How Medicare Advantage works
Medicare Advantage, also called Part C, is a way to receive your Medicare benefits through a private insurance company instead of directly through Original Medicare. You still have Medicare, and you still pay your Part B premium. But the plan, not Medicare, handles your claims, sets your copays and decides which doctors and hospitals are in its network.
A plan that includes Part D prescription coverage is called an MAPD, short for Medicare Advantage Prescription Drug plan. That means one card, one plan and one set of rules for doctor visits, hospital stays and pharmacy fills. A few plans leave out drug coverage, which can suit veterans who rely on VA benefits. For many people, though, an MAPD is simpler and avoids a gap in drug coverage.
Every Medicare Advantage plan must cover the services Original Medicare covers, though costs and rules differ from plan to plan. Hospice care stays with Original Medicare even while you’re enrolled. Plans can also require referrals or prior authorization for certain services, and those rules vary by carrier, so it pays to read the details before you commit.
- You must have Medicare Part A and Part B and live in the plan’s service area.
- You keep paying your Part B premium, plus any plan premium.
- Plans run on a calendar year, and benefits can change every January 1.
- You can’t pair a Medicare Advantage plan with a Medigap policy.
HMO vs. PPO: which network style fits you?
The biggest day-to-day difference between Medicare Advantage plans is the network. An HMO (Health Maintenance Organization) generally asks you to use doctors and hospitals in its network, except for emergencies and urgent care. Some HMOs also require a referral from your primary doctor before you see a specialist. In exchange, HMOs often have lower premiums and copays, depending on the plan.
A PPO (Preferred Provider Organization) also has a network, but it lets you see out-of-network providers who accept the plan, usually at a higher cost. PPOs typically don’t require referrals. If you split your year between Ohio and another state, or you want room to see a particular specialist, a PPO may be worth a closer look.
Neither style is right for everyone. The real question is which plan includes the doctors you already trust and how often you expect to need care. A healthy traveler and someone managing several specialists may land on very different answers.
| HMO | PPO | |
|---|---|---|
| Network | Generally must use in-network providers | In-network and out-of-network options |
| Specialist referrals | Often required | Usually not required |
| Out-of-network care | Emergencies and urgent care, in most cases | Covered at a higher cost share |
| Premiums and copays | Often lower, depending on the plan | Often somewhat higher, depending on the plan |
| Often a good fit for | People happy with a local network | Travelers and people who want flexibility |
Costs: premiums, copays and your out-of-pocket maximum
Medicare Advantage costs come in layers: any monthly plan premium, your Part B premium, deductibles, and the copays or coinsurance you pay when you use care. Some plans in the Toledo area may carry a low monthly premium, but a low premium alone doesn’t make a plan the right choice. It may come with higher copays for hospital stays, imaging or specialist visits.
One important protection is the maximum out-of-pocket limit, often called the MOOP. Every Medicare Advantage plan sets a yearly cap on what you pay for covered, in-network Part A and Part B services. Once you reach it, the plan pays for covered in-network care for the rest of the year. Federal rules set a ceiling, and each plan picks its own amount at or below it. Original Medicare by itself has no such cap.
Beyond core medical coverage, many plans add extras. Depending on the plan, extra benefits may include routine dental, eyewear, hearing aids, fitness memberships or an over-the-counter allowance. These vary widely by carrier and county and can change from year to year, so they work better as a tiebreaker than as the main reason to choose. If dental care matters a lot to you, a standalone dental, vision and hearing plan may be worth comparing too.
When you can enroll or switch plans
Medicare Advantage has set enrollment windows. The main one is the Annual Enrollment Period, October 15 through December 7, 2026. During this window you can join, switch or drop a Medicare Advantage plan, and the change takes effect January 1, 2027. If you’re already enrolled, this is the time to compare your current plan against what’s new.
If you start the year in a Medicare Advantage plan and aren’t happy, the Medicare Advantage Open Enrollment Period, January 1 through March 31, 2027, gives you one more chance. You can switch to a different Medicare Advantage plan once, or return to Original Medicare and add a standalone Part D plan.
