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.

What Items Are Covered by Medicare Part B: Clear Guide to Services, Supplies, and Durable Medical Equipment

February 8, 2026

You can expect Medicare Part B to cover most outpatient care you get from doctors, clinics, and outpatient hospitals, plus many preventive services, tests, and medically necessary supplies like durable medical equipment.

Part B pays for doctor visits, outpatient procedures, lab tests, mental health services, and certain injections and durable equipment when they’re medically necessary or preventive.

This post will walk you through what counts as covered care and what might not be.

If you want help sorting your options, The Modern Medicare Agency makes it simple: licensed agents you can talk to one-on-one review your needs, match you to plans, and do not add hidden fees.

Keep reading to see which doctor visits, tests, therapies, and supplies Medicare Part B typically covers and how to verify coverage for your situation.

Overview of Medicare Part B Coverage

Medicare Part B pays for many outpatient services you get from doctors and clinics.

It covers preventive care, tests, medical equipment, and some home health services, with costs shared between you and Medicare.

Eligibility Requirements

You qualify for Part B if you are age 65 or older and either already receive Social Security or Railroad Retirement Board benefits, or you enroll during your initial enrollment window.

Younger people with certain disabilities or those with end-stage renal disease may also qualify.

If you live in the U.S. as a legal resident and meet the work-history requirements tied to Social Security credits, you will typically be eligible for Part B.

You must have Part A coverage or be eligible for it; Part B stands alone but normally pairs with Part A for full Original Medicare benefits.

The Modern Medicare Agency can check your specific eligibility in minutes and explain exceptions, such as special enrollment periods after employer coverage ends.

Our licensed agents speak with you 1-on-1 to confirm when and how to enroll.

Enrollment Process

You usually enroll in Part B during your Initial Enrollment Period: the three months before your 65th birthday, the month you turn 65, and the three months after.

If you miss that window, you can sign up during the General Enrollment Period from January 1 to March 31 each year, but coverage starts July 1 and you may pay a late-enrollment penalty.

If you have active employer coverage at 65, you can delay Part B and use a Special Enrollment Period when that job-based coverage ends.

To enroll, you can sign up online at Social Security or call Social Security directly.

The Modern Medicare Agency helps you pick the right time to enroll and avoids penalties.

Our agents walk you through forms and deadlines so your start date and coverage match your needs.

Monthly Premiums and Costs

Part B has a monthly premium that most people pay.

In 2026 the standard premium is $202.90 per month; higher-income beneficiaries may pay an Income-Related Monthly Adjustment Amount (IRMAA).

You also owe an annual deductible—$283 in 2026—then typically 20% coinsurance for most services after Medicare approves the cost.

Costs vary by year and by your reported income from two years prior.

If you get Social Security benefits, your premium may be deducted from your benefit check.

Durable medical equipment, outpatient tests, and many doctor services all follow the 20% coinsurance rule unless supplemental coverage or a Medicare Advantage plan covers more.

The Modern Medicare Agency explains how premiums, IRMAA, deductibles, and coinsurance will affect your budget.

Our licensed agents compare options that fit your finances and won’t charge extra fees for this guidance.

Doctor and Outpatient Services

Medicare Part B pays for many visits, tests, and outpatient treatments you get from doctors and clinics.

It helps cover regular checkups, specialist care, outpatient procedures, and second opinions before surgery.

Primary Care Visits

Part B covers medically necessary visits with your primary care doctor.

This includes office visits for illness, chronic condition management like diabetes or high blood pressure, and preventive visits such as yearly wellness exams.

You pay the Part B deductible first, then usually 20% of the Medicare-approved amount for each visit unless you have supplemental coverage.

Your primary care provider can order lab tests, X-rays, and certain outpatient services that Part B also covers.

They can also refer you to specialists when needed.

If you want help choosing plans that lower out‑of‑pocket costs for regular doctor visits, The Modern Medicare Agency offers licensed agents who speak with you 1 on 1 and find Medicare options that match your needs without extra fees.

Specialist Consultations

Part B covers consultations with specialists when a doctor refers you or when care is medically necessary.

This includes visits to cardiologists, neurologists, orthopedists, and other specialty doctors for diagnosis and treatment.

You are responsible for the Part B coinsurance after meeting the deductible, typically 20% of the approved cost.

Specialists can perform diagnostic tests during visits, and Part B covers those tests when ordered by a doctor.

