Medicare Star Ratings: What They Mean for Benefits and Costs

Medicare Star Ratings: What They Mean for Benefits and Costs

Medicare Star Ratings run from one to five stars: five means excellent performance, four is above average, three is average, two is below average, and one is poor. If you’re learning how to understand Medicare Star Ratings, start with this scale, then look at the plan’s ratings for specific areas such as member experience and quality of care. A strong overall score is useful, but it doesn’t tell you everything about whether a plan fits your needs.

It’s natural to wonder whether more stars mean better benefits, lower costs, or a wider provider network. Ratings can reflect aspects of plan performance related to extra benefits, but they don’t replace a close review of coverage, costs, and network.

This guide explains what the ratings measure, how plans earn them, and what a rating can and can’t tell you as you compare options in 2026. You’ll have a clearer way to weigh the score alongside the details that matter to your health and budget.

Key Takeaways

  • Look beyond a plan’s overall score: category ratings can reveal strengths in care, drug safety, and member experience.
  • A higher rating may be linked to extra benefits, but it doesn’t tell you the plan’s full costs or coverage details.
  • Compare provider networks and prescription coverage alongside ratings to see how well a plan fits your needs.
  • Use the same rating scale to compare available plans, while considering your health, lifestyle, and budget.
  • Personalized guidance can help you weigh Medicare Advantage, Medigap, and Part D options against the details that matter to you.

What are the Medicare Star Ratings?

Medicare Star Ratings summarize how well Medicare Advantage and Part D plans perform across care, service, and drug-related measures. In 2026, the ratings use more than 40 quality measures, not a single test or member review.

Member Experience and Customer Service

Member-experience measures capture how people describe their care and health plan, while customer-service measures assess the plan’s support. Both matter because the overall rating reflects more than clinical care. Each spring, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey goes to a random sample of Medicare members. It asks about their experiences with care and their health plan.

The Medicare Health Outcomes Survey (HOS) gathers members’ views of their health, too. It surveys a random sample each spring, then follows up with the same members two years after the initial survey to measure changes in how they perceive their health. Together, CAHPS and HOS offer different perspectives on members’ experiences and reported outcomes.

Operational and Quality Measures

Operational measures assess how a plan manages member services, while quality measures assess care and health outcomes. This distinction helps explain why ratings can reflect both plan processes and members’ care. CMS evaluates customer service and other member services using health plan operations data. The score is therefore broader than a review of medical treatment alone.

Medicare Advantage ratings cover five categories: staying healthy, managing chronic conditions, plan responsiveness and care, member complaints and plan departures, and health plan customer service. Part D ratings cover four: drug plan customer service, member complaints and plan departures, member experience, and drug pricing and patient safety. Category scores show which parts of a plan contribute to its performance.

Preventive care measures can include whether members received flu shots or cancer screenings. The staying-healthy category also measures whether members’ physical health improved after two years. These examples show how prevention and longer-term health outcomes factor into Medicare Advantage ratings. The measures don’t simply count appointments; they assess specific aspects of care and reported health.

Drug coverage measures assess prescription-related performance, including drug pricing and patient safety. Medicare health plans also collect Prescription Drug Event data for drug-related measures. For people comparing Part D coverage, this means the rating considers more than customer service. It includes measures related to prescription drug use and safety, alongside member experience and complaints.

How high ratings may affect plan benefits and costs

A higher star rating can connect to extra benefits, but it doesn’t tell you a plan’s full cost. In 2026, compare the rating with the plan details that affect your care and prescriptions.

Effects on Benefits and Costs

High ratings can affect benefits because plans with four or more stars receive annual bonus payments. CMS requires plans to spend these payments on extra Medicare benefits for members, such as vision, hearing, or dental coverage. However, a high rating doesn’t mean every plan offers the same extras. A Medicare Advantage plan rated four or five stars may include added benefits, so review exactly what each plan covers.

Stars don’t show the full cost of using a plan. Review premiums, deductibles, copayments, and other cost-sharing details alongside benefits. Then consider whether the coverage fits your prescriptions, doctors, and expected care needs. Dental coverage, for example, could be helpful, but the plan’s rating alone won’t explain which services are covered or how costs apply.

