Medicare Advantage: Getting the Most from Your Coverage

Getting the most out of your Medicare Advantage plan means understanding extra benefits, managing provider networks, and knowing how to appeal denials.

Now chosen by over half of all Medicare beneficiaries, these plans offer an alternative to Original Medicare by combining hospital (Part A), medical (Part B), and often drug (Part D) coverage—plus perks like dental, vision, and transportation.

This comprehensiveguide will walk you through how Medicare Advantage works and how to use your plan more effectively.

Understanding the Basics of Medicare Advantage Coverage

Medicare Advantage plans, also known as Medicare Part C, are an all-in-one alternative to Original Medicare. These plans are offered by private insurers approved by Medicare and must follow federal coverage rules.

At a minimum, every Medicare Advantage plan must cover everything that Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) cover. (For a full list of what’s included, see the official Medicare & You 2025 handbook.)

Beyond those basics, Medicare Advantage works very differently from Original Medicare — and those differences matter.

Key differences from Original Medicare

• Provider networks vs. nationwide coverage: With Original Medicare, you can see any provider that accepts Medicare anywhere in the U.S. In contrast, most Medicare Advantage plans use provider networks. If you go out-of-network, you could face higher costs — or no coverage at all, depending on your plan.
• Out-of-pocket maximums: Medicare Advantage includes an annual cap on what you’ll pay out of pocket for covered services — something Original Medicare doesn’t offer unless you purchase a Medigap plan.
• Prior authorization requirements: Medicare Advantage plans often require prior approval for many services, procedures, or medications. This step can delay care and lead to denials if not managed carefully.
• Additional benefits: Unlike Original Medicare, many Medicare Advantage plans include extra services such as vision, hearing, dental, telehealth, and fitness benefits. These added benefits vary widely by plan.

Types of Medicare Advantage plans

There are several types of Medicare Advantage plans, each with different rules for coverage and provider access:

• Health Maintenance Organization (HMO): Requires you to use in-network providers and get referrals to see specialists. Typically has lower out-of-pocket costs.
• Preferred Provider Organization (PPO): Offers more flexibility to see out-of-network providers (at higher cost), and often doesn’t require referrals.
• Private Fee-for-Service (PFFS): Allows you to see any Medicare-approved provider who accepts the plan’s payment terms. Less common, with variable provider acceptance.
• Special Needs Plans (SNPs): Tailored for people with specific conditions (like diabetes or ESRD), those in nursing homes, or dual-eligible Medicare and Medicaid beneficiaries. These include coordinated care and targeted benefits.
• Medical Savings Account (MSA): Combines a high-deductible health plan with a medical savings account you can use for qualifying medical expenses. No drug coverage is included, so a separate Part D plan is needed.

To dive deeper into how each Medicare Advantage plan type works, check out the CMS guide to Medicare Advantage plans.

Understanding Medicare Advantage costs

Even though Medicare Advantage plans often advertise $0 premiums, there are still several types of costs to factor in:

• Premiums: You still pay your monthly Medicare Part B premium, and some Medicare Advantage plans charge an additional plan premium — though many do not.
• Deductibles: Plans may charge a yearly deductible before coverage begins for certain services.
• Copayments and coinsurance: These are your share of costs for services like office visits, lab tests, or hospital stays — and they vary by plan.
• Out-of-pocket maximums: Each Medicare Advantage plan sets a yearly cap on how much you’ll spend on covered services. Once you reach that limit, the plan pays 100% of your covered costs for the rest of the year.

Understanding the structure of Medicare Advantage is the first step toward making your plan work for you. From knowing the differences between HMOs and PPOs to tracking how much you’ve spent toward your out-of-pocket maximum, these foundational details shape everything from your monthly costs to your access to care. The more you know about how your plan operates — and how it compares to Original Medicare — the easier it becomes to take full advantage of the benefits available to you.

Hidden Benefits in Medicare Advantage Plans Many People Miss

Medicare Advantage plans often include a surprising range of supplemental benefits that go beyond what traditional Medicare offers. These extras are one of the top reasons why so many people switch from Original Medicare, yet many enrollees don’t fully use them — often because the benefits are buried in plan documents or come with limitations that aren’t well explained.