If you need help finding plans that reduce coinsurance or connect you with in‑network specialists, The Modern Medicare Agency’s licensed agents can review your options and explain costs clearly.

Outpatient Medical Procedures

Outpatient procedures done in a clinic or hospital outpatient department fall under Part B when they are medically necessary.

Examples include minor surgeries, certain biopsies, endoscopies, and wound care.

Part B covers the doctor’s service and usually part of the facility fee; you pay the deductible and the coinsurance portion.

Durable medical equipment and certain injectable drugs you receive during outpatient visits can also be covered by Part B.

If you want to lower facility or procedure costs, an agent at The Modern Medicare Agency can help compare Medicare plans and explain which coverages reduce your share of expenses.

Second Opinions for Surgery

Part B covers second‑opinion visits when you want confirmation that surgery is necessary or to explore less invasive options.

A covered second opinion must be with a qualified doctor and deemed medically appropriate.

You pay the same Part B cost-sharing as with other doctor visits.

Getting a second opinion can affect whether Medicare approves or helps pay for planned surgery.

The Modern Medicare Agency can connect you with licensed agents who help you understand coverage rules, find participating doctors, and choose plans that support access to second opinions without hidden fees.

Preventive Services Covered

Medicare Part B pays for many services that help find health problems early, prevent disease, and keep you healthy.

You get screenings, shots, and an annual visit that sets up a personalized prevention plan.

Screenings and Tests

Medicare Part B covers many screening tests to detect cancer, heart disease, diabetes, and other conditions early.

Commonly covered tests include mammograms for breast cancer, colon cancer screenings (like colonoscopy or stool tests), and Pap tests plus pelvic exams.

You also get screening for cardiovascular disease risk with blood tests and EKGs when appropriate, and diabetes screening for those at risk.

Most screenings are free if you use a provider who accepts Medicare and meet program rules.

Some tests require a doctor’s order or have specific frequency limits—mammograms yearly or every two years, colon cancer screening intervals vary by method.

Ask your provider if a test needs prior approval or if a copay applies for follow-up care.

Vaccinations and Immunizations

Part B covers several vaccines that protect you from serious illnesses.

Medicare pays for flu shots each year and one dose of the pneumococcal vaccines that help prevent pneumonia.

Part B also covers the COVID-19 vaccine and certain hepatitis B vaccines when you’re at medium or high risk.

You usually pay nothing for these vaccines if the provider accepts Medicare assignment.

Keep records of which vaccines you’ve had; timing matters—for example, flu shots are annual while pneumococcal shots follow a specific schedule.

If a vaccine is covered under Part D instead of Part B, ask your agent or provider which plan pays so you won’t get unexpected bills.

Annual Wellness Visits

Medicare Part B covers a yearly “Welcome to Medicare” and an Annual Wellness Visit (AWV) after the first year.

These visits focus on prevention, not treatment.

During an AWV, your provider creates or updates a personalized prevention plan based on your medical history, current health, risk factors, and screening schedule.

The visit includes measuring height, weight, blood pressure, and cognitive assessments when needed.

You’ll discuss vaccines, screenings, and steps to reduce health risks.

There’s no charge for the AWV if your provider accepts Medicare, but tests or services ordered during the visit might carry separate charges.

Medically Necessary Services and Supplies

Medicare Part B pays for items and services that a doctor says you need to treat an illness or injury.

You should expect coverage only when a licensed provider documents medical necessity and uses a Medicare-approved supplier.

Durable Medical Equipment

Durable Medical Equipment (DME) includes items you use at home to manage a health problem.

Examples are oxygen equipment, hospital beds, wheelchairs, walkers, and certain nebulizers.

To get DME covered, your doctor must write a prescription that shows why the item is medically necessary.

The supplier must be enrolled in Medicare.

Medicare typically pays 80% of the Medicare-approved amount after your Part B deductible, and you pay the remaining 20% unless you have other coverage.

Check whether the supplier accepts Medicare assignment.

If they do not, you may face higher out-of-pocket costs.

Your supplier should document the need and keep records to support coverage.

Ambulance Transportation

Medicare Part B covers ambulance rides when other transport is unsafe and EMS care is essential.

Covered trips often include emergency transport to the nearest appropriate facility and non-emergency transport when your condition requires ambulance-level care.

A doctor or other qualified provider must certify that ambulance transport is medically necessary.

Medicare pays its approved amount, leaving you responsible for 20% and any Part B deductible, unless you have secondary insurance.

