Comparing Medicare plans in Maryland
Medicare Part B is the foundational coverage for your day-to-day healthcare. While Part A acts as your hospital insurance—stepping in when you are formally admitted as an inpatient—Part B is your medical insurance. It is the component of Original Medicare that pays for the care you receive in your doctor’s office, the specialist you consult for a specific condition, the outpatient surgery you undergo, and the preventive screenings that keep you healthy.
Understanding how Medicare Part B functions in Maryland is crucial because it dictates not only what medical services you can access but exactly how much you will pay for them. Unlike a standard employer-sponsored health insurance plan that operates with flat copayments and a strict out-of-pocket maximum, Part B operates on an 80/20 cost-sharing mechanism with no ceiling on your potential financial liability.
This guide provides a comprehensive breakdown of Medicare Part B, explaining exactly what it covers, how the costs are structured, the critical timelines you must meet to avoid lifelong financial penalties, and how it interacts with other coverage forms like employer plans, Medigap policies, and Medicare Advantage plans across Maryland.
The federal Medicare program is divided into parts to separate different types of medical risk. When the Centers for Medicare & Medicaid Services (CMS) originally designed the program, they segmented inpatient facility risk (Part A) from outpatient and physician risk (Part B). Together, Part A and Part B form what is legally known as “Original Medicare.”
Part B is voluntary, meaning you are not legally required to carry it. However, because it covers the overwhelming majority of healthcare services a person needs outside of a hospital bed, nearly everyone who does not have equivalent coverage through an active employer chooses to enroll.
If you decline Part B when you are first eligible and later decide you need it, you will face significant hurdles. You may have to wait for the General Enrollment Period to sign up, causing a gap in your coverage, and you will likely be assessed a permanent late enrollment penalty that artificially inflates your monthly premium for the rest of your life.
Therefore, deciding when to enroll in Part B—and understanding the exact limits of its coverage—is the single most important decision in your Medicare transition.
Medicare Part B is defined by medical necessity. According to CMS rules, Part B covers services and supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. It also covers a broad array of preventive services designed to catch illnesses early.
The core of Part B is coverage for the physicians who treat you. This includes your primary care provider and any specialists you see, such as cardiologists, endocrinologists, or orthopedists. If the provider accepts Medicare, Part B will cover their services to diagnose and treat your conditions. This applies whether the doctor sees you in their private office, a clinic, or even while you are an inpatient in a hospital (Part A pays for the hospital’s room and board, but Part B pays the physicians who round on you during your stay).
Many procedures that once required hospital admission are now performed on an outpatient basis. Part B covers outpatient medical and surgical services, as well as the facility fees charged by ambulatory surgical centers and hospital outpatient departments.
Observation Status: This is a critical distinction in Medicare billing. If you go to the emergency room and are kept overnight in the hospital for monitoring, you may be classified under “observation status” rather than formally admitted as an inpatient. Even if you stay in a hospital bed for two days, observation status is billed entirely under Part B. You will be responsible for the Part B deductible and the 20% coinsurance for every individual service, test, and doctor visit during that stay.
Medicare places a heavy emphasis on prevention. When you see a provider who accepts Medicare assignment, most preventive services are covered at 100%, meaning you owe no deductible or coinsurance. Covered preventive services include:
This is one of the most misunderstood areas of Part B coverage. Medicare does not cover a traditional, comprehensive, head-to-toe “routine physical exam.”
Instead, Part B covers an Annual Wellness Visit. This is a conversation-based appointment designed to update your health risk assessment, review your current medications, and develop a personalized prevention plan for the upcoming year. The Annual Wellness Visit is free to you. However, if your doctor performs clinical exams, orders diagnostic blood panels to check your cholesterol or thyroid, or addresses a specific new medical symptom during that exact same appointment, the doctor is required to bill those actions as diagnostic services. You will then be billed for the Part B deductible and 20% coinsurance for those specific diagnostic actions.
If your doctor prescribes equipment for use in your home, Part B covers it. The equipment must be durable (can withstand repeated use), used for a medical reason, and generally not useful to someone who is not sick or injured. Common examples include:
To ensure coverage, both your prescribing physician and the equipment supplier must be enrolled in Medicare. If you purchase DME from a supplier who is not enrolled, Medicare will pay nothing, and you will be responsible for the entire bill.
Part B covers blood tests, urinalysis, tissue pathology, and other laboratory tests ordered by your doctor to diagnose a condition. It also covers diagnostic imaging, including X-rays, MRIs, CT scans, and EKGs.
