Medicare is voluntary — but the penalties are permanent
Nothing in federal law REQUIRES you to enroll in Medicare. You can refuse Part A (though it's tied to Social Security in complicated ways), refuse Part B, refuse Part D. The federal government won't fine you for not enrolling.
What it WILL do: charge a permanent late-enrollment penalty when you eventually enroll. And if you ever try to qualify for Medicaid or other assistance, your Medicare status matters.
The question isn't 'can I skip?' — yes, you can. The question is 'should I?' That's a math question.
When skipping Part B might make sense
Scenario 1: You're self-employed, well-insured through an HSA-paired high-deductible individual plan, and your premium for that plan plus deductible is genuinely cheaper than Medicare Part B + Medigap + Part D. Rare in 2026 because individual ACA plans for 65-year-olds are very expensive.
Scenario 2: You have access to a true group plan (small business group, association group, professional society group) that's cheaper than Medicare for your situation.
Scenario 3: You're moving abroad permanently and won't use U.S. healthcare. Part A is free so keep it. Drop Part B and accept the penalty if you ever return.
Scenario 4: You're VA-eligible and relying primarily on VA care. Many veterans defer Medicare. Note: the VA strongly recommends enrolling in Medicare anyway because Medicare gives you access to non-VA providers.
When skipping is a mistake
Scenario A: You're 'self-insured' meaning you'll just pay cash for any care. Bad math. A single hip replacement can be $40-60K. A heart attack can be $200K+. The Part B premium is a tiny fraction of catastrophic exposure.
Scenario B: You have an individual ACA plan. ACA plans price 65+ enrollees very high. Most 65+ ACA premiums exceed Medicare Part B + Medigap + Part D by 50-100%.
Scenario C: You assume you'll enroll later when you 'need' Medicare. You can — but with a permanent penalty, and during the GEP only. By then you may also have health issues that make Medigap impossible.
Scenario D: You're betting on Medicare-for-all or Medicare expansion. Even if expansion happens, your individual late penalty stays permanent.
The honest cost comparison
For a typical 65-year-old self-employed person in 2026:
Part B premium: $2,434.80/year ($202.90 × 12)
Plan G (cheapest carrier in most states): $135-180/month = $1,620-2,160/year
Part D (typical): $35/month = $420/year
Total Medicare cost: $4,475-5,015/year
Plus deductibles in heavy years: $257 Part B + drug deductible.
Compared to typical individual ACA plan for a 65-year-old: $1,000-1,500/month = $12,000-18,000/year
Medicare wins by ~$10,000/year at this baseline. For most self-employed people, skipping is bad math even if you're healthy.
What about Part A only
If you're already collecting Social Security at 65, you're auto-enrolled in Part A. You can't refuse it.
If you're not collecting Social Security, you CAN refuse Part A — but it's premium-free for most, so why? The only reason: HSA contributions. Part A enrollment ends HSA contribution eligibility. If you're maxing HSA in your last working years, defer Part A and don't collect SS until you stop HSA.
Otherwise: take premium-free Part A. It costs nothing, gives hospital backup if something goes wrong, and doesn't conflict with anything else.
The 'best of both worlds' play that doesn't actually exist
Some self-employed seniors think they can skip Medicare during healthy years and enroll later when they need it. The math doesn't work because:
Permanent late penalties stack: 10%/year for Part B, 1%/month for Part D.
Medigap underwriting after the initial 6-month OEP — if you skip Medigap and develop health issues, carriers can deny you in most states.
GEP-only enrollment: you can only enroll in Part B during Jan 1 – Mar 31, with coverage starting July 1. If you have a health emergency in October, you're stuck waiting.
Hospital admission rules: hospitals won't admit you on Medicare if you're not enrolled. They'll bill you privately, and the rates are MUCH higher than Medicare.
Bottom line: 'I'll enroll when I need it' is rarely the right move. Enroll on schedule.