Medicare in St. Augustine and St. Johns County, 2026: High Ratings, Seven Carriers, and the Income Surcharge

“My neighbor says I’m crazy for paying for a Medigap plan when Medicare Advantage is ‘free.’ What should I tell him?” That question was posted publicly on a consumer Medicare Q&A site, and some version of it comes up at nearly every St. Augustine kitchen table we sit at. It is really two claims wearing one sentence: that Medicare Advantage costs nothing, and that paying for a supplement is irrational. In St. Johns County, for the 2026 plan year, both claims are checkable against published numbers.

So let us check them. This county has a genuinely strong Medicare Advantage market by the one quality measure CMS publishes for every plan on the same basis. It also has a short list of companies behind that market, the widest gap in Florida between what the county earns and what the marketing assumes, and a state Medigap rule that makes one particular decision hard to reverse. None of that appears on a postcard.

What does the 2026 Medicare market in St. Johns County actually look like?

CMS publishes a landscape file every autumn with one row per plan offering per county. For contract year 2026, St. Johns County has 76 rows: 44 Medicare Advantage and MA-PD records plus 32 Special Needs Plan records. Those 76 records come from seven parent organizations — CVS Health, Centene, Devoted Health, Elevance Health, Guidewell (Florida Blue), Humana and UnitedHealth Group. That is more choice than Nassau County’s six carriers and fewer than Clay’s ten, Duval’s twelve or Broward’s sixteen.

Special Needs Plans are listed alongside everything else, but you cannot simply pick one. They exist for people who qualify on a specific basis, such as dual eligibility for Medicare and Medicaid or a qualifying chronic condition. Set those aside and the general-enrollment shelf in St. Johns is 44 records deep. Filter that for your own doctors and your own drug list and, in our experience, you are usually down to a shortlist of three or four before the premium ever enters the conversation.

Read the table twice, because the two columns pull in opposite directions. On measured quality, St. Johns leads the set, and its 4.26 mean beats every out-of-state comparison county in our data — Fulton County, Georgia sits at 3.81 and Dallas County, Texas at 3.74 on the same 2026 files. On depth of bench, only Nassau is thinner. High ratings on a short bench is a specific combination: the plans you can buy are good, and the places you can go when one of them changes are few.

What Medicare costs in 2026 before any plan is involved

Every plan decision sits on top of federal numbers that are identical in St. Augustine, Ponte Vedra, Hastings and everywhere else in the country. Medicare is a federal program; the county only decides which private plans you may layer on top. For the 2026 plan year the standard Part B premium is $202.90 a month, usually deducted from your Social Security payment, and the annual Part B deductible is $283. The Part A hospital deductible is $1,736 per benefit period — not per year, and a second admission months later can open a second benefit period.

Then comes the sentence that explains the entire private-plan industry: Original Medicare leaves you paying 20% of most Part B services with no annual cap. No ceiling, no maximum, no point at which it stops. Medicare Advantage answers that with an out-of-pocket maximum; a Medicare Supplement answers it by paying most of the 20% for you. Everything else is detail.

Why does a $0 premium tell you almost nothing in St. Johns County?

Because 27 of the county’s 33 MA-PD plans charge one for 2026 — 82%. When four plans in five share a price, the price has stopped carrying information. The mean MA-PD premium across the county is $13.61 a month, the highest-priced plan in the file is $184, and none of those numbers predicts what a bad year costs you. The number that does is the in-network maximum out-of-pocket, the ceiling on your copays and coinsurance for covered in-network care in a calendar year. On paperwork it is shortened to MOOP.

For the 2026 plan year the median in-network MOOP in St. Johns County is $6,750, the mean is $6,103, and the range runs from $2,500 to $9,250. Two neighbours on the same street in Murabella can both hold a $0-premium plan and be $6,750 apart on the year a knee replacement goes badly. For contrast, Broward County’s median MOOP is $3,900 and its mean is $4,697 — same state, same program, different worst case. The $6,750 median is the First Coast norm, and it is the single most useful number to write next to each plan on your shortlist.