Keep detailed records and ask the ambulance provider if they accept Medicare assignment.

If air transport is needed, Medicare covers it only when ground transport cannot meet your medical needs.

Home Health Care

Home health services cover skilled nursing care, physical therapy, speech therapy, and some medical supplies when you are homebound and a doctor certifies ongoing skilled care.

Medicare Part B pays for outpatient therapy services provided at home and some home health services when they are not covered under Part A.

A doctor must create and review your plan of care regularly.

Services must be provided by Medicare-certified home health agencies or qualified clinicians.

Medicare generally pays the approved amount for covered services; you may owe 20% for some outpatient therapy costs and any applicable deductible.

Mental Health and Therapy Services

Medicare Part B helps pay for many outpatient mental health and therapy services.

You’ll find coverage for therapy visits, certain substance use treatments, and therapy aimed at improving daily function after injury or illness.

Outpatient Mental Health Visits

Medicare Part B covers psychotherapy, psychiatry visits, and diagnostic assessments when a Medicare-approved provider gives them in an outpatient setting.

This includes individual and group therapy, family counseling when needed for your treatment, and annual depression screenings performed by a qualified clinician.

You pay the Part B deductible first, then typically 20% of the Medicare-approved amount for each covered visit if your provider accepts Medicare assignment.

If you see a non-participating provider, costs can be higher.

Telehealth mental health visits are usually covered if the provider follows Medicare rules.

To get covered care, choose providers enrolled in Medicare or participating in Medicare Advantage networks.

The Modern Medicare Agency can help you find in-network mental health providers and explain cost-sharing for visits.

Substance Use Disorder Treatment

Part B covers outpatient treatment for substance use disorders, including counseling and visits with psychiatrists or addiction specialists. Coverage applies to medically necessary services like medication management for addiction, psychotherapy, and certain office-based treatment programs.

You pay the Part B deductible and generally 20% coinsurance after the deductible. Inpatient detox and rehab may fall under Part A or need separate coverage, so confirm settings and billing before treatment.

Medicare requires services to be provided by eligible, credentialed providers for coverage to apply.

Occupational and Physical Therapy

Part B covers outpatient occupational therapy (OT) and physical therapy (PT) when they are medically necessary to improve or restore your ability to function. Covered services include evaluations, therapy sessions, and equipment needed during therapy, such as walkers or braces used in treatment.

You pay the Part B deductible first, then usually 20% of the Medicare-approved amount for each therapy visit. Medicare has limits on therapy “cap” amounts in some cases, but many services are covered if a doctor documents medical necessity and reviews progress periodically.

Make sure therapists are Medicare-enrolled or in your Medicare Advantage network so visits count toward coverage.

Laboratory and Diagnostic Tests

Medicare Part B pays for many tests your doctor orders to diagnose or treat health problems. You will usually need a provider’s order and the provider must accept Medicare assignment for Part B to cover the cost.

Blood Tests

Medicare Part B covers medically necessary blood tests ordered by your doctor. This includes basic panels like complete blood count (CBC), basic metabolic panel (BMP), and tests for blood sugar (glucose) or cholesterol.

It also covers many specialized tests used to monitor chronic conditions, such as hemoglobin A1c for diabetes or tests that track kidney and liver function. If the lab accepts assignment, Medicare pays its approved amount and you pay any Part B coinsurance or deductible that applies.

Preventive blood tests that Medicare specifically lists—such as certain screenings—may be covered with no cost-sharing when you meet eligibility rules. Always confirm the test is ordered by an authorized provider and that the lab files claims to Medicare.

X-rays and Imaging

Part B covers diagnostic X-rays and many outpatient imaging services when your doctor orders them. Covered items include standard X-rays, CT scans, MRI scans, and certain ultrasounds used to diagnose injury or illness.

The test must be medically necessary and performed by a Medicare-approved facility or provider. You normally pay the Part B coinsurance after Medicare pays its share.

Some advanced imaging may require prior authorization based on Medicare’s rules or local coverage determinations. Ask your provider to verify that the imaging center accepts Medicare assignment to avoid unexpected bills.

Pathology Screenings

Pathology services under Part B include tissue analysis, biopsies, and cytology tests used to identify cancer, infections, and other diseases. Medicare covers lab processing, pathology interpretation, and related technician services when ordered by your treating physician and tied to diagnosis or treatment.

