Are HMO plans cheaper than PPO plans in Queens?

No. Based on 2026 Medicare Advantage plan data for Queens, PPO plans have an average monthly premium of approximately $22.99, while HMO plans average about $42.90 per month. This is the opposite of the common assumption that HMOs are always the lower-cost option.

Which has better CMS Star Ratings in Queens, HMO or PPO plans?

CMS assigns Star Ratings at the Medicare contract level rather than to individual plan types. One notable example is Healthfirst's Medicare Advantage contract, which includes its 65 Plus Plan and Increased Benefits Plan (both HMOs) and received a 4.5-star CMS Star Rating for 2026. Star Ratings should be reviewed for each contract instead of assuming one plan type consistently scores higher than another.

Do more people choose HMO or PPO plans in Queens?

HMO and HMO-POS plans account for approximately 61 percent of Medicare Advantage enrollment in Queens. Although PPO plans have a lower average premium, many beneficiaries continue choosing HMO plans based on provider networks, plan benefits, carrier reputation, and personal healthcare preferences.

Is it true that HMO plans are always cheaper than PPO plans in New York City?

No. Available 2026 Medicare Advantage data for both Queens and Brooklyn shows that average PPO premiums are lower than average HMO premiums. While this may not be true in every market, these New York City boroughs demonstrate that premium costs vary by local market and insurance carrier.

Can I switch from an HMO to a PPO in Queens if my doctor leaves the network?

Yes. If your healthcare provider leaves your Medicare Advantage plan's network, you may qualify for a Special Enrollment Period (SEP), depending on Medicare rules and your circumstances. Otherwise, you can change plans during the Annual Enrollment Period or the Medicare Advantage Open Enrollment Period.

Does the Mount Sinai and Healthfirst provider situation affect Queens' most popular HMO plan?

Yes. According to Mount Sinai's published provider participation information, Mount Sinai primary care providers are not currently accepting new Healthfirst Medicare Advantage patients, including those enrolled in the Healthfirst 65 Plus Plan. Because provider participation can change, confirm network status directly with the provider before enrolling.

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.

HMO vs. PPO Medicare Advantage in Queens, NY

July 21, 2026

Medicare Advantage vs. Medigap in Brooklyn, NY: The Real 2026 Cost Comparison

By Paul Barrett, CMIP | The Modern Medicare Agency | Melville, NY 18+ years Medicare-exclusive experience | Licensed in 37 states | 40+ carriers Last updated: July 2026

Most articles on this topic give you a features chart — networks, referrals, premiums — and leave you to guess what it actually costs. I want to do something different: use Brooklyn’s real 2026 numbers, on both sides, and show you what a healthy year and a bad year actually look like in dollars.

I’m independent — I represent more than 40 carriers across both Medicare Advantage and Medigap, so nothing here is written to steer you toward one option. It’s written so you can see the real trade-off clearly.

KEY TAKEAWAYS

A $0-premium Brooklyn Medicare Advantage plan can cost as little as $300 a year beyond your Part B premium in a healthy year — but as much as $11,350 in a year with a major hospitalization or high drug costs.
The cheapest real Medigap Plan G rate in Brooklyn (UnitedHealthcare/AARP, $372.50/month) plus a standalone Part D plan runs $5,167 to $7,267 a year, almost regardless of how much care you actually use.
That’s the entire trade-off in one sentence: Medicare Advantage can be cheaper, but the cost swings wildly with your health. Medigap costs more on average, but the swing is small.
Brooklyn Medicare Advantage members are currently living a real example of network risk — the active UnitedHealthcare/NewYork-Presbyterian dispute — that simply doesn’t exist for Medigap.
Medicare Advantage enrollees have access to only about 48% of the physicians available to Original Medicare beneficiaries in the same area — a real gap most people underestimate, since only about 1% of physicians nationwide have opted out of Original Medicare entirely.
New York Medigap premiums are rising sharply — a confirmed 17.8% single-year increase for the market’s dominant carrier (UnitedHealthcare, ~70%+ of NY Medigap enrollees) in 2026, with 11.6%-13.5% more proposed for 2027 — and that trend is pushing more consumers toward Medicare Advantage on cost alone, not necessarily preference.
There’s no universal right answer. It depends on how much financial uncertainty you’re willing to carry in exchange for a lower average cost.

