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.

Do I have to do anything if I'm happy with my current plan?

Not always, but it's worth ten minutes to check. Plans can change their drug list, provider network, and costs every year, even if you don't touch a thing. Reading your plan's Annual Notice of Change letter is the fastest way to know if your current plan is quietly changing under you.

What documents should I have ready before I talk to an agent?

A current list of your medications with dosages, your doctors and any specialists you see, your red white and blue Medicare card, and your current plan's member ID card. Having these ready makes any conversation, whether with an agent or Medicare directly, faster and more accurate.

Is it safe to work with a Medicare broker or agent?

Working with a licensed, independent agent costs you nothing extra. Your premium is the same whether you enroll through an agent or directly with the carrier. A good agent should be able to explain how they're paid, show you more than one plan option, and check whether your specific doctors and medications are covered before you enroll.

When do Annual Notice of Change letters arrive and why do they matter?

Carriers are legally required to mail Annual Notice of Change (ANOC) letters to every plan member by September 30 each year. The letter explains exactly what's changing about your plan for the following year, including premium, deductible, drug costs, and network. These letters are often long and easy to mistake for junk mail, but skipping them can mean missing a significant change to your coverage, which matters even more in a year when many Medicare Advantage plans are changing substantially.

Can I change my mind after I submit a Medicare enrollment application during AEP?

Yes. During the Annual Enrollment Period, from October 15 through December 7, you can submit more than one application and change your mind as many times as you need to. Only your last submission before midnight on December 7 actually takes effect, so there's no need to feel rushed into a decision early in the window.

How can I avoid pushy Medicare sales calls during AEP?

Be cautious about clicking on Medicare ads online or filling out forms requesting 'more information,' since that often triggers calls from lead buyers rather than someone equipped to answer your specific questions. Direct mail and phone lines run by carriers during AEP are frequently staffed by seasonal, part-time representatives due to the high volume of calls this time of year, so it's worth verifying who you're actually speaking with before making a decision.

Are Medicare Supplement premiums increasing?

Medicare Supplement (Medigap) premiums have seen significant rate increases over the past couple of years. It's worth comparing your current Medigap rate against other available options during AEP rather than assuming your premium has stayed reasonable.

What does out-of-network care actually cost on a PPO Medicare plan?

Most Medicare Advantage PPO plans today charge coinsurance for out-of-network care rather than a flat copay, meaning you pay a percentage of the bill rather than a set dollar amount. Some plans also apply a deductible before that coinsurance kicks in. Before enrolling in a PPO, ask specifically what percentage applies and whether a deductible is involved, especially if you'd want the option to get a second opinion from a doctor outside the network.

Should I insist on a PPO Medicare plan?

PPO plans are becoming less common as more insurance carriers convert plans to HMO and HMO Point-of-Service structures to control costs, and the PPO plans that remain are increasingly local rather than regional. A PPO can still be a good fit, but it's important to understand the actual out-of-network coinsurance and deductible costs before assuming it offers the flexibility it used to.

What is a Medicare 'live transfer' phone call?

A live transfer happens when a call center cold-calls a Medicare consumer, gets them interested in improving their coverage or lowering costs, and then transfers the call to an agent who has paid roughly $50 to $100 for that connection. The paying agent's goal is to enroll the consumer in a plan to recoup that cost, which is different from receiving neutral, educational guidance. These calls often display as local or toll-free numbers even when the call center is located elsewhere.

How do I know if an unsolicited Medicare phone call is legitimate?

If you did not initiate the contact yourself, treat the call with caution regardless of how local the number appears, since caller ID can be spoofed. Avoid giving out your Medicare number or personal details to someone who called you unprompted. If something discussed on the call is genuinely interesting, hang up and call your own agent or Medicare directly using a number you already trust rather than continuing with the unsolicited caller.

Getting Ready for Medicare’s Annual Enrollment Period: Your Complete AEP Checklist

Q: 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.