Part B covers ground ambulance transportation when traveling in any other vehicle could endanger your health, and you require medically necessary services from a hospital, critical access hospital, or skilled nursing facility. Medicare will only cover transportation to the nearest appropriate medical facility that is able to provide the care you need. Air ambulance services are covered only if your condition is so severe that ground transportation is too slow to save your life or prevent severe harm.
Outpatient mental health care is covered under Part B. This includes visits with a psychiatrist, clinical psychologist, clinical social worker, or psychiatric nurse specialist. It covers individual and group psychotherapy, psychiatric evaluation, and family counseling if the primary purpose is to help with your treatment.
Original Medicare does not cover standard retail prescription drugs (the medications you pick up at a pharmacy counter like blood pressure pills or statins). Those require a separate Part D prescription drug plan.
However, Part B does cover a very specific subset of drugs. These are typically medications you cannot administer yourself and are given in a doctor’s office or outpatient setting. Examples include:
Understanding what Part B excludes is vital for financial planning. Original Medicare is not comprehensive health insurance. The following services are explicitly excluded from Part B coverage by federal law:
Medicare Part B costs are structured around three distinct financial mechanisms: the monthly premium, the annual deductible, and the ongoing coinsurance.
Everyone enrolled in Part B pays a monthly premium. The standard premium amount is calculated and published annually by CMS. For the vast majority of beneficiaries, this standard premium is the exact amount they pay.
However, if you have a higher income, you are legally required to pay an Income-Related Monthly Adjustment Amount (IRMAA) in addition to the standard premium. Medicare determines your IRMAA status by looking at your Modified Adjusted Gross Income (MAGI) reported on your IRS tax return from two years prior. (For example, your 2026 Part B premium is determined by your 2024 tax return).
The IRMAA brackets escalate progressively. If your income falls into higher tiers, the federal government reduces its subsidy of your Part B costs, and your premium increases accordingly.
Appealing IRMAA: If your income has dropped significantly due to a “life-changing event”—such as retirement, divorce, the death of a spouse, or loss of pension income—you do not have to wait two years for Medicare to adjust your premium. You can file Form SSA-44 with the Social Security Administration to request an immediate recalculation of your IRMAA based on your current, lower income.
Before Part B begins paying its 80% share for your medical services, you must satisfy an annual Part B deductible. This deductible resets every calendar year on January 1. Until you have paid this amount entirely out of your own pocket for covered medical services, Medicare will not contribute to your diagnostic or treatment costs. (Note: Preventive services, such as your Annual Wellness Visit or a flu shot, do not apply to the deductible and are covered immediately).
Once your annual deductible is met, Medicare Part B operates on a strict cost-sharing formula for almost all covered services: Medicare pays 80% of the Medicare-approved amount, and you are responsible for the remaining 20%.
The single most important financial fact about Original Medicare is that this 20% coinsurance has no out-of-pocket maximum.
If you undergo a minor outpatient procedure that costs $1,000, your 20% share is $200. But if you require a complex outpatient surgery, extended physical therapy, or expensive Part B-administered chemotherapy drugs that cost $100,000, your 20% share is $20,000. There is no ceiling to protect you from catastrophic medical debt under Original Medicare alone.
| Financial Mechanism | Original Medicare Part B Alone | Part B + Medigap Plan G | Medicare Advantage (Part C) |
|---|---|---|---|
| Monthly Premium | Standard Premium + IRMAA (if applicable) | Part B Premium + Medigap Premium | Part B Premium + MA Plan Premium (often $0) |
| Annual Deductible | Yes, standard Part B deductible | You pay the Part B deductible | Varies by plan, often a combined medical deductible |
| Outpatient Coinsurance | You pay 20% of the approved amount | Medigap pays your 20% liability | You pay fixed copayments (e.g., $10 for primary care, $40 for specialist) |
| Out-of-Pocket Maximum | None (Unlimited financial liability) | Virtually none (Medigap covers the remaining approved costs) | Yes, mandated by federal law (caps your financial risk) |
The 80/20 cost-sharing rule is based on the “Medicare-approved amount” for a service, not whatever price the doctor chooses to charge. How a doctor interacts with Medicare falls into three categories:
Failing to navigate Medicare’s strict enrollment timelines can result in permanent financial penalties and severe gaps in your healthcare coverage.
Use this checklist to determine if you need to take immediate action regarding Medicare Part B.