By understanding what your plan includes — and how to activate those perks — you can maximize your Medicare Advantage coverage and get more value from your plan.

Vision, dental, and hearing benefits

Most Medicare Advantage plans include some level of coverage for vision, dental, and hearing — areas not typically covered by Original Medicare.

• Vision: Plans may cover annual eye exams, glasses, or contact lenses. Some offer set dollar allowances; others use provider networks.
• Dental: Cleanings, X-rays, and basic services are common, with some plans covering major procedures like crowns or dentures — but often with annual limits or caps.
• Hearing: Hearing exams and hearing aids may be included, but with restrictions on which brands or providers are covered.

To get the most out of these benefits, check if your plan requires you to use specific in-network specialists and confirm whether any service limits or annual dollar caps apply.

Fitness and wellness programs

Many plans offer memberships in fitness programs like SilverSneakers or Silver&Fit, which provide free or low-cost access to participating gyms. Plans may also cover:

• Local gym memberships
• Virtual workout classes
• Wellness coaching and preventive care programs

These benefits not only promote physical activity, but may also reduce your long-term health risks — making them worth using regularly.

Over-the-counter (OTC) allowances

Many, but not all, Medicare Advantage plans offer OTC allowances—often on a quarterly basis. Over 70% of MA plans offer them. OTC cards let you buy approved non-prescription health items such as:

• Pain relievers
• Vitamins and supplements
• Cold and allergy medicine
• First-aid supplies
• Incontinence products

Benefits are usually accessed through a plan-issued card, catalog, or online store. To use your allowance effectively, track expiration dates and shop early in the benefit period — unused funds may not roll over.

Transportation benefits

Some Medicare Advantage plans cover non-emergency medical transportation to doctor visits or clinics. This benefit is especially useful if you don’t drive or live far from medical facilities.

• Plans may cover a set number of round-trip rides per year
• Limitations often include distance caps or service area restrictions
• Rides must usually be scheduled in advance, often through a dedicated phone line or app

Make sure to ask your plan how to activate this benefit before you actually need it.

Meal delivery services

After a hospital stay, some plans offer temporary meal delivery benefits to help you recover at home. These programs typically provide:

• Up to 10 to 14 meals delivered after a qualifying discharge
• Coverage through a partner service or pre-approved vendor
• Access with little or no cost sharing

Fewer than half of Medicare Advantage Plans offer post-discharge meal delivery benefits. To qualify, your discharge usually needs to meet specific criteria — and your provider may need to initiate the request. Ask about this benefit before leaving the hospital if it’s part of your plan.

Telehealth services

Medicare Advantage plans have significantly expanded telehealth coverage, including:

• Video visits with primary care doctors and specialists
• Behavioral health services
• Remote patient monitoring and virtual follow-ups

Telehealth often comes with lower copays than in-person visits and can save time and travel. These services are usually available through your plan’s preferred telehealth platform or provider network.

Home safety modifications and in-home support

Some plans now offer in-home support services and minor home safety modifications for eligible enrollees. These may include:

• Installation of grab bars, handrails, or shower chairs
• Help with light housekeeping, groceries, or personal care
• In-home health assessments or wellness visits

Not all plans offer this, and availability often depends on health status, recent hospitalizations, or participation in a chronic care program.

Caregiver support and respite care options

A small but growing number of Medicare Advantage plans offer caregiver support benefits, including limited respite care or counseling. This includes:

• Temporary respite care for family caregivers
• Counseling or caregiver training
• Access to case management and social work support

While not always promoted front and center, these services can make a big difference for people managing serious or chronic illnesses at home.

How to find these benefits in your plan

If you’re unsure whether your plan includes these supplemental benefits — or how to use them — the information is usually in one of three places:

• Your Evidence of Coverage (EOC): A detailed document that outlines exactly what your plan covers and any rules that apply.
• The Summary of Benefits: A higher-level overview that lists included services, costs, and extras.
• Your plan’s website or member portal: This is often the easiest place to track remaining OTC balances, check eligibility for extra services, and find contact numbers.

