Medicare · Cornerstone
Medicare late enrollment penalties, in actual dollars
Last reviewed June 11, 20263 min readBy the Goodsurance editorial team Reviewed by the Goodsurance editorial team
"The penalty" is not one thing. Medicare has three distinct late-enrollment penalties, and they differ in how they are calculated, how long they last, and how easy they are to trigger by accident. The two that matter most for the typical person, Part B and Part D, share an unwelcome feature: they generally last for life. The point of this page is to make each one concrete enough that you can see exactly what is at stake and, more usefully, how to avoid it.
1Part B: the lifetime mistake
This is the big one, both because Part B has a real monthly premium and because the penalty is permanent. If you do not sign up for Part B when you are first eligible and you do not have other qualifying coverage, the penalty adds 10% to your Part B premium for each full 12-month period you went without. It is added to your premium every month for as long as you have Part B, and because the base premium tends to rise over time, the dollar amount of the penalty tends to rise with it.
A concrete sense of scale: someone who delayed Part B for three full years would face roughly a 30% surcharge, about $61 a month, roughly $730 a year, for life. The Part B penalty has its own dedicated page that works through the math; this is the summary.
| Penalty | Trigger | Formula | Duration |
|---|---|---|---|
| Part A | Only if you buy Part A | A temporary surcharge | Limited period |
| Part B | Late without protected coverage | 10% per full 12 months | For life |
| Part D | 63+ days without creditable coverage | 1% of the base per month | For life |
Three penalties, three rules. Source: CMS.
2Part D: the quiet one people forget
The Part D penalty is easy to overlook precisely because Part D feels optional when you are healthy. If you go without creditable drug coverage for 63 or more days in a row after your initial window, you can owe a penalty when you finally enroll. It is calculated from the number of months you went without and a national base figure, then added to your Part D premium for as long as you have drug coverage.
The trap here is the "I do not take any medications" reasoning. Skipping Part D while healthy saves a small premium now and risks a permanent surcharge later, usually when health has changed and the stakes are higher. The way to avoid it without buying a plan you do not need is to make sure whatever coverage you do have counts as creditable.
The 63-day Part D clock
3Part A: rarely an issue, but worth a line
Most people pay no premium for Part A because they earned it through their work history, and there is no penalty for delaying something that is free and that you can pick up at any time. The Part A penalty only applies to the small group who do not qualify for premium-free Part A and have to buy it; for them, late enrollment can add a surcharge for a limited period. For the large majority, this one simply does not come up.
4How to avoid all of them
The reassuring part is that these penalties are almost entirely avoidable, and not only by rushing to enroll at 65. Two paths keep you safe: enroll during your Initial Enrollment Period if you do not have other qualifying coverage, or hold qualifying coverage that protects your window, active employer coverage at a large employer protects your Part B window, and any drug coverage certified as "creditable" protects your Part D window. When that coverage ends, you get a Special Enrollment Period to pick up Medicare without penalty.
One practical habit ties it together: keep the paperwork. Employer and drug plans send notices stating whether coverage is creditable, and holding onto those notices is how you prove you were protected. The penalties punish gaps, not timing per se, so coverage plus proof is the real protection.
Common questions about Medicare
Quick answers to common questions
Tap any question to expand. Each question links to a fuller standalone answer.
Does Medicare cover durable medical equipment?
Yes.
Medicare Part B covers durable medical equipment (DME): reusable medical gear your doctor prescribes for use at home, such as wheelchairs, walkers, hospital beds, oxygen equipment, CPAP machines, and blood sugar monitors. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026, and Medicare pays the other 80%. To be covered, the item must be ordered by a Medicare-enrolled doctor and supplied by a Medicare-enrolled supplier, and some items are rented rather than bought. Equipment meant mainly for use outside the home, or only for comfort or convenience, is not covered.
Does Medicare cover mental health services?
Yes.
Medicare covers mental health care across its parts in 2026. Part B covers outpatient services like therapy, counseling, and visits with psychiatrists, psychologists, and clinical social workers, and since 2024 it also covers marriage and family therapists and mental health counselors. You pay 20% of the Medicare-approved amount after the $283 deductible, and one depression screening each year is free. Part A covers inpatient mental health care, with a lifetime limit of 190 days in a freestanding psychiatric hospital. Part D covers most mental health medications. Many of these services are also available by telehealth, and Medicare Advantage plans cover at least the same benefits.
Does Medicare cover vision care?
Mostly no for routine care.
In 2026, Original Medicare does not cover routine eye exams for glasses or contact lenses, and it does not pay for the glasses or contacts themselves. It does cover some medical eye care: yearly glaucoma screenings for people at high risk, diabetic retinopathy exams, treatment for eye diseases, and cataract surgery (including one pair of standard glasses or contacts afterward). For those covered services you pay 20% after the $283 Part B deductible. Many Medicare Advantage plans add a routine vision benefit covering eye exams and an allowance for glasses.
Does Medicare cover physical therapy?
Yes.
Medicare Part B covers outpatient physical therapy that is medically necessary to treat your condition. You pay 20% of the Medicare-approved amount after the yearly Part B deductible ($283 in 2026). There is no longer a hard dollar cap on therapy, but once your physical and speech therapy together pass $2,480 in 2026, your therapist must add a note (called a KX modifier) confirming you still need care. Claims above $3,000 may be reviewed for medical necessity. Part A covers physical therapy you receive as a hospital inpatient or in a skilled nursing facility. A doctor or therapist must set up and regularly review your plan of care.
