Medicare Plan G vs. Plan N in 2026: Which One Is Actually Worth It?

  • By Paul Barrett, Principal Agent, The Modern Medicare Agency | Updated June 2026

    The Most Common Question I Get — and the Honest Answer Most People Never Hear

    “Paul, should I go with Plan G or Plan N?”

    After 18 years in Medicare, I hear this constantly. And I understand why — it looks like a simple choice between two similar plans, and the premium savings from Plan N can feel immediately compelling. Save $40, $50, even $60 a month? That adds up to real money.

    But here’s the truth most comparison articles won’t say plainly: the right answer depends entirely on your specific situation, and the math only points one way when you actually run it for your circumstances. For many people, Plan N genuinely wins. For others, Plan G is clearly the better choice. And for a third group — one most agents skip over entirely — High Deductible Plan G is the smartest option of all.

    I’m going to give you the real numbers, the genuine tradeoffs, and a framework to figure out which belongs in your situation. No soft-pedaling, no affiliate-driven “both are great!” conclusions. Just the honest math and 18 years of experience watching both go right and both go wrong.

    One thing before we start: I earn a commission regardless of which plan you choose. My commission on some plans is actually higher than on others — but that never changes my recommendation. If Plan N is right for you, I’ll tell you Plan N. If HD Plan G makes the most sense, I’ll tell you that even though it pays the lowest commission. That’s the only way to do this work honestly.

    Quick Answer: “Plan G averages $220/month nationally; Plan N averages $171/month — a $49 gap. Plan N wins financially for most healthy enrollees in states that ban excess charges (OH, PA, RI, VT, MA) or limit them (NY). Plan G is the better choice for frequent users, travelers, or anyone in states without guaranteed issue protections. HD Plan G ($50-91/month, $2,950 deductible) is the most underused option for healthy enrollees with savings to self-fund the deductible risk.”

    What Makes These Plans Identical

    Before we get to the differences, here’s what Plan G and Plan N share — and it’s substantial. Both cover:

    ✓ Part A hospital coinsurance, including up to 365 additional days after Medicare benefits are exhausted ✓ Part A deductible ($1,736 per benefit period in 2026) ✓ Skilled nursing facility coinsurance (days 21-100, up to $217.50/day in 2026) ✓ Part A hospice care coinsurance ✓ First three pints of blood ✓ Part B coinsurance (the 20% Medicare doesn’t pay) — with a small copay difference explained below ✓ Foreign travel emergency coverage (80% up to $50,000 lifetime maximum after a $250 deductible) ✓ Access to any doctor or hospital in the U.S. that accepts Medicare — no networks, no referrals

    That’s enormous shared coverage. The differences are narrower than most people realize — but in specific situations, they matter a great deal.

    Source: Medicare.gov: Compare Medigap Plan Benefits; CMS 2026 Medicare Costs

    The Three Differences — Explained Precisely

    Difference 1: The Part B Annual Deductible

    Neither Plan G nor Plan N covers the Medicare Part B annual deductible. In 2026, that deductible is $283.

    Both plans are identical here. You pay the $283 before either plan kicks in for Part B services. This is a wash.

    Source: CMS 2026 Medicare Costs

    Difference 2: The Plan N Copays

    Under Plan N, you pay:

    • Up to $20 copay for certain office visits
    • Up to $50 copay for emergency room visits that do not result in inpatient admission (if you’re admitted, the $50 copay is waived)

    Under Plan G, you pay $0 for both after your Part B deductible is met.

    A few important clarifications that most articles get wrong or leave vague:

    Not every visit triggers the $20 copay. Medicare Annual Wellness Visits, preventive care visits, and many lab-only visits do not trigger a Plan N copay. The copay applies to certain office visits billed under specific evaluation and management codes. Telehealth visits in many cases also do not trigger the copay. Your actual average annual copay exposure under Plan N is typically lower than a simple multiplication of visits × $20 would suggest.

    The $50 ER copay is not a hidden deductible. If you arrive at the ER and are admitted to the hospital, the copay is waived entirely. The copay only applies to ER visits that result in outpatient treatment and discharge.

    Difference 3: Part B Excess Charges — The One That Requires the Most Nuance

    Plan G covers Part B excess charges in full. Plan N does not cover them at all.

    What is a Part B excess charge? When a doctor accepts Medicare but declines Medicare “assignment” — meaning they don’t agree to accept Medicare’s approved rate as full payment — they can charge up to 15% more than the Medicare-approved amount. That extra amount is the excess charge. With Plan N, you pay it out of pocket. With Plan G, it’s covered.

    How often does this actually happen nationally?

    According to MedigapSeminars.org’s analysis of CMS data, more than 98% of medical doctors billing Medicare are participating providers who accept assignment and therefore cannot charge excess charges. The national rate of providers actually billing excess charges is under 2% — and of that group, a significant proportion are mental health providers, solo practitioners, and certain specialists in high-cost urban markets.

    The average excess charge when it does occur is modest — typically a small percentage above a service that Medicare has already priced. On a $300 Medicare-approved service, the maximum excess charge is $45 (15% of $300). In practice, most non-participating providers charge less than the maximum.

    The eight-state factor — and critical nuances:

    Eight states have enacted laws limiting or prohibiting Part B excess charges: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont.