By looking beyond hospital and doctor visits, you may uncover thousands of dollars in added services — many of which go unused each year. Whether it’s a new pair of glasses, a ride to your next appointment, or meals after a hospital stay, these hidden benefits can have a real impact on your health and your wallet.

Navigating Your Plan's Provider Network

When it comes to Medicare Advantage, your choice of doctors and specialists is directly tied to your plan’s provider network — and understanding that network is critical to avoiding surprise bills, referral delays, or even denied care. Unlike Original Medicare, which allows you to see any provider who accepts Medicare, most Medicare Advantage plans limit you to a specific group of in-network providers.

Why in-network providers matter

Staying in-network typically means:

• Lower out-of-pocket expenses
• Streamlined care coordination
• Greater likelihood of prior authorization approval
• Full coverage for included services

Going out-of-network — especially with HMO plans — can mean paying the full cost of care unless it's an emergency or urgent care visit.

How to find in-network providers

Finding doctors and facilities that accept your Medicare Advantage plan isn’t always straightforward. Here’s where to look:

• Your plan’s provider directory: Usually available in print or as a downloadable PDF, this is the most direct source for listing in-network doctors, hospitals, and specialists.
• Online search tools: Most plans offer searchable databases on their websites, often filtered by specialty, location, and language.
• Calling member services: Your plan’s customer service team can confirm a provider’s status and help with scheduling or referrals.

Since network status can change, it’s a good idea to confirm the provider’s participation each time you make an appointment — even if you've seen them before.

Questions to ask before choosing a provider

When selecting a new provider, ask:

• “Do you accept my Medicare Advantage plan?”
• “Are you contracted as an in-network provider?”
• “Will you bill my Medicare Advantage plan directly?”

These questions can help avoid confusion between providers who accept Medicare (as with Original Medicare) and those contracted with your specific plan.

Understanding referral requirements

Some Medicare Advantage plans — especially HMOs — require a referral from your primary care physician (PCP) before you can see a specialist.

• When referrals are needed: This varies by plan but is common in HMO models. PPOs and PFFS plans are typically more flexible.
• How to get a referral: Contact your PCP, who may need to submit a request through your plan’s portal. Timing matters — many referrals need to be submitted and approved in advance.
• If you skip the referral: You may be on the hook for the full cost of the specialist visit, even if that provider is in-network.

Out-of-network care: what it could cost you

Out-of-network costs can be steep — sometimes the full price of the service, especially under HMO plans. PPO and PFFS plans may offer partial coverage for out-of-network care, but copays and coinsurance will be significantly higher.

Before scheduling out-of-network care, always:

• Check if your plan allows it
• Confirm cost-sharing amounts
• Ask whether an in-network alternative is available

Coordinating care across multiple specialists

If you’re managing chronic conditions or seeing multiple specialists, coordinating your care becomes even more important. Medicare Advantage plans often assign a PCP to act as the hub of your care team, helping:

• Track medications and test results
• Prevent duplicate or conflicting treatments
• Facilitate referrals and prior authorizations

You can also use your plan’s case management services if available—especially if you’re navigating multiple providers, transitions between care settings, or complex health needs.

Understanding and actively managing your provider network puts you back in control of your healthcare experience. Whether it’s confirming referral requirements or making sure every specialist you see is covered, a little planning upfront can help you avoid major billing headaches later.

Tips for Staying In-Network with Medicare Advantage Providers

Once you’ve chosen your Medicare Advantage plan, keeping your care in-network is key to avoiding surprise charges and denied claims. But provider networks can shift — doctors leave plans, new specialists get added, and coverage rules change. Staying proactive helps you protect your benefits and control your out-of-pocket costs.

Keep a current provider list

Start by creating a written or digital list of all your regular providers — primary care, specialists, labs, imaging centers, and even pharmacies. At least once a year, verify each provider’s network status by checking your plan’s website, calling the provider’s office, or using your plan’s member services line.