The surcharge nobody mails you a postcard about: IRMAA

Here is the part of the 2026 conversation that is genuinely different in St. Johns County. The Census Bureau’s 2023 American Community Survey puts the county’s median household income at $106,169 — the highest of any county in Florida, 55% above Duval’s $68,447, with a median home value of $457,600. A county that earns like that retires into a Medicare rule most people first meet as a letter from Social Security: the income-related monthly adjustment amount, or IRMAA.

IRMAA is a surcharge on your Part B and Part D premiums that switches on once your modified adjusted gross income crosses set thresholds. For 2026 the surcharge starts above $109,000 for a single filer and above $218,000 for a joint return. The first step adds $81.20 a month to Part B, taking it from $202.90 to $284.10, plus $14.50 a month on Part D. The top bracket takes Part B to $689.90 a month per person. And the income being tested is not this year’s: Social Security states plainly that your 2026 premium is generally based on the tax return you filed in 2025, for tax year 2024.

Why this matters here specifically: IRMAA has a cliff shape. Cross a threshold by one dollar and the full surcharge for that bracket applies to both spouses for the whole year. A couple whose 2024 return lands at $220,000 — a large capital gain in the year they sold a business or a rental, say — sits $2,000 over the joint line, and each spouse pays $81.20 more for Part B and $14.50 more for Part D every month of 2026. That is roughly $2,297 for the household over the year, triggered by $2,000 of income two years earlier. This is arithmetic from the published tables, not tax advice; the planning conversation belongs with your tax professional, ideally before the gain is realized, not after the letter arrives.

One more thing the letter does not say loudly: IRMAA follows you into Medicare Advantage. A $0-premium plan does not reduce it, because the surcharge attaches to Part B and Part D themselves. If you’d rather just talk it through, call 888-627-0085 and ask for a plain-language answer.

Medigap or Medicare Advantage when you could afford either?

Back to the neighbour. In a county with this income profile, many households can genuinely afford the monthly premium of a Medicare Supplement, which makes the choice a real one rather than a budget default. The honest comparison is short. Medicare Advantage bundles your coverage into one plan, usually at a $0 or low premium, caps your in-network exposure at the MOOP, and in exchange runs on a local network that can change on 1 January. A supplement costs a real premium every month, including the healthy years, and in exchange pays most of Original Medicare’s 20% and travels anywhere in the country that takes Medicare — a point worth weighing if you split the year between St. Augustine and somewhere north. We lay the whole decision out in our Medicare Advantage versus Supplement comparison.

What tilts the decision in Florida is timing. Federal law gives you one 6-month Medigap open enrollment window, starting the first day of the month you are both 65 or older and enrolled in Part B. Inside it, a carrier must sell to you regardless of health. Outside it, Medicare.gov says it plainly: there is no federal guarantee that an insurance company will sell you a Medigap policy, and if it does, past or present health problems can make it cost more.

We read the Florida Office of Insurance Regulation’s 2026 Medigap FAQ end to end, and no birthday-based right to switch carriers without underwriting appears in it. What Florida law does give you: every Medicare Supplement policy sold here is guaranteed renewable, a 30-day free look lets you return a policy for a full refund, and if you joined Medicare Advantage when first eligible at 65 and leave within one year, the federal trial right lets you buy any Medigap policy from any carrier on a guaranteed-issue basis. What happens when people miss those windows is its own story — we wrote it up in our post on being denied a Medigap policy in Florida.

The healthiest county in the set — which changes the question, not the answer

On the CDC’s 2023 PLACES estimates, St. Johns County is the healthiest of the five counties we serve. It has the lowest adult smoking rate in the set at 10.1%, and the highest share of adults reporting a routine checkup in the past year, at 77.3% crude and 80.7% age-adjusted. Obesity is estimated at roughly 29%, diagnosed diabetes at roughly 8 to 11%, and high cholesterol among adults ever screened at 31.4% crude and 38.2% age-adjusted. These are model-based estimates with confidence intervals, so treat them as the shape of the county rather than a headcount.

