Dramatic illustration showing a hospital with “Closed” signs, storm clouds, and torn Medicare Advantage plan papers labeled “Plan Discontinued,” symbolizing Medicare Advantage plan disruptions for Huntington, NY residents.

Why Your Medicare Advantage Plan Might Disappear: What Huntington Residents Need to Know About Plan Discontinuations and Suppressed Enrollment

Key Takeaways

Medicare Advantage plans come and go—and 2025-2026 has been particularly disruptive for Long Island residents:

Cigna (now HealthSpring) dropped Northwell coverage – One of the most popular plans in the area suddenly stopped covering Northwell hospitals and doctors, affecting thousands of Long Island beneficiaries

Plan discontinuations are accelerating – More carriers are pulling out of markets or discontinuing specific plans mid-contract, leaving enrollees scrambling

Some carriers are quietly suppressing enrollment – HealthFirst, Humana, UnitedHealthcare, and Anthem BCBS are making it harder to enroll in their plans—not by eliminating them, but by removing them from quoting tools and making them non-commissionable

No local presence means unstable coverage – Carriers without local broker networks rely on independent agents to grow. When they stop paying commissions, they’re signaling they don’t want to grow—or they’re preparing to exit

You have MORE time than you think if your plan is discontinued – If your plan ends, you have until February 28th to enroll in a new plan, PLUS the Medicare Advantage Open Enrollment Period (January 1 – March 31) gives you another chance to switch

The “safest” choice isn’t always obvious – National brand names don’t guarantee stability. Regional plans with strong local presence are often more reliable long-term

Bottom line: The Medicare Advantage market on Long Island is more unstable than most consumers realize. What works this year might not exist next year—and the warning signs aren’t always obvious.

I’ve been helping Medicare consumers in Huntington since 2007. I’ve watched plans come and go. But what’s happened over the past 18 months is different.

This isn’t the normal churn of insurance companies tweaking benefits or adjusting networks. This is carriers making strategic decisions to exit markets, discontinue popular plans, and quietly suppress enrollment—all while leaving beneficiaries to figure it out on their own.

Let me tell you what’s really going on behind the scenes in the Medicare Advantage market, and what it means for Huntington residents trying to make smart coverage decisions.

The Cigna/HealthSpring Disruption: A Case Study in How Fast Things Can Change

Cigna was one of the biggest Medicare Advantage carriers on Long Island. Their plans were popular—competitive premiums, decent networks, reasonable drug coverage. Thousands of Long Island residents enrolled.

Then Cigna Healthcare was acquired and rebranded as HealthSpring. That alone raised eyebrows. Corporate restructuring usually signals changes ahead.

Then came the bombshell: HealthSpring decided to stop covering Northwell Health facilities and doctors.

Let that sink in. Northwell Health is the largest healthcare provider on Long Island. Huntington Hospital, Lenox Hill, Long Island Jewish Medical Center, North Shore University Hospital, Southside Hospital—all Northwell facilities. Hundreds of primary care doctors and specialists across Long Island—Northwell providers.

If you were enrolled in a Cigna/HealthSpring Medicare Advantage plan and your doctor worked for Northwell, or you preferred treatment at a Northwell facility, you suddenly faced a choice:

  1. Switch doctors and hospitals entirely – Find new providers who accept your plan
  2. Pay out-of-network rates – Significantly higher costs to continue seeing your current doctors
  3. Wait for an enrollment period – Either Annual Enrollment or the Medicare Advantage Open Enrollment Period to switch plans

This wasn’t a minor network adjustment. This was a seismic shift that disrupted care for thousands of Long Island Medicare beneficiaries who’d chosen their plan specifically because it covered their doctors and local hospitals.

Why Plans Get Discontinued (And Why It's Happening More Often)

Medicare Advantage plans get discontinued for several reasons, but they all come down to one thing: profitability.

The Business Reality:

Medicare Advantage plans are paid a fixed amount per enrollee by Medicare. The insurance company then has to cover all your care within that payment. If their costs exceed what Medicare pays them, they lose money.

