Comparing Medicare plans in Virginia
Medicare Part B is the cornerstone of your day-to-day healthcare in retirement. While Part A acts as your hospital insurance for inpatient stays, Part B is your medical insurance. It handles the vast majority of your routine healthcare needs: sitting in a primary care doctor’s office, consulting with a specialist, undergoing an outpatient surgery, getting an MRI, or calling an ambulance.
For Virginia residents approaching age 65, understanding Part B is not optional—it is the foundational step upon which all other Medicare decisions are built. Whether you intend to stick with Original Medicare and add a Medigap policy, or you plan to enroll in one of the 141 Medicare Advantage plans available across the state, you must have active Part B coverage first.
Because Part B is a fee-for-service federal program, the rules, premiums, and coverage criteria apply uniformly whether you live in Richmond, Norfolk, or Winchester. However, how you manage your Part B costs, how you transition from employer coverage, and how you choose your provider networks are heavily dependent on your specific circumstances. This comprehensive guide walks you through exactly what Part B covers, what it costs, how to avoid lifelong financial penalties, and how to structure your coverage for maximum protection.
Medicare Part B covers two broad categories of healthcare: medically necessary services and preventive services. The Centers for Medicare & Medicaid Services (CMS) defines medically necessary services as services or supplies that are needed to diagnose or treat a medical condition and that meet accepted standards of medical practice.
Understanding the boundaries of Part B coverage is critical, as assuming something is covered when it belongs under a different part of Medicare—or isn’t covered at all—can lead to thousands of dollars in surprise bills.
If you are receiving care but have not been formally admitted to a hospital as an inpatient, you are generally utilizing Part B. This includes:
Medicare places a heavy emphasis on prevention. When you see a doctor who accepts Medicare assignment, most preventive services are covered at 100%, meaning you pay nothing—no deductible and no coinsurance.
One of the most frequent billing surprises beneficiaries encounter is the shift from preventive to diagnostic care during a single visit.
If you undergo a routine screening colonoscopy, Medicare Part B covers it at 100%. However, if the doctor finds a polyp during that screening and removes it, the procedure immediately shifts from preventive to diagnostic. At that moment, the Part B deductible and the 20% coinsurance apply to the polyp removal. Understanding this distinction helps avoid the shock of receiving a bill for a procedure you assumed was fully covered.
Part B covers medically necessary durable medical equipment prescribed by a doctor for use in your home. This includes items like:
For most DME, you pay your standard 20% coinsurance after meeting your deductible. Medicare operates on strict rules regarding whether you must rent the equipment for a specific period before owning it, or whether it can be purchased outright. Furthermore, to be covered, the equipment must be supplied by a vendor enrolled in the Medicare program.
A common point of confusion is the line between Part B (Medical) and Part D (Prescription Drugs). As a general rule, Part D covers the medications you pick up at a retail pharmacy and take yourself at home.
Part B, on the other hand, covers drugs that you cannot generally self-administer and that are given to you in a doctor’s office or hospital outpatient setting. This includes intravenous (IV) chemotherapy, injectable osteoporosis drugs, medications given via a nebulizer or infusion pump, and antigens.
Original Medicare was designed in the 1960s, and its core structure still reflects the medical standards of that era. Unless you enroll in a Medicare Advantage plan that offers supplementary benefits, Part B will not cover:
| Cost Mechanism | Original Medicare Part B Structure | How It Works | Notes |
|---|---|---|---|
| Monthly Premium | Standard Base Amount (Updated Annually) | Paid directly to CMS or deducted from Social Security checks. | Higher earners pay more via IRMAA surcharges. |
| Annual Deductible | Set Annually by CMS | The out-of-pocket amount you must clear before Medicare starts paying. | Resets every January 1st. |
| Coinsurance | 20% of the Medicare-approved amount | Once the deductible is met, you pay 20% of every covered outpatient service. | You pay this for doctors, DME, and outpatient surgeries. |
| Out-of-Pocket Maximum | None (No Cap) | There is no limit to how much 20% coinsurance you can be charged in a year. | This is why a Medigap or Medicare Advantage plan is crucial. |
Part B is not free. It is a shared-cost system requiring you to pay premiums, deductibles, and coinsurance. Understanding exactly how these costs are structured is vital for long-term financial planning in retirement.
The vast majority of beneficiaries pay the standard Part B premium, which is recalibrated by CMS every year based on the projected costs of the Medicare program.
