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.

How Do I Apply for Medicare Supplement Insurance: Step‑By‑Step Guide to Eligibility, Enrollment, and Costs

February 1, 2026

You can apply for Medicare Supplement (Medigap) insurance by choosing a plan that fits your Original Medicare needs and confirming you meet eligibility (usually age 65 and enrolled in Part B). Contact a private insurer to enroll during your best window—your Medigap Open Enrollment Period.

The fastest way to get clear options and one-on-one help is to call The Modern Medicare Agency. Our licensed agents guide you through plan choices, eligibility checks, and enrollment without junk fees.

You will learn which plans cover copays, deductibles, and coinsurance and when your best time to apply is so you avoid medical underwriting. The Modern Medicare Agency’s agents talk with you directly and help complete applications online, by phone, or by mail.

Understanding Medicare Supplement Insurance

Medicare Supplement Insurance helps pay some costs Original Medicare doesn’t cover. You’ll learn what it covers, how it differs from other Medicare options, the main plan types, and who benefits most from adding a supplement.

What Is Medicare Supplement Insurance

Medicare Supplement Insurance (Medigap) is private coverage that works with Medicare Part A and Part B. It helps pay copayments, coinsurance, and deductibles that Original Medicare leaves for you to pay.

You must have both Part A and Part B to buy a Medigap policy. Policies follow federal and state rules, but prices and plan availability vary by insurer and state.

Medigap plans pay after Medicare pays its share. If a doctor or hospital accepts Medicare assignment, your claim goes to Medicare first, then the supplement pays what Medicare doesn’t.

The Modern Medicare Agency’s licensed agents explain plan benefits and costs to you, one-on-one. They help you find a plan that fits your budget without adding hidden fees.

How Medicare Supplement Differs from Other Plans

Medigap differs from Medicare Advantage (Part C) and Part D drug plans. Medigap keeps your Original Medicare benefits and adds cost-sharing protection.

Medicare Advantage replaces Original Medicare with a bundled plan that may limit providers. Medigap does not include prescription drug coverage.

If you need drug coverage, you must enroll in a separate Part D plan. Medigap also does not cover vision, dental, or hearing services beyond what Medicare covers.

Medigap plans generally let you see any provider that accepts Medicare. This gives you more freedom than many Medicare Advantage networks.

Your out-of-pocket costs depend on the plan you choose and the insurer’s price. The Modern Medicare Agency helps you compare these differences clearly so you can choose the option that fits your care needs and provider preferences.

Types of Medicare Supplement Plans

Medigap plans use standardized letters (for example, Plan A, Plan G) to describe basic benefits. Each lettered plan offers a defined set of benefits, so Plan G from one insurer must cover the same core items as Plan G from another.

Not every lettered plan is sold in every state. Common plans include those that cover most Part A and B cost-sharing, and some that cover Part A hospice coinsurance or skilled nursing facility coinsurance.

Costs vary by plan letter, insurer, and pricing method (community-rated, issue-age-rated, or attained-age-rated). Community-rated keeps the same premium for all policyholders of the same plan, while attained-age-rated increases with your age.

Ask The Modern Medicare Agency’s licensed agents for a side-by-side comparison of plan letters and premiums. They’ll show expected out-of-pocket costs and which plans match your care needs.

Who Needs a Medicare Supplement Plan

You may need Medigap if you want lower and more predictable out-of-pocket costs with Original Medicare. It suits people who travel often within the U.S. or prefer any-accepting providers.

Medigap makes less sense if you prefer lower monthly costs and are comfortable using a network-based Medicare Advantage plan. It also won’t cover prescription drugs, so those who need drug coverage must add Part D.

If you’re 65 or older and enrolling in Part B, you get a six-month Medigap Open Enrollment Period when insurers can’t deny you coverage for preexisting conditions. Outside that window, approval may depend on health underwriting.

Contact The Modern Medicare Agency to talk 1-on-1 with a licensed agent. They’ll review your medical needs, explain enrollment timing, and identify Medigap options that keep your costs predictable without extra fees.

Eligibility Requirements for Medicare Supplement Insurance

You need to meet specific rules to buy a Medicare Supplement plan. These rules focus on your age and Medicare enrollment, where you live and your citizenship, plus how pre-existing health issues affect acceptance and pricing.

Age and Enrollment in Original Medicare

To buy a Medigap policy, you must have Medicare Part A and Part B. Most people become eligible at age 65 when they enroll in Part A and Part B.

