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.

Medicare Advantage Plans in Farmingdale, NY: Your Honest 2026 Local Guide

June 30, 2026

By Paul Barrett, CMIP | The Modern Medicare Agency | Melville, NY 18+ years Medicare-exclusive experience | Licensed in 34 states | 40+ carriers

If you live in Farmingdale and you’re trying to figure out Medicare Advantage for 2026, here’s what I want you to know before we dive in:

There are 31 plans available to you in Nassau County this year. Eleven of them have a $0 monthly premium. And yet the most important number in this entire guide isn’t the premium at all — it’s whether your doctor at Northwell Health or St. Joseph University Medical Center is actually covered under the plan you choose.

I’ve been helping Long Island residents navigate Medicare since 2007. I’ve seen the confusion, the aggressive mailers, the TV commercials that promise everything. This guide is different. It’s written by someone who has sat across the kitchen table from Farmingdale residents and helped them make this decision — not by an algorithm generating location pages.

Let’s get into it.

2026 Medicare Advantage Fast Facts for Farmingdale (ZIP 11735)

For a deeper look at how Medicare Advantage compares to your other options in Nassau County, see our Medicare Advantage vs. Medigap guide for Farmingdale and our Medicare Agent Near Farmingdale local guide.

Fact	2026 Figure
Total Medicare Advantage plans available	31
Plans with $0 monthly premium	11
Average premium (for plans with a premium)	$43.29/month
Average out-of-pocket maximum	$8,625/year
Average Part D (Rx) deductible	$504.81/year
Plans rated 4 stars or higher	10
Plan types available	HMO, PPO, HMO-POS
Carriers offering plans	11
Nassau County MA enrollment rate	~33% of Medicare beneficiaries

Source: CMS Medicare Advantage Enrollment Data 2026 | Medicare.org Nassau County Plan Data

The Carriers Operating in Farmingdale in 2026

Eleven insurance companies offer Medicare Advantage plans in Nassau County for 2026:

Aetna Medicare
Anthem Blue Cross and Blue Shield
Elderplan
EmblemHealth
HealthSpring
Healthfirst Medicare Plan
Humana
UnitedHealthcare
VNS Health Medicare
VillageCareMAX
Wellcare

The top 5 by enrollment in Nassau County:

Healthfirst Health Plan — leading HMO, 4,286+ members locally
Aetna Life Insurance Company — largest PPO, 15,740+ enrollees (Aetna Medicare Elite PPO)
UnitedHealthcare — AARP Medicare Advantage HMO-POS, 7,052+ members
Sierra Health and Life Insurance Company (Anthem network)
Anthem HP, LLC

Paul's Take: What I Actually Think About These Carriers in 2026

This is the section you won’t find on any other website. I’m not a 1-800 call center. I’m an independent broker with 18 years in this market. Here’s my honest read on the major players for Farmingdale residents right now:

Aetna — The Aetna Medicare Elite PPO is the single most enrolled plan in Nassau County, and for good reason. It offers PPO flexibility, strong provider access, and a track record of solid customer service. If you have doctors at both Northwell and NYU Langone and want the freedom to see both without a referral, this is often the first plan I look at. Aetna has been taking rate corrections in recent cycles — something to monitor going forward — but for 2026, it remains one of the strongest options in Nassau County for people who want maximum flexibility.

UnitedHealthcare (AARP branded) — UHC is the largest Medicare Advantage carrier in the country, and the AARP-branded HMO-POS has historically been the most popular plan of its type in Nassau. However, in 2026, I want Farmingdale residents to understand a few things before assuming UHC is the right call. First, UHC removed their Regional PPO plans from this market for 2026, eliminating a plan type that gave members broader provider flexibility. Second, their remaining HMO-POS plan is what I’d describe as going through enrollment management — the plan has been structured in a way that makes it more difficult for agents to enroll consumers online, and agent compensation on this plan has been suspended. Carriers do this when they are not actively seeking enrollment growth. That’s not a knock on UHC as a company — all carriers go through cycles — but it is something worth knowing when you’re evaluating your options. Third, and most importantly: UHC’s network depth on Long Island is not what it is nationally. In the five boroughs, their provider relationships are strong. As you move east into Nassau and Suffolk, the network thins out noticeably compared to what you’d find in other markets. I always do a live provider search for any client before recommending this plan.

