Coordinator prepares a DME authorization request

Medicare DME Prior Authorization: How It Works and What to Expect

Medicare prior authorization for durable medical equipment (DME) is a pre-approval step. For a short list of items, your supplier asks Medicare to review the paperwork before the equipment is delivered, instead of waiting for a claim afterward. Your supplier files the request, a Medicare contractor decides it, and you do not fill out forms yourself. Most people only need to know which items are affected, what to ask the supplier, and what to do if the first answer is no.

This guide covers Original Medicare first, then Medicare Advantage, where the rules differ.

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TL;DR

  • Prior authorization applies only to certain DME items that CMS puts on a Required Prior Authorization List, not to all equipment.
  • Your DME supplier normally submits the request and the documentation, and the regional Medicare contractor (the DME MAC) decides it.
  • Under CMS’s current operational guide, an initial decision is due within 5 business days, not to exceed 7 calendar days, after complete documentation arrives.
  • A non-affirmed request can be fixed and sent again, so a first “no” is often a paperwork problem.
  • Medicare Advantage plans run their own authorization rules, so check your plan before you order.

Table of Contents

What prior authorization means for DME

CMS describes prior authorization for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) as a way to request provisional affirmation of coverage before the item is furnished and before a claim is submitted. The word “provisional” matters. A yes is a preliminary finding that a future claim likely meets Medicare’s coverage, coding and payment requirements. A no means the future claim, as documented, does not.

DME request, provisional decision, and claim sequence

The program exists because CMS wants to catch problems before payment. HHS says prior authorization is an effective way to reduce or prevent questionable billing practices and improper payments for these items. CMS also frames the program as a way to protect the Medicare Trust Fund while still getting beneficiaries needed equipment in a timely manner.

There is one more point that surprises people. The rule did not add new medical paperwork. CMS said in the final rule that there are no new clinical documentation requirements. It only asks for the documentation that already had to exist earlier in the process.

Which items need prior authorization

Not every wheelchair, walker or hospital bed is on the list. CMS keeps a Master List of DMEPOS items identified as having potentially unnecessary utilization and high costs. A subset of that list becomes the Required Prior Authorization List, under the 6050-F final rule.

To land on the Master List, an item generally has to meet two tests, according to the same CMS FAQ:

  • It shows potential for unnecessary utilization, as reported by the HHS Office of Inspector General or the Government Accountability Office.
  • It has an average purchase fee of $1,000 or more, or an average rental fee of $100 or more.

In practice that means expensive, frequently misbilled equipment, such as certain power mobility devices and some pressure-reducing support surfaces. The required list changes over time as CMS adds or removes items. Because of that, we do not print a fixed list here. Ask your supplier whether the exact item and billing code are currently on it, and use the CMS prior authorization page for the current list.

If your item is not on the list, Medicare’s usual coverage rules still apply. Your doctor still has to document medical necessity, and the supplier still has to be enrolled in Medicare. You just skip the pre-approval step. For a plain-English look at what Part B pays, see our guide to Medicare DME coverage and what you owe.

Who submits the request and what goes in it

The supplier does the filing. Medicare.gov explains that the DME supplier is generally responsible for sending the prior authorization request and the required documentation to Medicare on your behalf. Your doctor’s role comes before that: the order and the medical record notes are what the supplier submits.

CMS’s 2026 operational guide says a request should include these elements:

  • Beneficiary information: name, Medicare Beneficiary Identifier (MBI), date of birth, address, place of service and diagnosis code.
  • Supplier information: National Supplier Clearinghouse number, NPI, address and phone.
  • Requestor information and the specific HCPCS codes for the items.
  • Medical record documentation that supports medical necessity, plus anything else the contractor considers necessary.

Those details come from the DMEPOS prior authorization operational guide. Requests can go in by mail, fax, Electronic Submission of Medical Documentation (esMD), or an internet-based provider portal. That is the supplier’s choice, not yours.

What you can do to speed it up

You cannot file the request, but you can make it easier to get right:

  1. Ask your doctor’s office to document why you need the item: your diagnosis, what you can and cannot do now, and why a simpler device will not work.
  2. Use a supplier that is enrolled in Medicare and accepts assignment. Ask them directly whether this item requires prior authorization.
  3. Keep your Medicare card handy so the supplier has the right MBI the first time.
  4. Ask for the unique tracking number once a decision is made, and keep a note of the date.

How the process works, step by step

  1. Your doctor orders the item and documents medical necessity in your record.
  2. The supplier checks whether the item is on the Required Prior Authorization List.
  3. The supplier submits a prior authorization request (PAR) to the DME MAC, the regional contractor that handles DME claims.
  4. The DME MAC reviews it. For initial requests and resubmissions, CMS’s current guide sets a decision within 5 business days, not to exceed 7 calendar days, after it receives complete documentation.
  5. You get a decision. Either it is provisionally affirmed or non-affirmed, and the supplier is notified (and you, if you ask for notice).
  6. The supplier delivers the item and bills Medicare. The claim must carry the unique tracking number (UTN) the DME MAC issued with the decision. CMS explains that the UTN verifies the prior authorization process was followed.

Older versions of the guide used longer review windows, so if you read an older article that says 10 business days, it is out of date. The clock also starts only when documentation is complete. An incomplete package is where most delay comes from.

Does approval guarantee coverage or payment?