    However — and this matters significantly — these state protections are not uniform, and several have important limitations that most articles gloss over:

    Connecticut: CT doesn’t allow Part B excess charges for participants enrolled in the QMB program but does allow excess charges for other participants. Standard Medigap enrollees in Connecticut who are not in the QMB program can still face excess charges.

    New York: New York State law limits the amount that Medicare non-participating providers may charge to no more than 5% above Medicare’s approved amount. This limit applies to all services except certain home and office visits for basic medical examinations billed under procedure codes 99201-99215 and 99341-99353, for which the federal limit of 15% applies. New York doesn’t fully ban excess charges — it limits most of them to 5% rather than the federal maximum of 15%.

    Minnesota: MN does not allow Part B excess charges for its own citizens, but providers may charge excess fees to those coming from other states to use Minnesota facilities, such as the Mayo Clinic.

    The practical bottom line on excess charges:

    • If you live in OH, PA, RI, VT, or MA: excess charges are effectively banned for in-state care. The Plan G vs. Plan N excess charge difference is largely irrelevant — factor it out of your decision.
    • If you live in NY: excess charges are limited to 5% (not 15%) for most services. Still real but materially reduced compared to other states.
    • If you live in CT: the protection applies only to QMB enrollees. Standard Medigap holders should still consider their doctor assignment status.
    • If you live in any other state: excess charges are possible but rare. The relevant question is whether your specific providers accept assignment — easily verified at Medicare Care Compare.
    • Important regardless of state: If you travel frequently or live part of the year in a different state, your home state’s excess charge protections do not apply to out-of-state care. Plan N holders who snowbird or travel regularly face excess charge exposure in states that allow them, even if their home state doesn’t.

    Source: Humana: Medicare Part B Excess Charges; NY HIICAP Notebook 2026; NerdWallet: Medicare Excess Charges; MedigapSeminars.org: What Are Medicare Part B Excess Charges?

    The Premium Difference: What You Actually Save with Plan N

    Here are the 2026 national averages based on available market data:

    Plan

    Average Monthly Premium (Age 65)

    Average Monthly Premium (Age 75)

    Annual Cost Range

    Standard Plan G

    ~$220/month

    ~$278/month

    $2,640 – $3,336/year

    Plan N

    ~$171/month

    ~$213/month

    $2,052 – $2,556/year

    Premium gap

    ~$49/month

    ~$58/month

    ~$588 – $696/year

    Source: MoneyGeek: Medigap Plan N vs. Plan G

    Critical context before you use these numbers:

    These are national averages. Your actual premium depends on your state, ZIP code, age, gender, tobacco use, and pricing model. The premium gap between Plan G and Plan N varies enormously by market:

    • In some states, the gap is under $20/month — making Plan G easy to justify
    • In others, the gap exceeds $70/month — making Plan N’s premium savings very compelling
    • In New York specifically, both Plan G (~$372/month) and Plan N run significantly higher than national averages due to community rating and guaranteed issue requirements
    • Premiums for the same plan can vary by 50% or more between carriers offering coverage in the same ZIP code

    Always get actual quotes for your specific location before making this decision. National averages are a starting point, not your answer.

    Source: The Big 65: Medicare Supplement Plan N Guide; paulbinsurance.com carrier data

    The Math That Actually Matters: Three Real Scenarios

    This is the section most comparison articles skip entirely. Let’s run the actual numbers using a $49/month premium gap ($588/year savings with Plan N) — the national average difference.

    Scenario A: The Light User

    Profile: Healthy 65-year-old, 3-4 routine doctor visits per year, no ER visits, no hospitalizations

    With Plan N:

    • Part B deductible: $283
    • 3 office visit copays × $15 average (not all visits trigger the full $20): $45
    • Annual medical out-of-pocket beyond premium: $328
    • Annual premium savings vs. Plan G: $588
    • Net annual advantage of Plan N: $260

    With Plan G:

    • Part B deductible: $283
    • All other costs: $0
    • Annual medical out-of-pocket beyond premium: $283
    • Annual premium paid: $588 more than Plan N
    • Net annual disadvantage vs. Plan N: $305

    Verdict: Plan N clearly wins. The premium savings more than offset the copay exposure. Even in a year with 6 visits, Plan N still wins.

    Scenario B: The Moderate User

    Profile: 70-year-old managing blood pressure and cholesterol, 8-10 doctor/specialist visits per year, one ER visit (not admitted)

    With Plan N:

    • Part B deductible: $283
    • 9 office visit copays × $18 average: $162
    • 1 ER copay (not admitted): $50
    • Annual out-of-pocket beyond premium: $495
    • Annual premium savings vs. Plan G: $588
    • Net annual advantage of Plan N: $93

    With Plan G:

    • Part B deductible: $283
    • All other costs: $0
    • Annual out-of-pocket beyond premium: $283
    • Annual premium paid: $588 more than Plan N
    • Net annual disadvantage vs. Plan N: $93

    Verdict: Plan N still edges out Plan G, though the margin narrows significantly. At a smaller premium gap ($30/month), this scenario essentially breaks even. At a larger gap ($70/month), Plan N wins more decisively.