September 2, 2026

Medicare AEP Checklist 2026: What to Do Before Enrollment

Paul Barrett, CMIP · The Modern Medicare Agency

Getting Ready for Medicare's Annual Enrollment Period: Your Complete AEP Checklist

Updated for AEP 2026 (coverage effective January 1, 2027) · Reviewed by Paul Barrett, CMIP, AHIP-certified, 18+ years as a Medicare-exclusive broker

Every fall, mailboxes fill up with Medicare ads, TV commercials get louder, and phones start ringing with calls from numbers nobody recognizes. It's a lot. So before AEP even opens, let's sit down at the kitchen table and go through this the calm way — what to gather, what to check, and what to actually do. No jargon, no pressure.

What's In This Guide

Start here: what to do right now
What to do during AEP (Oct 15 – Dec 7)
After you enroll (or decide to stay put)
Why this AEP is different from recent years
Common AEP mistakes — and how to avoid them
Unsolicited calls and "live transfers"
Frequently asked questions

The Dates That Actually Matter

October 15 – December 7: Annual Enrollment Period (AEP). You can switch Medicare Advantage or Part D drug plans.

January 1: Any changes made during AEP take effect.

January 1 – March 31: Medicare Advantage Open Enrollment Period — a second, more limited window if you're already in a Medicare Advantage plan and want to switch once more.

Start Here: What to Do Right Now, Before AEP Opens

September — Early October

Paul's Honest Take — Don't Let Your ANOC Letter Become Junk Mail

Your Annual Notice of Change (ANOC) letter has already started arriving. Carriers began mailing these in September, and by law, every single one must be sent out by September 30. It explains exactly what's different about your plan for 2027 compared to this year — premium, deductible, drug costs, network, all of it.

Here's the problem: these letters are often long, dense, and not organized to help you. There's no bright headline that says "here's what actually matters to you." Nothing about the way it looks screams "important." A lot of people mistake it for junk mail and toss it without opening it.

This year, that would be a real mistake. Medicare Advantage plans are going through significant changes right now. Millions of people are going to see meaningful changes to their plan for 2027, and a couple million people are expected to lose their current coverage altogether and need to pick something new. Find that envelope, open it, and actually read it. It's worth the twenty minutes.

Find your Annual Notice of Change (ANOC). Your current plan is required to mail you this letter every September. It spells out exactly what's changing for next year — premium, deductible, drug tiers, doctor network. Read it before you assume "nothing changed."
Pull together your Medicare card and current plan ID card — and take a photo of it. You'd be surprised how many people have the wrong card in their wallet, or aren't actually sure which plan they're on. Knowing exactly what you have right now is what lets an agent compare apples to apples. And if you don't want to change your plan just to change it, having the right card in hand is one of the simplest ways to prevent an unnecessary switch by mistake.
Think honestly about how this year went. Any surprise bills? A drug that got expensive? A doctor visit that felt like a hassle to schedule? Those are the clues worth bringing into any conversation about next year's plan.

Your Prescription Drug List — Do This One Really Well

Of everything on this page, this is the part worth slowing down for. Nearly every Medicare beneficiary takes at least one prescription, and drug costs are usually the biggest swing factor in what a plan actually costs you over a year. A rushed, half-remembered list is the #1 reason people end up in the wrong plan without realizing it.

List everything you took over the whole year — not just what's in your pillbox today. If you started something in March or finished a short course in July, it still tells an agent (or the Plan Finder tool) something about your health needs. Don't limit the list to "right now."
Note anything you started, stopped, or switched, and why. If your doctor moved you off one drug and onto another, or you stopped taking something, write that down too. Those changes matter for next year's planning.
Know generic vs. brand name for each one — and write down which you actually take. "Metformin" and "Glucophage" are not the same line item to a drug plan's formulary, and the cost difference between the generic and brand-name version of the same drug can be significant. Don't guess — check the bottle or ask your pharmacist.
Include the dosage and how often you fill it. A 30-day supply and a 90-day supply can price out very differently plan to plan.
Write it out or type it out — don't rely on memory in the moment. Whether it's a note on your phone, an index card, or a printed sheet, have it in front of you before any call or appointment. Trying to recall seven medications and their doses off the top of your head, on the spot, is where mistakes creep in.