If you have Medicare because of a disability, you may qualify earlier, but private insurers set some rules differently for under‑65 applicants. Your best opportunity to buy without medical underwriting is the Medigap Open Enrollment Period.

This six‑month window starts the month you turn 65 and are enrolled in Part B. During that time, insurers must sell you any Medigap plan they offer at standard price, regardless of health problems.

If you apply outside this window, insurers can use medical underwriting. That means they can ask health questions, charge higher premiums, or deny coverage based on your health history.

State rules may give you extra protections in some cases.

Residency and Citizenship Criteria

You must live in the state where the Medigap policy is sold. Insurers generally only sell Medigap plans to residents of the plan’s state because rules and prices vary by state.

If you move, you’ll need to buy a plan in your new state or work with the insurer to transfer coverage. You must also be a U.S. citizen or lawfully present.

Proof of citizenship or legal residency is commonly required when you apply. Bring documents like a U.S. passport, birth certificate, or immigration papers to speed up the process.

The Modern Medicare Agency can confirm state‑specific rules for you. Our licensed agents guide you through residency and documentation needs so your application goes smoothly.

Pre-Existing Conditions

Insurers can consider your medical history when you apply outside the guaranteed issue period. They often ask about pre‑existing conditions and may:

Deny coverage;
Charge higher premiums; or
Exclude coverage for the condition for a limited time.

Look for a pre‑existing condition waiting period, which some states limit. During that period, related claims may not be covered until you’ve been insured for a set time, often six months.

If you qualify for guaranteed issue rights—such as losing certain employer coverage or moving from a Medicare Advantage plan—you can get Medigap without underwriting. The Modern Medicare Agency’s licensed agents review your records and identify any guaranteed issue rights you have.

They explain how pre‑existing conditions affect pricing and find plans that match your needs without hidden fees.

When to Apply for Medicare Supplement Insurance

You have a best time to apply and a few special situations that give you extra rights. Act during those windows to get the most choices and best pricing.

Medicare Supplement Open Enrollment Period

Your Medigap Open Enrollment Period starts the month you turn 65 and are enrolled in Medicare Part B. It lasts six months and gives you guaranteed access to any Medigap plan sold in your state.

During this time, insurers cannot deny you coverage or charge higher premiums because of health problems. Apply early in that six-month window to lock in the widest choice of plans and rates.

If you delay and have health issues, companies can use medical underwriting to limit options or raise costs. The Modern Medicare Agency’s licensed agents can walk you through timing and submit applications so you don’t miss this window.

Special Enrollment Scenarios

You may get another chance to buy Medigap outside the standard period. These scenarios include losing employer coverage, moving out of your plan’s service area, or leaving a Medicare Advantage plan under certain conditions.

Each scenario creates a limited time to apply, often 60–90 days from the triggering event. Document the event (for example, an employer coverage letter) and contact The Modern Medicare Agency right away.

Our agents will review your situation, tell you which deadlines apply, and help gather needed paperwork. Acting quickly preserves your rights and improves your chance of acceptance.

Guaranteed Issue Rights

Guaranteed issue rights (also called “medigap protections”) mean an insurer must sell you a Medigap policy without medical underwriting. These rights apply in specific cases, such as losing employer coverage when you turn 65 or certain errors by Medicare or your plan.

The exact triggers and time limits vary by state and situation. If you believe you qualify, contact The Modern Medicare Agency immediately.

Our licensed agents will confirm your eligibility, explain the proof insurers require, and file the application for you. We help protect your right to buy coverage without extra health questions or higher charges.

How to Apply for Medicare Supplement Insurance

Applying for a Medicare Supplement plan involves a few clear steps: complete the application, share proof of Medicare Part A and B enrollment, and pick the Medigap letter plan that fits your budget and needs.

You will also decide on a carrier and plan pricing, and you may speak with a licensed agent for help.

Step-by-Step Application Process

Start by confirming you have Original Medicare (Part A and Part B). If you aren’t enrolled in Part B, sign up before applying, since most carriers require Part B coverage.

Gather plan options next. Compare the Medigap letter plans available in your state and note monthly premiums, benefits, and any waiting periods.

Use a side-by-side list to compare premiums and covered costs like deductibles and coinsurance. Complete the insurer’s application online, by mail, or with a licensed agent.

Expect health questions; your answers affect acceptance and pricing. If you apply during your Medigap Open Enrollment Period, you get guaranteed issue rights and cannot be charged more for health issues.