Ratings can help you identify plans to examine more closely, but they don’t replace a careful comparison. A higher-rated plan might include an extra benefit you value, while another may better fit your prescription needs or budget. Focus on how the actual coverage and costs work for you, rather than treating stars as a promise of lower expenses.

Ratings for Advantage and Part D Plans

Medicare Advantage and Part D plans receive ratings based on their own performance areas. A score for an Advantage plan and a score for a drug plan don’t describe identical services. Compare each rating with the coverage you need, such as medical care through an Advantage plan or prescription drug coverage through Part D.

CMS updates Medicare Star Ratings each fall, with ratings released in early October annually. The Open Enrollment Period runs from October 15 through December 7 annually, according to the Centers for Medicare & Medicaid Services. Because ratings and plan details can change from year to year, use the 2026 rating when reviewing coverage for 2026.

To find current ratings, use Medicare Plan Finder to compare plans available in your area. Review the overall score and category ratings, then check costs, benefits, drug coverage, and provider network. A star score can help narrow your comparison, but the plan details show whether its care and coverage suit your needs. Satisfaction matters, too, but your prescriptions and preferred providers should guide your final comparison.

Comparing ratings with coverage, costs, and networks

A star rating can help you compare Medicare plans, but it can’t show whether a plan fits your daily needs. In 2026, weigh the score alongside coverage, costs, doctors, hospitals, and prescriptions that matter to you.

Start with plans available in your area and compare options with similar coverage. Medicare plans are evaluated using common criteria, which makes their ratings comparable. But a Medicare Advantage plan and a standalone Part D plan serve different needs, so their scores don’t answer the same questions.

Next, examine the category scores. For example, Medicare Advantage’s “staying healthy” category includes preventive screenings and measures related to chronic conditions. These details add context to the overall score, but don’t tell you whether your preferred doctor is in-network or whether a particular service fits your needs.

  • Coverage: Compare medical services, prescription drug coverage, and extra benefits.
  • Costs: Review premiums and cost-sharing details against the care and prescriptions you expect to use.
  • Networks: Check whether your preferred doctors, hospitals, and pharmacies are included.
  • Ratings: Compare overall and category scores among plans with similar coverage.

For example, two plans may have similar ratings but different provider networks. If one includes your regular doctor and the other doesn’t, that difference may matter to your care. Likewise, compare a Part D plan’s drug coverage with your prescriptions instead of relying on its rating alone.

Review costs plan by plan, too. A higher rating doesn’t tell you what you’ll pay for a specific service or prescription. Compare each plan’s cost-sharing details with the care you expect to need. Consider your health, lifestyle, and financial needs together, rather than treating the score as a substitute for those details.

A practical way to understand Medicare Star Ratings is to read each score alongside the plan’s coverage and access to care. The Centers for Medicare & Medicaid Services evaluates plans using shared criteria, but the categories vary by plan type. Keep your comparison focused on Medicare coverage and options available in your area.

To understand Medicare Star Ratings when choosing a plan, first match the plan type, then compare overall and category scores. Review benefits, providers, prescriptions, and costs before deciding which option best aligns with your priorities.

How Medicare rates Medicare Advantage and Part D plans

CMS rates Medicare Advantage and Part D plans annually, using measures tailored to each plan type. Ratings combine an overall score with category scores, showing both broad performance and specific strengths.

Rating Categories for Each Plan Type

Rating categories group related measures, helping you see which parts of a plan’s performance contribute to its score. Medicare Advantage ratings cover staying healthy, managing chronic conditions, plan responsiveness and care, member complaints and plan departures, and health plan customer service. These categories reflect care and plan operations, not just member satisfaction.

Part D ratings focus on drug plan customer service, member complaints and plan departures, member experience, and drug pricing and patient safety. CMS evaluates Medicare Advantage plans with prescription drug coverage, Medicare Advantage plans without it, and standalone Part D plans each year. Since the categories differ, compare plans of the same type when assessing their scores.

The Medicare Advantage Five-Star Scale

The five-star scale translates a plan’s measured performance into an overall rating, with category scores offering more detail. CMS evaluates between 12 and 38 quality and performance measures, depending on plan type. A five-star rating means excellent performance, four stars means above average, three means average, two means below average, and one means poor.