    The Break-Even Formula from MedigapSeminars.org: Take your monthly premium savings and divide by $20 (the max office copay). That tells you how many full-copay visits per month it would take before Plan N stops being the better value. If you save $50/month, you’d need 2.5 copay-triggering visits per month (30 per year) before Plan G matches Plan N on total cost. Most moderate users don’t reach that threshold.

    Source: MedigapSeminars.org: Plan N vs. Plan G

    Scenario C: The Heavy User

    Profile: 74-year-old with cardiac condition, 18-20 specialist visits per year including cardiology, one ER visit, one brief hospitalization

    With Plan N:

    • Part B deductible: $283
    • 18 specialist/office copays × $20: $360
    • 1 ER copay (not admitted): $50
    • Annual out-of-pocket beyond premium: $693
    • Annual premium savings vs. Plan G: $588
    • Net annual disadvantage vs. Plan N: $105 (Plan G is now cheaper)

    With Plan G:

    • Part B deductible: $283
    • All other costs including hospital: $0
    • Annual out-of-pocket beyond premium: $283
    • Plan G advantage: $105/year — plus predictability

    Verdict: Plan G wins for heavy users, and the advantage compounds with peace of mind. A patient managing a serious condition who sees specialists regularly may find that Plan G’s copay elimination significantly reduces both financial and psychological friction.

    Add potential excess charge exposure: If this heavy user is in a state that allows excess charges and sees a non-participating specialist, the exposure adds to Plan N’s cost disadvantage. In states where excess charges are effectively banned (OH, PA, RI, VT, MA), this factor disappears — making Plan N more competitive even for heavier users.

    High Deductible Plan G: The Third Option That Changes Everything

    Here is where most comparison articles stop, and it’s exactly the wrong place to stop.

    High Deductible Plan G (HD Plan G) is structurally identical to standard Plan G — same benefits, same nationwide access, same coverage for every Medicare-approved service. The only difference: you must meet an annual deductible ($2,950 in 2026) before the plan pays. After you hit that deductible, it functions exactly like standard Plan G — full coverage for all Medicare-approved costs for the rest of the year.

    In exchange for accepting that deductible, the premium is dramatically lower:

    Plan

    Typical Monthly Premium (Age 65)

    Annual Premium

    Annual Deductible

    Worst-Case Annual Medical Cost

    Standard Plan G

    ~$220/month

    ~$2,640/year

    $283 (Part B deductible only)

    ~$2,923

    Plan N

    ~$171/month

    ~$2,052/year

    $283 (Part B deductible only)

    ~$2,335 + unlimited excess charge exposure

    HD Plan G

    ~$50-91/month

    ~$600-1,092/year

    $2,950 (covers Part B deductible)

    ~$3,550-4,042

    Wait — the worst-case scenario for HD Plan G ($4,042) is actually higher than for standard Plan G ($2,923). Doesn’t that mean HD Plan G is riskier?

    Yes, in the worst case. But look at what happens in a healthy year:

    Healthy year with HD Plan G at $75/month:

    • Annual premium: $900
    • Out-of-pocket (light user): $283-$600
    • Total: $1,183-$1,500 — potentially $1,000-$1,500 LESS than standard Plan G

    Over 5 years of generally good health, the cumulative premium savings from HD Plan G vs. standard Plan G can easily exceed $6,000-$8,000. That’s a meaningful financial cushion — and it can serve as a self-funded reserve against the years when you do use more healthcare.

    HD Plan G is right for you if:

    • You are in generally good health with no chronic conditions requiring frequent specialist visits
    • You have savings to comfortably absorb a $2,950 expense in a high-use year without financial stress
    • You understand and are comfortable with the “pay as you go up to the deductible, then full coverage” structure
    • You’re disciplined enough to set aside the premium difference as a health savings reserve

    HD Plan G is probably not right for you if:

    • You see multiple specialists regularly and anticipate consistent high healthcare use
    • A $2,950 bill in a single year would cause real financial stress
    • You want absolute cost predictability above all other factors
    • You live in a state with very few HD Plan G carrier options

    One important caveat: The HD Plan G deductible increases annually based on the Consumer Price Index. The CMS-confirmed history: $2,370 in 2021, $2,490 in 2022, rising to $2,870 in 2025 and $2,950 in 2026 — a 24% increase over five years. It will continue rising each year. Factor that trajectory into your long-term planning, not just the 2026 figure.

    Source: Boomer Benefits: High Deductible Plan G; 65Medicare.org: HD Plan G Considerations and Cautions

    The Switching Trap: Why This Decision Is Stickier Than It Looks

    This section is critical and almost never covered adequately in Plan G vs. Plan N comparison articles.

    When you first enroll in Medicare and choose a Medigap plan, you are in your 6-month Open Enrollment Period — during which any carrier must accept you for any plan at standard rates, no health questions asked. This is the most consumer-friendly enrollment window in all of Medicare, and it’s one-time only.

    After it closes, switching Medigap plans in most states requires medical underwriting. The carrier can ask health questions, deny your application, or charge a higher premium based on your health history.

    The practical consequence for Plan N enrollees: if you choose Plan N at 65, stay in it for five years, develop a cardiac condition, and then want to upgrade to Plan G — in most states, you may not be able to. The carrier can decline to cover you. You chose Plan N when you were healthy and find yourself unable to upgrade when your health needs increase.