Certain screening tests—such as some cancer screenings—have specific coverage criteria that can reduce or eliminate your out‑of‑pocket cost if you meet the rules. Make sure your provider documents medical necessity and that the lab is Medicare‑approved.

Medications and Injections Covered

Medicare Part B pays for a narrow set of outpatient drugs when they are given in a medical setting or are tied to other covered services. You’ll mainly see coverage for drugs given by a clinician, certain vaccines, and specific post-transplant medications.

Limited Outpatient Drugs

Part B covers outpatient drugs only in specific situations, not routine prescriptions you fill at a retail pharmacy. Examples include drugs that are:

Given as part of a physician’s service (infusions, injections, or drugs “incident to” a doctor’s care).
Used with covered durable medical equipment (like certain drugs for infusion pumps).

Coverage often depends on medical necessity and the drug being administered in a clinic, office, or outpatient facility. You may still pay coinsurance and a provider-administered drug may be billed separately from the office visit.

Administered Injections

Medicare Part B covers many injectable and infused drugs when a clinician gives them in an outpatient setting. This includes cancer chemotherapy drugs, some biologics, and other physician-administered meds.

If the injection is typically self‑administered at home, Part B usually won’t cover it unless there’s a specific exception. When a provider gives the injection, billing goes through Part B and you may face a 20% coinsurance after the Part B deductible.

Ask your provider to confirm that the drug is billed under Part B and whether any prior authorization or step therapy rules apply.

Certain Immunosuppressive Drugs

Part B covers some immunosuppressive drugs for patients who have received a Medicare-covered organ transplant. These drugs help prevent organ rejection and must be medically necessary and tied to the covered transplant.

If you qualify, Part B may cover the medications for a defined period after the transplant. You should verify eligibility and coverage details with your provider and Medicare to avoid unexpected costs.

Exclusions and Limitations

Medicare Part B does not pay for everything. Some services, supplies, and settings are specifically excluded or limited, and you usually share costs for covered items.

Non-Covered Items

Medicare Part B generally excludes routine dental care, most eyeglasses and contact lenses for vision correction, and routine podiatry services. Cosmetic surgery and most long-term care or custodial care — like help with bathing or dressing — are not covered.

Services that Medicare considers experimental or not medically necessary also get denied. Some items are statutorily excluded by law; when that happens, you may get a voluntary Advance Beneficiary Notice (ABN) and be billed directly.

Always check before care: ask your provider whether Medicare will pay and request pre-authorization when available.

Coverage Restrictions

Many Part B benefits come with limits. Durable medical equipment (DME) must meet specific medical criteria and often requires a signed order and supplier enrollment.

Imaging, lab tests, and some outpatient procedures may need prior authorization or frequency limits. Home health coverage requires a doctor’s plan of care and intermittent skilled need.

Services provided “incident to” a physician’s service follow strict rules for payment. If a provider or supplier isn’t enrolled or if documentation is missing, Medicare can deny the claim.

Ask providers about medical necessity, documentation, and any prior authorization steps before receiving care.

With Part B, you typically pay the monthly premium, an annual deductible, then 20% coinsurance for most approved services. For certain preventive services, Medicare may pay 100% if you meet criteria.

If you receive care from an out-of-network provider without proper enrollment or billing, you could face full charges. When Medicare denies coverage, you may be billed for the full cost unless you signed an ABN.

Keep records: get itemized bills, ask for Medicare billing codes, and request an explanation of benefits (EOB).

How to Verify Medicare Part B Coverage

Start by checking your Medicare card. It shows whether you have Part B and your effective date.

Keep the card handy when you call or check online.

Use your MyMedicare.gov account to see covered items and claims. Sign in to review services, durable medical equipment, and preventive care records.

The site updates regularly after a provider submits a claim.

Call Medicare at the number on your card if you need a live answer. Have your Medicare number, date of birth, and service details ready.

The representative can confirm coverage and explain any cost sharing.

Ask your provider to verify coverage before services or equipment are ordered. Your doctor or supplier can submit a pre-claim or prior authorization request when needed.

This step helps avoid unexpected bills.

Contact The Modern Medicare Agency for one-on-one help from licensed agents. Our agents speak with you directly to review your needs and check Part B coverage details.

We match Medicare plans to your situation without charging extra fees.

Keep a record of all calls and authorizations. Note dates, names, and confirmation numbers.

These records simplify disputes or appeals if a coverage question arises.

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.