Healthfirst — A legitimate, locally rooted health plan with strong roots in the New York area. They offer several plans, each with slightly different network configurations and benefit structures, which means there’s a Healthfirst plan that fits certain client profiles very well. The important thing to know: Healthfirst’s network strength is considerably stronger in the five boroughs of New York City than it is on Long Island. If your doctors are primarily in Nassau County — as most Farmingdale residents’ are — I always verify your specific providers against their Long Island network before recommending any Healthfirst plan. Don’t assume that because a plan is popular in Queens or Brooklyn it will cover your Farmingdale or Nassau specialists.

Humana — I started my Medicare career with Humana and have a great deal of respect for them as a national carrier. But I’d be doing you a disservice if I didn’t tell you what’s been happening locally. Over the past few years, Humana has stumbled in the New York and Long Island market specifically. They’ve reduced their available plan options in this area, and for 2026, the plans they do have available in Nassau County are currently non-commissionable to agents — which, again, signals they are managing enrollment rather than growing it here. Their star ratings have also declined from where they were a few years ago. Nationally, Humana is a solid company. In Farmingdale and Nassau County specifically for 2026, I’d encourage you to compare carefully and not choose them on brand name alone.

Anthem Blue Cross Blue Shield (formerly Empire BCBS) — This is the carrier I’m most enthusiastic about for Farmingdale residents in 2026 — and the data backs it up. Anthem (known locally for years as Empire BCBS — same company, rebranded in 2023 under Elevance Health) has made a real comeback in this market. Their Medicare Advantage 2 HMO-POS plan earned a 5-star rating from CMS for 2026 — the highest possible score, and the only 5-star Medicare Advantage plan available on Long Island this year. CMS confirms this rating, with Anthem’s plan scoring well above New York’s state average of 3.8 stars. Their provider network on Long Island is strong, their customer service has been solid, and they offer an HMO-POS structure that gives clients meaningful flexibility when they need to go outside the primary network. For many Farmingdale and Nassau County residents, Anthem is the first plan I’m looking at seriously in 2026.

Wellcare and HealthSpring (formerly Cigna) — CRITICAL 2026 WARNING for Farmingdale residents: Two major carriers have severed their network relationships with Northwell Health, and every Nassau County resident needs to know about both.

HealthSpring (formerly Cigna Medicare): Northwell Health left the HealthSpring Medicare Advantage network effective December 31, 2025. This means that as of January 1, 2026, all Northwell hospitals, ancillary facilities, provider groups, and their clinically integrated network are out-of-network for HealthSpring Medicare Advantage members. This is not a future risk — it has already happened. If you are currently enrolled in a HealthSpring plan and see any Northwell providers, you are already paying out-of-network rates or facing access issues right now.

Wellcare: Northwell Health is also leaving the Wellcare Medicare Advantage network effective July 1, 2026. Established Wellcare patients may continue care at Northwell through August 29, 2026 subject to Wellcare’s authorization, but after that date, Northwell is fully out-of-network for Wellcare members as well. See Northwell’s official update for full details.

If you are enrolled in either a HealthSpring or Wellcare Medicare Advantage plan and rely on Northwell for any of your care — please call me immediately. You may qualify for a Special Enrollment Period to make a plan change. This is exactly the kind of local intelligence that no national website or 1-800 number is going to give you.

The Northwell Problem Every Farmingdale Resident Needs to Know

Northwell Health is the largest health system in New York State. Chances are, at least one of your doctors — your cardiologist, your orthopedist, your primary care physician — is affiliated with Northwell.

Here is what changes in 2026 that nobody in your mailbox is going to tell you:

Wellcare has chosen not to renew its contract with Northwell. As of July 1, 2026, Northwell is out-of-network for Wellcare Medicare Advantage members. This affects Nassau County, Long Island, and the broader New York area.

This is the exact reason I tell every Farmingdale client the same thing before we look at a single plan: give me your doctor’s name first, not the plan name.