Set annual reminders to check provider status

Networks change more often than many patients realize. It’s a smart move to:

• Set a calendar reminder once a year (ideally during open enrollment) to re-check your doctors
• Confirm whether your providers are still listed as in-network and contracted with your specific plan
• Review any plan update letters that mention changes to your provider network

How to check new providers before an appointment

When booking with a new doctor or specialist, ask:

• “Do you accept my Medicare Advantage plan?”
• “Are you in-network for this plan year?”
• “Will you bill my plan directly, or do I need to submit claims?”

These questions help prevent billing surprises and clarify if prior authorization or referrals are needed in advance.

What if you need to go out-of-network?

Sometimes, your preferred specialist isn’t in-network — or there’s no qualified in-network provider nearby. In that case:

• Ask your plan about exceptions: Some may allow coverage for out-of-network care if there’s no suitable in-network option.
• Request a referral or prior authorization: You may need documentation showing why the out-of-network provider is medically necessary.
• Document everything: Keep written records of any approval from your insurer and notes from your provider recommending the out-of-network care.

Managing care while traveling

Routine care is usually limited to your plan’s service area, unless you’re in a PPO or special travel plan:

• Emergency and urgent care is always covered, regardless of where you are in the U.S.
• Temporary absence provisions: Some plans allow temporary out-of-area coverage if you’ll be away for an extended time (e.g., snowbird travel).
• Routine care while traveling is usually not covered unless you’re in a special travel plan or PPO model.

Before you leave town, contact your plan to ask what’s covered and what steps to take if you need care while away.

If your provider leaves the network

Provider departures are common — and they can disrupt your care if you’re not prepared. Here’s what to do:

• Use transition of care provisions: Plans often allow short-term continued coverage with a departing provider, especially for ongoing treatments or pregnancy.
• Start looking for new in-network providers immediately through your plan’s directory or case management team.
• Ask about continuity of care exceptions if you’re in the middle of a serious health issue.

Use your plan’s case management for complex needs

Many Medicare Advantage plans offer case managers — nurses or care coordinators who help you:

• Schedule and track appointments
• Confirm provider network status
• Coordinate referrals and prior authorizations
• Communicate between multiple doctors

This service is especially useful for people with chronic conditions or frequent specialist visits.

Work with your PCP as a “home base”

Your primary care physician (PCP) is often your key to staying in-network. They’ll guide referrals, oversee your overall care, and act as a central point of contact. Building a strong relationship with your PCP can help prevent duplication of care and make it easier to navigate changing networks.

Keep written documentation

Whenever you verify provider participation, request referrals, or deal with changes to your care team, write it down:

• Save emails or call notes with dates and names
• Take screenshots of provider directories showing in-network status
• Record approval numbers for out-of-network exceptions or referrals

If billing issues arise, this documentation can protect you from out-of-network charges or denied claims.

Staying in-network isn’t just about saving money — it’s about keeping your care running smoothly. With a few habits in place, you can avoid unnecessary stress and keep your Medicare Advantage plan working the way it should.

Making the Most of Your Prescription Drug Coverage

Prescription drug costs can add up quickly — especially if you take multiple medications or rely on brand-name prescriptions. Fortunately, Medicare Advantage plans that include Part D drug coverage often provide several options to help you lower costs and manage access. But to get the full value, you’ll need to understand how your plan’s pharmacy benefits actually work.

Understand your plan’s drug formulary

Each Medicare Advantage plan with drug coverage has a formulary—a list of covered medications. These drugs are organized into tiers, and your out-of-pocket costs depend on where your medication falls.

• Tier levels and cost-sharing: Tier 1 drugs (often generics) usually have the lowest copays. Higher tiers — especially Tier 4 or 5 — may include specialty or brand-name drugs with higher cost-sharing.
• Prior authorization: Some drugs require pre-approval before they’ll be covered. Your provider must submit documentation showing medical necessity.
• Step therapy: Plans may require you to try a lower-cost or formulary-preferred drug before approving a more expensive one.
• Quantity limits: Certain drugs may be limited to a set number of doses or pills per fill unless your doctor requests an exception.