When you first become eligible, you can join during your seven-month Initial Enrollment Period around your 65th birthday month. Certain life events, such as moving or losing employer coverage, can open a Special Enrollment Period. Not sure which window applies to you? Try the Medicare enrollment window tool.
- Annual Enrollment: Oct 15 – Dec 7, 2026, with coverage starting Jan 1, 2027
- Medicare Advantage Open Enrollment: Jan 1 – Mar 31, 2027, one change for current MA members
- Initial Enrollment: 7 months, centered on your 65th-birthday month
- Special Enrollment Periods: opened by events like moving or losing other coverage
Medicare Advantage plans can change premiums, copays, drug lists and networks every January. Your plan mails an Annual Notice of Change each fall. Open it as soon as it arrives, and call Kris before December 7 if anything looks different.
Medicare Advantage in Toledo, Perrysburg and northwest Ohio
Plan choices are set county by county, so the options in Lucas and Wood counties may differ from those in Hancock County or across the line in Monroe County, Michigan. Kris has helped clients across northwest Ohio since 2017, and she knows the local questions that matter. Are your ProMedica, Mercy Health or University of Toledo Medical Center doctors in the network? Networks vary by plan and can change each year.
Carriers she works with for Medicare Advantage in Ohio include Aetna, Anthem, Devoted Health, Humana, Medical Mutual, Molina, Paramount, SummaCare and UnitedHealthcare, among others. You can see the full list on the carriers page. Because she’s independent, she can lay plans from several companies side by side instead of steering you toward one.
If you spend winters in Florida or visit family in Michigan, mention it early. Travel affects whether an HMO or a PPO makes more sense. Kris is licensed in Ohio, Michigan, Indiana and Florida, so she can keep helping if you move. Local clients can meet her in person at the Perrysburg office on West South Boundary Street.
How Kris helps you choose a Medicare Advantage plan
Kris starts with you, not a plan. In a no-cost, no-pressure conversation by phone, video or at her office, she gathers your doctors, your prescriptions and your preferred pharmacy. Then she checks each plan’s network and drug list against your list, so you see real differences in coverage instead of marketing headlines.
Next she compares the plans available in your county from the carriers she represents, explains the trade-offs in plain English and answers questions until the choice makes sense. When you’re ready, she handles the enrollment with you. After that, she stays your contact year-round for ID card questions, billing confusion and the yearly review each fall.
Every year brings new plans, and your health can change too, so a choice that fit last year deserves a fresh look. Want to weigh Medicare Advantage against a Medigap approach before you decide? Read about Medicare Supplement plans and how they pair with a standalone drug plan, or request a quote and Kris will reach out to set up a time that works for you.
- Review your doctors, hospitals and specialists
- Check every prescription against each plan’s formulary
- Compare MAPD, HMO and PPO options from multiple carriers
- Enroll you and confirm your coverage start date
- Review your plan again every Annual Enrollment Period
Who Medicare Advantage may be right for
- People turning 65 in the Toledo area who want medical and drug coverage in one plan
- Anyone who wants a yearly cap on in-network medical costs
- Those whose doctors are in a local network they’re comfortable using
- Retirees leaving employer coverage who prefer predictable copays
- Current Medicare Advantage members who want their plan reviewed before December 7
Medicare Advantage Carriers Kris represents
Availability varies by county and changes every year. Kris will show you which of these carriers offer plans where you live.
- Aetna
- Anthem
- Devoted Health
- Humana
- IU Health Plans
- Medical Mutual
- Molina
- MVP Healthcare
- Paramount
- SummaCare
- UnitedHealthcare®
We do not offer every plan available in your area. Currently, we represent 14 organizations which offer 119 products in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. This is a proprietary website and is not associated, endorsed or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains decision-support content and information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Medicare program please visit the Official U.S. Government Site for People with Medicare located at www.medicare.gov.