Your Initial Enrollment Period is a 7-month window that revolves around your 65th birthday. It includes:
If you sign up during the first three months, your Part B coverage will begin on the first day of your birth month. If you sign up during your birth month or the three months after, your coverage start date will be delayed.
Note on Automatic Enrollment: If you are already receiving Social Security retirement benefits when you turn 65, you do not need to proactively apply. The Social Security Administration will automatically enroll you in both Part A and Part B, and your Medicare card will arrive in the mail about three months before your birthday.
Many Maryland residents choose to continue working past age 65 and remain on their employer-sponsored health insurance. If your employer has 20 or more employees, your group health plan pays primary, and Medicare pays secondary. In this scenario, you can safely delay enrolling in Part B to save on the monthly premium.
When you eventually retire or lose that employer coverage, you are granted a Special Enrollment Period. You have an 8-month window to sign up for Part B without facing any late penalties.
Critical Warning on COBRA and Retiree Plans: COBRA coverage, retiree health insurance, and severance health benefits do not count as “current active employment” coverage according to CMS. If you retire at 65 and take COBRA for 18 months instead of signing up for Part B, your 8-month Special Enrollment Period will expire while you are on COBRA. When you finally try to enroll in Part B, you will face severe late penalties.
If you missed your IEP and do not qualify for a Special Enrollment Period, your only opportunity to sign up for Part B is during the General Enrollment Period, which runs from January 1 to March 31 every year.
If you enroll during the GEP, your Part B coverage will begin the month after you sign up. You will also be assessed the Part B late enrollment penalty.
The federal government penalizes beneficiaries who do not enroll in Part B when they are first eligible, as a mechanism to prevent people from waiting until they are sick to pay premiums.
If you fail to enroll during your IEP and do not have creditable active employer coverage to protect you, you will face a 10% penalty added to your standard Part B premium for every full 12-month period you were eligible but did not enroll.
This is not a one-time fee. This penalty is permanently attached to your monthly premium for the rest of your life. For example, if you wait three full years to sign up for Part B after turning 65, you will pay a 30% penalty on top of the standard Part B premium every single month for the duration of your enrollment.
Because Original Medicare Part B leaves you entirely exposed to an uncapped 20% coinsurance liability, the vast majority of Maryland residents do not rely on Original Medicare alone. They protect their assets through one of two primary pathways: Medigap or Medicare Advantage.
A Medicare Supplement Insurance policy, commonly known as Medigap, is a private insurance plan designed to wrap around Original Medicare and pay the costs that Part B leaves behind.
If you purchase a Medigap plan (such as Plan G), you will pay your monthly Part B premium to the government, plus a monthly premium to the private Medigap carrier. In exchange, when you receive a Part B service, Medicare pays its 80% share, and the Medigap policy automatically pays the remaining 20%. You can see any doctor or specialist in the United States who accepts Medicare, without needing referrals or worrying about localized network restrictions.
Medicare Advantage plans are an alternative way to receive your Part A and Part B benefits. These plans are offered by private insurance companies approved by Medicare. When you enroll in an MA plan, you must continue to pay your monthly Part B premium, but the private carrier takes over the administration of your medical benefits.
Maryland has a robust Medicare Advantage market, with 60 real Medicare plans available across the state depending on your specific county. Major carriers offering these plans in Maryland include:
Instead of paying a volatile 20% coinsurance for services, Medicare Advantage plans utilize a structured copayment system (e.g., $10 for a primary care doctor, $45 for a specialist visit). Crucially, federal law mandates that every Medicare Advantage plan must include a maximum out-of-pocket limit, protecting you from catastrophic medical debt. Many of these plans also bundle in the dental, vision, and hearing benefits that Original Medicare Part B strictly excludes.
However, Medicare Advantage plans utilize managed care networks (HMOs and PPOs). You will typically need to use doctors and hospitals within the plan’s specific Maryland network to receive the best pricing, and you may need a primary care physician to issue referrals before you can see a specialist.
When you use your Part B benefits under Original Medicare, you will receive a Medicare Summary Notice (MSN) in the mail every three months. This is not a bill. The MSN is an itemized statement showing all the services providers billed to Medicare on your behalf, what Medicare approved, what Medicare paid, and the maximum amount you can be billed.
If you see a service on your MSN that was denied by Medicare, you have the right to appeal. The appeals process involves five sequential levels:
You must follow the instructions on the back of your MSN and file your initial appeal within 120 days of receiving the notice.
Deciding how to handle Medicare Part B depends entirely on your current employment status and age.
Speak with a licensed producer to compare your Part B Medigap and Medicare Advantage options across Maryland.
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