    State-level exceptions to this rule:

    • New York, Connecticut, Vermont, Washington: Year-round guaranteed issue. You can switch between Plan G and Plan N (or any other plan) at any time without underwriting. For New Yorkers, this makes the initial choice between Plan G and Plan N somewhat less permanent — though the NY community-rated market still has limited carrier competition.
    • 16 birthday rule states: Annual window around your birthday to switch to a plan of equal or lesser benefits without underwriting. California, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maryland, Nevada, Oklahoma, Oregon, Rhode Island, Delaware, Virginia, West Virginia, Wyoming, and Missouri (anniversary rule) all have some form of this protection.
    • MA trial right: If you move from Medigap to Medicare Advantage for the first time, you have 12 months to return to Medigap without underwriting.

    If you’re in a state without guaranteed issue or birthday rule protections, and you believe your health may change significantly in the next several years — the initial choice between Plan G and Plan N carries more long-term weight than the monthly premium math alone suggests.

    Source: KFF: Medigap May Be Elusive for Medicare Beneficiaries with Pre-Existing Conditions; The Big 65: Birthday Rule State Guide

    Who Should Choose Plan G

    Plan G is the right choice when:

    • You see specialists frequently (more than 10-12 visits per year) and the copay math tips against Plan N
    • You have a chronic condition with predictable, ongoing healthcare needs
    • You live in a state that allows excess charges and your doctors include non-participating providers
    • You travel frequently or live part of the year in another state where excess charge protections don’t follow you
    • You are in a state without guaranteed issue or birthday rule protections and you’re concerned about your ability to switch plans if your health declines
    • Cost certainty is paramount to your sense of financial security — some people find the unpredictability of copays genuinely stressful regardless of the math
    • You’re 70+ and your health trajectory suggests increasing care needs where Plan G’s coverage advantage compounds

    Who Should Choose Plan N

    Plan N is the right choice when:

    • You are in good to excellent health with relatively few routine care visits per year
    • You live in one of the states where excess charges are effectively banned — OH, PA, RI, VT, MA — or where they’re substantially limited (NY)
    • All your current providers accept Medicare assignment (easily verified in 5 minutes at Medicare Care Compare)
    • You live in a guaranteed issue state (NY, CT, VT) or a birthday rule state where you have a protected annual window to upgrade if your health changes
    • The premium gap in your market is substantial ($50+/month) — at that savings level, the math strongly favors Plan N in most usage scenarios
    • You are comfortable with known, modest copays in exchange for meaningfully lower monthly costs

    Paul’s Bottom Line: Here’s What I Actually Tell My New York Clients

    Since the majority of my clients are in New York, and because NY has unique rules, I want to be specific about what I recommend in this market.

    In New York, Plan N deserves serious consideration for most healthy new enrollees — and here’s why:

    1. The premium gap between Plan G (~$372/month) and Plan N in NY is meaningful, often $50-80/month or more
    2. NY limits excess charges to 5% (not 15%) for most services — reducing the Plan G excess charge advantage substantially
    3. NY’s year-round guaranteed issue means you can switch between plans at any time if your health changes — removing the “stuck forever” risk that makes the initial choice feel permanent in other states
    4. All that said: if you see specialists very frequently or have an active condition requiring regular care, Plan G’s premium is buying real coverage value

    For clients outside New York in states without guaranteed issue protections, I’m more cautious about Plan N — not because Plan N is wrong, but because the switching trap is real. If your health changes and you want to upgrade, you may not be able to.

    For the right client, HD Plan G is my most underutilized recommendation. It pays lower commission than both Plan G and Plan N, which is exactly why most agents don’t bring it up. But for a healthy 65-70-year-old with sufficient savings to absorb the deductible in a high-use year, the cumulative premium savings over 10 years can be substantial.

    My honest summary:

    • Plan N wins for most healthy enrollees in ban states or guaranteed-issue states
    • Plan G wins for frequent users, travelers, and anyone in underwriting states concerned about their health trajectory
    • HD Plan G wins for healthy enrollees who want maximum premium savings and can self-fund the deductible risk

    The 6-Question Decision Framework

    Work through these honestly. The answers will point you clearly in one direction.

    1. How many copay-triggering visits do you realistically have each year? Divide your monthly premium gap by $20. That’s how many full-copay visits per month it takes for Plan N to break even with Plan G. Are you above or below that threshold?
    2. Do you live in one of the states where excess charges are effectively banned? Ohio, Pennsylvania, Rhode Island, Vermont, Massachusetts: Plan N’s excess charge gap is largely irrelevant for in-state care. Connecticut: only for QMB enrollees. New York: limited to 5% for most services.
    3. Have you verified whether your current doctors accept assignment? A 5-minute search at Medicare Care Compare answers this definitively. If all your providers accept assignment, Plan G’s excess charge protection has zero current value for you.
    4. Do you live in a guaranteed issue or birthday rule state? If yes, the switching trap risk is reduced — your initial plan choice is less permanent. If no, consider whether your likely health trajectory over the next 10 years makes Plan G’s extra protection worth the premium.
    5. Are you in good enough health to seriously consider HD Plan G? If you’re healthy, rarely need healthcare, and have savings to cover $2,950 in a high-use year — HD Plan G deserves to be in the conversation.
    6. What is the actual premium gap in your specific ZIP code? National averages tell you nothing useful about your specific market. A $20/month gap makes Plan G very easy to justify. A $70/month gap makes Plan N very difficult to pass up. Get real quotes before deciding anything.

