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Someone from your Medicare Advantage plan wants to visit your home: what a health risk assessment actually is, Sioux Falls 2026

The visit can be real, free, and genuinely useful — and it can also be the reason your plan gets paid more by the federal government. Both things are true at once.

Big Sioux Benefits Data Desk

Published October 10, 2026 · 19 min read · Sourced from CMS.gov, HHS OIG, KFF, and GovInfo

If someone has recently called or come to your door in Sioux Falls saying your Medicare Advantage plan sent them to check on your health at home, you're not imagining something strange — this is a real, widespread practice, and it is also one of the most scrutinized corners of Medicare Advantage policy heading into 2027. This guide walks through what that visit actually is, why your plan wants it, what's genuinely changing in how the federal government pays for it, and exactly how to handle the invitation — whether you say yes, no, or something in between.

Every figure in this guide comes from a primary source fetched this week: CMS's own Calendar Year 2027 Medicare Advantage and Part D Rate Announcement, KFF's independent analysis of Medicare Advantage coding intensity, the HHS Office of Inspector General's own report on health risk assessments, the official bill text of the No UPCODE Act at GovInfo.gov, Medicare.gov's own fraud-reporting guidance, and the CMS PY2026 Medicare Advantage plan landscape for Minnehaha County. No numbers from memory.

A knock on the door, and a clipboard

It usually starts with a phone call, a postcard, or sometimes a knock with no warning at all. Someone says they're with a company you've never heard of, working on behalf of your Medicare Advantage plan, and they'd like to schedule a free in-home health check. They ask about your medications, your falls, your mood, your memory, whether you can get your own groceries. Sometimes they listen to your heart and lungs. Then they leave, you never hear the results discussed with your own doctor, and you're left wondering what just happened — and whether you should have let them in at all.

That confusion is reasonable, and it isn't a sign you did anything wrong either way. The visit you're describing has a name — a health risk assessment, often delivered in-home — and it sits at the center of a real, current fight in Washington over how Medicare Advantage plans get paid. You don't need to follow that fight to make a good decision about the invitation sitting on your kitchen counter. You do need to know what the visit actually is, who it's actually for, and how it's different from the one thing it will never be: a call from Medicare itself.

What a health risk assessment actually is

A health risk assessment, usually shortened to HRA, is a structured questionnaire and brief exam covering your chronic conditions, medications, daily function, mental health, and home safety. The CDC originally developed HRA content standards for use in Medicare's Annual Wellness Visit, and CMS has published that guidance on its own site. Medicare Advantage plans adopted the same basic tool for a broader purpose: a yearly check-in with members, often delivered not by your own doctor but by a nurse practitioner or physician assistant working for a company the plan hires specifically to run this program.

These visits can happen in a clinic, over a video call, by phone, or — the version that tends to catch people off guard — in your home. The clinician isn't necessarily local, isn't necessarily someone you'll see again, and generally isn't coordinating your ongoing care the way your primary care doctor does. Their job, as the company that employs them understands it, is to complete a thorough questionnaire and exam, document what they find, and send that documentation back to your plan.

Your doctor's wellness visit vs. this visit

Part of the confusion is that Original Medicare also uses a tool called a health risk assessment, as part of the free Annual Wellness Visit (AWV) you're entitled to once you've had Part B for 12 months. That visit happens with your own doctor's office, costs $0 under Part B, and the HRA inside it is one short piece of a broader appointment that also includes a review of your current providers, a personalized prevention plan, and cognitive screening.

A Medicare Advantage plan's in-home assessment program is a different thing wearing a similar name. It's run by the insurance plan, not your doctor's office; it's delivered by a contracted clinician who typically doesn't become part of your regular care team; and its primary institutional purpose, beyond any genuine care-coordination value, is to generate a complete diagnosis record the plan can report to CMS. The table below lays out the practical differences.

Source: CMS Annual Wellness Visit coverage guidance and CDC health risk assessment standards, as described on CMS.gov; carrier member-materials describing in-home assessment programs.