Coverage runs the same direction. The 2023 American Community Survey counts 18,668 uninsured people in a coverage universe of 290,093 — 6.4%, the lowest uninsured rate of the five counties, against 13.3% in Broward. A healthy, insured, checkup-going county produces a specific temptation: choosing a plan for the healthy year you expect. The MOOP exists for the year you do not expect, and in this county the difference between the bottom and top of the 2026 range is $6,750 of exposure. Healthy is a probability, not a guarantee, and the plan is priced for the whole distribution.

Hospitals: the network question is a driving question here

CMS Care Compare rates hospitals on a five-star scale, and the rated acute-care hospital physically inside St. Johns County in our July 2026 pull is Ascension St Vincent’s St Johns County, in ZIP 32259, at 4 stars with an emergency department. Much of the specialist and hospital care the county actually uses sits up the road in Jacksonville, where the ratings spread is wide: Mayo Clinic in ZIP 32224 holds 5 stars, several Baptist and Ascension facilities hold 4, and HCA Florida Memorial holds 2. A 5-star hospital and a 2-star hospital operate in the same metro.

That spread is why the network page of a Medicare Advantage plan matters more than its premium page. Two St. Johns plans with identical premiums can route a heart workup to differently rated systems, and the drive from St. Augustine makes “which Jacksonville hospitals are in network” a practical daily question, not an abstraction. When you shortlist plans, check the hospital systems by name, not just your doctors.

The drug plan is a separate decision, and the Florida shelf is short

If you choose Original Medicare, with or without a supplement, your drug coverage comes from a stand-alone Part D plan, and Florida’s 2026 shelf is short: ten plans statewide from five parent organizations, with premiums from $0.00 to $217.00 a month. Seven of the ten charge the full $615 maximum deductible, and none of the ten earned a 4-star Part D summary rating for 2026. The saving grace is federal: every plan carries the same $2,100 annual out-of-pocket cap on covered drugs. We walked through all ten in our review of Florida’s 2026 stand-alone Part D plans, and the short version is that your specific drug list, run through the Plan Finder, picks the winner — the premium does not.

How to run your own St. Johns County review in one evening

You can do the core of this work yourself in about ninety minutes the first year and thirty each autumn after. Do the steps in order; each one shortens the list for the next.

1. Write down every prescription with the exact doseGeneric name, strength, how often. Include the seasonal ones and the specialist’s ones. This list moves more money than any premium comparison you will make.
2. List the doctors and hospital systems you refuse to losePrimary care, each specialist, the imaging centre — and, in this county, the Jacksonville hospital system you would want a serious problem handled by. Mark which are negotiable.
3. Pull your Medicare number and your Part A and Part B start datesThey are on your red, white and blue card. The Part B date governs your one-time 6-month Medigap open enrollment window, which in Florida is the window that matters.
4. Check your 2024 tax return against the IRMAA tableIf your 2024 modified adjusted gross income is anywhere near $109,000 single or $218,000 joint, read the 2026 bracket table above and loop in your tax professional. If a Social Security IRMAA letter has already arrived, keep it with your Medicare papers.
5. Run your lists through the Plan Finder at Medicare.govUse the official tool at Medicare.gov, enter your ZIP code, your drugs and your pharmacy, and let it estimate total annual cost. A St. Augustine ZIP will return the county’s 44 general-enrollment records filtered to what is sold at your address.
6. Write the in-network out-of-pocket maximum next to each finalistFor 2026 the St. Johns range is $2,500 to $9,250. This column is your worst case, and it varies more than any other number on the page.
7. Call each finalist and confirm the network in writingName your doctor, the practice, and the hospital system, and ask whether each is contracted for the coming plan year — not the current one. Ask for the answer by email. Directories go stale.
8. If you spend part of the year elsewhere, say so firstA local-network plan behaves differently in another state. Snowbirds and part-year residents should raise this at the start of any comparison, because it can rule out whole categories before the details matter.
9. Get a second opinion from someone with nothing to sellCall 1-800-MEDICARE, or Florida’s free counselling programme SHINE on 1-800-963-5337, run by the Florida Department of Elder Affairs. Both are free and neither is paid by a carrier.