THE CORE TRADE-OFF, IN PLAIN ENGLISH

Medicare Advantage (Part C) bundles your Part A, Part B, and usually Part D coverage through a private carrier, typically built around a network — HMO, PPO, or HMO-POS. Many Brooklyn plans charge $0 or a low monthly premium. In exchange, your out-of-pocket costs depend on how much care you use in a given year, up to an annual maximum.

Medigap (Medicare Supplement) works alongside Original Medicare. You keep Original Medicare as your base coverage, and the Medigap policy picks up most of what Original Medicare leaves you owing — coinsurance, copays, deductibles, depending on the plan letter. You can see any doctor nationwide who accepts Medicare, with no network and no referrals. The trade-off is a real monthly premium, plus a separate Part D plan for drug coverage, since Medigap doesn’t include it.

	Medicare Advantage	Medigap
Provider access	Usually limited to a network	Any doctor nationwide who accepts Medicare
Referrals	Often required (HMO plans)	Never required
Monthly premium	Often $0-$60 in Brooklyn	$223-$840+ depending on plan letter and carrier
Annual cost predictability	Varies significantly by how much care you use	Highly predictable
Drug coverage	Usually bundled in	Requires a separate Part D plan
Network risk	Real — see below	None
Underwriting to switch later	N/A — switch during enrollment periods	Guaranteed-issue, year-round in New York

WHAT IT ACTUALLY COSTS: TWO REAL BROOKLYN SCENARIOS

Here’s where the features table stops being useful and the real math starts. I built this using an actual $0-premium Brooklyn Medicare Advantage HMO (Healthfirst 65 Plus Plan, 13,006 enrollees, $9,250 out-of-pocket maximum) against the cheapest real Medigap Plan G rate available in Brooklyn’s NYC Proper rating region (UnitedHealthcare/AARP at $372.50/month), paired with the 2026 average standalone Part D premium ($34.50/month).

Both scenarios below exclude the Part B premium ($202.90/month, or $2,435.60/year), since you pay that regardless of which path you choose — it’s not a differentiator.

A healthy year — routine care only:

	Medicare Advantage	Medigap Plan G + Part D
Annual premium	$0	$5,847
Additional out-of-pocket costs	~$300 (a handful of copays)	~$283 (Part B deductible, if any care used)
Total for the year	~$300	~$5,167 (fixed low, mostly premium)

A major health event year — hospitalization, high drug costs, or both:

	Medicare Advantage	Medigap Plan G + Part D
Annual premium	$0	$5,847
Out-of-pocket maximum hit (medical)	$9,250	$0 (Plan G covers it)
Part D drug spending hits the cap	$2,100	$2,100
Total for the year	Up to $11,350	Up to $7,267

The gap tells the whole story. In a healthy year, the Medicare Advantage member comes out roughly $4,900 ahead. In a bad year, the Medigap member comes out roughly $4,100 ahead — and critically, the Medigap member’s cost barely moved between the two scenarios, while the Medicare Advantage member’s cost moved by more than $11,000.

WHY THIS ISN’T JUST A HYPOTHETICAL: THE NETWORK RISK IS REAL RIGHT NOW

Medicare Advantage’s cost variability isn’t the only thing that swings — network access can too, and Brooklyn residents are living through a real example of it as this is written.