In recent years, several factors have made Medicare Advantage less profitable:

  • Medical costs are rising faster than Medicare’s payment rates
  • Sicker enrollees cost more to cover – Plans that attracted members with generous benefits are now paying for expensive care
  • Regulatory changes – CMS has tightened rules around prior authorizations, network adequacy, and Star Ratings
  • Market saturation – Too many plans competing for the same pool of beneficiaries

When a plan stops making money, carriers have three options:

  1. Reduce benefits and increase cost-sharing (makes the plan less attractive)
  2. Narrow the network (cut contracts with expensive hospitals and doctors)
  3. Discontinue the plan entirely

What we’ve seen recently:

Cigna/HealthSpring chose option #2—they cut Northwell from their network to reduce their costs. Other carriers are choosing option #3 and simply discontinuing plans that aren’t profitable enough.

And here’s what most consumers don’t know: carriers don’t need your permission to do this. They notify CMS. They send you a letter. And you’re left figuring out your next move.

The Plans You Can't Enroll In (Even Though They Exist)

Now let me tell you about something even more insidious: enrollment suppression.

There are several major Medicare Advantage carriers operating in the Huntington area—HealthFirst, Humana, UnitedHealthcare, Anthem Blue Cross Blue Shield—that are quietly making it harder for new people to enroll in their plans.

How? Two main tactics:

  1. Removing Plans from Quoting Tools

When you go to Medicare.gov or use an online comparison tool to shop for plans, you see a list of available options. What you don’t see are the plans carriers have deliberately removed from those tools.

These plans still exist. They’re still approved by CMS. Current members can keep them. But new enrollments? The carriers have made them nearly invisible.

Why would they do this? Because they don’t want to grow those plans. Maybe the plan is profitable for existing members but they don’t want to add new ones. Maybe they’re planning to discontinue it next year and don’t want to deal with angry new enrollees. Maybe they’re testing the market to see if they even want to stay in the region.

  1. Making Plans Non-Commissionable

Here’s how Medicare Advantage distribution really works: Most carriers don’t have local sales offices or employed agents in every market. They rely on independent insurance brokers like me to educate consumers and help them enroll.

Brokers get paid a commission by the insurance company when we help someone enroll. That’s how we make our living.

But increasingly, carriers are making certain plans non-commissionable—meaning brokers don’t get paid if we enroll someone in those plans.

What happens when a plan becomes non-commissionable? Independent brokers stop offering it.

Why would I spend an hour educating someone about Medicare, comparing their options, and helping them enroll in a plan that pays me nothing? I can’t. I have a business to run. So I focus on the plans where I can actually earn a commission for my time and expertise.

The result? These non-commissionable plans get almost no new enrollments except from people who find them on their own and enroll directly.

And here’s the kicker: This is by design.

When a carrier makes a plan non-commissionable, they’re sending a signal: We don’t want to grow this plan. They’re either planning to exit the market, discontinue the plan, or they’ve decided the local market isn’t profitable enough to justify investing in distribution.

The Carriers Suppressing Enrollment in Huntington Right Now

As of 2026, here are the carriers I’m watching closely because they’re showing clear signs of enrollment suppression in the Long Island market:

HealthFirst – Limited plan availability, minimal broker support, very small local presence

Humana – Historically strong in other parts of the country but struggling in the New York metro area. Several plans have become non-commissionable or hard to access through normal enrollment channels

UnitedHealthcare – Despite being one of the largest carriers nationally, their Medicare Advantage presence on Long Island is inconsistent. Plans come and go, commissions get cut, and local broker support is minimal

Anthem Blue Cross Blue Shield – Once a major player, their Medicare Advantage footprint has shrunk significantly. Limited plan options, reduced broker compensation, and a general sense they’re not prioritizing this market

What does this mean for you?

If you’re enrolled in a plan from one of these carriers, it doesn’t mean your plan is going away tomorrow. But it does mean you should be extra vigilant:

  • Read every letter from your plan – Network changes, benefit reductions, and discontinuation notices often come with little fanfare
  • Check your plan every Annual Enrollment Period – Don’t assume it’ll still be there or that the benefits will stay the same
  • Use the Medicare Advantage Open Enrollment Period – Between January 1 and March 31 each year, you have one more chance to switch Medicare Advantage plans or move to Original Medicare before you’re locked in for the year
  • Have a backup plan – Know what other options exist in case your current plan gets discontinued

Why Carriers Without Local Presence Are Riskier

Here’s something most Huntington residents don’t think about when choosing a Medicare Advantage plan: Does this carrier have a real presence on Long Island?

National brand recognition doesn’t mean much if the company doesn’t have:

  • Local provider contracts that are stable and well-negotiated
  • A network of local brokers who understand the market and advocate for members
  • Regional offices or claims processing infrastructure
  • A track record of staying in the market long-term

Carriers that rely entirely on independent brokers to grow their business are essentially outsourcing their market presence. When they cut broker commissions or make plans non-commissionable, they’re signaling they don’t want to invest in this market.