If you are already receiving Social Security retirement benefits, or benefits from the Railroad Retirement Board or Office of Personnel Management, your Part B premium is automatically deducted from your monthly check. If you have delayed taking Social Security, you will receive a quarterly bill from CMS known as a “Medicare Premium Bill.” You must pay this directly via mail, online through your Medicare account, or by setting up Medicare Easy Pay for automatic bank withdrawals.
While most pay the standard premium, higher-income earners pay significantly more due to the Income-Related Monthly Adjustment Amount (IRMAA). By law, standard premiums are designed to cover about 25% of the true cost of Part B, with federal tax revenues covering the rest. If your income exceeds certain statutory thresholds, the government requires you to cover a larger percentage of the true cost—ranging from 35% up to 85%.
IRMAA is strictly a mathematical formula based on your Modified Adjusted Gross Income (MAGI). Crucially, the Social Security Administration looks at your tax return from two years prior to determine your current year’s premium. For example, your Part B premium in 2026 is determined by the MAGI on your 2024 federal tax return.
The IRMAA brackets are historically adjusted annually for inflation. They operate on a tiered cliff system; earning even one dollar over a threshold pushes you entirely into the next surcharge bracket for the entire calendar year.
Appealing an IRMAA surcharge: Because IRMAA looks two years backward, it often penalizes people for income they no longer make, especially right after retirement. If your income has dropped due to a life-changing event—such as retiring, reducing work hours, divorce, or the death of a spouse—you can file Form SSA-44 with the Social Security Administration to request an immediate reduction in your premium based on your newly projected income.
Before Medicare pays a single dime toward your medically necessary Part B services, you must pay the annual Part B deductible out of pocket. This deductible resets every year on January 1st. It is a relatively low threshold (historically hovering around the low two-hundred-dollar mark), but it must be met annually. Once you have paid this amount toward approved medical care, your coverage transitions into the coinsurance phase.
After your deductible is met, the foundational rule of Part B takes over: Medicare pays 80% of the CMS-approved amount for the service, and you are responsible for the remaining 20%.
There is a glaring hole in this coverage design: Original Medicare has no out-of-pocket maximum.
If you need a simple doctor visit, 20% of the cost is highly manageable. But if you are diagnosed with cancer and require an outpatient biological chemotherapy drug that costs $10,000 per infusion, your 20% responsibility is $2,000 per treatment, with absolutely no cap on how much you can be billed over the year. Because of this limitless financial exposure, relying solely on Original Medicare Part A and Part B is incredibly risky. It is highly recommended that beneficiaries secure secondary coverage, either through a Medigap policy to cover that 20% coinsurance, or by transferring to a Medicare Advantage plan that establishes a hard cap on annual out-of-pocket expenses.
Medicare eligibility is federal, so the rules in Virginia are the exact same as anywhere else in the country. You generally qualify in one of two ways: age or disability.
Unlike Medicare Part A, which is premium-free for anyone who has worked and paid Medicare taxes for at least 10 years (40 quarters), Part B has no work history requirement. You simply have to meet the age and residency requirements, and agree to pay the monthly premium.
Enrolling in Part B requires strict attention to the calendar. The Medicare system does not issue leniency for ignorance of the rules. Enrolling at the wrong time can result in delays in coverage or permanent financial penalties.
Your standard entry point into the Medicare system is your Initial Enrollment Period. This is a 7-month window structured entirely around your 65th birthday:
When does coverage start? If you enroll during the 3 months prior to your birthday month, your Part B coverage begins on the first day of your birthday month. (If your birthday falls on the 1st of the month, the entire timeline shifts one month earlier). If you enroll during your birthday month or the 3 months after, your coverage will begin on the first day of the month following the month you enroll.
Many Virginians, particularly in the contractor-heavy regions of Arlington, Fairfax, and Norfolk, continue to work well past age 65. If you or your spouse are actively working and you have health insurance through that employer, you likely do not need to enroll in Part B during your IEP.
To safely delay Part B, your employer coverage must meet the strict definition of Creditable Coverage:
If you meet these criteria, you are granted a Special Enrollment Period. Your SEP allows you to enroll in Part B without penalty at any time while you are still covered by the employer plan, or during the 8-month window that begins the month after your employment ends or the coverage ends (whichever happens first).
If you missed your IEP and you do not qualify for an SEP, you are locked out of the system until the General Enrollment Period. The GEP runs from January 1st through March 31st every year.
