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Family Guide

Medicare Advantage vs. Original Medicare for home health

Both must cover the same core home health benefit — but the rules around network, prior authorization, and appeals are very different. Here is what Florida families need to know before they need care.

The short answer

Medicare Advantage (MA) plans must cover the same home health benefit as Original Medicare — including skilled nursing, therapy, and aide services with $0 copay. What differs is the process: MA plans typically require prior authorization, restrict you to in-network agencies, and have their own appeals timeline. Original Medicare has no prior auth and no network. Both honor the same homebound and skilled-care eligibility rules under 42 CFR §422.101. 1

Medically reviewed by Kassy Health Medical Team Last reviewed May 2026 · Next review May 2027 · 11 min read
An older woman at home thoughtfully reviewing Medicare plan paperwork at a coffee table
Plain-English Definitions

Five terms that decide which plan rules apply to you

Knowing these five terms before you call your plan turns a confusing call into a short one.

Original Medicare (Parts A & B)
The traditional federal program. Part A covers inpatient hospital and skilled nursing facility care. Part B covers outpatient services, durable medical equipment, and most home health visits. Both administered directly by CMS. Identified by the red, white, and blue Medicare card. No network. No prior authorization for home health.
Medicare Advantage (Part C / MA plan)
A private insurance plan that contracts with CMS to deliver all Part A and Part B benefits, plus typically Part D (prescription drugs). Common Florida MA insurers include Humana, UnitedHealthcare, Aetna, Cigna, and WellCare. Identified by a separate plan card from the private insurer. MA plans must cover the same home health benefit as Original Medicare but typically add network and authorization rules. 1
Prior authorization
A requirement for the plan to approve a service before it is delivered. Most MA plans require prior authorization for home health; the agency typically handles the submission, but families should confirm authorization is in place before the start of care. The 2024 CMS Final Rule shortened MA prior authorization decision timelines and required plans to disclose denial reasons in writing. 4
In-network provider
A provider that has a contract with the MA plan to deliver services at agreed-upon rates. For home health, this means the agency has signed a network agreement with your plan. Out-of-network use generally requires an exception and may result in higher costs or denial. Original Medicare has no network — any Medicare-certified agency serving your address is eligible.
Network adequacy
A federal standard requiring MA plans to maintain enough in-network providers within reasonable travel distance of beneficiaries. If your plan lacks an in-network home health agency that serves your address, you have the right to request an out-of-network exception — and the plan must approve it or pay for out-of-network care at the in-network rate. This protection is in 42 CFR §422.112. 1
The Floor

What both plans must cover — by federal law

Under 42 CFR §422.101, every Medicare Advantage plan must cover the same Part A and Part B services Original Medicare covers, using the same eligibility criteria. These are the non-negotiables. 1

  1. Same skilled disciplines

    Skilled nursing, physical therapy, occupational therapy, speech-language pathology, home health aide services (when skilled need is present), and medical social work. The discipline list is identical under Original Medicare and Medicare Advantage.

  2. Same eligibility criteria

    Both require the patient to be under a physician’s care, need intermittent skilled care, be certified as homebound, and receive care from a Medicare-certified agency. MA plans cannot apply stricter criteria than Original Medicare, per the 2024 CMS Final Rule. 4

  3. Same face-to-face encounter requirement

    Both require a documented F2F encounter with the certifying physician or allowed practitioner within 90 days before or 30 days after the home health start of care. Same rules under 42 CFR §424.22.

  4. $0 out-of-pocket for the core benefit

    Both pay 100 percent of approved skilled nursing, therapy, aide, and medical social work visits. No copay, no deductible, no coinsurance. The only divergence is durable medical equipment, where MA plans may apply their own cost-sharing structure (Original Medicare is 80% / 20%).

Where They Differ

Original Medicare vs. Medicare Advantage — six key differences

The benefit is the same. The administration is different. These six dimensions cover almost every practical question families ask.

