Yes, a Medicare Advantage plan has to cover home health. Federal rules require the plan to cover the services Original Medicare covers and to use the same home health coverage criteria. What changes is the path to the first visit: the plan may want to approve the care first, may send you to an agency in its network, and in some plans may charge part of the cost.
The first half of this page is for families asking whether a parent's plan will cover home health. The second is for agencies asking what a plan can refuse and what it must approve.
Every regulation quoted is from 42 CFR, read on Cornell's Legal Information Institute, or from the CMS final rules that changed it. Original Medicare's side is from Medicare.gov. No plan is named.
For Families: What the Plan Must Still Cover
The rule is 42 CFR 422.101. A plan must "provide coverage of, by furnishing, arranging for, or making payment for, all services that are covered by Part A and Part B of Medicare." Paragraph (b)(2) makes it follow Traditional Medicare's coverage conditions and names home health: "requirements for payment of Skilled Nursing Facility (SNF) Care, Home Health Services under 42 CFR part 409." Medicare.gov puts it plainly: "Plans must cover all medically necessary services that Original Medicare covers."
The requirements in who qualifies for home health care apply to a plan member too: confined to the home, a skilled need, and a plan of care from a physician or allowed practitioner (42 CFR 409.42). The agency must be Medicare-certified. Under 42 CFR 422.204(b)(3), basic benefits from providers like home health agencies "may only be provided through these providers if they have a provider agreement with CMS."
The plan cannot invent its own reasons to say no. Under 422.101(c)(1)(i)(A), it "may not deny coverage for basic benefits based on coverage criteria not specified in paragraph (b) or (c) of this section."
Original Medicare and Medicare Advantage, Side by Side
| Question | Original Medicare | Medicare Advantage | Source |
|---|---|---|---|
| Coverage rules for home health | 42 CFR part 409 | The same part 409 rules | 42 CFR 422.101(b)(2) |
| Approval before care | "In most cases, you don't need approval (prior authorization)" | "You may need to get approval (prior authorization) from your plan before it covers certain services or supplies" | Medicare.gov comparison page |
| Which agency | "a Medicare-certified home health agency must provide it" | A coordinated care plan "may specify the networks of providers," but must cover care out of network "at in-network cost sharing" when its network is "unavailable or inadequate" | Medicare.gov; 42 CFR 422.112(a), (a)(1)(iii) |
| What you pay for visits | "You pay nothing for covered home health services" | In-network, no more than Original Medicare, except in plans with the lower out-of-pocket limit | Medicare.gov; 42 CFR 422.100(j)(1)(i)(D) |
If the plan limits you to its network, ask which contracted agencies serve the address, then compare them: how to choose a home health agency covers star ratings and the questions to ask.
Warning
Ask the plan what it charges for home health before the first visit. The federal cap in 42 CFR 422.100(j)(1)(i)(D) covers in-network cost sharing and depends on which yearly out-of-pocket limit the plan chose. A plan on the lower limit may charge up to "20 percent coinsurance or an actuarially equivalent copayment." What patients pay under Original Medicare has the rest of that picture.
For Families: How Fast the Plan Has to Answer
The plan's yes or no is called an organization determination. The deadlines are in 42 CFR 422.568 and 422.572.
- Standard request. "Beginning on or after January 1, 2026, for a service or item subject to the prior authorization rules in § 422.122, 7 calendar days after receiving the request for the standard organization determination" (422.568(b)(1)(ii)). A service the plan does not put under prior authorization keeps the older limit of "14 calendar days" ((b)(1)(i)).
- Expedited request. Due "no later than 72 hours after receiving the request" (422.572(a)(1)), when the standard timeframe "could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function" (422.570(c)(2)).
- Extensions. Up to 14 calendar days, only for the reasons the rule lists. The plan must give its reasons in writing (422.568(b)(2), 422.572(b)).
- Silence. A missed deadline "itself constitutes an adverse organization determination and may be appealed" (422.568(f)).
- Reasons. A denial notice must "state the specific reasons for the denial" (422.568(e)(2)). Since January 1, 2026, the response to the provider on a prior authorization denial "must include a specific reason for the denial" (422.122(a)).