    Want Me to Run the Numbers for Your Specific Situation?

    The right answer for you depends on your health, your location, your doctors, your premium quotes, and your state’s switching rules. I can pull all of that together in a single conversation — at no cost, with zero obligation.

    I’ll tell you honestly which plan makes sense for your situation, show you the math, and compare rates from the 40+ carriers I represent. If the answer is HD Plan G, I’ll tell you that even though it pays me less. If the answer is Medicare Advantage instead of any Medigap plan, I’ll tell you that too.

    Paul Barrett | The Modern Medicare Agency 📞 (631) 358-5793 ✉️ medicare@paulbinsurance.com 🌐 paulbinsurance.com

    Sources and Further Reading

    Paul Barrett is the founder and Principal Agent of The Modern Medicare Agency. He has worked exclusively in Medicare for 18+ years, holds licenses in 34 states, and represents 40+ carriers. He is the author of Medicare Mastery Unlocked and hosts the Insurance Wise Guys Podcast. This article is for educational purposes only. Premium ranges are national averages and vary significantly by state, ZIP code, age, gender, tobacco use, and carrier. Excess charge state rules are subject to change — verify current rules with your state insurance department or a licensed independent broker. Contact a licensed Medicare broker for guidance specific to your situation.

What Is Medicare Part B and What Does It Actually Cover?

The complete guide to Medicare’s medical insurance — every service it covers, exactly what it costs in 2026, how it works with group insurance and VA benefits, and the excess charges most people have never heard of until they get a surprise bill.

The Short Answer

Medicare Part B is medical insurance — it covers doctor visits, outpatient care, preventive services, durable medical equipment, and more. Unlike Part A, Part B is not premium-free for anyone: everyone pays a monthly premium (202.90in2026formostpeople),anannualdeductible(283), and 20% coinsurance on most covered services, with no yearly cap on that 20% under Original Medicare alone. Whether you need to enroll at 65, and whether delaying is safe, depends heavily on your employment status and your employer’s size — getting this wrong is one of the most consequential and permanent mistakes in all of Medicare.

Key Takeaways

  • Part B is never premium-free — everyone pays a monthly premium, and higher earners pay significantly more through IRMAA.
  • The 20% coinsurance under Original Medicare alone has no yearly cap — this is the single biggest financial risk in Medicare, and it’s the reason Medigap and Medicare Advantage exist.
  • Whether you can safely delay Part B without a penalty depends on your employer’s size: 20+ employees generally allows delay; fewer than 20 generally does not.
  • Missing your enrollment window triggers a permanent 10% penalty for every 12-month period you went without coverage.
  • Veterans can and generally should enroll in Part B even with VA benefits, since Medicare and VA coverage don’t coordinate — each only pays for care received within its own system.
  • “Excess charges” from non-participating providers can add up to 15% on top of what Medicare approves, and only some Medigap plans protect you from them.

What Part B Actually Covers

While Part A handles hospital room and board, Part B is the half of Original Medicare that covers medical care and most services delivered outside a hospital admission — doctor visits, outpatient procedures, and ongoing medical needs.

What’s covered

  • Doctor visits — primary care and specialists
  • Outpatient surgeries and procedures
  • Diagnostic lab work, X-rays, and MRIs
  • Emergency room visits
  • Ambulance services
  • Outpatient mental health care
  • Physical, occupational, and speech therapy
  • Chemotherapy and radiation received in an outpatient clinic
  • Durable Medical Equipment (DME) — wheelchairs, oxygen equipment, blood sugar monitors, walkers, and similar equipment
  • Ambulatory surgical center services

Preventive services: the part Medicare gets genuinely right

Most preventive services are covered at 100%, with no deductible and no copay, as long as your provider accepts Medicare assignment. This includes:

  • Your one-time “Welcome to Medicare” wellness visit, available within your first 12 months on Part B
  • Annual wellness visits after that
  • Flu shots and most other recommended vaccines
  • Mammograms
  • Colonoscopies and other cancer screenings
  • Diabetes and cardiovascular screenings
  • Many other screenings recommended by the U.S. Preventive Services Task Force

Paul’s Honest Take: This is one of the most underused parts of Medicare, full stop. I’ve had clients who paid for a private physical every year out of habit and never realized their annual wellness visit through Medicare was completely free. If you haven’t used your Welcome to Medicare visit or your annual wellness visit, that’s real value sitting on the table.

What’s NOT covered

  • Routine dental care — cleanings, fillings, dentures, extractions
  • Routine vision exams and eyeglasses
  • Hearing aids (though diagnostic hearing tests ordered by a doctor may be covered)
  • Long-term custodial nursing home care — help with daily living activities, as opposed to short-term skilled or medical care
  • Routine prescription drugs you pick up at a retail pharmacy — that’s Part D’s job, not Part B’s
  • Cosmetic surgery, unless medically necessary (such as reconstruction after an accident or mastectomy)
  • Most care received outside the United States, with very limited exceptions
  • Routine foot care, such as nail trimming, in the absence of a qualifying medical condition
  • Acupuncture, except for a narrow, specific chronic low back pain benefit
  • Concierge medicine fees and membership-style charges some practices add on top of standard care
  • Long-term care insurance-style services, including most home-based personal care that isn’t tied to a skilled medical need

Paul’s Honest Take: The dental and vision exclusions are the ones that surprise people most, especially since they’re such routine parts of healthcare for most adults. This is exactly why so many Medicare Advantage plans build dental, vision, and hearing benefits into their coverage — Original Medicare was simply never designed to include them, and that gap doesn’t go away on its own.