Original Medicare (Parts A & B)
  • NetworkNo network. Any Medicare-certified agency serving your address is eligible.
  • Prior authorizationNone. Care can begin immediately on a physician’s verbal order, with written certification within 30 days.
  • Choosing your agencyYou choose any Medicare-certified agency. The hospital discharge planner must give you a list of all eligible agencies and cannot steer you to one.
  • Switching agencies mid-episodeAllowed at any time. The new agency picks up the plan of care and coordinates the transition. No penalty.
  • AppealsStandard Medicare appeals process. NOMNC notice triggers a BFCC-QIO review with a one-business-day decision.
  • Supplemental benefitsNone beyond the core benefit. DME is covered at 80% (you pay 20%, or Medigap may cover it).
Medicare Advantage (Part C)
  • NetworkNetwork-restricted in most cases. The agency must be in-network. Out-of-network exceptions are available but require approval.
  • Prior authorizationTypically required. The agency submits the request; the plan must respond within CMS-defined timeframes. Care can be delayed pending authorization.
  • Choosing your agencyLimited to in-network agencies. The plan’s member services can supply the in-network list for your ZIP code.
  • Switching agencies mid-episodeAllowed but requires the new agency to obtain new prior authorization. May cause a brief gap in care.
  • AppealsPlan-specific timelines, governed by Medicare rules. Expedited appeals available when delay would harm the patient.
  • Supplemental benefitsMany plans offer extras — expanded aide hours, transportation to appointments, meal delivery after discharge, in-home support. Varies by plan.
Common myth: "Medicare Advantage covers less home health than Original Medicare." Not by law. Under 42 CFR §422.101, MA plans must cover the same benefit as Original Medicare. What MA plans can do is add administrative requirements (prior auth, network) that may slow access — but the underlying coverage is the same. 1
Before You Need Care

How to verify your plan’s home health benefit in six steps

A 20-minute call to your plan before you need home health saves hours of frustration when you do. These six steps work for any MA plan.

  1. Identify your plan type from the Medicare card

    Original Medicare uses the red, white, and blue federal card. Medicare Advantage uses a separate plan card from a private insurer (Humana, UnitedHealthcare, Aetna, Cigna, WellCare, etc.). Some beneficiaries have both — the MA card supersedes the federal card for billing.

  2. Call the member services number on the plan card

    Ask three direct questions: Does this plan require prior authorization for home health? What is the in-network agency list for my ZIP code? Are the F2F encounter requirements the same as Original Medicare? Take notes on the date, time, representative name, and any reference number.

  3. Get the in-network agency list in writing

    Ask the representative to email or mail the list of in-network home health agencies that serve your address. A verbal list is not enforceable. The written list becomes your fallback evidence if a referral is later denied for being out-of-network.

  4. Verify F2F and homebound requirements are unchanged

    MA plans must apply the same eligibility criteria as Original Medicare. If member services describes extra hurdles — weekly recertifications, additional physician sign-offs, conditions not in the Medicare manual — those add-ons may be improper and can be appealed.

  5. Ask about the appeals timeline

    Request the plan’s appeals timeline in writing — standard appeals and expedited appeals. CMS requires MA plans to respond to standard prior authorization decisions within 14 calendar days and expedited decisions within 72 hours. Knowing the timeline before you need it eliminates surprise. 4

  6. Document the call with a reference number

    Always ask for a call reference number. If a future denial contradicts what you were told, the reference number is your evidence in an appeal. Keep the notes with the rest of your Medicare paperwork.

Evidence & Local Context

The Florida picture: a state where Medicare Advantage dominates

Florida has one of the highest Medicare Advantage penetration rates in the country. According to the Kaiser Family Foundation, approximately 56% of Florida Medicare beneficiaries were enrolled in Medicare Advantage plans in 2024 — well above the national average of 51%. In counties like Miami-Dade, MA enrollment exceeds 75%. 3

This matters for home health because Florida home health agencies serve a population where most patients have MA, not Original Medicare. Agencies that have spent years building network agreements with multiple MA plans — and processes for fast prior authorization — can typically start care faster than agencies with limited network participation. When choosing an agency, families should ask which MA plans the agency is in-network with.

A 2024 Office of Inspector General (OIG) report found that 13% of Medicare Advantage prior authorization denials were for services that would have been approved under Original Medicare rules. The report led directly to the 2024 CMS Final Rule, which clarified that MA plans cannot apply stricter coverage criteria than Original Medicare and shortened decision timelines for prior authorization. The rule took effect in 2024. 4 5

Kassy Health is in-network with most major Medicare Advantage plans serving Central Florida, including Humana, UnitedHealthcare, Aetna, and several regional plans. Our intake team verifies coverage and submits prior authorization at the same time we accept the referral — so the start-of-care visit is not delayed.

Frequently Asked Questions

Questions families ask about Medicare Advantage and home health

Yes. Under 42 CFR §422.101, Medicare Advantage plans must cover all Part A and Part B services that Original Medicare covers — including home health — using the same eligibility criteria. CMS’s 2024 Final Rule strengthened this requirement, clarifying that MA plans cannot apply more restrictive coverage criteria than Original Medicare.

