits, outpatient procedures, and ongoing medical needs.

What’s covered

Doctor visits — primary care and specialists
Outpatient surgeries and procedures
Diagnostic lab work, X-rays, and MRIs
Emergency room visits
Ambulance services
Outpatient mental health care
Physical, occupational, and speech therapy
Chemotherapy and radiation received in an outpatient clinic
Durable Medical Equipment (DME) — wheelchairs, oxygen equipment, blood sugar monitors, walkers, and similar equipment
Ambulatory surgical center services

Preventive services: the part Medicare gets genuinely right

Most preventive services are covered at 100%, with no deductible and no copay, as long as your provider accepts Medicare assignment. This includes:

Your one-time “Welcome to Medicare” wellness visit, available within your first 12 months on Part B
Annual wellness visits after that
Flu shots and most other recommended vaccines
Mammograms
Colonoscopies and other cancer screenings
Diabetes and cardiovascular screenings
Many other screenings recommended by the U.S. Preventive Services Task Force

Paul’s Honest Take: This is one of the most underused parts of Medicare, full stop. I’ve had clients who paid for a private physical every year out of habit and never realized their annual wellness visit through Medicare was completely free. If you haven’t used your Welcome to Medicare visit or your annual wellness visit, that’s real value sitting on the table.

What’s NOT covered

Routine dental care — cleanings, fillings, dentures, extractions
Routine vision exams and eyeglasses
Hearing aids (though diagnostic hearing tests ordered by a doctor may be covered)
Long-term custodial nursing home care — help with daily living activities, as opposed to short-term skilled or medical care
Routine prescription drugs you pick up at a retail pharmacy — that’s Part D’s job, not Part B’s
Cosmetic surgery, unless medically necessary (such as reconstruction after an accident or mastectomy)
Most care received outside the United States, with very limited exceptions
Routine foot care, such as nail trimming, in the absence of a qualifying medical condition
Acupuncture, except for a narrow, specific chronic low back pain benefit
Concierge medicine fees and membership-style charges some practices add on top of standard care
Long-term care insurance-style services, including most home-based personal care that isn’t tied to a skilled medical need

Paul’s Honest Take: The dental and vision exclusions are the ones that surprise people most, especially since they’re such routine parts of healthcare for most adults. This is exactly why so many Medicare Advantage plans build dental, vision, and hearing benefits into their coverage — Original Medicare was simply never designed to include them, and that gap doesn’t go away on its own.

What Part B Costs in 2026

Part B has three separate cost components, and understanding all three matters:

Cost Component	2026 Amount
Standard monthly premium	$202.90
Annual deductible	$283
Coinsurance on most covered services	20%

The premium is deducted automatically from your Social Security check if you’re already collecting benefits. If you’re not yet collecting Social Security, you’ll receive a bill, typically every three months.

The deductible works differently than Part A’s — it’s a straightforward annual figure. You pay the first $283 of Medicare-approved outpatient costs each calendar year, and then Medicare’s cost-sharing kicks in.

The coinsurance is where the real risk lives. After your deductible is met, Medicare pays 80% of the Medicare-approved amount for most covered services, and you’re responsible for the remaining 20%. There is no yearly cap on this 20% under Original Medicare alone. If you have a $100,000 course of cancer treatment, your 20% share is $20,000 — unless you have a Medigap policy or Medicare Advantage plan absorbing that cost.

Paul’s Honest Take: I put this in bold because it’s genuinely the single most important number in this entire guide. That uncapped 20% is the whole reason Medigap and Medicare Advantage exist as products in the first place. Original Medicare by itself was never designed to protect you from a truly expensive year — it was designed to cover 80% of it and leave the rest to you.

IRMAA: What Higher Earners Actually Pay

If your income is above certain thresholds, you’ll pay more for Part B through the Income-Related Monthly Adjustment Amount (IRMAA) — based on your tax return from two years prior. For 2026, that means your 2024 income determines your premium tier.

2024 Income (Individual)	2024 Income (Married, Joint)	Total Part B / Month
$109,000 or less	$218,000 or less	$202.90
$109,001 – $137,000	$218,001 – $274,000	$284.10
$137,001 – $171,000	$274,001 – $342,000	$405.80
$171,001 – $205,000	$342,001 – $410,000	$527.50
$205,001 – $499,999	$410,001 – $749,999	$649.20
$500,000 and above	$750,000 and above	$689.90

At the top tier, you’re paying more than three times the standard premium. If your income has recently dropped — retirement, the loss of a spouse, or certain other life-changing events — you can appeal your IRMAA determination using Form SSA-44.