And if they’re not investing in the market, how long before they exit entirely?

Compare that to carriers with strong local presence:

  • They’ve invested in provider relationships (which means more stable networks)
  • They have local broker networks (which means better member support and advocacy)
  • They’ve built infrastructure (which means they’re committed for the long term)
  • They understand the regional market dynamics (which means better benefit design)

I’m not saying you should only choose local or regional plans. But I am saying you should factor in a carrier’s local commitment when evaluating stability.

What Happens When Your Plan Gets Discontinued

Let’s walk through what actually happens when a Medicare Advantage plan gets discontinued, because most people don’t understand their rights and options—or how much time they actually have to make decisions.

The Timeline:

  • By October 1 – Insurance carriers must notify CMS of any plan discontinuations for the following year
  • By October 15 – You should receive a written notice if your plan is being discontinued
  • October 15 – December 7 – Annual Enrollment Period when you can choose a new plan
  • January 1 – Your old plan ends
  • January 1 – February 28 – Extended enrollment period for discontinued plans – If your plan was discontinued, you have until February 28th to enroll in a new Medicare Advantage plan or return to Original Medicare
  • January 1 – March 31 – Medicare Advantage Open Enrollment Period – Even if your plan wasn’t discontinued, ALL Medicare Advantage members get one more opportunity to switch plans or move to Original Medicare during this window

Here’s what most people don’t realize: You’re not stuck making a decision during the October-December Annual Enrollment Period. You have MORE time and MORE opportunities to make changes than you think.

Your Options:

If your Medicare Advantage plan is discontinued, you can:

  1. Enroll in a different Medicare Advantage plan – You can do this during Annual Enrollment (Oct 15-Dec 7), during the extended period for discontinued plans (through Feb 28), or during the MA Open Enrollment Period (Jan 1-Mar 31)

  2. Return to Original Medicare + Medigap – But here’s the catch: You’ll face medical underwriting for a Medigap plan unless you qualify for guaranteed issue rights

  3. Do nothing during Annual Enrollment – If you don’t choose a new plan by December 7, you’ll automatically be enrolled in Original Medicare (Parts A & B only) with no supplemental coverage starting January 1. But you still have until February 28th to enroll in a new Medicare Advantage plan if you change your mind.

Understanding the Medicare Advantage Open Enrollment Period (January 1 – March 31):

This is a window that far too many people don’t know about or don’t use. Here’s how it works:

  • Who can use it: Anyone currently enrolled in a Medicare Advantage plan
  • What you can do: Switch to a different Medicare Advantage plan OR drop your Medicare Advantage plan and return to Original Medicare (and add a Medigap plan if you can pass underwriting)
  • When changes take effect: The first of the month following your enrollment. If you enroll on January 15th, your new coverage starts February 1st. If you enroll on March 20th, your new coverage starts April 1st.
  • How many times you can use it: Once. You get one opportunity to make a change during this period.

This is your safety valve. If you enrolled in a plan during Annual Enrollment and realized by January or February that it’s not working—the network is too limited, prior authorizations are a nightmare, your doctors don’t accept it—you have until March 31st to make one more change.

The Guaranteed Issue Rights You Need to Know:

In New York, you have guaranteed issue rights to buy a Medigap plan without medical underwriting if:

  • Your Medicare Advantage plan is being discontinued or is leaving your service area
  • You’ve been in the plan for less than 12 months
  • You apply within 63 days of when your coverage ends

This is a big deal. Normally, if you’re past your initial Medigap Open Enrollment Period (the 6 months after you turn 65 and enroll in Part B), insurance companies can decline you or charge you more based on your health. But if your Medicare Advantage plan gets discontinued, New York law gives you a second chance.

Most people don’t know this right exists. Don’t be one of them.