Paul's Honest Take — Why Part D Help Can Be Hard to Find

Here's something most people don't know, and I think you deserve to. If you pair Original Medicare with a Medicare Supplement (Medigap) plan, your drug coverage doesn't come bundled in — you need a separate, standalone Part D plan. If you're in a Medicare Advantage plan instead, drug coverage is usually built into that plan, and the agent who enrolls you gets compensated for that work.

Standalone Part D plans are different. The large majority of them — in my experience, somewhere around 90% — pay agents little to nothing for helping you enroll. That doesn't make the work less important; prescription costs are often the single biggest recurring expense for people on Medicare. But it does mean a lot of agents can't take on unpaid Part D work at scale. It's real time, and it carries real licensing risk to do carelessly for zero compensation. That's just the honest state of things, and it's a big part of why so many people struggle to find an agent willing to sit down and work through Part D with them.

Here's what that means for you: if you want help with a standalone Part D plan, the best thing you can do is walk in with your drug list already done — every medication, dose, generic vs. brand, and any changes from the past year, written out clearly, like above. An agent who can run a clean list through the plan comparison tool in five minutes is far more likely to help than one facing "I take a few pills, I don't remember what they're called." And if you can't find an agent for this piece specifically, you're not stuck — Medicare.gov's Plan Finder tool lets you compare Part D plans yourself, using that same list.

Your Provider List — Names, Offices, and Locations

This one needs more detail than most people think. "I see Dr. Patel" isn't enough anymore — you need to know exactly where you see Dr. Patel, because it's increasingly common for a doctor to split time across two or three different offices, and only one of those locations may actually be in a given plan's network.

List every doctor and specialist by full name — primary care, cardiologist, dermatologist, physical therapist, anyone you see regularly.
Note the specific office address you actually go to for each one. Not just the practice name — the street address. Many providers now work out of more than one location, sometimes under different practice groups, and a plan can be in-network at one address and out-of-network at another for the very same doctor.
If your doctor has multiple locations, ask which ones a plan actually covers. Don't assume — verify it for the exact office you use.
Be honest with yourself about whether you'd travel to a different location. If your preferred office isn't in-network but the same doctor sees patients at a covered location across town, would that work for you? That answer changes which plans are realistic options.

Paul's Honest Take — Networks Are Getting Tighter This Year

I want to flag a trend so it doesn't catch you off guard. More plans are converting into HMO and HMO Point-of-Service structures this year, and there will be fewer PPO options overall. On top of that, most of the PPO plans that remain aren't staying regional — they're shrinking down to local PPO networks. That means smaller networks, and it means the cost of stepping outside that network is going up.

For years, a lot of people leaned on PPOs as their safety net — the idea that even if a doctor was "out of network," it wouldn't cost much extra to see them anyway. That safety net is getting thinner. Which is exactly why the office-by-office, address-by-address level of detail above matters so much more this year than in years past. A doctor's name being "in-network" in general isn't the full picture anymore — the specific office you walk into is what determines whether you're covered.

A quick word on the "I just want a PPO" instinct. I hear this constantly, and I understand why — PPOs feel like more freedom. But the honest truth is that PPOs are going to be harder and harder to find in most counties going forward. Insurance carriers save money by controlling who you see and making sure the providers you do see have agreed to their payment terms, and that's simply easier to do with a tighter network. If you do find a PPO that looks good and fits you, that's great. Just go in with your eyes open about what "out of network" actually costs on that plan. Most PPOs today charge coinsurance for out-of-network care, not a flat copay — meaning you pay a percentage of the bill rather than a set dollar amount, and that percentage can add up fast. Some plans layer a deductible on top of that coinsurance before it even kicks in. So if you ever want a second opinion from a doctor outside your network, that's where the real cost surprises show up.

This year, ask more questions than you ever have before. Sit down with your agent or whoever enrolls you and ask directly: if I go out of network for a second opinion, what will it actually cost me? Is it 30%? 40%? Is there a deductible before that even applies? Get a real number, not a general sense of "it costs a bit more." Understanding your rights and your actual out-of-pocket exposure is the single most important thing you can do as a consumer this year.