Why your plan wants this visit: the money behind it

Medicare Advantage plans are paid by the federal government on a risk-adjusted basis: a healthier-looking member brings in a lower monthly payment, and a member with more, and more severe, documented diagnoses brings in a higher one, because the plan is expected to need more money to cover that person's care. The system exists for a defensible reason — it keeps plans from avoiding sicker members — but it also creates a direct financial incentive to document every diagnosis a member might plausibly have, every single year, whether or not that diagnosis gets treated.

An in-home health risk assessment is one of the most efficient ways to do that. A visiting clinician who spends 45 minutes asking structured questions and performing a basic exam can surface diagnoses — a vision problem, a mobility limitation, early cognitive decline, uncontrolled diabetes — that may never have been formally coded anywhere else that year. KFF's own analysis is direct about the mechanic: "plans can submit diagnosis codes for conditions identified in an HRA questionnaire, even when no related services were delivered that year," and that submission can raise the member's risk score and, with it, what the plan is paid.

Sources: HHS Office of Inspector General — Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions (Report OEI-03-23-00380, issued Oct. 21, 2024); KFF — Decoding Medicare Advantage Coding Intensity (Biniek & Sroczynski, published Jul. 1, 2026).

A worked example of how one diagnosis moves the dollars

KFF's own analysis lays out the mechanism with real model numbers, and it's worth walking through once because it explains why a 45-minute home visit matters financially in a way a 15-minute office visit often doesn't. In KFF's illustration, using the 2026 payment model, a plan enrolling a member whose diagnosis codes match what traditional Medicare would show gets paid roughly $10,943 for the year, after normal payment adjustments. Add a single morbid obesity diagnosis found through a chart review — the kind of finding an in-home assessment commonly produces — and the same member's annual payment rises to about $12,911. That's a difference of roughly $1,968, or about 18%, from one additional documented diagnosis, in KFF's modeled example.

None of that extra payment is a bill to you. It's a federal payment from CMS to your plan, and it happens whether or not the diagnosis found at your kitchen table ever leads to an appointment, a prescription, or a follow-up call. That gap — a diagnosis that moves money but doesn't necessarily move your actual care — is exactly what regulators have spent the past two years trying to narrow.

Spot the difference: your plan's visit vs. a scam

Here's the part worth getting exactly right, because getting it wrong in either direction has a real cost. Treating a legitimate plan benefit like a threat means missing a visit that might genuinely catch something useful. Treating a scam like a legitimate benefit means letting a stranger into your home, or onto a call, under false pretenses. The two situations look similar on the surface and are not the same thing at all.

If anything about a specific call or visit doesn't fit cleanly into the right-hand column, the safe move costs you nothing: hang up, don't open the door, and call the number on your own member card to ask whether your plan actually scheduled this. A genuine benefit will still be there next week. A genuine scam will not survive you calling your plan directly.

What's changing for 2027, and why

The financial incentive behind these visits hasn't gone unnoticed in Washington, and 2026 was the year the pushback turned into an actual rule change. Three separate threads converged on the same problem from three different directions: an inspector general's audit, a bipartisan bill in Congress, and a final CMS payment rule.

The HHS Office of Inspector General didn't just flag the $7.5 billion figure above — it went further and recommended that CMS impose additional restrictions specifically on diagnoses reported only through in-home HRAs, or through chart reviews linked to them, before those diagnoses count toward a plan's payment. CMS's own written response, recorded in the same report, was that the agency did not concur with that specific recommendation at the time.

A bipartisan group in the Senate pushed from a different angle. S. 1105, the No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act — shortened to the No UPCODE Act — was introduced March 25, 2025 by Senator Bill Cassidy of Louisiana, with Senator Jeff Merkley of Oregon as a cosponsor, aiming to tighten the rules around exactly this kind of diagnosis coding across Medicare Advantage. As of this writing it remains a bill, not law — introduced, not yet enacted — which is worth stating plainly rather than implying it has already changed anything.