Pay your first premium when required to activate the policy. Keep copies of the application and any correspondence.

If you work with The Modern Medicare Agency, a licensed agent will walk you through each step and submit the application for you.

Required Documentation

Have proof of Medicare enrollment ready. You need your Medicare card showing Part A and Part B effective dates, or a Letter from the Social Security Administration if your card is not available.

Bring a valid photo ID such as a driver’s license or state ID. The insurer may also ask for your Social Security number and contact information for identity verification and premium billing.

Prepare medical history details. Some companies ask health questions or request medical records; answers affect underwriting if you apply outside guaranteed issue periods.

If you have prior Medigap coverage, provide policy numbers and effective dates. If you work with The Modern Medicare Agency, your agent will list precisely which documents a chosen carrier needs and can help gather and submit them safely.

Choosing a Plan

Decide which Medigap letter plan fits your budget and health needs. Plans with higher premiums often lower out-of-pocket costs.

Compare what each letter plan covers beyond Original Medicare, such as Part A coinsurance, skilled nursing coinsurance, and foreign travel emergency care. Think about your expected health care use.

If you visit specialists often or expect hospitalization, choose a plan with broader coverage. If you are generally healthy, a plan with lower premiums but some cost-sharing might work.

Check price factors like age, tobacco use, and location. Ask about rate change history and whether the carrier uses community-rated, issue-age-rated, or attained-age-rated pricing.

Work with The Modern Medicare Agency to get personalized comparisons. Our licensed agents speak one-on-one with you, match plans to your needs, and help avoid extra fees while keeping costs affordable.

Comparing Medicare Supplement Insurance Plans

You need clear details on what each plan covers, what it costs, and how state rules may change availability. The right choice matches your health needs, budget, and where you live.

Evaluating Plan Benefits and Coverage

Focus on the standardized benefits each Medigap plan offers. Plans labeled by letters (for example Plan A, Plan G, Plan N) have set benefits the federal government defines, so the core coverage for a specific letter is the same across insurers.

Check whether a plan pays Part A hospital coinsurance, Part B coinsurance, skilled nursing facility coinsurance, foreign travel emergency care, and Part A and B deductibles. Look at how much the plan covers for each item you expect to use.

If you visit doctors often, pick a plan with low Part B cost-sharing. If you travel, choose one with foreign emergency coverage.

Read the policy details for exclusions and limits. Ask a licensed agent from The Modern Medicare Agency to explain how each benefit applies to your care patterns.

Comparing Premiums and Costs

Premiums vary by company, location, and how insurers set prices. You pay a monthly premium to the Medigap insurer in addition to your Medicare Part B premium.

Also compare out-of-pocket costs like deductibles, copays, and coinsurance that the plan does not cover. Understand pricing methods: community-rated (same for all), issue-age-rated (based on your age at purchase), and attained-age-rated (goes up as you age).

Ask for written quotes from multiple insurers and check how often they raise premiums. The Modern Medicare Agency’s licensed agents will run side-by-side premium comparisons for plans you qualify for and highlight long-term cost trends.

State-Specific Offerings

State laws can limit which Medigap plans insurers sell or change how policies are priced. Some states offer additional protections, like limiting premium increases or requiring coverage of certain benefits.

Other states might not allow new sales of certain plan letters to younger buyers or those under specific programs. Always verify available plan letters and pricing rules in your state before applying.

A local licensed agent from The Modern Medicare Agency knows state rules and can tell you which plan letters are sold in your area, which pricing method each insurer uses, and any extra state benefits. You can speak 1 on 1 with a real agent who will match plan availability to your needs without adding hidden fees.

Enrolling Directly Through Private Insurers

You can buy a Medicare Supplement (Medigap) policy directly from a private insurer. Learn how to find licensed providers and how to contact them so you get accurate pricing, clear quotes, and one-on-one help from a licensed agent.

Finding Licensed Insurance Providers

Look for insurers that sell Medigap in your state and are licensed by your state’s insurance department. Use your state insurance department website or call them to confirm a company’s license status and any recent complaints.

Focus on plans available in your ZIP code, since not every insurer offers every Medigap plan everywhere. Check plan letters (A–N) that a company offers and compare premiums, benefits, and whether they require medical underwriting.

Ask about open enrollment rules and guaranteed-issue rights so you avoid denials or higher rates. The Modern Medicare Agency has licensed agents who know state rules and can show plans that match your budget and health needs.