The Red Flags That Your Plan Might Be in Trouble

How do you know if your Medicare Advantage plan is at risk of being discontinued or having major network disruptions? Here are the warning signs:

🚩 Your plan’s Star Rating dropped significantly – CMS rates plans on a 1-5 star scale. Plans below 3 stars are underperforming and often get discontinued

🚩 You’re getting frequent network change notices – If doctors and hospitals are regularly leaving your plan’s network, that’s a sign the carrier is struggling with provider contracts

🚩 Your broker stopped offering the plan – If independent agents are no longer recommending or enrolling people in your plan, ask why

🚩 Benefits got significantly reduced – Major cuts to benefits (especially drug coverage, dental, vision, or gym memberships) often signal financial problems

🚩 The carrier doesn’t have a local presence – No local broker network, no regional offices, minimal customer service presence = higher risk of exit

🚩 Prior authorization denials are increasing – If your plan is suddenly denying or delaying authorizations for care that was previously approved, they’re trying to cut costs

🚩 You’re seeing news about corporate restructuring – Mergers, acquisitions, rebranding (like Cigna → HealthSpring) often precede major coverage changes

What Huntington Residents Should Do Right Now

If you’re currently enrolled in a Medicare Advantage plan, here’s what I recommend:

During Annual Enrollment (October 15 – December 7 every year):

☐ Review your current plan’s performance – Did you have network issues? Prior authorization problems? Unexpected costs?

☐ Check if your doctors and Huntington Hospital are still in-network – Don’t assume it’s the same as last year

☐ Look at your plan’s Star Rating – If it dropped below 3 stars, start shopping

☐ Compare what you actually spent this year vs. what you’d spend on other plans

☐ If your plan is from a carrier with weak local presence (HealthFirst, Humana, UnitedHealthcare, Anthem BCBS), strongly consider switching

During Medicare Advantage Open Enrollment (January 1 – March 31):

☐ If you’re unhappy with your current Medicare Advantage plan, this is your second chance to switch

☐ Evaluate whether the plan you chose in October is actually working for you

☐ Remember: You can make ONE change during this period, and it takes effect the first of the following month

☐ This is your last opportunity to make changes before you’re locked in until next October

If your plan is discontinued:

☐ Don’t panic – You have until February 28th to enroll in a new plan

☐ Explore your guaranteed issue rights for Medigap if you want to return to Original Medicare

☐ Work with a local broker who can help you navigate your options quickly

Throughout the year:

☐ Read every piece of mail from your plan – Network changes and benefit reductions often come with minimal notice

☐ Keep a list of your current doctors and their contact info – If you need to switch plans, you’ll want to verify they accept your new coverage

☐ Know your rights – Understand guaranteed issue periods and when you can change coverage

☐ Have a relationship with a local independent broker – We see the warning signs before most consumers do

The Case for Original Medicare + Medigap (Despite the Cost)

I know I sound like I’m beating up on Medicare Advantage. I’m not anti-MA—I help plenty of Huntington residents enroll in these plans when they’re the right fit.

But here’s what I am: Anti-surprise. Anti-disruption. Anti-instability.

And increasingly, the Medicare Advantage market is defined by all three.

When someone asks me “Paul, what’s the safest Medicare option?”, my answer is always the same: Original Medicare with a Medigap plan.

Yes, Plan G costs $372-$500+ per month in Huntington. Yes, that’s expensive. Yes, you’re paying more than you would for most $0 premium Medicare Advantage plans.

But here’s what you’re paying for:

✓ Your coverage can never be discontinued – Original Medicare isn’t a plan that can go away. Medigap supplements are guaranteed renewable.

✓ No network restrictions – Any doctor who accepts Medicare (which is virtually all of them) works with your coverage

✓ No network changes mid-year – You’ll never get a letter saying Northwell or Huntington Hospital dropped your plan

✓ No prior authorizations – If your doctor orders it and Medicare covers it, it’s covered. Period.

✓ Nationwide coverage – Travel, move, spend winters in Florida—your coverage works everywhere

✓ Stability – What you enroll in at 65 will work the same way at 85. The benefits don’t change.

✓ No enrollment period concerns – You’re not watching the calendar hoping you can switch plans during a narrow window if something goes wrong

Is it more expensive? Absolutely. But you’re not paying for insurance—you’re paying for certainty and stability.

For some Huntington residents, especially those with complex health needs, frequent travelers, or people who highly value continuity of care, that certainty is worth every penny.

How to Choose a Medicare Advantage Plan That's Less Likely to Disappear

If you decide Medicare Advantage is the right choice for you—and for many people it is—here’s how to pick a plan that’s more likely to stick around:

  1. Prioritize carriers with strong local presence

Look for carriers that:

  • Have been in the Long Island market for 5+ years
  • Have a network of local independent brokers
  • Process claims locally or regionally (not just at a national call center)
  • Invest in local provider relationships
  1. Check the plan’s Star Rating

Plans rated 4+ stars are generally stable and well-managed. Plans below 3 stars are at higher risk of discontinuation.