Do You Have to Enroll? And What Happens If You Don’t?

Technically, Part B is optional — Medicare won’t force you into it. But opting out without a valid alternative is genuinely risky, because of how the penalty structure works.

If you don’t sign up during your Initial Enrollment Period (the 7-month window around your 65th birthday) and you don’t have qualifying employer coverage, you’ll face a permanent 10% penalty added to your premium for every full 12-month period you went without Part B. That penalty doesn’t expire — you pay it for as long as you have Part B, which for most people means for the rest of your life.

Example: If you delayed enrollment by 24 full months without a valid exception, you’d pay an extra 20% on top of the standard $202.90 premium in 2026 — roughly $40.58 more, every month, permanently.

How Part B Works with Group Insurance

Just like Part A, whether you can safely delay Part B without penalty comes down to one specific number: how many employees your company has.

Companies with 20 or more employees: If you or your spouse are actively working and covered by a genuine group health plan, your workplace insurance is primary, and you can legally delay Part B without any penalty. When that employment or coverage eventually ends, you get an 8-month Special Enrollment Period to enroll in Part B penalty-free.

Companies with fewer than 20 employees: Medicare automatically becomes your primary insurer at 65, regardless of your employment status. You need to enroll in Part B right on schedule. If you don’t, your small employer’s plan can legally refuse to pay claims that Medicare should have covered first — potentially leaving you responsible for the full cost.

Paul’s Honest Take: I say this in nearly every guide I write, because it’s genuinely one of the costliest misunderstandings I encounter: “I have good coverage at work” and “I’m protected from Medicare’s enrollment deadlines” are two completely different statements, and whether the second one is true depends entirely on your employer’s size — not how generous the coverage feels. Confirm the actual employee count before you decide to delay anything.

Retiree Coverage Is Not the Same as Active Employer Coverage

This is a distinction that catches a genuinely large number of people off guard: the “20 or more employees” exception only applies to active employment. If you retire and your former employer offers you retiree health benefits — sometimes a genuinely good, comprehensive plan — that coverage does not create a Special Enrollment Period the way active group coverage does, and it does not exempt you from enrolling in Part B on time.

Paul’s Honest Take: I’ve seen this mistake more than once, and it’s an especially painful one because it happens to people who did everything right during their working years. Someone retires with a strong retiree health plan from a large employer, assumes it works the same way their active coverage did, and delays Part B — only to find out later that retiree coverage was never a valid reason to delay in the first place. The moment you stop actively working, that clock starts, regardless of how good your retiree plan looks on paper. If you’re retiring and keeping employer retiree benefits, treat enrolling in Part B as something to handle right on schedule, not something retiree coverage lets you postpone.

Why You Need Both Part A and Part B for Medigap or Medicare Advantage

Here’s a foundational requirement worth understanding clearly, since it shapes every other coverage decision in Medicare: you must be enrolled in both Part A and Part B before you can buy a Medigap policy or enroll in a Medicare Advantage plan. Neither product exists as a standalone substitute for Original Medicare — both are built specifically to work alongside it.

Medigap fills the cost-sharing gaps left by Original Medicare (Parts A and B) — it has nothing to fill in if you’re not enrolled in both parts to begin with.
Medicare Advantage legally must provide at least the same coverage as Parts A and B combined, which is only possible because you’re required to be enrolled in both before a Medicare Advantage carrier can enroll you.

Paul’s Honest Take: This surprises people who assume they can somehow “skip” Part B and go straight into a Medicare Advantage plan to avoid the extra premium. It doesn’t work that way — Part B enrollment, and its premium, is a prerequisite either way, whether you end up on Original Medicare with Medigap or on a Medicare Advantage plan. There’s no path through Medicare that avoids the Part B premium once you’re actually using the system.

Does Medicare Work If You’re a Veteran?

Yes — and if you have VA health benefits, understanding how the two systems relate is genuinely important, because they work differently than most people assume.

Medicare and VA benefits do not coordinate. These are two entirely separate systems that each pay only for care received within their own network. Medicare doesn’t pay for care you receive at a VA facility, and VA benefits don’t pay for care you receive from a non-VA doctor or hospital. You, the veteran, choose which system to use each time you seek care.