Contacting Insurance Companies

Start by calling the insurer or requesting a written quote online. When you talk, have your Medicare Part A and B effective dates, ZIP code, and current medications ready.

Ask for: plan letter, premium, any enrollment medical questions, waiting periods, and whether extra riders are available. Request a clear, written list of covered costs and any network or provider limits.

If you prefer direct help, call The Modern Medicare Agency to speak with a licensed agent one-on-one. Our agents explain costs, compare plan options side-by-side, and help you apply without hidden fees.

Common Application Mistakes to Avoid

Read deadlines carefully and double-check every field on your form. Missing a date or leaving out a document can cost you higher premiums or delayed coverage.

Our agents at The Modern Medicare Agency guide you through dates and paperwork to prevent those problems.

Missing Enrollment Deadlines

Missing your initial or special enrollment period can lead to late-enrollment penalties and higher monthly costs. Note exact dates: your Initial Enrollment Period starts three months before your 65th birthday month, includes your birthday month, and ends three months after.

If you have employer coverage, track your group plan end date and your Special Enrollment Period window, which usually lasts eight months after your employer coverage stops. Set reminders for those calendar windows and confirm with your HR office when employer coverage ends.

If you delay past the enrollment window, expect possible higher premiums or gaps in coverage. The Modern Medicare Agency’s licensed agents monitor these dates for you and will remind you so you don’t miss critical deadlines.

Providing Incomplete Information

Incomplete forms slow processing and can cause denial or coverage delays. Common omissions include missing Social Security numbers, Medicare claim numbers, exact plan codes, current prescription lists, or signatures.

Always attach proof of prior coverage if you claim a Special Enrollment Period. Use a checklist when you apply: full name as shown on Social Security records, Medicare number and Part A/Part B start dates, list of regular medications with dosages, and copies of any employer coverage letters.

The Modern Medicare Agency’s agents review your application line-by-line with you, confirm supporting documents, and submit complete packets to insurers so your enrollment proceeds without avoidable hold-ups.

What to Expect After Applying

You will get a confirmation from the insurer when your application is received. That notice often lists any missing information or documents you still need to provide.

An insurer may require a phone call or medical underwriting. Be ready to answer questions about health history.

Underwriting can affect whether you qualify and what your premium will be. Expect a waiting period before coverage starts if your application is accepted.

Review the policy start date and any retroactive coverage details so you know when benefits begin. If the insurer approves your policy, you will receive an insurance packet with your plan details and ID card.

Keep these documents in a safe place and note any deadlines for premium payments. If your application is denied or you get a higher premium, ask for a clear explanation.

You have options: appeal, submit more medical records, or speak with an agent to explore alternatives.

Keep a short checklist handy:

Confirmation receipt or email
Requests for more information
Policy start date and ID card
Premium due dates
Appeal or review instructions

Contact The Modern Medicare Agency if you need help understanding any notice or next step.

Additional Resources for Applicants

Find trusted help, compare official information, and connect with a licensed agent who can walk you through Medigap options. These resources help you understand costs, guaranteed issue rights, and enrollment timing.

State Health Insurance Assistance Programs

State Health Insurance Assistance Programs (SHIPs) offer free, one-on-one counseling about Medicare Supplement (Medigap) plans. You can get help comparing Medigap plan letters, checking whether you qualify for guaranteed issue rights, and understanding how supplements work with Part A and Part B.

SHIP counselors explain timelines like the Medigap Open Enrollment Period and special enrollment situations. They’ll review your current coverage, estimate out-of-pocket costs, and walk you through application steps.

To connect, call your state SHIP phone number or visit your state’s aging or insurance department website. You can also contact The Modern Medicare Agency for personalized help.

Our licensed agents speak with you directly, identify Medigap packages that match your budget and health needs, and answer paperwork questions without charging extra fees.

Accessing Official Medicare Information

Use official Medicare resources to confirm plan basics, rights, and coverage rules. Visit Medicare.gov for authoritative guides on Medigap benefits, standardized plan letters (A–N), and national rules that affect costs and protections.

Look up specific details like deductible amounts and what each standardized plan covers. Learn how Medigap coordinates with Medicare Part D drug plans.

Official pages also explain guaranteed issue protections. Your state may add extra rules.

Print or save pages to reference when you compare quotes.

If you want direct help interpreting official guidance, call The Modern Medicare Agency. Our agents review Medicare.gov information with you and show how it applies to your situation.

We help you complete applications by phone or online so you don’t miss key deadlines.

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.