Before filling a new prescription, it’s a good idea to check where it lands in your plan’s formulary and whether any restrictions apply.

Strategies for lowering prescription costs

Even if your medication is covered, there are still smart ways to reduce your out-of-pocket expenses:

• Use preferred pharmacies: Many Medicare Advantage plans partner with specific pharmacy chains that offer lower copays. Be sure you’re filling prescriptions at a “preferred” — not just “in-network” — pharmacy.
• Try mail-order options: Plans often offer a discount for ordering 90-day supplies through their mail-order pharmacy. It’s convenient and may reduce per-dose costs.
• Ask about generics: Switching to a generic or therapeutic equivalent can save hundreds per year — without compromising on effectiveness.
• Consider 90-day retail fills: Some plans offer 90-day supplies at retail pharmacies, allowing you to skip mail-order but still save on costs and reduce trips to the pharmacy.

Understand the coverage gap (the “donut hole”)

The Medicare Part D coverage gap, also known as the “donut hole,” kicks in after you and your plan spend a certain amount on prescriptions in a calendar year.

• In the coverage gap, you pay a percentage of the drug’s cost — currently 25% for brand-name and generic drugs.
• Once your total spending hits a second threshold, you enter “catastrophic coverage,” where your share of costs drops significantly.

While recent policy changes have made the donut hole less severe, it still surprises many people each year — especially those on high-cost medications.

Use medication therapy management (MTM) programs

If you take multiple prescriptions for chronic conditions, your plan may offer a Medication Therapy Management program. These are free services that:

• Review your entire medication list for safety and effectiveness
• Identify possible drug interactions
• Help you organize dosing schedules
• Work with your doctors to eliminate unnecessary or duplicate meds

Not everyone qualifies automatically — you may need to meet specific usage or cost thresholds — but if offered, MTM can improve outcomes and reduce risks.

Request prescription drug exceptions

If your medication isn’t covered—or falls on a high-cost tier—you can request an exception. This is a formal process that may allow:

• Coverage for a non-formulary drug
• Tier reduction (so you pay a lower copay)
• Higher quantity limits when medically necessary

To request an exception:

1. Ask your doctor to submit a supporting statement explaining why the drug is necessary.
2. Follow your plan’s process, usually involving a faxed or online form.
3. If denied, you have the right to appeal — and a Solace advocate can help manage this process if needed.

Getting the most from your Medicare Advantage drug coverage takes a little upfront work — but the payoff can be significant. By checking formularies, using preferred pharmacies, and knowing your rights when it comes to exceptions and coverage gaps, you’ll be better equipped to keep your medication costs under control without compromising your health.

Special Situations: Chronic Conditions and Complex Care

For Medicare Advantage members with serious or ongoing health conditions, standard coverage may not be enough. Many plans offer specialized programs designed to support people with chronic illnesses, multiple providers, and frequent transitions between care settings. Taking advantage of these services can reduce hospitalizations, improve treatment outcomes, and help you stay organized and supported.

Special Needs Plans (SNPs) for chronic conditions

Special Needs Plans (SNPs) are Medicare Advantage plans tailored to people with specific needs, including:

• Certain chronic conditions like diabetes, congestive heart failure, or end-stage renal disease (ESRD)
• Institutional needs, such as living in a nursing home
• Dual eligibility for both Medicare and Medicaid
• SNP availability varies by location and condition eligibility

SNPs typically offer enhanced care coordination, access to condition-specific providers, and expanded supplemental benefits — including transportation, nutrition support, and in-home services. If you qualify, switching to an SNP can dramatically improve how well your care fits your needs.

Care coordination programs for complex needs

Many Medicare Advantage plans offer care coordination services for people managing multiple conditions or recent hospitalizations. These programs help you:

• Connect your primary care provider with your specialists
• Avoid duplicate tests and conflicting prescriptions
• Ensure that all members of your care team are on the same page

Care coordinators may reach out after a hospital stay or high-risk diagnosis — but you can also proactively ask if you’re eligible.

