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.

When Is the Best Time to Switch Medicare Supplement Plans — and When Is It Too Late?

June 23, 2026

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

The Question Behind the Question

When someone calls me after their Medigap premium just jumped 17%, they’re not really asking “can I switch?” They’re asking something deeper: why didn’t anyone warn me this could happen, and is there anything I can do about it now?

That’s the question this article answers — completely, honestly, and with enough specificity to actually be useful. Because the generic answer (“you can switch anytime but may face underwriting”) that fills most online articles is just sophisticated enough to sound helpful while leaving you no better off than before you read it.

What you actually need to know:

The one window that gives you full freedom — and why most people don’t use it wisely
The specific federal situations that reopen that door
Which states have built their own consumer protections — and exactly what each one does
Why New York’s rules are genuinely special — and the catch nobody mentions
When switching makes clear financial sense, and when it doesn’t
The three situations where switching is a mistake, even when you can

Let’s go.

The Rule Most People Learn Too Late

Here is the foundational truth about Medigap switching that the industry doesn’t advertise clearly:

Your Medigap Open Enrollment Period is a one-time event. It does not repeat annually.

When you turn 65 and enroll in Medicare Part B, you receive a six-month window during which every Medigap carrier operating in your state must accept you for any plan they offer — at standard rates, with no health questions, no medical underwriting, and no ability to deny you coverage based on pre-existing conditions. This is the most consumer-friendly enrollment window in all of Medicare, and Medicare.gov confirms it explicitly: “After this period, you may not be able to buy a Medigap policy, or it may cost more.”

This window does not come around again next October like Medicare Advantage or Part D enrollment. It is a one-time opportunity that closes after six months and, in most states, does not fully reopen — ever.

After your initial open enrollment period closes, switching Medigap plans in most states means submitting to medical underwriting. The carrier can:

Ask you detailed health questions
Review your medical history
Charge you a higher premium based on your health status
Decline to cover you at all if you have certain conditions

This reality surprises people constantly — because the plans themselves appear identical on paper, and because Medicare Advantage and Part D do allow annual switching. The assumption that Medigap works the same way is understandable and wrong.

Source: Medicare.gov: When Can I Buy a Medigap Policy?

What Underwriting Actually Looks Like

Before we discuss when you can switch without underwriting, it’s worth understanding what underwriting actually means in practice — because it ranges from inconvenient to disqualifying depending on your health history.

Common conditions that can lead to a Medigap denial or rating surcharge in underwriting states include:

Active cancer diagnosis or cancer treatment within recent years
Heart disease, recent cardiac events, stents, or bypass surgery
COPD or other significant pulmonary conditions
Diabetes with complications (neuropathy, retinopathy, kidney involvement)
Stroke or TIA history
Kidney disease or dialysis
Multiple sclerosis, Parkinson’s, ALS, or other neurological conditions
Recent hospitalization or major surgery

This list is not exhaustive, and underwriting criteria vary by carrier. Some carriers are more restrictive than others. Some will accept certain conditions that others won’t. An experienced independent broker who knows the underwriting preferences of multiple carriers can make a material difference in whether you’re approved — but there are conditions that will result in denial regardless of carrier.

The brutal truth: the people who most want to switch Medigap plans are often the people least able to do so. Someone who enrolled at 65, stayed healthy for years, then developed heart disease at 72 — and now wants to move to a less expensive carrier when their premium jumps — may find that the carrier they’d like to switch to won’t accept them.

Source: Boomer Benefits: Can I Pass Medigap Underwriting?

The Five Federal Guaranteed Issue Situations

Federal law carves out specific situations — called Guaranteed Issue rights — where carriers cannot deny you, cannot charge more based on health, and cannot impose waiting periods for pre-existing conditions. These rights exist regardless of what state you live in.

Federal GI Situation 1: The Medicare Advantage Trial Period (12 Months)

If you leave a Medigap plan to try Medicare Advantage for the first time, you have a 12-month trial period during which you can return to Original Medicare and reclaim your Medigap coverage — ideally the same plan from the same carrier. If that exact plan is no longer available, you have the right to buy Plan A, B, C, D, F, or G from any carrier in your state.

Key details:

This right applies only to your first time joining Medicare Advantage
You must return within 12 months of when your MA coverage began
After 12 months, this right expires and you lose this protected pathway back

This is one of the most valuable and least-used federal protections in Medigap. If you’re considering Medicare Advantage and haven’t already used this trial right, you have a safety net — but only once, and only for 12 months.