During AEP: October 15 – December 7

While the window is open

If you want a PPO, ask exactly what out-of-network care costs. Get the real numbers — the coinsurance percentage, whether a deductible applies first, and what that means specifically for something like a second opinion. A vague answer isn't good enough this year.
Compare your options — even if you like your plan. Ten minutes of comparing can confirm you're in the right place, or catch something before it costs you money in January.
Check that your medications are covered — and at what tier. A drug being "covered" isn't the whole story. The tier it's placed in changes what you pay out of pocket.
Confirm your doctors are in-network — at the specific office you use. Don't take a plan's word for it from a brochure, and don't stop at the doctor's name. Verify the exact address, since the same doctor can be in-network at one location and out at another.
Ask about total cost, not just the premium. A $0 premium plan can still cost more overall once you add up copays, deductibles, and drug costs. Look at the whole picture.
If you talk to an agent, ask how they're paid and how many carriers they represent. A good, honest agent will answer both without hesitation.
Get your confirmation in writing. Whether you enroll through an agent, Medicare.gov, or the carrier directly, keep a copy of your confirmation number and enrollment date.

After You Enroll (or Decide to Stay Put)

December — January

Watch for your new member ID card if you switched plans. It should arrive before January 1.
Confirm your first prescription refill under the new plan processes correctly in early January.
Know that you get a second look. If you're in a Medicare Advantage plan and something feels off once January hits, the Medicare Advantage Open Enrollment Period (Jan 1 – Mar 31) gives you one more chance to switch.

Paul's Honest Take

The biggest mistake I see every fall isn't picking the "wrong" plan — it's not checking at all. People assume that because their plan worked fine last year, it'll work fine again. Carriers change formularies and networks every single year, quietly, in a letter most people don't read closely. You don't need to switch plans to benefit from AEP. You just need to look. That's the whole ask.

Why This AEP Is Different From Recent Years

A few things are happening in the Medicare market right now that are worth understanding before you compare plans, because they change what "the right plan" even means this year.

Medicare Supplement premiums have been climbing sharply. Rate increases on Medigap plans have been significant the last couple of years, and it's worth checking your current rate against what else is out there rather than assuming it's stayed reasonable.
Medicare Advantage plans are pulling out of areas. Some carriers are exiting specific counties altogether, which is part of why the ANOC letter above matters so much — your current plan may simply not be offered where you live next year.
Some plans are quietly making themselves hard to enroll in. This is called enrollment suppression, and it's real. More on it below.

Paul's Honest Take — Just Because a Plan Exists Doesn't Mean the Carrier Wants You In It

Here's something going on behind the scenes that most people never hear about. A growing number of Medicare Advantage plans are technically still active — you might see them listed on Medicare.gov or in a plan comparison — but when you go to the carrier's own website, they're not shown prominently. They're hard to find on purpose. And often, there's no agent support available to help you enroll in them either.

This is called enrollment suppression, and it happens because those specific plans are currently losing the carrier money. The carrier isn't ready to cancel the plan and cut off the members already on it, but they also don't want to add new members who'd add more claims cost. So they walk a line: keep the plan technically available, but make it genuinely difficult to find and enroll in. Sometimes carriers don't give agents access to these plans in our enrollment systems at all — which means we can't enroll you the normal way even if you ask us to. You'd need to request a paper application directly and often submit it yourself.

Why does this matter to you? Because just because a plan exists doesn't mean it's the right plan for you, and just because it's listed somewhere doesn't mean the carrier actually wants you as a member. If an agent isn't showing you a particular plan, ask why — a good one will tell you honestly if it's because they don't have access to enroll people in it, rather than just steering you toward whatever's easiest for them to sell. When a carrier genuinely wants members, they make it easy. When they don't, they make it hard. That difficulty is information, and it's worth paying attention to.

Common AEP Mistakes — And How to Avoid Them

Every fall I watch the same handful of mistakes trip people up. Worth naming them directly.