UnitedHealthcare and NewYork-Presbyterian are in an active contract dispute, with in-network access extended only through July 31, 2026. This directly touches Brooklyn: NewYork-Presbyterian Brooklyn Methodist Hospital and its Brooklyn Medical Group practices are named among the facilities that would go out-of-network if no new agreement is reached — not just the Manhattan campuses. Starting August 1, 2026, those facilities could become out-of-network for most UHC Medicare Advantage members.

Anthem and Mount Sinai already went through this in 2026. When their contract lapsed, Mount Sinai’s entire system — including Mount Sinai Brooklyn — went out-of-network for all Anthem Blue Cross Blue Shield members starting March 4, 2026. A new agreement restored access about six weeks later, effective April 13, 2026. It’s resolved now, but it happened, and it’s proof this risk is concrete, not theoretical.

A Medigap member never has this conversation. Since Medigap works alongside Original Medicare rather than a private network, there’s no hospital system to lose access to — you can see any doctor nationwide who accepts Medicare, full stop.

For a deeper look at how network type affects this trade-off within Medicare Advantage itself, see HMO vs. PPO Medicare Advantage in Brooklyn, NY — PPO plans generally handle a situation like this better than HMOs, since you can go out-of-network at a higher cost instead of losing access entirely.

THE PROVIDER ACCESS POINT MOST PEOPLE MISS

Here’s something worth sitting with if you spent your working years on an employer group health plan: you likely never had access to anywhere near “any doctor.” Group and individual private insurance plans are built around networks too, often narrow ones. Original Medicare works differently — the vast majority of physicians nationwide accept it. Only about 1% of non-pediatric physicians have formally opted out of the Medicare program entirely.

That matters because Medigap rides on top of Original Medicare, so a Medigap member inherits that same broad access. Medicare Advantage doesn’t work the same way. According to KFF’s analysis of federal data, the average Medicare Advantage enrollee is in a plan whose network includes only about 48% of the physicians available to Original Medicare beneficiaries in the same area — less than half. That’s not a knock on Medicare Advantage; plenty of people never notice, because their doctors happen to be in-network and stay that way. But for people who’ve spent decades navigating employer-plan network restrictions, the idea of walking into nearly any doctor’s office nationwide and knowing you’re covered isn’t a small thing — for a lot of people, it’s the first time in their adult life they’ve had that kind of access. That psychological comfort is real, even if it’s hard to put a dollar figure on it.

WHY NEW YORK MEDIGAP PREMIUMS KEEP CLIMBING

If you’ve shopped Medigap in New York recently and felt sticker shock, you’re not imagining it — and understanding why helps explain where this market is headed.

New York’s consumer protections are also what makes the market expensive to compete in. The same guaranteed-issue, community-rated rules that let you buy a Medigap policy year-round regardless of your health also mean insurers can’t use medical underwriting to manage their risk the way they can in most other states. Every applicant gets the same rate regardless of age or health status. That protects consumers, but it also means a carrier can’t price a policy differently for a healthier or sicker applicant — the whole risk pool gets priced together.

The market is dominated by one carrier. UnitedHealthcare, through its AARP-branded Medigap program, holds roughly 70%+ of New York’s Medigap market — a far bigger share than in most states. Because the state’s rules make it hard for smaller, price-competitive carriers to profitably undercut a dominant player at this kind of scale, real competitive pressure on pricing is limited. Several of the carriers in Brooklyn’s own rate table (Bankers Conseco, Humana, Mutual of Omaha) are priced well above UnitedHealthcare for identical, federally standardized coverage — a sign of a market with a dominant player and comparatively thin competition beneath it, not a market where carriers are fighting hard for your business on price.

Rates have been rising sharply. UnitedHealthcare’s own 2026 New York filing carried a confirmed 17.8% single-year increase for Plan G — the largest DFS-approved increase of its kind in recent memory — and the carrier has already filed a proposed 11.6% to 13.5% increase for 2027. High utilization among the existing Medigap risk pool is a major driver: because New York carriers can’t underwrite, they can’t price out unhealthy individual applicants — the primary lever they have left to manage a book of business with rising claims costs is raising rates across the board, which affects everyone in the pool, healthy or not.