No. A provisional affirmation is a preliminary finding, not a payment promise. The claim still has to be filed correctly, match what was approved, and meet Medicare’s other requirements. What approval does give you and your supplier is some comfort: CMS says paid claims tied to an affirmed decision receive some protection from future audits.

An approved item is also still subject to your normal cost sharing. Under Original Medicare you generally owe the Part B deductible and 20% coinsurance of the Medicare-approved amount, which we break down in our Medicare DME coverage guide. A Medigap plan can pick up that coinsurance, and we cover how in the section on Medicare Supplement plans.

If you want to compare the price of an item before you commit, it can help to see what similar equipment costs out of pocket. One example is compression therapy costs, which shows how a purchased unit compares with ongoing sessions.

If your request is not approved

A non-affirmative decision is not the end of the road. In CMS’s operational guide, a non-affirmative decision is a preliminary finding that the future claim does not likely meet requirements, and it is treated as an incomplete request. The decision letter explains what was missing. The supplier can submit another complete request with the documentation the letter describes, and that guide states that unlimited submissions are permitted.

Here is a practical way to handle it:

  • Read the letter with your supplier. The reason is usually specific: a missing face-to-face note, a diagnosis that does not match the code, or no evidence the item is needed.
  • Call your doctor’s office and ask for an updated note or order that addresses exactly that gap.
  • Have the supplier resubmit. Resubmissions get the same 5-business-day target under the current guide.
  • Ask about your options if you still disagree. If the supplier delivers the item anyway, you may get an Advance Beneficiary Notice that says you might have to pay. Do not sign one until you understand the cost, and call 1-800-MEDICARE (1-800-633-4227) if you want to know what your appeal rights would be on a denied claim.

Original Medicare versus Medicare Advantage

The CMS DMEPOS prior authorization program described above is an Original Medicare process. Medicare Advantage plans work differently. They must cover the same medically necessary categories of DME as Original Medicare, but suppliers and specific costs depend on the plan. Many plans require their own prior authorization, limit you to in-network suppliers, and set their own copays.

That difference is the reason DME is such a common point of confusion for people switching plans. If you are on Original Medicare with a Medigap plan, you can generally use any supplier that accepts Medicare assignment. If you are on Advantage, the first call should be to your plan, and the second should be to an in-network supplier.

Original Medicare Medicare Advantage
Who sets prior authorization rules CMS, through the Required Prior Authorization List Your plan, within Medicare’s coverage requirements
Who files the request The DME supplier Usually the supplier or your doctor, as your plan directs
Supplier choice Any enrolled supplier that accepts assignment Typically the plan’s network
Cost sharing Part B deductible and 20% coinsurance Set by the plan; check your Evidence of Coverage

If you are on an Advantage plan and a request is denied, our guides to common Medicare Advantage claim denials and to Medicare Advantage prior authorization wait times explain what the process looks like. For prosthetics and orthotics specifically, see what Medicare covers for prosthetics and orthotics.

Our perspective

Most of the DME stress we hear about comes from not knowing who does what. People assume they have to chase approval themselves, or they sign for equipment before anyone has told them whether Medicare will pay.

Our advice is simple. Ask the supplier two questions before delivery: is this item on the prior authorization list, and has a decision with a tracking number been issued? Then check how your own plan treats the item. This is exactly why we believe in education first. It is hard to make a good decision when you do not understand your next step.

As independent agents who have helped Medicare consumers since 2007, we can compare how Original Medicare with a Medigap plan and Medicare Advantage plans handle equipment, suppliers and out-of-pocket costs, so you choose coverage that fits the care you actually expect to need.

Paul

Choosing coverage that fits your equipment needs

If you already use a CPAP machine, a power wheelchair or a hospital bed, or you know you will need one, your plan choice matters more than it does for someone who rarely sees a doctor. Look at three things: whether your preferred suppliers are in network, how the plan handles prior authorization, and what you will owe each month for rental items.

We are an independent agency that works with 40+ carriers, and a plan review is built around your needs rather than a sales pitch. We can walk you through Medicare Advantage plans or Medicare Supplement plans side by side, check your equipment and suppliers against each, and revisit your coverage every year. To start a conversation with our team, visit Paul B Insurance.

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For a broader look at the equipment benefit, read our Medicare durable medical equipment guide for 2026.

FAQ

Does Medicare require prior authorization for all DME?

No. It applies only to items on CMS’s Required Prior Authorization List, a subset of a larger Master List of costly, frequently misused equipment. Other DME is covered under normal rules, with no pre-approval step. Your supplier can tell you whether your item is currently on the list.

How long does a Medicare DME prior authorization decision take?

CMS’s current operational guide sets a decision within 5 business days, not to exceed 7 calendar days, after the DME MAC receives complete documentation. Resubmissions follow the same target. Missing records are the usual cause of longer waits.

Do I have to submit the prior authorization request myself?

No. The DME supplier generally submits the request and the supporting documents. Your part is to make sure your doctor has documented why you need the item, and to confirm that the supplier is enrolled in Medicare.

What happens if my DME prior authorization request is not approved?

The decision letter explains what was missing. Your supplier can gather the updated documentation and submit a new complete request, and CMS guidance says unlimited submissions are permitted. Ask your doctor to address the specific gap in the letter before resubmitting.

Is Medicare Advantage prior authorization for DME the same as Original Medicare’s?

No. Advantage plans must cover the same medically necessary DME categories, but the plan sets its own supplier network, authorization rules and costs. Check your plan’s documents or call the number on your member card before you order.

Sources

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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