CMS can also assign half-star ratings, including 1.5, 2.5, 3.5, and 4.5 stars. These provide a more detailed comparison than whole-star scores alone. Medicare Advantage and Part D plans receive overall ratings alongside category ratings, so a plan’s summary score does not show every area equally. Reviewing both levels helps you understand what the score represents.

Limitations When Comparing Plans

Star ratings can’t tell you whether a plan’s coverage, providers, or costs suit your needs. They summarize measured performance, not every detail that matters when choosing care or prescription drug coverage.

For example, a high-rated Medicare Advantage plan may not include your preferred doctor, while another plan may better match your health care needs. A Part D rating also doesn’t tell you whether your prescriptions fit the plan’s coverage. Use overall and category scores to compare performance, then weigh each plan’s network, benefits, and costs separately.

CMS uses Prescription Drug Event data to inform prescription-related measures. This data contributes information about drug use, but doesn’t replace checking coverage details for your prescriptions. Likewise, an Advantage plan’s staying-healthy score reflects measures such as preventive care and chronic-condition management, not a personal prediction of your future health.

Treat ratings as one comparison tool. Match the plan type first, review overall and category scores, then compare the specific coverage and care arrangements you need. This approach keeps the star score useful without asking it to settle questions it wasn’t designed to answer.

Medicare Star Ratings: What They Mean for Benefits and Costs

Medicare Star Rating scale

In 2026, Medicare Star Ratings give plans an overall score from one to five stars. The Centers for Medicare & Medicaid Services (CMS) also assigns half-star ratings, making the scale more detailed than five whole-number choices.

Each star level has a plain-language meaning: five stars indicates excellent performance, four is above average, three is average, two is below average, and one is poor. A rating below three stars generally signals below-average performance. These labels help you read a score quickly, but it describes measured plan performance, not a personal guarantee about care.

  • Five stars: Excellent performance.
  • Four stars: Above-average performance.
  • Three stars: Average performance.
  • Two stars: Below-average performance.
  • One star: Poor performance.

Half-star scores include 1.5, 2.5, 3.5, and 4.5 stars. For example, a 3.5-star plan sits between average and above-average performance on the rating scale. That extra step helps distinguish plans with nearby results, but it doesn’t explain which specific measures shaped the score. Look at the plan’s category ratings for that context.

The overall rating also condenses multiple measures into one summary. A Medicare Advantage plan’s score can reflect categories such as staying healthy, managing chronic conditions, member experience, and customer service. A Part D score reflects drug-related categories, including patient safety and member experience. Two plans with the same overall score can therefore have different category strengths.

For the 2026 ratings, CMS evaluated 769 Medicare plans, and 207 received four stars or more. That gives the scale practical context: a four-star rating marks above-average performance, but it doesn’t mean every plan detail suits every enrollee. Preventive care measures, provider access, and coverage still need to be considered separately.

Use the scale as a first filter, then compare category scores and plan details that matter to your health care. A three-star plan with a useful provider network could fit your needs better than a higher-rated plan with different coverage. The score helps organize your choices; it doesn’t make the decision for you.

If you’re comparing Medicare Advantage plans, use the rating scale alongside the plan’s coverage and network details. Explore Medicare Advantage plan options to understand what to compare beyond the stars.

The Modern Medicare Agency: Medicare Advantage Plans

The Modern Medicare Agency helps you compare Medicare Advantage plans with their ratings, coverage, costs, and provider networks in mind. A star score is one part of the decision; your doctors, prescriptions, and health needs matter too.

If you’re also weighing Original Medicare coverage options, The Modern Medicare Agency can help you compare Medicare Supplement (Medigap) and Medicare Part D plans. As an independent Medicare broker, the agency offers personalized guidance to help you consider how different options fit your priorities, without treating a higher rating as the only measure of a good choice.

If you’d like support comparing your options for 2026, contact The Modern Medicare Agency to talk through what matters to you.

Make Your Next Medicare Choice With Clarity

Your next step is to decide which plan details matter most in your situation. Understanding Medicare Star Ratings gives you a useful starting point, but your priorities should guide the final comparison. Consider which doctors you want to keep, which prescriptions you use, and what kind of coverage fits your health needs.