Bring your current plan and your prescription list; we’ll do the comparison with you. The person who arrives with the two lists finished has already done the hard part.

Before and after: one Ponte Vedra couple, on paper

Meet Tom and Carol, both 66, who moved to the county after selling a business in 2024. They are invented, and the table below applies published 2026 figures to their invented situation — no carrier is named and no premium is quoted, so read it as arithmetic, not as an offer.

In the before column they did what the mail suggested: enrolled in the first $0-premium plan a caller offered, never checked the out-of-pocket maximum, and were surprised by an IRMAA letter their business sale had triggered. In the after column they ran the nine steps above, chose a plan at the low end of the county MOOP range with their doctors confirmed in writing, and — for future years — put the IRMAA cliff on their tax professional’s radar before realizing further gains.

Notice what the after column did not require: spending more on premiums. It required sorting on different columns and asking one tax question a year earlier. That is the whole method.

So — was the neighbour right?

Half right, which is the most dangerous kind. He is right that Medicare Advantage in St. Johns County is not a compromise product: the 2026 records here average 4.26 stars, 60 of 76 sit at 4 stars or better, and for someone with local doctors, a modest drug list and a plan chosen on its MOOP rather than its premium, it is a reasonable choice we recommend without embarrassment. He is wrong that the plans are free — the household still pays $202.90 per person per month for Part B before any IRMAA, plus every copay up to the MOOP — and he is wrong that paying for Medigap is crazy. It is a different trade: national mobility and predictable bills, bought with a real premium, and in Florida it is a trade most easily made inside a 6-month window that does not come back.

The honest answer to the neighbour is a question: which of you has checked your out-of-pocket maximum, and which of you knows what your 2024 tax return does to your 2026 premium? Timing the whole review matters too — the Annual Enrollment Period runs 15 October to 7 December for coverage starting 1 January, and if you are already in a Medicare Advantage plan, the 1 January to 31 March window allows one switch. Our guide to the 2026 enrollment periods maps every window, and if you are comparing this county with the rest of the region, our Nassau County and Clay County reviews use the same 2026 files.

Where to get help that has nothing to sell you

Keep an unbiased source in your pocket. Medicare.gov is the official government site, and its Plan Finder works from the same landscape data every agent uses. 1-800-MEDICARE is staffed around the clock. Florida’s State Health Insurance Assistance Program is SHINE, on 1-800-963-5337, and its counsellors are volunteers paid by no carrier. For IRMAA questions specifically, the Social Security Administration is the agency that determines the surcharge, and its Medicare premiums page explains both the brackets and what to do when a life-changing event makes an old tax return unrepresentative.

McDowell Business Resources is an independent agency, not an insurance carrier, and we are not affiliated with or endorsed by the U.S. government, the federal Medicare program or CMS. We do not offer every plan available in your area, and the information we give is limited to the plans we do offer here. The numbers above plus Medicare.gov will get you most of the way to a good decision without us.

How we help in St. Johns County

What we add is the labour. We run your exact doctors, your exact drug list and your preferred Jacksonville hospital system against every plan we represent at your address, and we show you the total expected cost in a healthy year and a heavy-care year — not the premium, the whole year. Where income is the live issue, we will tell you plainly when the question belongs with your tax professional rather than with an insurance agent, because IRMAA is a tax-return problem wearing a Medicare costume.

Then we repeat the whole exercise every autumn, because networks and formularies reset on 1 January whether or not anyone warns you. The county detail lives on our St. Johns County page, the service outline on our Medicare page, and the statewide picture in our Florida Medicare guide for 2026. There’s no cost and no pressure — book a free consultation and we’ll walk through it together.

What you get out of doing this properly

You stop comparing plans on the number 82% of them share and start comparing on the numbers that differ by thousands. You know your worst case before the year that produces it, you know which hospital system answers a 2 a.m. problem, and you know what your last tax return does to next year’s premium before the letter tells you. In the county with Florida’s highest household income and its best-rated plan shelf, the expensive mistakes are not bad plans. They are good plans chosen on the wrong column.

The review takes one evening a year. Whatever you decide, decide it on the numbers. If you want help getting to them, we’re here.