What Part B Costs in 2026

Part B has three separate cost components, and understanding all three matters:

Cost Component

2026 Amount

Standard monthly premium

$202.90

Annual deductible

$283

Coinsurance on most covered services

20%

The premium is deducted automatically from your Social Security check if you’re already collecting benefits. If you’re not yet collecting Social Security, you’ll receive a bill, typically every three months.

The deductible works differently than Part A’s — it’s a straightforward annual figure. You pay the first $283 of Medicare-approved outpatient costs each calendar year, and then Medicare’s cost-sharing kicks in.

The coinsurance is where the real risk lives. After your deductible is met, Medicare pays 80% of the Medicare-approved amount for most covered services, and you’re responsible for the remaining 20%. There is no yearly cap on this 20% under Original Medicare alone. If you have a $100,000 course of cancer treatment, your 20% share is $20,000 — unless you have a Medigap policy or Medicare Advantage plan absorbing that cost.

Paul’s Honest Take: I put this in bold because it’s genuinely the single most important number in this entire guide. That uncapped 20% is the whole reason Medigap and Medicare Advantage exist as products in the first place. Original Medicare by itself was never designed to protect you from a truly expensive year — it was designed to cover 80% of it and leave the rest to you.

IRMAA: What Higher Earners Actually Pay

If your income is above certain thresholds, you’ll pay more for Part B through the Income-Related Monthly Adjustment Amount (IRMAA) — based on your tax return from two years prior. For 2026, that means your 2024 income determines your premium tier.

2024 Income (Individual)

2024 Income (Married, Joint)

Total Part B / Month

$109,000 or less

$218,000 or less

$202.90

$109,001 – $137,000

$218,001 – $274,000

$284.10

$137,001 – $171,000

$274,001 – $342,000

$405.80

$171,001 – $205,000

$342,001 – $410,000

$527.50

$205,001 – $499,999

$410,001 – $749,999

$649.20

$500,000 and above

$750,000 and above

$689.90

At the top tier, you’re paying more than three times the standard premium. If your income has recently dropped — retirement, the loss of a spouse, or certain other life-changing events — you can appeal your IRMAA determination using Form SSA-44.

Do You Have to Enroll? And What Happens If You Don’t?

Technically, Part B is optional — Medicare won’t force you into it. But opting out without a valid alternative is genuinely risky, because of how the penalty structure works.

If you don’t sign up during your Initial Enrollment Period (the 7-month window around your 65th birthday) and you don’t have qualifying employer coverage, you’ll face a permanent 10% penalty added to your premium for every full 12-month period you went without Part B. That penalty doesn’t expire — you pay it for as long as you have Part B, which for most people means for the rest of your life.

Example: If you delayed enrollment by 24 full months without a valid exception, you’d pay an extra 20% on top of the standard $202.90 premium in 2026 — roughly $40.58 more, every month, permanently.

How Part B Works with Group Insurance

Just like Part A, whether you can safely delay Part B without penalty comes down to one specific number: how many employees your company has.

Companies with 20 or more employees: If you or your spouse are actively working and covered by a genuine group health plan, your workplace insurance is primary, and you can legally delay Part B without any penalty. When that employment or coverage eventually ends, you get an 8-month Special Enrollment Period to enroll in Part B penalty-free.

Companies with fewer than 20 employees: Medicare automatically becomes your primary insurer at 65, regardless of your employment status. You need to enroll in Part B right on schedule. If you don’t, your small employer’s plan can legally refuse to pay claims that Medicare should have covered first — potentially leaving you responsible for the full cost.

Paul’s Honest Take: I say this in nearly every guide I write, because it’s genuinely one of the costliest misunderstandings I encounter: “I have good coverage at work” and “I’m protected from Medicare’s enrollment deadlines” are two completely different statements, and whether the second one is true depends entirely on your employer’s size — not how generous the coverage feels. Confirm the actual employee count before you decide to delay anything.

Retiree Coverage Is Not the Same as Active Employer Coverage

This is a distinction that catches a genuinely large number of people off guard: the “20 or more employees” exception only applies to active employment. If you retire and your former employer offers you retiree health benefits — sometimes a genuinely good, comprehensive plan — that coverage does not create a Special Enrollment Period the way active group coverage does, and it does not exempt you from enrolling in Part B on time.

Paul’s Honest Take: I’ve seen this mistake more than once, and it’s an especially painful one because it happens to people who did everything right during their working years. Someone retires with a strong retiree health plan from a large employer, assumes it works the same way their active coverage did, and delays Part B — only to find out later that retiree coverage was never a valid reason to delay in the first place. The moment you stop actively working, that clock starts, regardless of how good your retiree plan looks on paper. If you’re retiring and keeping employer retiree benefits, treat enrolling in Part B as something to handle right on schedule, not something retiree coverage lets you postpone.