CMS moved on its own separate track, through the annual rate-setting process rather than new legislation. Its Calendar Year 2027 Medicare Advantage and Part D Rate Announcement, finalized April 6, 2026, states that for risk score calculation starting with CY2027, CMS is "finalizing the exclusion of diagnoses from audio-only encounters and diagnoses from unlinked [chart review records], with an exception to include diagnoses from unlinked [chart review records] for beneficiaries who switch from one MA organization to another." In plain terms: a diagnosis that shows up only in a chart review not tied to any specific patient encounter — exactly the category an in-home assessment-only finding can fall into — generally stops counting toward what CMS pays your plan, starting with 2027.

Source: KFF — Decoding Medicare Advantage Coding Intensity (Biniek & Sroczynski, published Jul. 1, 2026), citing MedPAC's measure of uncorrected Medicare Advantage coding intensity.

CMS's own fact sheet puts rough numbers on the policy's bite: fully excluding unlinked chart-review diagnoses, with no exception at all, would have cut industry-wide risk scores by about 1.78%; with the plan-switching exception the final rule actually includes, the net effect CMS books under its "Sources of Diagnoses" category for 2027 is a smaller 1.53% reduction. That sits inside a much larger calculation — CMS projects Medicare Advantage payments will rise about 2.48% on average for 2027 (roughly $13 billion), growing toward an estimated 4.98% once that year's broader coding trend is included. The 1.53% is a real, sourced policy change; it is also a small piece of a payment system that is still, on net, growing.

What this actually means for you

None of this changes your benefits, your network, or what your Medicare Advantage plan covers in Sioux Falls. It changes how much the federal government pays your plan, which is a real policy fight — but it is not the fight that decides whether your knee replacement is covered or your cardiologist is in network. Keep that distinction clear, because the trade press covering this story is writing for insurers and investors, not for someone deciding whether to answer a knock at the door this October.

What it should change is how you weigh the invitation itself. The visit can be genuinely useful: a trained clinician looking at your home, your medications, and your daily function with fresh eyes sometimes catches a fall risk, a medication conflict, or an early symptom your regular doctor's 15-minute visit didn't have time to surface. It's also fair to go in knowing the visit exists, in significant part, because it's financially valuable to the company that scheduled it — and that a finding from the visit may never make it back into your own doctor's chart unless you specifically ask for that to happen.

Both things can be true without either one being a reason to panic. The honest answer is that this is a genuinely close call for a lot of people, and reasonable, well-informed Sioux Falls Medicare beneficiaries land on different decisions about it.

How to handle the visit, step by step

1. Verify before you schedule anything. Call the member services number printed on your own Medicare Advantage card — not a number a caller gives you — and ask directly whether your plan has a contract with the company that reached out.
2. Ask what happens to the findings. Specifically ask whether the visit's results will be sent to your own primary care doctor, and if so, how. If the answer is vague, ask for it in writing.
3. Bring your real medication list. If you decide to go ahead, the visit is more useful to you, not just to the plan, if you have an accurate, current list of everything you take.
4. Ask follow-up questions on anything they flag. If the visitor notes a concern — a fall risk, a medication issue, a cognitive screening result — ask what you should do next, and follow up with your own doctor rather than treating the visit as a substitute for one.
5. It's fine to say no, and fine to stop partway through. Declining the invitation, or ending the visit once it's started, doesn't cost you a benefit you'd otherwise keep, and there's no penalty either way.
6. If anything doesn't check out, stop and report it. Hang up, don't open the door, and call 1-800-MEDICARE or the I-MEDIC line at 1-877-772-3379 if something feels like fraud rather than a benefit.

A worked example: Tom's October visit

Here's how this plays out for a composite situation, built from the mechanics above rather than from any one client's details. Call him Tom. He's 71, lives in Harrisburg, and enrolled in a Sioux Falls-area Medicare Advantage PPO three years ago. In early October, a letter arrives from a company he's never heard of, explaining it works with his health plan and offering a free in-home wellness check. A week later, the same company calls to schedule it.

