How Home Health Coverage Works Under Medicare Advantage vs Original Medicare

What are your options?

Home health care can be a lifeline after a hospital stay or during recovery from illness. But when people need it most, they’re often surprised by how Medicare home health coverage actually works — especially the differences between Original Medicare and Medicare Advantage.

Understanding these differences ahead of time can prevent delays, frustration, and unexpected denials.

Let’s break it down clearly.

What Is Home Health Care Under Medicare?

Home health care typically includes medically necessary services provided in your home, such as:

• Skilled nursing care
• Physical, occupational, or speech therapy
• Medical social services
• Limited home health aide services

Home health care is not the same as long-term custodial care or 24/7 assistance with daily living.

Home Health Coverage Under Original Medicare

Original Medicare (Parts A and B) offers nationwide, standardized coverage for home health services.

✔ What’s Covered

If you qualify, Original Medicare generally covers:
• Skilled nursing care (part-time/intermittent)
• Therapy services
• Medical social services
• Some home health aide care (when paired with skilled care)

✔ Key Requirements

To qualify, you must:
• Be under a doctor’s care
• Need skilled services
• Be considered homebound
• Use a Medicare-certified home health agency

✔ Costs

• $0 for covered home health services
• You may pay 20% for durable medical equipment

✔ Provider Choice

One of the biggest advantages:
👉 No networks.
You can use any Medicare-certified home health agency nationwide.

Home Health Coverage Under Medicare Advantage

Medicare Advantage plans must cover everything Original Medicare covers — but they can set different rules for how care is delivered.

This is where things can feel very different.

✔ What’s Covered

Medicare Advantage plans cover the same types of home health services as Original Medicare.

However, how you access them may vary.

⚠️ Key Differences to Understand

1️⃣ Provider Networks Matter

Medicare Advantage plans usually require you to use:
• In-network home health agencies
• Preferred providers tied to the plan

Using an out-of-network agency may result in:
• Higher costs
• Delays
• Or no coverage at all

2️⃣ Prior Authorization Is Common

Many Medicare Advantage plans require prior authorization before home health services begin.

This can mean:
• Additional paperwork
• Approval delays
• More oversight on length and frequency of care

3️⃣ Care Coordination Can Be Tighter

Some Medicare Advantage plans use value-based care arrangements, meaning:
• Agencies must meet performance standards
• Care is closely tracked
• Readmissions are closely monitored

When it works well, this can mean smoother transitions. When it doesn’t, it can feel restrictive.

✔ Costs Under Medicare Advantage

Costs vary by plan, but often include:
• $0 cost for approved home health services
• Potential copays depending on plan design

The biggest variable isn’t cost — it’s access and approval.

Side-by-Side Comparison🔎

Feature Original Medicare Medicare Advantage

Provider choice Any Medicare-certified agency In-network agencies

Prior authorization Rare Common

Coverage rules Standard nationwide Plan-specific

Cost for services $0 Often $0, varies

Travel flexibility Strong Limited by network

Which Option Is Better?⚖️

There’s no universal “better,” only better for you.

Original Medicare may be a stronger fit if:
• You value provider flexibility
• You travel frequently
• You want fewer authorization hurdles

Medicare Advantage may work well if:
• Your providers are in-network
• You’re comfortable with managed care
• You value extra benefits and coordinated care

Why This Matters Before You Need Care🩻

Most people don’t think about home health coverage until they urgently need it. At that point, plan limitations can come as a surprise.

Understanding these differences before enrolling helps you:
• Avoid delays after hospital discharge
• Choose plans that match your health needs
• Protect access to trusted providers

Jon’s Final Thought💭

Home health care is about recovery, safety, and independence. How Medicare delivers that care depends heavily on which type of coverage you choose.

Taking the time to understand your options now can make a meaningful difference later.

If you’re unsure how your current Medicare plan handles home health services — or want help comparing options — guidance matters.

I’m here to Help!