Does Medicare cover chiropractic care?
Partly.
Medicare Part B covers one specific chiropractic service: manual manipulation of the spine to correct a subluxation (when one or more bones of the spine are out of position) that a doctor confirms is medically necessary. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. Medicare does not cover other services a chiropractor might offer, such as X-rays, massage therapy, acupuncture, or routine wellness visits, so you would pay the full cost for those. Some Medicare Advantage plans include extra chiropractic or wellness benefits beyond this.
Does Medicare cover ambulance services?
Yes, in limited situations.
Medicare Part B covers emergency ambulance transportation when traveling any other way could endanger your health, taking you to the nearest appropriate hospital or facility. You pay 20% of the Medicare-approved amount after the $283 Part B deductible in 2026. Air ambulance is covered only when ground transport cannot reach you or would take too long. Non-emergency ambulance trips, for example to dialysis, are covered only when a doctor provides a written order stating they are medically necessary. Medicare does not cover ambulance rides taken purely for convenience.
Does Medicare cover skilled nursing facility care?
Yes, on a short-term basis.
Medicare Part A covers skilled nursing facility (SNF) care after a qualifying inpatient hospital stay of at least 3 days, when you need daily skilled care like nursing or therapy. In 2026 you pay $0 for days 1 through 20 of each benefit period, $217 per day for days 21 through 100, and all costs after day 100. Coverage is for skilled care while you recover, not for long-term or custodial care (help with daily activities like bathing or dressing), which Medicare does not cover. Long-term nursing home care is generally paid through Medicaid or private funds.
Does Medicare cover hearing aids?
No, not under Original Medicare.
In 2026, Original Medicare (Parts A and B) does not pay for hearing aids or the exams to fit them. Part B does cover diagnostic hearing and balance exams when your doctor orders them to help diagnose or treat a medical condition, and for those you pay 20% after the $283 deductible. Many Medicare Advantage plans, however, include a hearing benefit that helps pay for routine hearing exams and hearing aids, often through a specific network or allowance. If hearing coverage matters to you, it is worth comparing Advantage plans or a standalone hearing plan.
Does Medicare cover home health care?
Yes, when you qualify.
Medicare Parts A and B cover home health care if a doctor certifies that you are homebound (leaving home takes a major effort) and need part-time skilled care, such as skilled nursing, physical therapy, occupational therapy, or speech therapy. A Medicare-certified home health agency must provide the care under a plan your doctor reviews. You pay $0 for covered home health visits in 2026, and 20% for any durable medical equipment. Medicare does not cover 24-hour home care, meal delivery, or homemaker services like cleaning when that is the only care you need.
Does Medicare cover diabetes supplies and testing?
Yes.
In 2026 Medicare covers most diabetes care across two parts. Part B (outpatient care and equipment) covers blood sugar monitors, test strips, lancets, and continuous glucose monitors (CGMs) as durable medical equipment, plus diabetes screenings and a self-management training program. You pay 20% of the Medicare-approved amount after the $283 Part B deductible. Part D (drug coverage) covers insulin and related supplies like syringes, and in 2026 your insulin is capped at $35 for a month's supply. If you have a Medicare Advantage plan, it covers at least the same diabetes benefits, sometimes with added extras.
Which is better, Medigap or Medicare Advantage?
Neither is better for everyone; they suit different needs.
Medigap (also called Medicare Supplement, a private policy that pairs with Original Medicare) lets you see any doctor nationwide who accepts Medicare with no network and very predictable out-of-pocket costs, but you pay a monthly Medigap premium and add a separate Part D drug plan. Medicare Advantage (Part C, your Medicare benefits through a private plan) often has a lower or $0 plan premium, bundles drug coverage and extras like dental and vision, and caps your yearly out-of-pocket costs, but uses provider networks and may require prior approval. People who travel, want maximum doctor freedom, and prefer steady costs often lean Medigap; people who want low premiums, extras, and a network they are comfortable with often lean Medicare Advantage. With both, you still pay the Part B premium ($202.90 per month in 2026). To find out which fits your situation, reach out to a licensed Goodsurance advisor at 1-888-301-8091 (TTY 711), Mon to Fri 8 am to 5 pm PT.
Can I see out-of-network doctors on a Medicare Advantage PPO?
Yes.
A Medicare Advantage PPO (Preferred Provider Organization plan, where your Medicare benefits come through a private plan) lets you see doctors and hospitals outside the plan's network, but you usually pay more for out-of-network care than for in-network care. Staying in network keeps your costs lower, while going out of network is allowed and can be worth it if you want a specific provider. This flexibility is a key difference from a Medicare Advantage HMO (Health Maintenance Organization plan), which generally only covers in-network care except in emergencies. With a PPO, you also typically do not need a referral to see a specialist. Keep in mind the provider must accept the plan and Medicare. Emergency and urgent care are covered regardless of network on both plan types. The trade-off with a PPO is more freedom in exchange for generally higher costs than an HMO.
References
- Medicare.govThe Part A, Part B, and Part D late enrollment penalties.
- CMS, Centers for Medicare & Medicaid ServicesCreditable coverage and Special Enrollment Periods. cms.gov