Not preparing at all. The single biggest mistake is skipping everything above — no updated drug list, no doctor list, an unopened ANOC letter — and then trying to make a decision on the fly. Everything on this page exists to prevent this one.
Skipping the ANOC letter. Worth repeating: it's the one document that tells you, in writing, exactly what's changing about your plan. Skip it, and you find out about a change after it's already cost you money.
Vague, outdated notes on doctors, prescriptions, and hospitals. "My heart doctor" and "a water pill" aren't enough to compare plans accurately. If your notes wouldn't help a stranger understand your care, they need more detail — see the lists above.
Getting pulled in by the advertising. TV commercials, direct mail, and internet ads all ramp up hard this time of year. Click on a Medicare ad online and expect to keep seeing more of them — that's how retargeting works. Fill out a form asking for "more information" and expect your phone to start ringing, often from people who paid to get your contact information and have no real interest in just answering a question.
Assuming mail is trustworthy just because it looks official. Even mail that appears to come from a real carrier during AEP is often handled by seasonal, part-time staff. Nobody has enough year-round agents to cover the sheer volume of calls into Medicare, Social Security, and every major carrier this time of year. Be careful about who's actually answering your questions.
Enrolling on the spot from a commercial's 1-800 number. A decision made in the middle of a commercial break isn't the same as one made with your own notes in front of you.

Paul's Honest Take — You Have Seven Weeks. Use Them.

AEP runs a full seven weeks, October 15 through December 7. You can submit an application any time in that window, and you're allowed to change your mind as many times as you need to between those dates — only your last submission before midnight on December 7 actually counts. There's no reason to let a commercial, a postcard, or a pushy phone call rush you into a decision on day one. Take your time, do the homework above, and change your mind if you need to. That's exactly what the window is there for.

Unsolicited Phone Calls Are About to Spike — Here's What's Really Happening

This goes on year-round, but it ramps up enormously during AEP — easily a hundred times over. It's worth understanding exactly what's happening on the other end of the line, because it changes how you should treat a call you didn't ask for.

Paul's Honest Take — What a "Live Transfer" Actually Is

As an agency owner, I get contacted daily — multiple times a day — by call centers wanting to sell me "live transfers." Here's what that means: someone cold-calls a Medicare consumer, gets them interested in talking to "someone who can improve their situation" — more benefits, lower costs, whatever the hook is — and then transfers that call to an agent. That agent typically pays somewhere between $50 and $100 just to speak with you. Either way, the person on the other end has one goal: enroll you in something, because they've spent real money to get you on the phone and they need to make it back.

These calls can look completely legitimate. Carriers can now buy access to millions of phone numbers and make a call display as a local number in your area, or as an 888 number, when the call center itself could be anywhere. If you hear an unfamiliar voice with an accent, that alone tells you nothing — plenty of honest, hardworking people in this industry have accents, and depending on where you live, someone might say the same about mine. The accent isn't the warning sign. The fact that you didn't ask for the call is.

Here's the simple rule: if you didn't reach out to someone yourself, you probably shouldn't be giving out your information or staying on the line. Their job, plainly, is to sell you something. Your job is to get educated and make the right choice for yourself — and that's very hard to do on a call you didn't initiate, with someone whose paycheck depends on getting you to say yes.

Don't answer numbers you don't recognize — even ones that look local. Spoofing a local number or an 888 number is common and doesn't tell you anything about where the call is actually coming from.
If you didn't initiate the contact, be cautious about staying on the line. A call you didn't ask for, about your Medicare coverage, is reason enough to be skeptical from the start.
Never give out your Medicare number or personal details to someone who called you. Legitimate help doesn't require you to hand over information to a stranger who rang your phone.
Remember what their job actually is. A live transfer agent's goal is to enroll you, because they paid to get you on the phone. That's not the same thing as someone trying to educate you.
If something they said interests you, hang up and call back on your own terms. Reach out to your own agent or Medicare directly using a number you already trust — not one they gave you.

Common Questions Beneficiaries Ask This Time of Year

When is Medicare's Annual Enrollment Period?

October 15 through December 7, every year. Changes take effect January 1.

What can I actually change during AEP?

You can move between Original Medicare and Medicare Advantage, switch Medicare Advantage plans, or join, switch, or drop a Part D drug plan.