  1. Look at enrollment trends

Is the plan growing or shrinking? If new enrollments are down year-over-year, that’s a red flag. (Your broker should be able to tell you this.)

  1. Verify the provider network is broad and stable

Does the plan include Huntington Hospital AND multiple local hospital systems? Or is it dependent on contracts with just one or two provider groups? More network diversity = more stability.

  1. Avoid plans that are non-commissionable

If brokers aren’t getting paid to enroll people in the plan, the carrier isn’t investing in growth. That’s a warning sign.

  1. Work with a local independent broker who’s been in the market for years

We see patterns you don’t. We know which carriers are solid and which ones are struggling. We know when a carrier starts suppressing enrollment before it becomes obvious to consumers.

  1. Remember you have safety nets

Even if you choose a plan and regret it, you have the Medicare Advantage Open Enrollment Period (Jan 1-Mar 31) to make one more change. And if your plan gets discontinued, you have until February 28th to enroll in something new. You’re not as locked in as you think

The Question You Should Be Asking

Not “What’s the cheapest plan?” or “What plan has the best drug coverage?”

The question is: “What’s the most stable coverage option that will work for me 5 years from now, not just today?”

Because here’s the truth: Saving $200/month on premiums doesn’t matter if your plan gets discontinued in 18 months and you’re scrambling to find new doctors, navigate a new network, and hope your medications are still covered.

I’ve been doing this since 2007. I’ve seen plans come and go. I’ve helped clients navigate discontinuations, network disruptions, and carrier exits.

The Medicare Advantage market on Long Island is more unstable today than it’s been in years. Cigna/HealthSpring dropping Northwell is just the most visible example. Behind the scenes, multiple carriers are quietly suppressing enrollment, reducing broker support, and sending signals they’re not committed to this market long-term.

You deserve to know what’s really going on. And you deserve coverage that won’t disappear when you need it most.

The good news? You have more options and more time to make decisions than most people realize. Use the Annual Enrollment Period. Use the Medicare Advantage Open Enrollment Period if you need a second chance. And if your plan gets discontinued, remember you have until February 28th—not just December 7th—to figure out your next move.

Paul Barrett is an independent Medicare insurance broker serving Huntington and Long Island since 2007. He represents 40+ carriers and works exclusively with independent agents—which means he sees the market dynamics most consumers never hear about. No pressure. No gimmicks. Just honest guidance about what’s really happening in the Medicare marketplace.

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

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

The Short Answer

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

Key Takeaways

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

What Part B Actually Covers

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

What’s covered

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

Preventive services: the part Medicare gets genuinely right

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

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

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

What’s NOT covered

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

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

What Part B Costs in 2026

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

Cost Component

2026 Amount

Standard monthly premium

$202.90

Annual deductible

$283

Coinsurance on most covered services

20%

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

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

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

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

IRMAA: What Higher Earners Actually Pay

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

2024 Income (Individual)

2024 Income (Married, Joint)

Total Part B / Month

$109,000 or less

$218,000 or less

$202.90

$109,001 – $137,000

$218,001 – $274,000

$284.10

$137,001 – $171,000

$274,001 – $342,000

$405.80

$171,001 – $205,000

$342,001 – $410,000

$527.50

$205,001 – $499,999

$410,001 – $749,999

$649.20

$500,000 and above

$750,000 and above

$689.90

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

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

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

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

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

How Part B Works with Group Insurance

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

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

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

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

Retiree Coverage Is Not the Same as Active Employer Coverage

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

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

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

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

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

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

Does Medicare Work If You’re a Veteran?

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

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

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

Why the VA itself recommends enrolling in Medicare anyway:

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

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

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

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

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

Enrollment Situation

Typical Processing Time

When Coverage Actually Starts

Initial Enrollment Period (around 65)

2–4 weeks, sometimes up to 6

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

Special Enrollment Period (leaving employer coverage)

4–8 weeks, sometimes longer

1st of the month after your application is submitted

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

4–6 weeks

1st of the month after you apply

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

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

Practical tips to avoid delays

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

Excess Charges: The Cost Almost Nobody Knows to Ask About

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

Providers fall into three categories:

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

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

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

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

The HSA Rule: Part B Closes the Door Too

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

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

Frequently Asked Questions

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

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

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

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

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

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

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

The Bottom Line

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

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

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

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

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

Sources

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