Medicare Advantage and home health

All Medicare Advantage Plans must provide at least the same level of home health care coverage as Original Medicare Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , but they may impose different rules, restrictions, and costs. Depending on your plan, you may need to:

• Get care from a home health agency (HHA) home health agency (HHA) A home health agency (HHA) is an organization that provides home care services, such as skilled nursing, physical therapy, occupational therapy, speech-language pathology, and personal care. that contracts with your plan
• Request prior authorization prior authorization Prior authorization, also known as pre-authorization or pre-approval, is a restriction placed on coverage by Part D plans and Medicare Advantage Plans. If a service or drug requires prior authorization, you must first get approval from the plan for it to be covered. If you fail to get prior authorization before you get the service or drug, your plan generally will not cover it. or a referral referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam. before receiving home health care
• Pay a copayment copayment A copayment, also known as a copay, is a set amount you are required to pay for each medical service you receive (like $35 for a doctor’s visit). for your care (Original Medicare fully covers home health)

Know that HHAs can choose who to accept as a patient or refuse to provide you with home health services if they do not believe they can ensure your safety. If no HHA in your plan’s network will take you as a patient, call your plan. Your plan must provide you with home health care if your doctor says it is medically necessary medically necessary Medically necessary refers to procedures, services, or equipment that meet accepted medical standards and are necessary for the diagnosis and treatment of a medical condition. . If no in-network in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. HHA will provide you with care, but an out-of-network out-of-network Out-of-network means not part of a private health plan’s network of health care providers. If you use doctors, hospitals, or pharmacies that are not in your Medicare Advantage Plan or Part D plan’s network, you will likely have to pay the full cost out of pocket for the services you received. HHA will, your plan must provide coverage for your out-of-network home health care. If no HHA in your area can provide you with care, speak to your doctor about other options for receiving care.

If you need information about the costs and coverage rules for home health care, or if you are experiencing problems, contact your Medicare Advantage Plan.