Disease management programs

If you’re living with a chronic condition like COPD, heart failure, or diabetes, you may qualify for a disease management program through your plan. These typically include:

• Educational resources about your condition
• Regular check-ins with nurses or health coaches
• Medication reminders and adherence tools
• Goal-setting and progress tracking

Participating in these programs is usually free and may also unlock additional services, such as remote monitoring or home visits.

Utilizing case managers

Medicare Advantage plans often assign case managers to patients with complex health needs. Case managers are usually nurses, social workers, or trained care coordinators who help with:

• Scheduling appointments
• Securing referrals and prior authorizations
• Coordinating care across specialists
• Tracking test results and follow-up plans
• Helping with transitions in care, like hospital discharges

If you’ve had repeated hospitalizations, difficulty managing medications, or complex treatment plans, ask your plan if a case manager is available to help.

Questions to ask about condition-specific benefits

To make sure you’re getting all the support available, ask your plan:

• “Do I qualify for a Special Needs Plan?”
• “Do you offer disease management or coaching for my condition?”
• “Can I be assigned a case manager?”
• “Are there any added benefits for people with [your condition]?”

Your plan may not advertise these programs widely — but asking directly can help you unlock support you didn’t know existed.

Transitioning between care settings

Whether you’re moving from hospital to rehab, from home to outpatient therapy, or between specialists, transitions of care can be risky. Miscommunication, missing paperwork, or uncoordinated treatment can delay recovery or even lead to readmission.

Medicare Advantage plans may offer:

• Discharge planning assistance
• Follow-up visit scheduling
• Medication reconciliation
• Home health visits or check-ins

Don’t hesitate to ask your plan what services are available during a care transition — especially after an ER visit or hospitalization.

Working with your care team to maximize benefits

The more your care team communicates, the better your outcomes. Here’s how to keep things running smoothly:

• Share a complete list of all providers and medications with each doctor you see
• Ask your primary care physician to act as your central coordinator
• Make sure each provider knows your Medicare Advantage plan and any referral requirements
• Bring your plan’s Summary of Benefits or EOC to complex appointments to discuss covered options

If you’re dealing with complex medical issues, you shouldn’t have to manage everything on your own. Between Special Needs Plans, case managers, and care coordination programs, your Medicare Advantage plan likely has more support available than you realize — you just have to ask.

Preventing Claim Denials and Coverage Issues

Even with a comprehensive Medicare Advantage plan, coverage issues and denied claims can happen — and often for reasons that could’ve been avoided. Whether it’s a missing referral, an out-of-network provider, or a small paperwork error, these issues can delay care or lead to unexpected bills. The good news? A little preparation can prevent most of them.

Common reasons for Medicare Advantage claim denials

Understanding the most frequent denial triggers can help you avoid them:

• Medical necessity issues: If your plan decides a service or procedure isn’t “medically necessary,” it may deny payment — even if your doctor recommends it.
• Network restrictions: Seeing a provider who’s out-of-network without proper approval — even for lab work or anesthesia — can result in a full denial.
• Coding or billing errors: Mistakes in how a service is billed or coded can trigger automatic denials, even if the service is actually covered.
• Missing prior authorization: Many Medicare Advantage plans require approval before services like MRIs, surgeries, or specialty medications. Skipping this step is a common reason for denial.

New federal rules are shaping how prior authorization and coverage determinations are handled in 2025. You can read the full CMS 2025 Medicare Advantage final rule for more details.

Work with your providers on documentation

Good communication with your care team is key. Before receiving services, ask your provider’s office to:

• Submit any required prior authorizations
• Include supporting documentation for why a service is necessary
• Double-check whether all involved providers (especially anesthesiologists, radiologists, and labs) are in-network for your specific plan

Make sure your doctor uses the correct billing codes and attaches medical records when needed — especially for high-cost procedures.