Federal GI Situation 2: Your Medicare Advantage Plan Discontinues or Leaves Your Area

If your Medicare Advantage plan stops serving your county or exits the market entirely, you have a guaranteed issue right to purchase a Medigap policy. This has become increasingly relevant — Johns Hopkins research published in JAMA found that approximately 10% of MA enrollees faced forced disenrollment in 2026, a tenfold increase from historical norms.

Key details:

You must apply for Medigap within 63 days of losing MA coverage
Save the termination letter — you’ll need it as proof of your GI right
This is also triggered if you move to an area your MA plan doesn’t serve

Federal GI Situation 3: Your Medicare SELECT Policy Leaves Your Area

Medicare SELECT is a type of Medigap plan that requires you to use specific network hospitals and providers. If you have a SELECT policy and move out of your plan’s service area, or if your plan reduces its service area, you have a GI right to purchase standard Medigap.

Federal GI Situation 4: Your Medigap Policy Ends Through No Fault of Your Own

If your Medigap carrier goes bankrupt, loses its license, or otherwise terminates your policy without cause, you have a GI right to purchase a new policy. You must apply within 63 days of coverage ending.

Federal GI Situation 5: Your Employer or Union Coverage Ends

If you have Medigap through an employer or union group health plan and that coverage ends — through retirement, layoff, or the employer dropping the benefit — you have a GI right to purchase an individual Medigap policy. This is also triggered if the employer or union plan deceived you or violated the rules.

The 63-day rule applies to all of these. You must act within 63 days of the triggering event. Miss the window and you lose the right — no extensions, no grace periods in most cases.

Source: Medicare.gov: Guaranteed Issue Rights; KFF: Medigap May Be Elusive for Medicare Beneficiaries with Pre-Existing Conditions

State-Level Protections: The Map Is Changing Fast

Beyond federal GI rights, states have increasingly enacted their own consumer protections. This is the fastest-moving area in Medigap policy right now — six states added birthday rule protections in 2024, 2025, and 2026, and more are considering legislation. Here’s the current landscape as of June 2026.

Continuous Guaranteed Issue States (Switch Anytime, No Health Questions)

Three states provide year-round guaranteed issue rights for Medigap — meaning you can apply for a new Medigap policy at any time, from any carrier, without medical underwriting. Washington also allows year-round switching but with a same-plan-type restriction (see details below):

New York: Community-rated pricing and year-round guaranteed issue. Any insurer selling Medigap in NY must accept all applicants at standard rates, regardless of health status, at any time of year. The most consumer-protective Medigap environment in the country.

Connecticut: Year-round guaranteed issue for Medigap policyholders. All plans are community-rated. CT also bans Part B excess charges.

Vermont: Year-round guaranteed issue rights for Medigap plan changes — most carriers in Vermont offer continuous open enrollment without underwriting, though this is not universally mandated on every carrier the way NY and CT rules are. Vermont also uses community-rated pricing.

Washington: Year-round Medigap switching without underwriting — with an important limitation: you must switch to the same plan type offered by a different insurer. For example, if you have Plan G, you can switch to Plan G from another carrier without health questions at any time. You cannot upgrade to a higher-benefit plan using this rule.

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

Massachusetts: Annual Guaranteed Issue Window

Massachusetts requires all insurers to offer continuous open enrollment throughout the year, and formally mandates a guaranteed issue open enrollment period from February 1 to March 31 annually. MA also prohibits pre-existing condition waiting periods for Medigap.

Birthday Rule States: 16 and Growing

As of June 2026, 16 states have enacted some form of a Medicare Supplement birthday rule — a state-level protection that gives Medigap enrollees an annual window around their birthday to switch plans without medical underwriting. The number has grown rapidly and continues to expand.

The birthday rule is powerful but comes with important limitations that vary significantly by state. Most states limit you to plans of equal or lesser benefits than what you currently hold — meaning you typically cannot upgrade your coverage through the birthday rule, only maintain or reduce it.

Here is the current birthday rule state-by-state breakdown:

State	Window	Carrier Flexibility	Plan Flexibility
California	60 days starting first day of birth month	Any carrier	Equal or lesser benefits
Delaware	30 days before + 30 days after birthday	Any carrier	Equal or lesser benefits
Idaho	63 days starting on birthday	Any carrier	Equal or lesser benefits
Illinois	45 days starting on birthday	Same carrier or affiliate only	Equal or lesser benefits; ages 65-75 only
Indiana	60 days after birthday (eff. Jan 2026)	Any carrier	Same plan type only
Kentucky	60 days after birthday	Any carrier	Same plan type only
Louisiana	93 days (30 before, 63 after birthday)	Same carrier or affiliate	Equal or lesser benefits
Maryland	30 days after birthday	Any carrier	Equal or lesser benefits
Missouri	63 days (Anniversary Rule — 30 days before + 33 days after policy anniversary date, not birthday)	Any carrier	Equal or lesser benefits
Nevada	60 days starting first day of birth month	Any carrier	Equal or lesser benefits
Oklahoma	60 days after birthday	Any carrier	Equal or lesser benefits
Oregon	31 days starting on birthday	Any carrier	Equal or lesser benefits
Rhode Island	30 days starting on birthday	Any carrier	Equal or lesser benefits
Utah	60 days after birthday	Same carrier only	Equal or lesser benefits
Virginia	60 days after birthday (eff. July 2025)	Any carrier	Same plan type only
West Virginia	60 days starting first day of birth month (eff. June 11, 2026)	Same carrier or affiliate	Equal or lesser benefits; must have held current plan 2+ years
Wyoming	63 days starting on birthday (eff. June 4, 2025)	Any carrier	Equal or lesser benefits

Coming soon: New Mexico signed birthday rule legislation in March 2026, effective January 1, 2027 (60-day window, first day of birth month, equal or lesser benefits from any carrier).

Under consideration: Iowa, Nebraska, Pennsylvania, and Michigan all have birthday rule legislation pending as of mid-2026.

Source: MedicareResources.org: The Birthday Rule; Boomer Benefits: Medigap Birthday Rule States; The Big 65: Birthday Rule State Guide

Maine: The Annual Plan A Guarantee

Maine has a unique rule: insurers must offer Plan A to any applicant during an annual one-month window of the insurer’s choosing. Maine also allows policyholders to change to a plan of equal or lesser benefits if they haven’t had a coverage gap longer than 90 days since initial enrollment.

Minnesota: New Limited Window (Effective August 2026)

Effective August 1, 2026, Minnesota individuals ages 65 to 70 have a one-time opportunity to switch to a Medigap policy outside their initial enrollment period without medical underwriting. However, a premium penalty applies — 15% above community rate in 2026, increasing 5% per year until reaching 35% maximum starting in 2029.

New York: The Special Case That Requires an Honest Conversation

New York deserves its own section because it combines genuine consumer protection with a market reality that surprises people.

The protection is real. Under NY insurance regulations, every carrier selling Medigap in New York must:

Accept all applicants regardless of health status
Use community-rated pricing (everyone the same age in the same plan pays the same rate)
Sell to applicants at any time of year — no annual window, no birthday trigger, no qualifying event required

This means a 75-year-old New Yorker with heart failure, diabetes, and a recent hospitalization can apply for Plan G from any carrier tomorrow and must be accepted at standard rates. In 47 other states, that person almost certainly cannot get Medigap at all outside of a specific qualifying event.

For anyone with health conditions, New York’s rules are extraordinarily protective and genuinely rare.

The catch that nobody talks about.

Being guaranteed the right to switch doesn’t mean there’s anywhere better to switch to.

New York’s community rating and open-pool enrollment mean carriers price in the risk of accepting all comers — and that’s reflected in premiums that are among the highest in the country. According to MoneyGeek’s 2026 state-by-state analysis, New York averages $354/month for Plan G — the most expensive state in the country.

When UHC raised their Plan G premiums by 17.8% in New York in 2026, many policyholders immediately asked: “Can I switch to someone cheaper?” The honest answer: UHC is already the lowest-priced Plan G carrier in New York. There is nowhere meaningfully cheaper to go — because every carrier in the state faces the same actuarial reality of covering an open pool. The rate increases are market-wide, not UHC-specific.

What switching in NY actually accomplishes:

For New Yorkers, switching carriers often saves little or nothing on the monthly premium — but it can still make sense in some scenarios:

Moving from Plan G to Plan N (same carrier or different) to reduce premium while accepting copays
Moving from standard Plan G to High Deductible Plan G if you’re in good health and the premium savings are substantial
Changing carriers for non-price reasons: better customer service history, different rate-increase trajectory, or carrier stability concerns

Source: NY Department of Financial Services: Medicare Supplement Premium Comparison Tables; paulbinsurance.com rate tracking

Medigap and Medicaid: A Special Consideration for Low-Income Beneficiaries

One important scenario worth knowing: if you qualify for both Medicare and Medicaid (dual eligible), you can suspend — not cancel — your Medigap policy while Medicaid is covering your costs. If you later lose Medicaid eligibility, you have 90 days to reinstate your Medigap policy without underwriting. This suspension option protects your ability to return to comprehensive Medigap coverage if your financial situation changes.