Under recent CMS rules, if you enroll during the GEP, your coverage will begin on the first day of the month after you sign up. However, you will likely be subject to the late enrollment penalty.
The Medicare Part B penalty is severe because it is permanent. It is designed to prevent healthy people from delaying their entry into the risk pool until they actually get sick.
If you go 12 full months without Part B and without creditable active employer coverage, you are assessed a 10% penalty on top of the standard premium. This penalty is not a one-time fee; it is added to your monthly premium for as long as you have Medicare.
Calculation Example: If you retired and lost your employer coverage at age 65, but waited until you were 68 to sign up for Part B during the General Enrollment Period, you went three full 12-month periods without coverage. You will face a 30% penalty. Every month, for the rest of your life, you will pay the standard Part B premium plus an additional 30%. Furthermore, as the standard premium increases with inflation over the years, the dollar amount of your 30% penalty will increase alongside it.
The only way to avoid this is to transition smoothly from creditable employer coverage directly into Part B within your 8-month SEP window, and to retain the documentation (CMS Form L564, Request for Employment Information) proving you had that coverage.
Original Medicare (Parts A and B) is administered directly by the federal government. But because of the financial risks mentioned earlier (specifically the uncapped 20% coinsurance and the lack of a drug plan), almost no one in Virginia relies on Original Medicare alone. You generally have two paths to complete your coverage, and both require you to keep paying your Part B premium.
Many Virginians choose to stay on Original Medicare and purchase a Medicare Supplement (Medigap) policy from a private insurance company. Medigap policies are heavily standardized by the government and are designed to pay the costs that Part B leaves behind.
For instance, if you purchase a Medigap Plan G—currently the most comprehensive plan available to new enrollees—the Medigap policy pays the entirety of your 20% Part B coinsurance. Once you pay your annual Part B deductible, Plan G covers 100% of your approved outpatient medical costs for the rest of the year.
Because Original Medicare is managing the core coverage, there are no networks. You can see any doctor, specialist, or hospital in Virginia—or anywhere in the United States—that accepts Medicare.
Alternatively, you can choose to enroll in a Medicare Advantage plan. In Virginia, companies like UnitedHealthcare, Anthem HealthKeepers, Humana, and Aetna Medicare offer these private plans.
If you choose this route, you are bundling your Part A, Part B, and usually Part D benefits into a single plan administered by the private carrier. The private carrier sets its own deductibles, copays, and strict localized provider networks (HMOs or PPOs).
Critical Requirement: Even if you choose a Medicare Advantage plan that advertises a “$0 monthly premium,” you must continue paying your federal Part B premium to CMS. Medicare Advantage takes over the administration of your benefits, but maintaining your underlying Part B enrollment is a non-negotiable legal requirement to stay in the Advantage plan.
When utilizing Part B in Virginia, the amount you pay out of pocket is heavily influenced by the relationship your specific doctor has with the Medicare program. Doctors fall into three categories:
Always verify a provider’s status before receiving services. Do not simply ask, “Do you take Medicare?” Ask explicitly, “Do you accept Medicare assignment?”
One of the most complex intersections of Part A and Part B happens inside the walls of a hospital. You can be taken to a hospital in an ambulance, given a bed, assigned nurses, receive meals, and stay overnight for days, yet never be formally admitted as an inpatient.
Instead, the hospital may classify you under “Observation Status.”
If you are under observation, you are legally an outpatient. Your entire stay is billed under Part B, not Part A. You will owe the 20% coinsurance for every individual service, diagnostic test, and doctor visit during that stay. Furthermore, Part B does not cover the routine medications a hospital hands you while you are in an observation bed—those will be billed directly to you. Finally, if you need to be transferred to a Skilled Nursing Facility for rehabilitation after the hospital, Medicare Part A will not cover it, because Part A requires a prior 3-day inpatient admission, which observation status does not satisfy.
Federal law requires hospitals to provide you with a Medicare Outpatient Observation Notice (MOON) if you are kept under observation for more than 24 hours, explaining your status and its financial implications.
If you receive a service that you and your doctor believe is medically necessary, but Medicare denies the claim and refuses to pay the 80%, you have the legal right to appeal the decision. The Part B appeals process consists of five distinct levels:
Your physician can submit a detailed letter of medical necessity to significantly strengthen your appeal at the Redetermination and Reconsideration levels.
Our licensed producers can help you map out your Part B costs, evaluate Medigap and Advantage options, and ensure you transition without penalties.
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