A $0 premium plan that takes your Northwell cardiologist out-of-network isn’t a deal. It’s a problem.

Other major systems in the Farmingdale area — including St. Joseph University Medical Center and NYU Langone — have their own network arrangements that vary by carrier and by plan type. I verify every physician’s status before any client enrolls.

HMO vs. PPO vs. HMO-POS: What Actually Matters for Farmingdale Residents

HMO (Health Maintenance Organization)

Requires you to use in-network providers only (except emergencies)
Requires a primary care physician to coordinate referrals
Typically the lowest premiums — many $0 options available
Best for: Farmingdale residents whose doctors are all within one system (Northwell OR NYU Langone, not both)
Restriction: If you want to see a specialist in Manhattan or split care across systems, this can create friction

PPO (Preferred Provider Organization)

See any Medicare-accepting provider — in-network or out
No referrals required for specialists
Average PPO premium in Nassau County: $27.82/month
12 PPO plans available in 2026 covering 25,000+ Nassau enrollees
Best for: Snowbirds, travelers, anyone with specialists at multiple systems, or anyone who values total freedom of choice
The Aetna Medicare Elite PPO is the most popular plan in all of Nassau County

HMO-POS (Point of Service)

A middle ground — HMO structure with limited out-of-network access for select services
The AARP/UHC HMO-POS is the most popular plan of this type in Nassau (7,000+ members)
Best for: People who want HMO pricing but occasionally need to go outside the network

My honest take: For most healthy Farmingdale residents turning 65 with predictable doctor relationships, an HMO or HMO-POS can work beautifully and save money. For anyone managing a complex or chronic condition, seeing multiple specialists, or valuing flexibility above all else — a PPO is almost always worth the modest premium difference.

The One Number Most People Ignore (That Matters Most)

Everyone focuses on the $0 premium. I get it — it sounds like a great deal.

Here’s what I want you to look at instead: the out-of-pocket maximum.

The average out-of-pocket maximum for Medicare Advantage plans in Nassau County is $8,625 per year for in-network services. For combined in and out-of-network, some plans go higher.

That means if you have a serious illness, a surgery, or a significant hospital stay — you could owe up to $8,625 before the plan pays 100%. That’s real money.

Now compare that to a Medigap Plan G: your total out-of-pocket exposure for covered Medicare services is $283 for the year — the Part B deductible. After that, nothing.

I’m not saying Medicare Advantage is wrong for you. For many Farmingdale residents, it’s an excellent choice. I’m saying: look at the full picture, not just the monthly premium. That’s the honest conversation most agents won’t have with you because it’s easier to just enroll you in the $0 plan.

What About Medigap (Medicare Supplement) in Farmingdale?

Because New York is a community-rated, guaranteed-issue state, Medigap works very differently here than in most of the country. For a full breakdown of how Medigap works in New York and when switching makes sense, see our Medicare Supplement Plan G guide and our Medigap switching rules article.

In New York, you can apply for a Medigap plan at any time of year — not just during a one-time window. You cannot be denied for health reasons. Every carrier must offer you coverage at standard rates regardless of your health history. This is an enormous consumer protection that most people don’t know about — and it’s unique to New York.

But let’s be honest about what Medigap actually costs in 2026 — because this matters.

Medigap Plan G is the most popular supplement plan for new enrollees in New York. It covers nearly all of your Medicare-approved costs after a single $283 Part B deductible. After that, your out-of-pocket exposure for covered services is essentially zero.

Here’s the full picture though:

Plan G premium in New York: approximately $373/month ($4,476/year)
Annual Part B deductible: $283
Plan G does not include prescription drug coverage — you need a separate Part D plan
The lowest-cost Part D plan available in New York adds additional monthly cost on top

Add it all up — Plan G premium + Part B deductible + even a modest Part D plan — and your minimum annual commitment as a Medigap enrollee in New York easily exceeds $5,100 per year before you use a single medical service.

