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

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. In 2024, most people with Medicare Advantage (MA) plans (90%) were enrolled in plans that required approval (called prior authorization) before they could receive home health care after a hospital stay. To understand how this process works and its effects, we interviewed 44 leaders from MA plans, organizations that assist these plans, and home health agencies across the country.Our interviews showed that MA plans and their partners have different reasons and methods for requiring prior authorization, leading to mixed experiences for home health providers. Both sides agree that the process is often challenging, but they handle it in different ways and don't always agree on whether these methods are effective. Home health agencies shared concerns that these requirements can make it harder for patients to access care, change how care is provided, and affect patients' overall experiences.Our study highlights the need for more research and careful consideration of policies to ensure that these approval processes don't unintentionally harm patients, especially those who are most vulnerable and in need of post-hospital home health care.