Why You Need Both Part A and Part B for Medigap or Medicare Advantage

Here’s a foundational requirement worth understanding clearly, since it shapes every other coverage decision in Medicare: you must be enrolled in both Part A and Part B before you can buy a Medigap policy or enroll in a Medicare Advantage plan. Neither product exists as a standalone substitute for Original Medicare — both are built specifically to work alongside it.

  • Medigap fills the cost-sharing gaps left by Original Medicare (Parts A and B) — it has nothing to fill in if you’re not enrolled in both parts to begin with.
  • Medicare Advantage legally must provide at least the same coverage as Parts A and B combined, which is only possible because you’re required to be enrolled in both before a Medicare Advantage carrier can enroll you.

Paul’s Honest Take: This surprises people who assume they can somehow “skip” Part B and go straight into a Medicare Advantage plan to avoid the extra premium. It doesn’t work that way — Part B enrollment, and its premium, is a prerequisite either way, whether you end up on Original Medicare with Medigap or on a Medicare Advantage plan. There’s no path through Medicare that avoids the Part B premium once you’re actually using the system.

Does Medicare Work If You’re a Veteran?

Yes — and if you have VA health benefits, understanding how the two systems relate is genuinely important, because they work differently than most people assume.

Medicare and VA benefits do not coordinate. These are two entirely separate systems that each pay only for care received within their own network. Medicare doesn’t pay for care you receive at a VA facility, and VA benefits don’t pay for care you receive from a non-VA doctor or hospital. You, the veteran, choose which system to use each time you seek care.

Here’s the critical point: having VA benefits does not exempt you from Medicare’s enrollment deadlines. VA coverage is not considered a qualifying reason to delay Part B without penalty. If you don’t enroll in Part B during your Initial Enrollment Period and you’re relying solely on VA benefits, you can still trigger the permanent late enrollment penalty.

Why the VA itself recommends enrolling in Medicare anyway:

  • It gives you access to civilian doctors and hospitals outside the VA system
  • VA healthcare funding depends on annual Congressional appropriations, which isn’t guaranteed to remain stable
  • If VA authorizes only part of your needed care at a non-VA facility, Medicare can help cover the rest
  • Having both gives you meaningfully more flexibility and security than relying on either system alone

Paul’s Honest Take: This is one of the most common misconceptions I run into with veterans specifically, and it’s an expensive one to get wrong. Good VA coverage feels like it should be enough, and it might genuinely handle most of your care — but it doesn’t protect you from the Part B enrollment clock the way employer coverage from a large company can. The VA itself actively encourages enrolling in Medicare Parts A and B for exactly this reason. If you have VA benefits and are approaching 65, this is worth a direct conversation before you assume you’re covered.

Veterans who enroll in Part B can also purchase a Medigap policy, which can be particularly valuable if you use non-VA providers regularly — though if you primarily rely on VA facilities for most of your care, the value of an added Medigap policy may be more limited, and worth weighing carefully.

How Long Does It Actually Take to Get Part B Approved?

This is one of the most practical, and most overlooked, pieces of planning — especially if you’re leaving a job after 65 and coordinating your Part B start date around the end of your employer coverage. Applying isn’t instant, and the timeline depends heavily on which enrollment window you’re using.

Enrollment Situation

Typical Processing Time

When Coverage Actually Starts

Initial Enrollment Period (around 65)

2–4 weeks, sometimes up to 6

1st of your birthday month (if applied in the 3 months before) or 1st of the month after you apply (if applied during or after your birthday month)

Special Enrollment Period (leaving employer coverage)

4–8 weeks, sometimes longer

1st of the month after your application is submitted

General Enrollment Period (Jan 1–Mar 31, missed window)

4–6 weeks

1st of the month after you apply

Why the Special Enrollment Period takes longer: applying after leaving employer coverage requires two forms, not one — Form CMS-40B (the actual Part B application) and Form CMS-L564 (Request for Employment Information), which your employer needs to complete to verify you had qualifying coverage. Social Security has to manually review both, which is exactly why this route consistently takes longer than a standard Initial Enrollment Period application.

Paul’s Honest Take: This timeline question comes up constantly with clients who are retiring or leaving a job after 65, and it deserves real attention — not just because of the penalty risk we’ve already covered, but because a slow approval can leave you with an actual gap in coverage if you time it too tightly. My standard advice: start this process at least 2 to 3 months before you need Part B to actually begin, not the week your employer coverage ends. If your former employer is slow to complete their portion of Form CMS-L564, that alone can hold up the entire application — so it’s worth following up with your HR or benefits department directly rather than assuming it’s been submitted.

Practical tips to avoid delays

  • Apply online through SSA.gov whenever possible. It’s consistently the fastest method — mailed or faxed forms are more prone to getting lost or delayed.
  • If you’re on a Special Enrollment Period, submit Form CMS-L564 alongside Form CMS-40B, not separately. They need to arrive together, and one incomplete form can stall the whole application.
  • Expect a short intake lag even with online applications. It can take several business days for an online submission to actually appear on a local Social Security agent’s screen — don’t panic if you call shortly after applying and they say they don’t see it yet.
  • Once approved, you don’t have to wait for your physical card. Your Medicare Beneficiary Identifier typically appears in your online Social Security or Medicare.gov account within a day or two of approval, and you can print a temporary card from there — the physical card generally arrives by mail within about 30 days.