That is not a knock on Plan G. For someone with serious health conditions, significant specialist needs, or anyone who values absolute certainty in their costs, Plan G’s near-zero out-of-pocket exposure when you actually use care can easily justify that annual commitment. If you have a hospitalization, a surgery, or a complex treatment course, Plan G often saves you significantly compared to hitting an Advantage plan’s out-of-pocket maximum.

But for a generally healthy person on a fixed income who wants to minimize what they spend every month, a well-chosen $0 Medicare Advantage plan with a manageable out-of-pocket maximum can make real financial sense too.

There is no universally right answer. There is only the right answer for your specific situation — your health, your doctors, your drugs, your finances, and your risk tolerance. That’s the conversation I have with every Farmingdale client before we look at a single plan.

The Farmingdale Enrollment Deadlines You Cannot Miss

For a complete guide to Medicare enrollment windows and penalty rules, visit Medicare.gov’s official enrollment page or our Original Medicare Explained guide.

Initial Enrollment Period (IEP) Seven months: starts 3 months before your 65th birthday, includes your birth month, ends 3 months after. This is your first chance to enroll with no penalties.

Annual Enrollment Period (AEP) October 15 – December 7 each year. Changes take effect January 1. This is when most plan switching happens.

Medicare Advantage Open Enrollment Period (OEP) January 1 – March 31. If you enrolled in an MA plan and want to switch to another MA plan or return to Original Medicare, you can do so during this window.

Special Enrollment Periods (SEPs) Triggered by specific life events: moving, losing other coverage, your plan exiting the market. The Wellcare/Northwell situation may trigger SEP rights for affected members — contact me to discuss your specific situation.

Late enrollment penalties are permanent. A missed Part B enrollment window can cost you 10% added to your premium for every 12-month period you were eligible but didn’t enroll — and it follows you for life.

My 5-Step Process for Farmingdale Residents

After 18 years of doing this, here’s the process I walk every client through:

Step 1: List your doctors. Every physician, specialist, and facility you currently see. We check every single one against the 2026 plan networks before we look at anything else.

Step 2: List your medications. Every prescription by name and dosage. Under the new 2026 rules, the out-of-pocket cap on drugs is $2,100. But what you pay within that cap depends entirely on how your drugs are tiered in each plan’s formulary.

Step 3: Look at your TOTAL annual cost picture — not just the monthly premium. This is where most people get confused, and where I want to be completely straight with you.

A $0 Medicare Advantage plan still has costs — copays, coinsurance, and an out-of-pocket maximum that averages $8,625 in Nassau County. If you have a significant health event, you could owe thousands before the plan covers everything.

A Medigap Plan G, on the other hand, covers nearly all of your Medicare-approved costs after a single $283 annual deductible. But Plan G is not free either. In New York, Plan G premiums run approximately $373 per month — that’s $4,476 per year in premiums alone, plus the $283 Part B deductible. And Plan G does not include prescription drug coverage — you need a separate Part D plan for that, which in New York adds cost on top. When you add a Plan G premium, the Part B deductible, and even the lowest-cost Part D plan available in New York, your minimum annual out-of-pocket commitment easily exceeds $5,100 per year before you use a single medical service.

So the honest comparison is not “$0 vs. Plan G.” It’s a full side-by-side of your total likely annual spend under each path — premiums, deductibles, copays, drug costs, and realistic usage — against the financial protection each one provides if something serious happens. That’s the conversation I have with every client, because the right answer is genuinely different depending on your health, your doctors, your medications, and your financial situation.

Step 4: Consider your lifestyle. Do you travel? Spend winters in Florida? Split time between New York and another state? PPO or Medigap. Do you stay local, see the same doctors, and want to keep things simple? HMO may work beautifully.

Step 5: Talk to an independent broker. Not a call center. Not a carrier-captive agent who only shows you one company’s plans. Someone who represents 40+ carriers and can lay everything out side by side without an agenda.

That’s what I do. My consultation is free. My advice is honest. And I’m not going anywhere after you enroll — I’m here year-round when questions come up.

Frequently Asked Questions: Medicare Advantage in Farmingdale, NY

How many Medicare Advantage plans are available in Farmingdale, NY in 2026?

