The Alliance Comments on Proposed MA Plan Changes

WASHINGTON—The National Alliance for Care at Home (The Alliance) submitted comments on the proposed Centers for Medicare & Medicaid Services (CMS) contract year 2026 policy and technical changes to Medicare Advantage (MA) programs.

The proposed rule seeks to address refinements for several existing provisions and protect MA plan enrollees. While the rule does not address home health specifically, certain proposals have implications for Medicare beneficiaries that may be of interest to providers delivering care in the home. 

Clarifying the Definition of an Organization Determination

CMS has proposed to include concurrent reviews, intending to cover enrollees in receipt of inpatient or outpatient services under section 422.138(c), as follows.

Section 422.138(c): Effect of prior authorization, preservice or concurrent approval. 

If the MA organization approves the furnishing of a covered item or service through a prior authorization preservice determination of coverage or payment, or through a concurrent determination made during the enrollee’s receipt of inpatient or outpatient services, it may not deny coverage later on the basis of lack of medical necessity and may not reopen such a decision for any reason, except for good cause (as provided at section 405.986 and section 422.616 of this chapter) or if there is reliable evidence of fraud or similar fault per the reopening provisions at section 422.616. The definitions of the terms ‘‘reliable evidence’’ and ‘‘similar fault’’ in section 405.902 of this chapter apply to this provision.

The Alliance recommended that CMS clarify the circumstances with which the MA plan is prohibited from reopening a determination for medical necessity, and that CMS provide transparency to the provider community and enrollees in the enforcement activities around non-compliance with the requirements.

Promoting Community-Based Services & Enhancing Transparency of In-Home Service Contractors

CMS has proposed to codify the definition of community-based organizations (CBOs) that provide in-home or at-home supplemental benefits to enrollees. The definition would limit CBOs to not-for-profit organizations. Although CMS does not require organizations that provide supplemental benefits be not for profit, it has proposed that CBOs are notated in the provider directory, which suggest that these organizations are preferred providers.

The Alliance requested that CMS not finalize the proposed definition or in any way limit CBO service providers to nonprofits. Additionally, The Alliance submitted the following concerns and comments related to MA plans, prior authorizations and payment policies.

Prior Authorization

The Alliance recommended that CMS should require MA plans to provide prior authorization determinations for home health services within 72 hours of a request for authorization, align the time frame with the home health conditions of participation (CoPs) and establish policies to protect providers from the impact of delayed authorization decisions caused by the payer. The Alliance also suggested that CMS should consider aligning the time frame for MA plan prior authorization with CMS CoPs for home health services. 

Additionally, The Alliance recommended CMS should require MA plans to waive prior authorization requirements for enrollees in need of home health care immediately following an acute or post-acute care facility stay.

Payment Policies

The Alliance recommended that CMS should require plans to reimburse home health agencies on an episodic basis, which would be consistent with traditional Medicare.

The full comment letter from The Alliance is available here.