Do I have to do anything if I like my current plan?

You're not required to, but it's worth checking your plan's Annual Notice of Change letter — costs and coverage can shift even when you don't touch a thing.

What should I bring to a conversation with an agent?

Your medication list with dosages, your doctors' names, and your current Medicare and plan ID cards. That's really it.

Is working with an agent going to cost me more?

No. Your premium is identical whether you enroll through an independent agent, directly with the carrier, or on Medicare.gov. A good agent should be transparent about how they're paid and willing to show you more than one option.

Why is it hard to find an agent to help with a standalone Part D plan?

If you pair Original Medicare with a Medicare Supplement, drug coverage is a separate standalone Part D plan. Most of those plans pay agents little to nothing, so it's genuinely harder to find help. Coming prepared with a clean, written medication list is the best way to make it easy for an agent to say yes — or you can run the comparison yourself on Medicare.gov.

Why do I need to check my doctor's specific office location, not just their name?

Many doctors work out of more than one office, and a plan can be in-network at one location and out at another for the same doctor. Networks are also shrinking this year — more HMO and HMO Point-of-Service plans, fewer PPOs, and the PPOs that remain are turning local instead of regional. Checking network status by the exact office address, not just the doctor's name, is how you avoid a surprise bill.

When do Annual Notice of Change letters arrive?

Carriers must mail every ANOC letter by September 30. It spells out exactly what's changing about your plan for next year. These letters are easy to mistake for junk mail, but this year — with major changes hitting Medicare Advantage plans and millions of people affected — skipping it is a bigger risk than usual.

Can I change my mind after I submit an application during AEP?

Yes. You can submit more than one application between October 15 and December 7, and only your last one before midnight on December 7 actually takes effect. There's no need to feel rushed early in the window.

How do I avoid pushy Medicare sales calls?

Be careful about clicking Medicare ads online or filling out "more information" forms — that's often what triggers a flood of calls from lead buyers rather than someone equipped to actually answer your question. And know that carrier phone lines and direct mail during AEP are frequently staffed by seasonal, part-time help, so it's worth confirming who you're really talking to.

What is Medicare Advantage enrollment suppression?

It's when a plan is technically still active — you might see it on Medicare.gov — but the carrier makes it deliberately hard to find or enroll in, because the plan is losing them money and they don't want new members adding to that. Agents are sometimes locked out of enrolling people in these plans entirely, which means a paper application straight to the carrier may be the only path in.

Are Medicare Supplement premiums going up?

Yes — Medigap rates have seen significant increases the last couple of years. Worth comparing your current rate against other options during AEP rather than assuming it's stayed reasonable.

What does out-of-network care cost on a PPO?

Most PPOs today charge coinsurance for out-of-network care — a percentage of the bill, not a flat copay — and some layer a deductible on top before that even kicks in. Ask for the real number before you enroll, especially if getting a second opinion outside your network matters to you.

Should I insist on a PPO plan?

PPOs are getting harder to find as more plans convert to HMO and HMO Point-of-Service structures, and the PPOs that remain are shrinking to local networks. A PPO can still be right for you — just go in knowing the actual out-of-network costs rather than assuming the flexibility works the way it used to.

What is a Medicare "live transfer" call?

It's when a call center cold-calls you, gets you interested in "improving your coverage," then transfers you to an agent who paid roughly $50–$100 for that connection. Their goal is to enroll you and recoup that cost — not to give you neutral, educational guidance. These calls often show up as a local or 888 number even when the call center itself is somewhere else entirely.

How do I know if an unsolicited Medicare call is legitimate?

If you didn't reach out first, treat it with caution no matter how local the number looks — caller ID can be spoofed. Don't hand over your Medicare number or personal details to someone who called you out of the blue. If something they say genuinely interests you, hang up and call your own agent or Medicare directly using a number you already trust.

Want a second set of eyes on your plan before AEP closes?

No pressure, no sales pitch — just a straight comparison so you know where you stand.

Call 631-358-5793 Email Paul

Licensed in 37 states · 40+ carriers represented · Free plan reviews, every AEP

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.