What this means going forward: as Medigap premiums keep climbing, it becomes financially out of reach for a growing share of consumers — even though guaranteed-issue rules technically keep the option open to everyone regardless of health. That’s part of why Medicare Advantage enrollment has kept growing in New York even as Medigap has gotten more expensive: for a lot of people, it’s less a preference than a budget decision. It’s also worth understanding that this dynamic cuts both ways — a New York-specific pressure that doesn’t exist the same way in most other states, and one more reason the “which is right for you” answer here isn’t static. It’s worth revisiting with your specific numbers each year, not just deciding once and assuming it still holds.

A separate, unrelated development worth being aware of: CMS launched a new prior authorization pilot for Original Medicare (the “WISeR” model) on January 1, 2026, running through 2031 — but it’s currently limited to six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington). New York is not currently included. It’s a trend worth watching nationally, since it signals Medicare is looking for new ways to control costs in Original Medicare too, not just Medicare Advantage — but it doesn’t affect Original Medicare or Medigap coverage in Brooklyn today.

QUALITY: ONE SIDE OF THIS COMPARISON VARIES, THE OTHER DOESN’T

This is a distinction worth understanding clearly. Medigap plans are federally standardized — a Plan G from one carrier covers exactly the same benefits as a Plan G from any other carrier. The only real differences between Medigap carriers are price, customer service, and financial stability. There’s no CMS star rating for Medigap because there’s nothing to rate differently; the coverage is identical by law.

Medicare Advantage plans are not standardized. Brooklyn’s 38 traditional MA plans carry CMS star ratings ranging from 3.0 to 5.0 stars, and — as we found when comparing HMO and PPO plans directly — the highest-rated plans aren’t necessarily the cheapest, and $0-premium plans often carry only average ratings. If you’re leaning toward Medicare Advantage, the star rating and specific plan details matter enormously, in a way they simply don’t for Medigap.

WHO ACTUALLY FITS EACH OPTION

Medicare Advantage tends to make sense if:

Lower average cost matters more to you than cost predictability.
You’re in good health with few chronic conditions and don’t expect major medical events.
Your doctors and preferred hospital are solidly in-network with a plan you trust, and you’re comfortable monitoring that relationship year to year.
You want dental, vision, and hearing benefits bundled in without a separate purchase.

Medigap tends to make sense if:

You’d rather pay a predictable amount every month than risk a five-figure bad year.
You have ongoing health conditions, take expensive medications, or anticipate needing significant care.
You want the freedom to see any doctor nationwide without worrying about networks — including specialists outside Brooklyn, or care while traveling or spending part of the year elsewhere.
The current network disputes (UHC/NewYork-Presbyterian, or situations like Anthem/Mount Sinai) make you uncomfortable with the idea of a plan-specific network at all.

PAUL’S HONEST TAKE

I don’t think this is a “which is better” question — I think it’s a “how much uncertainty are you comfortable carrying” question. If you’re healthy, watching your budget, and your doctors are solidly in-network with a strong local plan, a $0 Medicare Advantage plan can be a genuinely smart choice — plenty of my clients do great on one for years. But I’ve also sat with people who picked the cheapest premium without understanding that “cheapest” and “lowest cost” aren’t the same thing once a bad year hits. The Medigap premium isn’t a waste of money — it’s the price of not having to think about any of this again.

Here’s the part I want to be direct about, though: the math above isn’t static, and it’s tilting in one direction. New York’s Medigap rates have been climbing hard — a confirmed 17.8% jump in 2026 alone for the largest carrier — and I don’t see anything in this market that suggests that slows down soon. That means fewer people every year will find Medigap genuinely affordable, even though guaranteed issue technically keeps the door open to everyone. I think that’s part of why Medicare Advantage keeps growing here even as more people become aware of its network trade-offs — for a real chunk of Brooklyn’s Medicare population, it’s becoming less a lifestyle preference and more a budget reality.