Questions to ask before receiving care

To avoid denials before they happen, ask these questions at scheduling or check-in:

• “Is this service covered under my Medicare Advantage plan?”
• “Do I need prior authorization — and has it been submitted and approved?”
• “Are all providers involved in-network for my plan?”

Getting the answers upfront helps you avoid the “I didn’t know” surprises after the bill arrives.

Keep detailed records

Whether you’re managing routine appointments or a complex procedure, document everything:

• Keep written notes of phone calls, including dates, names, and what was said
• Save emails and confirmation letters
• Take screenshots of online authorization approvals or network status listings

This documentation can be crucial if you need to dispute a denial later.

Track claims through your member portal

Most Medicare Advantage plans offer a member portal where you can:

• View the status of submitted claims
• Check prior authorization approvals
• Review Explanation of Benefits (EOB) statements
• Contact member services if something looks off

Logging in regularly helps catch problems early and makes it easier to spot billing mistakes or delays.

Understand your Explanation of Benefits (EOB)

Your EOB statement is not a bill — it’s a breakdown of what your plan was billed, what was paid, and what you may owe. Each EOB includes:

• The date of service
• The provider’s name
• The type of service performed
• The amount billed and allowed
• What your plan paid
• What portion (if any) you owe

If you see a denial listed, check for explanation codes and call your plan to ask for clarification. In many cases, you may still be able to appeal the decision — especially if the issue was paperwork-related.

How A Solace Advocate Can Help

Medicare Advantage plans can offer tremendous value—but only if you know how to use them. That’s where Solace comes in. Solace advocates are trained healthcare experts who can help you navigate your Medicare Advantage plan. This includes untangling the fine print, unlocking overlooked benefits, and avoiding costly missteps.

Whether you’re struggling with prior authorizations, switching providers, or dealing with claim denials, a Solace advocate can help make your coverage work for you, not against you.

Maximize your Medicare Advantage benefits with expert support

Solace advocates do more than just answer questions—they help you make the most of your plan. That includes:

• Identifying hidden benefits like dental, vision, transportation, and meal delivery services that many members miss
• Navigating complex provider networks, including verifying network status and coordinating care across multiple specialists
• Tracking your care by organizing appointments, referrals, and medical paperwork
• Reviewing plan documents like your Evidence of Coverage (EOC) or Summary of Benefits to make sure you understand everything your plan offers

Advocates help you avoid the confusion that causes so many people to underuse—or lose—valuable benefits.

Help with appeals when coverage is denied

If your plan refuses to cover a service, Solace can help manage your Medicare Advantage appeals. Advocates assist by:

• Preparing documentation and working with your doctor to gather medical evidence
• Helping you file appeals on time, according to your plan’s specific rules
• Following up with your insurer to track progress and address delays
• Communicating directly with providers to clarify prior authorizations, coding issues, or denials based on “medical necessity”

Many patients give up after a denial, but an advocate keeps pushing until every option is exhausted.

Support for staying in-network and coordinated care

Maintaining in-network care is one of the most common—and frustrating—challenges with Medicare Advantage. Solace advocates can:

• Research network status for every provider involved in your care
• Find new in-network specialists if your doctor retires, relocates, or leaves the plan
• Help with transitions of care, like moving from hospital to rehab or finding a new primary care provider
• Coordinate across multiple providers so your care stays connected and nothing gets lost in the shuffle

With an advocate’s help, you can avoid costly out-of-network surprises and stay focused on your health.

Medicare covers advocacy services

Solace works within Medicare-approved care coordination codes. That means if you’re eligible—and many Medicare Advantage members are—you may pay nothing out of pocket for your advocate’s services.

You don’t need a referral to get started. Just book a short call, and Solace will help you determine eligibility and match you with an advocate who understands your situation.

Take the next step with Solace

If you’re overwhelmed by paperwork, dealing with claim denials, or just not sure whether you’re getting everything your plan offers, you don’t have to figure it out alone. Solace advocates have already helped thousands of people with Medicare Advantage maximize their coverage, fight denied claims, and get access to the care they deserve.