There are 31 Medicare Advantage plans available to Farmingdale residents in Nassau County for 2026. These include HMO, PPO, and HMO-POS plan types from 11 different insurance carriers

Are there $0 premium Medicare Advantage plans in Farmingdale?

Yes. Eleven plans available in the 11735 zip code have a $0 monthly premium for 2026. However, $0 premium does not mean $0 cost — you still pay for care through copays and coinsurance, and your out-of-pocket maximum in Nassau County averages $8,625 per year.

Does Northwell Health accept all Medicare Advantage plans in Farmingdale?

No — and two major network changes are directly affecting Northwell access for Nassau County residents right now. HealthSpring (formerly Cigna Medicare) terminated its relationship with Northwell effective December 31, 2025, meaning all Northwell hospitals, provider groups, ancillaries, and their clinically integrated network have been out-of-network for HealthSpring members since January 1, 2026. Wellcare is also losing Northwell from its network effective July 1, 2026. If you are enrolled in either a HealthSpring or Wellcare Medicare Advantage plan and see any Northwell providers, call me immediately — you may qualify for a Special Enrollment Period. I verify every client’s specific provider network status before enrollment, without exception.

What is the difference between Medicare Advantage and Medigap in New York?

Medicare Advantage replaces Original Medicare with a private plan that has network restrictions, copays when you use care, and additional benefits like dental and vision. Medigap (Medicare Supplement) works alongside Original Medicare, covering most out-of-pocket costs with no network restrictions. In New York, you can switch Medigap plans year-round with no medical underwriting — a protection most states don’t offer.

How do I find a local Medicare agent in Farmingdale, NY?

Paul Barrett of The Modern Medicare Agency has served Farmingdale and Nassau County residents since 2007. He is an independent broker licensed in 34 states who represents 40+ Medicare carriers. Consultations are free. Call 631-358-5793 or visit paulbinsurance.com.

What is the best Medicare Advantage plan in Farmingdale, NY?

There is no single “best” plan — it depends entirely on your doctors, your medications, your budget, and your lifestyle. The most enrolled plan in Nassau County is the Aetna Medicare Elite PPO (15,740+ members). The most popular HMO-POS is AARP Medicare Advantage from UHC (7,052+ members). I compare all 31 plans against your specific situation before making any recommendation.

What happens if my Medicare Advantage plan drops my doctor?

If your plan exits the market or makes a significant network change mid-year, you may qualify for a Special Enrollment Period to choose a new plan. CMS continuity of care rules also require plans to allow you to continue active treatment with a non-network provider for up to 90 days at in-network rates when you first join a plan. Call me immediately if your plan has dropped your doctor — I help navigate exactly these situations.

Is Farmingdale in Nassau County or Suffolk County?

The 11735 zip code spans both counties. Your county of legal residence — not your mailing address — determines which Medicare Advantage plans you’re eligible for. Nassau County residents have access to 31 plans. Suffolk County residents have a different set of options. Confirm your county using your voter registration or property tax records before comparing plans. We’ve written a full guide to this exact question: Medicare in Farmingdale: Why Your County Matters.

Ready to Compare Your 2026 Options?

I serve Farmingdale, Nassau County, and Long Island residents from my office in Melville. My consultations are always free, always honest, and always in plain English — no pressure, no sales pitch, no disappearing after enrollment.

Paul Barrett, CMIP The Modern Medicare Agency 📞 631-358-5793 ✉️ medicare@paulbinsurance.com 🌐 paulbinsurance.com 📍 445 Broad Hollow Rd, Melville, NY 11747

Licensed in 34 states | 40+ carriers | 18+ years Medicare-exclusive experience | 5,000+ clients served

Related guides from Paul Barrett:

External sources cited:

Disclaimer: The Modern Medicare Agency is not connected with or endorsed by the United States government or the federal Medicare program. Plan data reflects CMS-published figures for 2026. Provider network information is subject to change — always verify your specific physicians’ network status before enrolling. We do not offer every plan available in your area. Contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Northwell/Wellcare network change information sourced from Northwell Health’s official notice, May 2026. HealthSpring/Northwell termination sourced from direct HealthSpring broker partner communication, effective December 31, 2025.

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.