You don’t have to sort through every plan detail alone. The Modern Medicare Agency offers a free Medicare review and personalized comparisons to help you talk through your options in light of what matters to you. Book a free consultation to take a clear, manageable next step.

Contact The Modern Medicare Agency to discuss your Medicare options. Take the time you need, ask the questions that matter to you, and move forward with greater confidence.

Frequently Asked Questions

How are Medicare plans rated?

CMS rates Medicare Advantage and Part D plans by evaluating performance measures and assigning overall and category scores. The measures vary by plan type, reflecting the different services each plan provides. For example, an Advantage plan is assessed on areas that include care and member service, while a Part D plan is assessed on prescription-related performance. When comparing two plans, first make sure they address the same coverage need.

What are Medicare star ratings and what do they measure?

Medicare Star Ratings are CMS’s annual performance scores for Medicare Advantage and Part D plans. They bring together measures related to quality of care, member experience, customer service, and prescription drug performance. For instance, a plan’s results may reflect whether members received preventive screenings or how they rated their health plan experience. The score offers a shared way to review performance, but doesn’t describe every service or provider available to you.

How are Medicare Advantage and Part D star ratings calculated?

CMS calculates ratings from quality and performance measures, with the number depending on plan type. The evaluation uses between 12 and 38 measures for an individual plan type. Health plans also provide operational information, while prescription-related measures draw on Prescription Drug Event data. A practical way to read the result is to look at the overall score, then examine relevant category ratings to see which areas influenced the plan’s performance.

What do Medicare star ratings from 1 to 5 mean?

The scale describes performance: one star is poor, two is below average, three is average, four is above average, and five is excellent. CMS also assigns half-star scores, such as 3.5 or 4.5, to show more distinctions. Treat a star level as a summary, not a personal prediction. For example, a five-star plan may still have a network that doesn’t include your preferred doctor.

Which quality measures affect a Medicare plan’s star rating?

Measures depend on whether a plan provides Medicare Advantage or Part D drug coverage. Advantage measures can include preventive screenings, chronic-condition management, member complaints, responsiveness, and customer service. Part D measures include drug pricing and patient safety, member experience, and drug plan service. These categories can point you to areas to examine, such as whether the plan’s prescription coverage fits the medicines you take.

How often are Medicare star ratings updated?

CMS updates Medicare Star Ratings annually and publishes the new ratings each fall, with releases in early October. That timing gives you a current rating to consider during the year’s plan review. Use the rating for the coverage year you’re evaluating, rather than assuming last year’s score still applies. If you’re comparing plans in 2026, look at the 2026 ratings and review the plan’s current coverage details too.

Where can I find and compare Medicare plan star ratings?

You can find plan ratings in Medicare Plan Finder and compare plans available in your area. Start by choosing the coverage type you need, then compare plans within that group. For example, compare Medicare Advantage options with one another and review Part D plans separately. Once you’ve narrowed the list, consider category scores alongside the plan’s provider network, prescription coverage, and costs.

How should I use star ratings when choosing a Medicare Advantage or Part D plan?

Use the rating as one comparison point, then match plan details to your needs. For a Medicare Advantage plan, consider whether its network includes your doctors and whether its coverage suits the care you use. For Part D, compare the plan’s prescription coverage with your medicines. A higher rating can help you decide which options deserve a closer look, but the right choice depends on how the plan’s details fit your priorities.

Paul Barrett

Article by

Paul Barrett

Paul Barrett, CMIP is the founder of The Modern Medicare Agency, an independent Medicare-only brokerage based in Melville, NY. With 18 years of Medicare-exclusive experience, a CMIP designation, and more than 5,000 clients served across 37 states, Paul is one of the most credentialed independent Medicare specialists on Long Island — and one of the most direct.

He represents 40+ carriers with no quotas and no allegiances, which means his recommendations are based entirely on what fits each client's specific situation. He is the author of Medicare Mastery Unlocked and host of the Wise Guys Retirement Talk podcast. His content is grounded in primary sources, real carrier intelligence, and 18 years of watching what happens when people get Medicare right — and when they don't.

📞 631-358-5793 | paulbinsurance.com

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.

Sources

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