Original Medicare uses a fee-for-service structure — care is approved based on whether eligibility criteria are met, evaluated after services are delivered. Medicare Advantage plans manage their own risk under a capitated payment from CMS, so they use prior authorization to control utilization. The trade-off is more oversight before care can start. A 2024 OIG report found that 13% of MA prior authorization denials were for services that would have been approved under Original Medicare rules.

You can switch during specific enrollment windows: the Annual Enrollment Period (October 15 – December 7), the Medicare Advantage Open Enrollment Period (January 1 – March 31), or a Special Enrollment Period if you qualify. The change takes effect the first of the following month. If you switch mid-episode, the home health agency will need to verify coverage under the new plan and may need to re-obtain authorization. Talk to your agency before switching during active care.

You generally must use an in-network agency, but exceptions exist: if no in-network agency is available in your area, if your medical condition requires specialized care no in-network agency provides, or if you receive emergency or post-hospital care. You can request an out-of-network exception through the plan’s member services. If denied, the appeals process applies. Original Medicare has no network restrictions.

The basic home health benefit is the same — both cover intermittent skilled nursing, therapy, aide services, and medical social work. Some Medicare Advantage plans offer expanded supplemental benefits that go beyond Original Medicare, including additional home health aide hours, transportation to medical appointments, meal delivery after hospital discharge, or in-home support services. These supplemental benefits vary widely by plan and are not guaranteed.

Yes. The physician’s referral establishes medical necessity, but the MA plan separately evaluates whether the requested services meet the plan’s coverage criteria. If the plan denies a referral that meets Original Medicare’s eligibility standards, that denial can be appealed. Per the 2024 CMS Final Rule, MA plans cannot apply criteria stricter than Original Medicare for services Original Medicare would cover.

A retrospective denial after prior authorization is unusual and typically signals a documentation problem rather than a coverage issue. The plan must explain why the post-service denial differs from the pre-service approval. You and the home health agency have appeal rights, and the appeal can include the documented prior authorization as evidence. The plan generally cannot recoup payment for services rendered in good faith after a written prior authorization unless there is fraud or willful misrepresentation.

For the core home health benefit (skilled nursing, therapy, aide, social work), both pay 100 percent with no copay. Differences emerge in durable medical equipment, where Original Medicare covers 80 percent after the Part B deductible and you pay 20 percent (Medigap may cover that 20 percent), while Medicare Advantage may apply its own copay structure for DME. If your plan includes supplemental benefits like extra aide hours or transportation, those are typically also $0, but verify with your specific plan.

Sources

Sources cited in this guide

Every regulatory and policy claim is drawn from primary CMS guidance, federal regulations, Kaiser Family Foundation analysis, or HHS Office of Inspector General reports. Verified May 2026.

  1. Centers for Medicare & Medicaid Services (CMS). Code of Federal Regulations, Title 42, Part 422: Medicare Advantage Program. 42 CFR §422.101 (Requirements relating to basic benefits) and 42 CFR §422.112 (Access to services). ecfr.gov →
  2. Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual, Chapter 7: Home Health Services. Publication 100-02. Updated 2024. cms.gov →
  3. Kaiser Family Foundation (KFF). Medicare Advantage in 2024: Enrollment Update and Key Trends. Including state-by-state penetration data for Florida. kff.org →
  4. Centers for Medicare & Medicaid Services (CMS). Contract Year 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F). Strengthened prior authorization rules and coverage equivalence requirements. cms.gov →
  5. U.S. Department of Health and Human Services, Office of Inspector General. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. OEI-09-18-00260. oig.hhs.gov →
  6. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare Payment Policy. March 2025. Chapters on Medicare Advantage and Home Health Services. medpac.gov →
  7. Medicare.gov. How do Medicare Advantage Plans work? U.S. Centers for Medicare & Medicaid Services. medicare.gov →
  8. Florida Agency for Health Care Administration (AHCA). Florida Health Finder — Provider Verification. Accessed May 2026. healthfinder.fl.gov →
Talk to an intake nurse

Not sure if your plan covers home health here?

Kassy Health is in-network with most Medicare Advantage plans serving Central Florida — Humana, UnitedHealthcare, Aetna, and several regional plans. Our intake team verifies your coverage and submits prior authorization while we accept the referral, so the start-of-care visit is not delayed.

(407) 875-1801 Mon–Fri 8 am–5 pm · Bilingual (English · Español) Read: What Medicare covers

Kassy Health · Medicare-certified home health agency founded by Sandra Morales, RN in 2006. Serving Orange, Seminole, Osceola, Lake, and Volusia counties. CHAP-accredited · 4-star CMS Quality of Patient Care.

Sandra Morales, RN, Founder of Kassy Health