To appeal, ask for a reconsideration "within 60 calendar days after receipt of the written organization determination notice" (42 CFR 422.582(b)). The plan has 30 calendar days on a standard appeal and 72 hours on an expedited one (422.590(a), (e)(1)).
For Families: Switching Plans in the Middle of Care
A new plan cannot simply stop home health already under way. Under 42 CFR 422.112(b)(8)(i)(B), a coordinated care plan must allow "a minimum 90-day transition period for any active course(s) of treatment when an enrollee has enrolled in an MA plan after starting a course of treatment, even if the service is furnished by an out-of-network provider." It "must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days."
Does home health count? In the Contract Year 2024 final rule, CMS wrote that "an active course of treatment may include situations when a patient is transferred from an acute inpatient setting to a SNF, HHC, and care in other post-acute care settings" (88 FR 22208). HHC is home health care.
For Agencies: What the Plan Can Refuse
- It can require approval first, for limited purposes. Under 42 CFR 422.138(b), coordinated care plans may use prior authorization only "to confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations," or to ensure a basic benefit "is medically necessary based on standards specified in § 422.101(c)(1)." Private fee-for-service plans "are not permitted to use prior authorization policies" (422.138(a)).
- It can apply its own criteria, only where Medicare's run out. Internal criteria are allowed "when coverage criteria are not fully established" in Medicare law, NCDs or LCDs, and must be public (422.101(b)(6)). Naming part 409 home health in the same passage, CMS wrote that plans may not use commercial screening products "to change coverage or payment criteria already established under Traditional Medicare laws" (88 FR 22194).
For Agencies: What the Plan Must Do
- Decide on the chart. Medical necessity decisions rest on "the enrollee's medical history (for example, diagnoses, conditions, functional status), physician recommendations, and clinical notes" (422.101(c)(1)(i)(C)).
- Keep its word. Approval of a course of treatment "must be valid for as long as medically necessary to avoid disruptions in care" (422.112(b)(8)(i)(A)). After a prior authorization, pre-service or concurrent approval, the plan "may not deny coverage later on the basis of lack of medical necessity" (422.138(c)).
- Publish its list. By March 31, a plan must post the previous year's "list of all items and services that require prior authorization" with its approval and denial rates (422.122(c)). Check it, then confirm with the plan.
Who may ask matters. Any provider that "furnishes, or intends to furnish, services to the enrollee" may request a standard decision (422.566(c)(1)(ii)). An expedited request must come from the enrollee or "a physician" (422.566(c)(2)), and the plan must expedite when the physician indicates the standard timeframe could seriously jeopardize the patient's life, health or ability to regain maximum function (422.570(c)(2)(ii)).
Tip
Practice, not rule: the plan's clock and the agency's clock differ. Under 42 CFR 484.55(a)(1), "the initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner-ordered start of care date," whatever the payer. A 7-day decision can outrun that. Send the request the day the referral is accepted, with the orders, the face-to-face note and clinical notes showing homebound status and the skilled need. When a delay would cost function, ask the physician for an expedited request. Otherwise get an ordered start of care date that fits. The intake steps are in referral to first visit.
The final rules behind these sections:
| Rule | What it did for home health |
|---|---|
| CMS-4201-F, CY2024 (88 FR 22120) | Traditional Medicare coverage criteria, limits on internal criteria, the 90-day transition |
| CMS-0057-F (89 FR 8758) | The 7-day standard decision from January 1, 2026, a specific denial reason, public prior authorization lists |
| CMS-4208-F, CY2026 (90 FR 15792) | Notice to the physician or provider involved, concurrent approvals protected |
| CMS-4208-F3 and CMS-4212-F, CY2027 (91 FR 17384) | No change to these timeframes or to the coverage criteria rule |
When the Plan Ends the Visits
Under 42 CFR 422.624(a)(2), a termination "includes cessation of coverage at the end of a course of treatment preauthorized in a discrete increment, regardless of whether the enrollee agrees that such services should end." The end of an approved block of visits counts.
The agency delivers the plan's notice "no later than two days before the proposed end of the services," and when visits are more than two days apart, "no later than the next to last time services are furnished" (422.624(b)(1)). It is valid only once the member or representative "has signed and dated the notice" (422.624(c)(1)). If the notice is late or invalid, the plan stays liable "until 2 days after the enrollee receives valid notice" (422.624(d)).