Source: Medicare.gov: Switching or Dropping Medigap

The “Same Plan, Better Rate” Strategy

One of the most underutilized switching strategies is straightforward: keep the same plan letter but move to a different carrier offering it at a lower price.

Because Medigap plans are federally standardized, Plan G from Carrier A provides identical medical coverage to Plan G from Carrier B. The only things that differ are:

The monthly premium
The carrier’s rate-increase history
The carrier’s financial stability rating
Customer service quality

If you live in a state where you have guaranteed issue rights (NY, CT, VT, MA) or in a birthday rule state during your window — and a competing carrier offers Plan G for meaningfully less — switching makes straightforward financial sense. You get the same coverage, same doctors, same benefits — just a lower bill.

The math to run before switching:

Before any switch, even a same-plan carrier change, verify:

What is the actual monthly savings? Calculate the difference between your current premium and the new premium. Is it $15/month? $60/month? $120/month? The answer changes everything about whether it’s worth the administrative effort of switching.
What is the new carrier’s rate-increase history? A carrier offering $40/month less today but with a history of 20% annual rate increases may end up costing more within two years. Ask your broker for a 5-year rate history on any carrier you’re considering. A good independent broker will provide this without hesitation.
Are there enrollment discounts that will phase out? Many carriers offer introductory enrollment discounts for new policyholders that gradually phase out over 3-5 years. A premium that looks attractively low today may look different once those discounts expire. Ask specifically whether the quoted rate includes any time-limited discounts.
What is the carrier’s AM Best financial strength rating? For long-term coverage you may hold for 20+ years, carrier financial stability matters. Look for an AM Best rating of A- or better. Note: UHC’s Medigap-writing subsidiaries were downgraded from A+ to A (Excellent) by AM Best in August 2025, though A (Excellent) remains a strong rating.
Is there a waiting period for pre-existing conditions? Even in guaranteed issue situations, carriers in some states may impose up to a 6-month waiting period on coverage related to pre-existing conditions you had before enrolling. This is different from being denied — you’re still covered for new conditions — but existing conditions may have a coverage gap. Check whether this applies before switching.

The Three Times Switching Is a Terrible Idea

Despite all the scenarios where switching makes sense, here are three situations where switching is likely a mistake even when you technically can.

Terrible Switch #1: Switching Purely to Avoid a Rate Increase When You Have Health Conditions

If your rate went up and you’re considering switching carriers — but you’ve developed health conditions since you first enrolled — you’re in a precarious position in most states.

Attempting to switch triggers underwriting. Underwriting reveals your health conditions. The new carrier declines you or rates you up significantly. Now you’ve potentially started an application clock, and in some cases you may have difficulty returning to your current carrier at the old terms. A bad outcome from an ill-timed switch attempt can leave you worse off than the rate increase you were trying to escape.

Before attempting any switch when your health has changed: consult with an experienced independent broker who knows both the underwriting landscape and your state’s rules. Do not apply speculatively.

Terrible Switch #2: Switching from Medigap to Medicare Advantage Because the Premium Increase Makes MA Look Attractive

When your Medigap premium jumps $50/month, a $0-premium Medicare Advantage plan suddenly looks compelling. For some people, it may genuinely be the right move.

But this switch is often one-way. Once you leave Medigap for Medicare Advantage, your protected return pathway (the 12-month trial right) only exists if it’s your first time joining MA. If you’ve done this before, or if you go past 12 months in MA, getting back to Medigap requires underwriting in most states. And if your health has changed — which often happens to the same people who decide they need the lower premium — you may not be able to get back in.

The calculation: does $600/year in premium savings justify the risk of being permanently unable to return to Medigap if your health changes and you find yourself facing a serious diagnosis while in Medicare Advantage’s managed care structure?

For many people the answer is yes. For others — especially those over 70 with emerging health concerns — the answer may be no. Think carefully before making this switch.

Terrible Switch #3: Switching in the Last 30 Days Before a Rate Increase Takes Effect Without Fully Thinking It Through

When people receive their rate increase notice, the urgency to act immediately is understandable. But rushing a switch without properly evaluating the alternative can mean:

Enrolling with a carrier that has a worse rate-increase history
Losing enrollment discounts from your current carrier that actually partially offset the increase
Missing the fact that your current carrier’s new rate is still lower than the competition’s rate
Switching mid-year in a way that creates coverage timing complications

Take a breath. You have time. A rate increase notice typically gives you 30-60 days or more before the new rate takes effect. Use that time to have a real conversation with an independent broker who can compare options systematically rather than emotionally.