None of this means Medicare Advantage is the “right” answer or Medigap is the “wrong” one. It means both sides of this decision are moving targets, and a plan that made sense for you two years ago might not be the strongest option for you today. That’s true whether you’re on Medigap watching your renewal notice, or on Medicare Advantage watching your plan’s network and star rating shift year to year. Neither answer is wrong. What’s wrong is picking either one once and assuming it stays the right call forever.

FREQUENTLY ASKED QUESTIONS

Is Medicare Advantage or Medigap cheaper in Brooklyn?

It depends on your health year. In a healthy year with routine care only, a $0-premium Medicare Advantage plan can cost around $300 beyond your Part B premium, compared to roughly $5,167 for Medigap Plan G plus a standalone Part D plan. In a year with a major hospitalization or high drug costs, Medicare Advantage could cost up to $11,350, while Medigap Plan G stays capped around $7,267.

Why is Medigap so much more predictable than Medicare Advantage?

Medigap Plan G covers nearly all of the cost-sharing that Original Medicare leaves you responsible for, so your annual cost is close to fixed: your premium plus the Part B deductible. Medicare Advantage plans have an annual out-of-pocket maximum, but you can be charged copays and coinsurance up to that maximum depending on how much care you use — so your actual cost varies year to year.

Does Medigap cost more every single month than Medicare Advantage?

Usually, yes. The cheapest real Medigap Plan G rate in Brooklyn’s NYC Proper region is $372.50/month (UnitedHealthcare/AARP), compared to several $0-premium Medicare Advantage HMO and PPO options. You’re paying that higher premium for predictability and unrestricted provider access, not for lower cost.

Why do I have access to more doctors with Medigap than I had on my old employer plan?

Original Medicare, which Medigap works alongside, is accepted by the vast majority of physicians nationwide — only about 1% have formally opted out. Most employer group and private insurance plans are built around narrower networks. For many people, Medigap is actually the broadest provider access they’ve had access to in their adult life, not a downgrade from what they’re used to.

Why are Medigap premiums so high in New York?

A few factors compound. New York requires guaranteed-issue, community-rated Medigap coverage year-round, which protects consumers but limits insurers’ ability to price risk individually. UnitedHealthcare holds roughly 70%+ of the state’s Medigap market, leaving limited price competition beneath it. And because carriers can’t underwrite out high-utilization applicants, rising claims costs get passed through as across-the-board rate increases — UnitedHealthcare’s own New York Plan G rate rose 17.8% in 2026 alone, with an additional 11.6%-13.5% increase already proposed for 2027.

Can I switch from Medicare Advantage to Medigap in Brooklyn if I change my mind?

Yes, but the details matter. New York’s guaranteed-issue rule makes it easier here than in most states — you generally can’t be denied a Medigap policy or charged more due to your health, on a continuous, year-round basis. That said, timing your switch away from Medicare Advantage typically still follows Medicare’s enrollment period rules, so it’s worth confirming your specific situation before deciding.

Does the current UnitedHealthcare/NewYork-Presbyterian dispute affect Medigap members?

No. Medigap works alongside Original Medicare rather than through a private network, so there’s no hospital system to lose in-network access to. This kind of network dispute is a Medicare Advantage-specific risk.

Which is better for someone with ongoing health conditions?

Generally, Medigap’s cost predictability becomes more valuable the more care you expect to need, since your annual cost stays close to fixed rather than climbing toward the out-of-pocket maximum. That said, the right answer still depends on your specific conditions, medications, and doctors — worth a direct conversation rather than a generic rule.

Not sure which side of this makes sense for your specific health, doctors, and budget? Call or text 631-358-5793. No pressure, no cost — just the real numbers for your situation, not averages.

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.