Medigap vs Medicare Advantage in Ohio

These are two genuinely different ways to receive care, not two prices for the same thing. Original Medicare with a Medigap supplement lets you use any provider in the country that accepts Medicare, with no prior authorization, for a higher predictable monthly premium. Medicare Advantage bundles everything into a private plan with a network, prior authorization, and an annual out-of-pocket cap, usually for a much lower premium. In Ohio, the decision is harder to reverse than in many states.

That last sentence is the part most comparisons leave out, and it is the reason this page exists.

I am Steve Almeroth, an independent Medicare broker in Middleburg Heights. I am appointed with carriers on both sides and paid similarly either way. What follows is how I actually think about it.

The structural difference

The honest summary: you are choosing between paying a predictable amount every month and paying less every month but more when you are sick. Both are defensible. Which is right depends on your health, your providers, your travel, and your tolerance for administration.

The claim to be careful about

You will hear that a Medicare Advantage PPO “lets you see any provider that takes Medicare.” That is not accurate, and it matters.

A PPO gives you out-of-network benefits — the plan will pay something toward a non-contracted provider, usually at a higher coinsurance. What it does not do is obligate that provider to see you. A non-contracted provider is not required to accept an Advantage plan member, and many decline. Out-of-network coverage is a promise from your insurer about payment, not a promise from a doctor about access.

“Any provider that accepts Medicare” is an accurate description of Original Medicare with a Medigap supplement. It is not an accurate description of any Advantage plan, PPO included.

Prior authorization is the practical difference

Premiums get the attention; prior authorization is what people actually notice.

Under Original Medicare with a supplement, your doctor orders something and it happens. Under Medicare Advantage, certain services need the plan’s approval first — and the categories that most often require it are the ones people over 65 use: physical therapy, skilled nursing facility stays, imaging, durable medical equipment, and some outpatient procedures.

This is not an argument against Advantage plans. It is an argument for being honest about your expected year. If you are heading toward a joint replacement with a long course of PT, or you are managing a condition that needs frequent imaging, that friction is real and recurring. If you are healthy and see a doctor twice a year, you may never encounter it.

Cost, concretely

Original Medicare leaves gaps a supplement is designed to fill. In 2026:

Note “per benefit period” on the Part A deductible — it is not annual. A new benefit period can start after 60 days out of hospital, so a bad year can mean paying it more than once. That open-ended exposure is what a supplement removes.

Medigap plans are standardized by letter — a Plan G is the same set of benefits from every carrier, by federal law. What differs between carriers is the premium, how it is rated, and the size of future increases. This makes shopping unusually straightforward: identical coverage, so compare price and rating method. It also means anyone selling you a supplement on its benefits is selling you something you can get anywhere.

I am not listing specific plans or premiums here, because those are carrier- and county-specific and go stale. That is what a conversation is for.

The Ohio rule that makes this decision one-directional

Everything above applies in every state. This part does not.

Your protected window to buy a Medigap policy is the six months beginning the first month you are both 65 or older and enrolled in Part B. During it, Ohio Administrative Code Rule 3901-8-08 forbids an insurer from refusing you, conditioning the policy, or pricing you differently because of your health, tobacco use, claims history, or medical condition.

Outside that window, Ohio permits full medical underwriting.

And:

• Ohio has no “birthday rule.” Several states give existing Medigap holders an annual window to switch without health questions. Ohio does not. I checked the controlling regulation — the word does not appear in it. You will see this claimed online; the only source is a bill that was introduced and never became law.
• There is no annual Medigap open enrollment. The October 15 – December 7 Annual Enrollment Period does not apply to supplements.

Ohio does provide guaranteed issue on specific triggering events — your employer or retiree plan ends, your Advantage plan terminates or leaves your area, you move out of its service area, your insurer becomes insolvent, or you are exercising a trial right after enrolling in Medicare Advantage for the first time. Those are events, not a calendar.

The practical consequence. Choosing Medicare Advantage at 65 is easy to do and, in Ohio, often hard to undo. Going the other direction — Medigap to Advantage — is available every year during AEP. Going Advantage back to Medigap after your six months means answering health questions, and by 68 or 72 most people have an answer that costs them. An atrial fibrillation diagnosis on an anticoagulant, for instance, is a routine decline or rate-up.

So the decision is not symmetric. One door stays open; the other closes quietly.

The trial right worth knowing about

If you join a Medicare Advantage plan when you first become eligible at 65, and you leave within 12 months, you have a guaranteed-issue right to buy a supplement without underwriting.

This is a genuinely useful safety valve, and most people are never told about it. It applies to your first Advantage enrollment at 65 — not to a switch you make at 70 after years on Advantage.

How I would think about it

Not advice for you specifically, but the questions that usually decide it:

Lean supplement if: you have an established panel of specialists you intend to keep; you expect significant care in the next few years; you travel or spend months elsewhere; you have a condition that would make you hard to underwrite later; or predictability is worth real money to you.

Lean Advantage if: you are healthy and use little care; the premium difference is material to your budget; your doctors are solidly in-network; the extra benefits genuinely match what you use; and you are comfortable with authorizations and annual plan changes.

In either case: verify each of your actual doctors, and price your actual prescriptions. Not the hospital system — the individual providers.

Common questions

Is one of these better for you to sell? Compensation is broadly comparable, and I would rather tell you that plainly than have you wonder. The larger point is that a supplement decision made correctly at 65 rarely comes back to me, and an Advantage plan is reviewed every year — if I were optimizing for my own revenue, I would not steer people toward supplements.

Can I have both? No. A Medigap policy cannot pay toward Medicare Advantage cost-sharing. You are on one path or the other.

What if I move out of state? A supplement travels — it works anywhere Medicare is accepted. An Advantage plan is tied to a service area, and moving out of it triggers a Special Enrollment Period and, usually, a guaranteed-issue right.

What about dental and vision? Original Medicare covers essentially neither, which is a real argument for Advantage plans. Standalone dental and vision policies exist as an alternative. Worth pricing rather than assuming.

Does a broker cost me anything? No. Premiums are identical whether you buy through me, direct, or on Medicare.gov, and Medigap benefits are standardized by law.

Talk it through before your six months run out

If you are approaching 65, or Part B is about to start, this is the decision worth spending an hour on. It is the one I most often wish people had made with better information.

Steve Almeroth · MedStar Insurance Agency · Middleburg Heights, OH · 440-622-2112 · steve@medstar.agency

Free consultation, no obligation. Check your dates first if you like.

Sources

• CMS — 2026 Medicare Parts A & B Premiums and Deductibles
• CMS — Final CY 2026 Part D Redesign Program Instructions
• Medicare.gov — Joining a plan
• Ohio Administrative Code — Rule 3901-8-08, Medicare supplement
• Ohio Revised Code — § 3923.332

For information on all of your options, including plans I do not offer, contact Medicare.gov, call 1-800-MEDICARE, or reach Ohio’s State Health Insurance Assistance Program (OSHIIP) at 800-686-1578.