The member can ask an independent review entity for a fast-track appeal "by noon of the first day after the day of delivery of the termination notice" (422.626(a)(1)). The burden of proof "rests with the MA organization" (422.626(c)).
See which agencies serve your ZIP code
From Medicare's own Care Compare data: star ratings, on-time starts and hospital stays for every agency that serves the ZIP code, and a side-by-side view of up to four.
Key Takeaways
- A Medicare Advantage plan must cover home health under the same part 409 criteria as Original Medicare, through a Medicare-certified agency.
- What differs is the path: approval first, a network, and possible cost sharing in plans with the lower out-of-pocket limit.
- Since January 1, 2026, a standard prior authorization decision is due within 7 calendar days and an expedited one within 72 hours. Silence is an appealable denial.
- A new member already in home health gets at least 90 days without disruption or reauthorization. An approval cannot later be denied for lack of medical necessity.
- When visits end, the agency delivers the plan's notice, and the member can ask for a fast-track appeal by noon of the next day.
Frequently asked questions
Does a Medicare Advantage plan have to cover home health care?
Yes. A Medicare Advantage plan must cover the services Original Medicare covers, and the federal rule requires it to apply the home health coverage criteria in 42 CFR part 409. It may require approval first and may limit you to agencies in its network, but it may not deny home health on criteria the federal rule does not allow.
How long does a Medicare Advantage plan have to decide a home health prior authorization?
Since January 1, 2026, a standard decision on a service that falls under the plan's prior authorization rules is due no later than 7 calendar days after the plan receives the request. An expedited decision is due no later than 72 hours after the request. The plan may extend either one by up to 14 calendar days, only for reasons the rule lists, and it must explain the delay in writing.
Can a home health agency ask for an expedited decision?
Not by itself. The agency can request a standard decision because it intends to furnish the service. An expedited request has to come from the patient, the patient's representative, or a physician, and the plan must expedite when a physician indicates the standard timeframe could seriously jeopardize the patient's life, health or ability to regain maximum function.
What happens to home health if someone switches from Original Medicare to a Medicare Advantage plan mid-care?
A coordinated care plan must give a new enrollee in an active course of treatment a transition period of at least 90 days. During it the plan must not disrupt the treatment or require reauthorization, even if the agency is out of network. CMS has said an active course of treatment may include a patient moved from a hospital to home health care.
What can a family do when the plan says home health is ending?
The agency must give you the plan's written notice no later than two days before covered services end, or by the next-to-last visit when visits are more than two days apart. You can ask the independent review entity named on the notice for a fast-track appeal by noon of the day after you receive it, and the plan carries the burden of showing the decision is correct.
Sources
- 42 CFR 422.101: basic benefits, Traditional Medicare coverage criteria including part 409 home health, internal coverage criteria, medical necessity determinations.
- 42 CFR 422.112: networks, out-of-network coverage, the 90-day transition and approval validity in (b)(8).
- 42 CFR 422.100(j): in-network cost sharing limits for home health.
- 42 CFR 422.122 and 422.138: prior authorization requirements and limits.
- 42 CFR 422.566, 422.568, 422.570, 422.572: organization determinations and their timeframes.
- 42 CFR 422.582 and 422.590: reconsiderations.
- 42 CFR 422.624 and 422.626: termination notices and fast-track appeals.
- 42 CFR 422.204, 409.42 and 484.55: certified providers, home health eligibility, the initial assessment visit.
- CMS-4201-F, Contract Year 2024 final rule, 88 FR 22120, April 12, 2023 (preamble at 88 FR 22194 and 22208).
- CMS-0057-F, Interoperability and Prior Authorization final rule, 89 FR 8758, February 8, 2024.
- CMS-4208-F, Contract Year 2026 final rule, 90 FR 15792, April 15, 2025; CMS-4208-F3 and CMS-4212-F, Contract Year 2027 final rule, 91 FR 17384, April 6, 2026.
- Medicare.gov, Home health services and Compare Original Medicare and Medicare Advantage.
- Related on this site: who qualifies for home health care, what patients pay under Original Medicare, how to choose a home health agency, referral to first visit.