Prior authorization and utilization management for post-acute home health in Medicare Advantage: the motivations, players, processes, unique challenges, and impacts on patient care

Topic: Risk, prevention and care in population studies

Abstract In 2024, 90% of Medicare Advantage (MA) enrollees were in a plan that required prior authorization of home health care. We conducted semi-structured interviews with 44 leaders of MA plans, post-acute care (PAC) management companies, and home health agencies (HHAs) across the country to understand their experiences with prior authorization and utilization management (UM) of post-acute home health care. Our analysis of these interviews revealed that representatives of MA plans and PAC management companies report varying motives and approaches to prior authorization for post-acute home health care, resulting in varied experiences for HHAs. Both MA plan and HHA representatives view prior authorization and UM of post-acute home health as burdensome, and each have taken distinct approaches to manage the process but have conflicting views on the utility of these approaches. Home health agency representatives report that prior authorization and UM requirements impact access to care, the way that care is delivered, and ultimately patients' experiences. Our findings warrant additional research and policy attention so that MA plans' UM techniques do not unintentionally cause patient harm, particularly among vulnerable Medicare enrollees in need of post-acute home health care.

Key findings

• Our analysis of these interviews revealed that representatives of MA plans and PAC management companies report varying motives and approaches to prior authorization for post-acute home health care, resulting in varied experiences for HHAs.
• Our findings warrant additional research and policy attention so that MA plans' UM techniques do not unintentionally cause patient harm, particularly among vulnerable Medicare enrollees in need of post-acute home health care.

Why it matters

This interview study of 44 leaders found that prior authorization and utilization management of post-acute home health care were viewed as burdensome, with home health agency representatives reporting impacts on access to care and patients' experiences. It calls for additional research and policy attention so these techniques do not unintentionally cause patient harm.

Study details

• Evidence strengthLow

Read the original

• DOI: 10.1093/haschl/qxaf020
• Original source →
• Free full text: Health Affairs Scholar →

Full text: free to read — OpenAlex lists this copy as free to read: the link above (checked 6 Feb 1020).

@article{thomas2025-613407fb,
  author  = {Thomas, Kali S and Daus, Marguerite and Jones, Christine and Bunker, Jennifer N and Smith, Jamie M and Marr, Jeffrey and Gadbois, Emily A},
  title   = {{Prior authorization and utilization management for post-acute home health in Medicare Advantage: the motivations, players, processes, unique challenges, and impacts on patient care}},
  journal = {Health Affairs Scholar},
  year    = {2025},
  doi     = {10.1093/haschl/qxaf020},
  url     = {https://doi.org/10.1093/haschl/qxaf020}
}

Studies this one cites

Referenced by this study and also in the alzhub library, so you can read them here.

• Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage JAMA Health Forum · 2024-03-01 · usefulness score 57/100 · Health systems and care delivery
• Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage BMJ · 2024-03-07 · usefulness score 49/100 · Health systems and care delivery

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• Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data PLoS Medicine · 2018-06-26 · usefulness score 58/100
• Improving Prior Authorization in Medicare Advantage JAMA · 2022-10-18 · usefulness score 46/100

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