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Frequently Asked Questions

1. How does Medicare Advantage compare to Traditional Medicare?

Traditional Medicare offers broad nationwide access to providers but doesn’t include most supplemental benefits like dental, vision, or fitness. Medicare Advantage plans are managed by private insurers and usually require you to stay within a provider network. They often bundle Part A, Part B, and Part D coverage, include extra services, and cap out-of-pocket expenses—but they also come with prior authorization requirements, narrower networks, and plan-specific rules. Comparing these side by side can help you maximize your Medicare Advantage coverage if you choose to enroll.

2. What is the Medicare Advantage star rating system, and why does it matter?

Each year, the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage plans from one to five stars based on quality measures like customer service, preventive care, member satisfaction, and chronic condition management. Higher-rated plans may offer better care coordination and even special enrollment periods. Choosing a plan with a strong star rating can improve your overall experience and reduce your risk of coverage issues.

3. Can I switch Medicare Advantage plans if my provider leaves the network?

Yes. If your primary care physician or specialist leaves your plan’s in-network provider list, you may qualify for a Special Enrollment Period (SEP). You can also request a transition of care provision to continue treatment temporarily. A Solace advocate can help you confirm eligibility and explore new plan options during the switch.

4. How do Part D late enrollment penalties work with Medicare Advantage?

If you delay enrolling in Part D coverage (drug coverage) and don’t have other creditable prescription coverage, you may face a Part D late enrollment penalty. This can still apply even if you join a Medicare Advantage plan with drug coverage later on. The penalty is calculated based on how many months you went without coverage and is added to your monthly premium — often permanently.

5. Does Medicare Advantage cover services when I travel out of state?

Emergency and urgent care are always covered nationwide, even outside your plan’s service area. But for routine care, you’ll generally need to stay within your plan’s provider network. Some PPOs and employer group plans offer broader travel coverage or temporary out-of-area arrangements. Always check with your plan before extended travel — and save all out-of-network provider documentation in case you need to request reimbursement.

6. What happens if I enroll in a Medicare Advantage plan and then want to go back to Traditional Medicare?

You can return to Original Medicare during the Annual Enrollment Period (Oct 15–Dec 7) or the Medicare Advantage Open Enrollment Period (Jan 1–Mar 31). If you had a Medigap policy before, you may not be guaranteed the same plan or pricing if you want to buy it again — unless you're eligible for a trial right or guaranteed issue period. Solace advocates can help evaluate your options and the timing of such transitions.

7. How are Medicare Advantage plans funded and regulated?

Medicare pays private insurers a set amount per enrollee based on risk adjustment, which accounts for factors like age, gender, and chronic conditions. Plans must meet medical loss ratio standards, meaning they must spend a minimum percentage of revenue on healthcare, not administrative costs. These plans are also regulated by CMS, which oversees plan approval, network adequacy standards, and quality reporting.

8. Can Medicare Advantage plans deny care that Original Medicare would approve?

Yes, and this is a common point of frustration. While plans are required to cover all medically necessary Part A and B services, they can require prior authorization, apply network restrictions, and define "necessity" more narrowly. If your claim is denied, you have the right to manage your Medicare Advantage appeals — and a Solace advocate can assist with gathering medical evidence and tracking the appeal process.

9. What’s the difference between supplemental coverage and Medicare Advantage?

Medicare Advantage replaces your Original Medicare benefits with a private plan, often including Part D and extra perks. Supplemental coverage, like a Medigap policy, works with Original Medicare to cover deductibles, copays, and coinsurance — but doesn’t include drug coverage or supplemental benefits. You can’t have both at the same time, so it’s important to choose based on your budget, provider preferences, and coverage needs.

10. What role does preventive care play in Medicare Advantage?

Preventive care is a core focus of Medicare Advantage. Plans are incentivized (through CMS’s value-based insurance design) to offer and track services like screenings, immunizations, annual wellness visits, and chronic disease management. These services are often free or low-cost and can prevent higher medical expenses down the line. Using them regularly is one of the best ways to maximize your Medicare Advantage coverage and avoid hospitalizations or complications.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

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