Here’s the critical point: having VA benefits does not exempt you from Medicare’s enrollment deadlines. VA coverage is not considered a qualifying reason to delay Part B without penalty. If you don’t enroll in Part B during your Initial Enrollment Period and you’re relying solely on VA benefits, you can still trigger the permanent late enrollment penalty.

Why the VA itself recommends enrolling in Medicare anyway:

It gives you access to civilian doctors and hospitals outside the VA system
VA healthcare funding depends on annual Congressional appropriations, which isn’t guaranteed to remain stable
If VA authorizes only part of your needed care at a non-VA facility, Medicare can help cover the rest
Having both gives you meaningfully more flexibility and security than relying on either system alone

Paul’s Honest Take: This is one of the most common misconceptions I run into with veterans specifically, and it’s an expensive one to get wrong. Good VA coverage feels like it should be enough, and it might genuinely handle most of your care — but it doesn’t protect you from the Part B enrollment clock the way employer coverage from a large company can. The VA itself actively encourages enrolling in Medicare Parts A and B for exactly this reason. If you have VA benefits and are approaching 65, this is worth a direct conversation before you assume you’re covered.

Veterans who enroll in Part B can also purchase a Medigap policy, which can be particularly valuable if you use non-VA providers regularly — though if you primarily rely on VA facilities for most of your care, the value of an added Medigap policy may be more limited, and worth weighing carefully.

How Long Does It Actually Take to Get Part B Approved?

This is one of the most practical, and most overlooked, pieces of planning — especially if you’re leaving a job after 65 and coordinating your Part B start date around the end of your employer coverage. Applying isn’t instant, and the timeline depends heavily on which enrollment window you’re using.

Enrollment Situation	Typical Processing Time	When Coverage Actually Starts
Initial Enrollment Period (around 65)	2–4 weeks, sometimes up to 6	1st of your birthday month (if applied in the 3 months before) or 1st of the month after you apply (if applied during or after your birthday month)
Special Enrollment Period (leaving employer coverage)	4–8 weeks, sometimes longer	1st of the month after your application is submitted
General Enrollment Period (Jan 1–Mar 31, missed window)	4–6 weeks	1st of the month after you apply

Why the Special Enrollment Period takes longer: applying after leaving employer coverage requires two forms, not one — Form CMS-40B (the actual Part B application) and Form CMS-L564 (Request for Employment Information), which your employer needs to complete to verify you had qualifying coverage. Social Security has to manually review both, which is exactly why this route consistently takes longer than a standard Initial Enrollment Period application.

Paul’s Honest Take: This timeline question comes up constantly with clients who are retiring or leaving a job after 65, and it deserves real attention — not just because of the penalty risk we’ve already covered, but because a slow approval can leave you with an actual gap in coverage if you time it too tightly. My standard advice: start this process at least 2 to 3 months before you need Part B to actually begin, not the week your employer coverage ends. If your former employer is slow to complete their portion of Form CMS-L564, that alone can hold up the entire application — so it’s worth following up with your HR or benefits department directly rather than assuming it’s been submitted.

Practical tips to avoid delays

Apply online through SSA.gov whenever possible. It’s consistently the fastest method — mailed or faxed forms are more prone to getting lost or delayed.
If you’re on a Special Enrollment Period, submit Form CMS-L564 alongside Form CMS-40B, not separately. They need to arrive together, and one incomplete form can stall the whole application.
Expect a short intake lag even with online applications. It can take several business days for an online submission to actually appear on a local Social Security agent’s screen — don’t panic if you call shortly after applying and they say they don’t see it yet.
Once approved, you don’t have to wait for your physical card. Your Medicare Beneficiary Identifier typically appears in your online Social Security or Medicare.gov account within a day or two of approval, and you can print a temporary card from there — the physical card generally arrives by mail within about 30 days.

Excess Charges: The Cost Almost Nobody Knows to Ask About

Here’s a detail that surprises even people who’ve been on Medicare for years: not every doctor who accepts Medicare agrees to accept Medicare’s approved amount as full payment.

Providers fall into three categories:

Participating providers accept Medicare assignment, meaning they agree to accept the Medicare-approved amount as payment in full. This covers the vast majority of providers — roughly 98% of doctors nationally.
Non-participating providers still accept Medicare patients but haven’t agreed to accept the standard rate. They can charge an excess charge of up to 15% above the Medicare-approved amount.
Opted-out providers have left the Medicare system entirely and can charge whatever they want under a private contract — Medicare pays nothing at all for care from these providers, except in emergencies.