How to Evaluate Whether Switching Makes Sense in Your Specific Situation

Here’s the framework I use with every client who calls after a rate increase:

Step 1: Determine what switching rights you actually have Are you in a continuous GI state (NY, CT, VT)? In a birthday rule state during your window? Did a qualifying federal GI event occur within the last 63 days? Or are you in a state where switching requires underwriting?

Step 2: If underwriting is required, assess your health candidly Be honest. If you have multiple chronic conditions or recent significant health events, underwriting-required switching may not be feasible regardless of how attractive the alternative premium looks. Know this before applying anywhere.

Step 3: Get actual competitive quotes for your ZIP code and age National averages don’t apply to your situation. Your independent broker should pull real quotes from every carrier available in your ZIP code for your plan type, age, and gender.

Step 4: Ask for the rate-increase history of any carrier you’re considering A 5-year track record of rate filings tells you far more than today’s premium about what you’ll be paying in year 3. Some carriers price aggressively to attract new business, then correct sharply. Others are more gradual and predictable.

Step 5: Calculate the true break-even on switching If there’s an administrative cost or timing gap in switching, how many months does it take for the lower premium to recoup that? If you’re saving $30/month and there’s a 1-month dual-premium overlap, you break even in month 2. Easy math.

Step 6: Consider whether changing plan type makes more sense than changing carriers Sometimes the best move isn’t a same-plan carrier switch — it’s moving from Plan G to Plan N (and accepting copays for premium savings) or moving to High Deductible Plan G. These are plan-type changes that may require underwriting in most states but qualify under birthday rules in applicable states.

The 30-Day Free Look Period: Your Safety Net When You Switch

Here’s something many people don’t know: when you enroll in a new Medigap policy, federal law gives you a 30-day free look period during which you can cancel the new policy and receive a full refund of any premiums paid.

Critical rule: Do NOT cancel your old Medigap policy until you’ve decided to keep the new one. You’ll pay two premiums for the overlap month — that’s unavoidable — but you should not cancel your current coverage until the 30-day evaluation period has concluded and you’re certain you’re keeping the new plan.

This protection gives you a genuine trial window with your new carrier before committing fully.

Source: Medicare.gov: Change Your Medigap Policy

The Enrollment Timing Mistake That Costs People Real Money

One pattern I’ve seen repeatedly: someone learns about birthday rule protections, decides to switch during their window, applies — and then misses the window deadline by a few weeks.

The consequences are real. Outside the birthday window, you’re back to full underwriting requirements (in states that have underwriting). Your application that would have been guaranteed-approved three weeks ago now depends on your health history. If you’ve had any health events, you may be declined.

Birthday rule timing notes:

The window is measured carefully and often ends strictly on the deadline date — not extended
Apply several weeks before the window closes, not in the final days
Different carriers may have different application cutoff requirements even within the same state window
Some states require the new coverage to start within the birthday window period, not just the application

Work with a broker who tracks these windows, not one who vaguely mentions birthday rules in passing.

Paul’s Honest Bottom Line

The switching landscape is genuinely complex, and anyone who gives you a simple answer — “you can switch anytime” or “you’re stuck forever” — is oversimplifying in ways that could hurt you.

Here’s what’s actually true:

Your initial open enrollment window at 65 is your most valuable asset in Medigap. Use it deliberately, with full information about rate histories and carrier stability — not just on the lowest current premium. The decision you make at 65 is sticky in most states.

If your rate just went up, the first call you should make is to an independent broker who can tell you: what your actual switching rights are in your state, whether competing carriers are meaningfully cheaper after accounting for rate history, and whether changing plan types makes more sense than changing carriers.

If you live in New York, you have genuine switching rights but limited carrier competition at the low end. The most important move is usually not switching carriers but considering whether Plan N or High Deductible Plan G makes more sense at your current premium trajectory.

If you’re in a birthday rule state, mark your birthday on your calendar and have a conversation with your broker 60 days before your window opens. That’s not overkill — that’s appropriate planning for a decision that affects your healthcare costs for years.

If you have health conditions and live in a state with underwriting, be honest with yourself before applying anywhere. An application denial goes on record and can complicate future applications. Know your realistic options before you move.

Your Rate Just Went Up. Let Me Check Your Actual Options.

If you received a rate increase notice and you’re trying to figure out what to do, I can look at your specific situation — your state, your plan, your current carrier, and what alternatives actually exist in your market.

No generic advice. No pressure toward any particular option. Just an honest assessment of what your realistic choices are.

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. Medigap rules, birthday rule protections, and guaranteed issue rights vary by state and are subject to legislative change. Verify current rules with your State Insurance Department or a licensed independent Medicare broker before making any coverage decisions.

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.