Excess Charges: The Cost Almost Nobody Knows to Ask About

Here’s a detail that surprises even people who’ve been on Medicare for years: not every doctor who accepts Medicare agrees to accept Medicare’s approved amount as full payment.

Providers fall into three categories:

  • Participating providers accept Medicare assignment, meaning they agree to accept the Medicare-approved amount as payment in full. This covers the vast majority of providers — roughly 98% of doctors nationally.
  • Non-participating providers still accept Medicare patients but haven’t agreed to accept the standard rate. They can charge an excess charge of up to 15% above the Medicare-approved amount.
  • Opted-out providers have left the Medicare system entirely and can charge whatever they want under a private contract — Medicare pays nothing at all for care from these providers, except in emergencies.

How excess charges actually work: if the Medicare-approved amount for a service is $300 and you see a non-participating provider, they can legally charge up to an additional $45 (15%) on top, for a total bill of $345 — and that excess amount doesn’t count toward your Part B deductible.

Eight states currently prohibit or limit excess charges entirely: Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont. If you live in one of these states, you’re generally shielded from excess charges from providers within your state — though you could still face them if you receive care from a non-participating provider elsewhere.

Paul’s Honest Take: This is exactly why Medigap Plan G matters so much for people who want maximum flexibility. Plan G covers excess charges in full — Plan N does not. If you’re the kind of person who wants the freedom to see any doctor without worrying about billing surprises, that distinction is worth understanding clearly before you pick between the two. And regardless of which plan you choose, it’s always worth asking a new provider directly whether they accept Medicare assignment before your first appointment.

The HSA Rule: Part B Closes the Door Too

If you’re hoping to keep contributing to a Health Savings Account, know this clearly: enrolling in Part B — or any part of Medicare — ends your ability to make new HSA contributions. This isn’t unique to Part B; it applies the moment you enroll in Medicare in any form, including premium-free Part A.

If keeping your HSA active matters to you, the only way to legally delay both Part A and Part B is through qualifying employer coverage — which, as covered above, generally requires an employer with 20 or more employees. And because Part A enrollment can be backdated up to 6 months once you do enroll, it’s smart to stop HSA contributions 6 months before you plan to sign up for Medicare or file for Social Security, whichever comes first.

Frequently Asked Questions

Is there a cap on what I’ll pay for Part B services in a year? Not under Original Medicare alone — the 20% coinsurance has no yearly limit. A Medigap policy or Medicare Advantage plan is what actually caps your exposure.

What happens if I don’t sign up for Part B on time? You’ll generally face a permanent 10% penalty on your premium for every 12-month period you went without coverage, unless you qualify for a Special Enrollment Period through active employer coverage.

Do I need Part B if I have good coverage through a small employer? Almost certainly yes. If your employer has fewer than 20 employees, Medicare becomes your primary insurer at 65 regardless of your job coverage, and not enrolling can leave you exposed to unpaid claims and a lifelong penalty.

Do veterans need Medicare Part B if they have VA benefits? Generally, yes. Medicare and VA benefits don’t coordinate — each only pays for care within its own system — and VA coverage doesn’t exempt you from Medicare’s enrollment deadlines or penalties.

What is a Part B excess charge? An additional charge, up to 15% above the Medicare-approved amount, that a non-participating provider can legally bill you. It doesn’t count toward your deductible, and only Medigap Plan G (among current plans) covers it in full.

Can I keep contributing to my HSA if I enroll in Part B? No. Enrolling in any part of Medicare, including Part B, ends your HSA contribution eligibility going forward.

How long does it take to get approved for Part B? It depends on the enrollment window. Initial Enrollment Period applications typically process in 2–4 weeks. Special Enrollment Period applications, used when leaving employer coverage, generally take 4–8 weeks since Social Security must manually verify your prior coverage using Form CMS-L564. Start the process at least 2–3 months before you need coverage to begin, especially when coordinating around a job ending.

The Bottom Line

Part B is the half of Medicare that covers your everyday medical care — and it’s also where the real financial exposure of Original Medicare lives, thanks to that uncapped 20% coinsurance. Whether you should enroll at 65, whether you can safely delay, and how much of that exposure you’re carrying all depend on details specific to your situation: your employer’s size, your income, your VA status, and which doctors you actually see.

If you want help sorting out exactly how Part B applies to your specific circumstances — or want to understand how Medigap or Medicare Advantage could close that uncapped coinsurance gap — that’s exactly the conversation I have with clients every day, at no cost to you.

Call 631-358-5793 or visit paulbinsurance.com to set up a time to talk it through.

Paul Barrett, CMIP, is the founder of The Modern Medicare Agency, based in Melville, NY, and has spent 18+ years exclusively helping people navigate Medicare — never life insurance, never annuities, just Medicare. He’s licensed in 37 states, represents more than 40 carriers, and has personally helped over 5,000 clients choose coverage that actually fits their lives.

Figures current as of 2026 and sourced from CMS, Medicare.gov, and the Social Security Administration. Individual circumstances vary, especially around employer coverage, VA benefits, and income-based premiums — always verify your specific situation before making enrollment decisions.

Sources

Related Post

Scroll to Top

Request a Callback with
Paul Barrett

Fill out the form below, and we'll call you within 24 hours.