Before agreeing to a date, Tom calls the member services number on the back of his plan card and asks directly whether his plan has a relationship with that company. The representative confirms it's a real, contracted part of the plan's annual outreach program, entirely optional, and offered at no cost. Tom schedules the visit, and a nurse practitioner spends about 40 minutes at his kitchen table going through his medications, his recent falls history, and a short memory screening.

The visit turns up something real: Tom mentions he's had two near-falls in his bathroom in the past few months, something he hadn't brought up with his own doctor because it hadn't felt worth a separate appointment. The nurse practitioner documents it and recommends a grab bar and a home safety evaluation. Tom asks for the full visit summary to be sent to his primary care doctor, follows up at his next regular appointment, and gets a referral for physical therapy aimed at fall prevention. The visit also, separately and without changing anything about Tom's experience of it, documents diagnoses the plan reports to CMS — which is the part of the transaction Tom will never see a bill or a statement for, in either direction.

How a local advisor fits into this

We don't run these assessment programs, and we don't get paid based on whether you schedule one — our role is entirely separate from the company that might call you. Where a conversation with us tends to help is in the surrounding questions: understanding what your specific Medicare Advantage plan actually offers as a supplemental benefit, confirming that a caller's claims match what your plan's own materials describe, and making sure a finding from a home visit gets folded into your actual care rather than disappearing into a file nobody follows up on.

Big Sioux Benefits is a licensed independent insurance agency here in Sioux Falls. We don't run risk-adjustment programs for any carrier, and carriers pay us, not you, so the conversation costs nothing. We do not offer every plan available in your area; any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

You shouldn't have to become a health-policy analyst to decide whether to answer your own front door. That's exactly the kind of plain-English sorting-out we do, for free, as part of an ongoing relationship rather than a one-time sales pitch.

The Sioux Falls Medicare Advantage landscape

In-home health risk assessments are an industry-wide Medicare Advantage practice, not something specific to any single carrier in this market, and nothing in the federal reporting above names a Sioux Falls-area plan. For context on what's actually available here, Minnehaha County has 11 Medicare Advantage (Part C) plans for 2026 — 5 standard PPOs open to anyone with Medicare, 4 Dual-Eligible Special Needs Plans, and 2 Institutional Special Needs Plans — plus 4 Medicare Cost plans, for 15 total drug-carrying plans serving the county's 39,532 Medicare beneficiaries. Here's the full roster, so the plan counts above aren't bare numbers.

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County, 2026.

If you want to understand how your own plan's annual outreach — including any in-home visit offer — fits alongside its star rating, network, and formulary, that's exactly the kind of side-by-side we build during an annual coverage review, for the plans we offer in the Sioux Falls area.

What to watch before this year's enrollment period

1. Any outreach from a company you don't recognize — verify it against your plan's own member services line before scheduling anything, especially as outreach volume typically rises heading into AEP.
2. Whether a visit's findings reach your own doctor — ask specifically, and follow up yourself if the answer is unclear.
3. Anyone claiming to call or visit "on behalf of Medicare" itself — per Medicare.gov, that claim alone is a fraud red flag worth hanging up on.
4. Further movement on the No UPCODE Act — it remains a bill, not law, as of this writing; a real change would need Senate and House passage and a signature.
5. Your own Annual Notice of Change letter — a plan's supplemental benefits, including any wellness-visit program, can change year to year the same way premiums and networks do.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references CMS's own Calendar Year 2027 Medicare Advantage and Part D Rate Announcement, the HHS Office of Inspector General's own audit reports, KFF's independent analysis of Medicare Advantage coding intensity, official federal bill text from GovInfo.gov, Medicare.gov's own consumer fraud guidance, and the CMS PY2026 Medicare Advantage plan landscape for Minnehaha County — built by Strategic AI Architects. Every figure on this page was fetched from its primary source on October 10, 2026 and carries the period it covers. This is education, not legal or medical advice; confirm any specific outreach with your own plan and report suspected fraud to 1-800-MEDICARE. We take no payment from any carrier to feature a plan.