How excess charges actually work: if the Medicare-approved amount for a service is $300 and you see a non-participating provider, they can legally charge up to an additional $45 (15%) on top, for a total bill of $345 — and that excess amount doesn’t count toward your Part B deductible.

Eight states currently prohibit or limit excess charges entirely: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont. If you live in one of these states, you’re generally shielded from excess charges from providers within your state — though you could still face them if you receive care from a non-participating provider elsewhere.

Paul’s Honest Take: This is exactly why Medigap Plan G matters so much for people who want maximum flexibility. Plan G covers excess charges in full — Plan N does not. If you’re the kind of person who wants the freedom to see any doctor without worrying about billing surprises, that distinction is worth understanding clearly before you pick between the two. And regardless of which plan you choose, it’s always worth asking a new provider directly whether they accept Medicare assignment before your first appointment.

The HSA Rule: Part B Closes the Door Too

If you’re hoping to keep contributing to a Health Savings Account, know this clearly: enrolling in Part B — or any part of Medicare — ends your ability to make new HSA contributions. This isn’t unique to Part B; it applies the moment you enroll in Medicare in any form, including premium-free Part A.

If keeping your HSA active matters to you, the only way to legally delay both Part A and Part B is through qualifying employer coverage — which, as covered above, generally requires an employer with 20 or more employees. And because Part A enrollment can be backdated up to 6 months once you do enroll, it’s smart to stop HSA contributions 6 months before you plan to sign up for Medicare or file for Social Security, whichever comes first.

Frequently Asked Questions

Is there a cap on what I’ll pay for Part B services in a year? Not under Original Medicare alone — the 20% coinsurance has no yearly limit. A Medigap policy or Medicare Advantage plan is what actually caps your exposure.

What happens if I don’t sign up for Part B on time? You’ll generally face a permanent 10% penalty on your premium for every 12-month period you went without coverage, unless you qualify for a Special Enrollment Period through active employer coverage.

Do I need Part B if I have good coverage through a small employer? Almost certainly yes. If your employer has fewer than 20 employees, Medicare becomes your primary insurer at 65 regardless of your job coverage, and not enrolling can leave you exposed to unpaid claims and a lifelong penalty.

Do veterans need Medicare Part B if they have VA benefits? Generally, yes. Medicare and VA benefits don’t coordinate — each only pays for care within its own system — and VA coverage doesn’t exempt you from Medicare’s enrollment deadlines or penalties.

What is a Part B excess charge? An additional charge, up to 15% above the Medicare-approved amount, that a non-participating provider can legally bill you. It doesn’t count toward your deductible, and only Medigap Plan G (among current plans) covers it in full.

Can I keep contributing to my HSA if I enroll in Part B? No. Enrolling in any part of Medicare, including Part B, ends your HSA contribution eligibility going forward.

How long does it take to get approved for Part B? It depends on the enrollment window. Initial Enrollment Period applications typically process in 2–4 weeks. Special Enrollment Period applications, used when leaving employer coverage, generally take 4–8 weeks since Social Security must manually verify your prior coverage using Form CMS-L564. Start the process at least 2–3 months before you need coverage to begin, especially when coordinating around a job ending.

The Bottom Line

Part B is the half of Medicare that covers your everyday medical care — and it’s also where the real financial exposure of Original Medicare lives, thanks to that uncapped 20% coinsurance. Whether you should enroll at 65, whether you can safely delay, and how much of that exposure you’re carrying all depend on details specific to your situation: your employer’s size, your income, your VA status, and which doctors you actually see.

If you want help sorting out exactly how Part B applies to your specific circumstances — or want to understand how Medigap or Medicare Advantage could close that uncapped coinsurance gap — that’s exactly the conversation I have with clients every day, at no cost to you.

Call 631-358-5793 or visit paulbinsurance.com to set up a time to talk it through.

Paul Barrett, CMIP, is the founder of The Modern Medicare Agency, based in Melville, NY, and has spent 18+ years exclusively helping people navigate Medicare — never life insurance, never annuities, just Medicare. He’s licensed in 37 states, represents more than 40 carriers, and has personally helped over 5,000 clients choose coverage that actually fits their lives.

Figures current as of 2026 and sourced from CMS, Medicare.gov, and the Social Security Administration. Individual circumstances vary, especially around employer coverage, VA benefits, and income-based premiums — always verify your specific situation before making enrollment decisions.