UnitedHealth Causes Heightened Alarm

by Kristin Rowan | Jan 9, 2026 | Breaking News, CMS, Legal, Medicare Advantage, Outcomes, Regulatory

by Kristin Rowan, Editor

UnitedHealth Causes Heightened Alarm

Guardian Investigation Launches Probe

In July of 2025, The Guardian reported that UnitedHealth had secretly paid nursing homes to reduce hospital transfers. The investigation revealed that UnitedHealth was placing its own medical teams inside nursing homes and pushing them to cut care expenses, delay transfers, and deny care.

Senators Push for Answers

In the weeks following The Guardian report, Senators Ron Wyden (D-OR) and Elizabeth Warren (D-MA) launched their own investigation of the insurance giant’s cost cutting measures in nursing homes. Wyden and Warren sent a letter to then UnitedHealth Group leaders requesting documents and information about the nursing home incentive program.

New Allegations

A new letter from Senators Wyden and Warren states that UHG has refused to comply with the initial request. In the months since the demand for information, UHG has provided only “brief and unsubstantial answers” to their questions.

“Because you have failed to respond adequately to our inquiry – and in light of additional recent reporting – we are renewing our inquiry with heightened alarm.”

Ron Wyden and Elizabeth Warren

United States Senators

Additional Reports

The Senators’s letter alludes to recent additional reports. They were referring to a December story, also from The Guardian, reporting allegations of wrongful deaths inside the nursing home care program. In a statement, UnitedHealth denied any allegations their practices “endanger patient safety or violate ethical standards.”

No Response is a Response

When asked about the second letter, UnitedHealth Group did not respond to reporters at The Guardian. UHG leadership said in statement that they would “continue to engage” with the senators. The company’s leadership also maintains that its nursing home program “improves outcomes” and “reduces unnecessary hospitalizations.”

Unanswered Questions

UnitedHealth attended a briefing with the senators’ offices last July. During that meeting, UnitedHealth made several claims the Senators are now questioning.

UHG maintained their nurses are not required to contact company representatives prior to taking a nursing home patient to the hospital, but a document provided by a whistleblower alleges the opposite
UHG failed to adequately explain why hospital admission rates are part of the metrics for determining bonuses
UHG chose not to respond to questions about pending wrongful death lawsuits for Mary Grant, Cindy Deal, and an unnamed nursing home resident in New York

Deadline to Comply

Senators Wyden and Warren allege that UnitedHealth Group has withheld internal documents that directly relate to their initial request for information. The senators gabve a deadline of January 28, 2026 to respond with the following information:

Hospitalization policies, including clinical protocols for determining when transfers are warranted, definitions of avoidable versus unavoidable hospitalizations, and whether staff must consult Optum supervisors before hospital transfers.
Bonus program metrics and thresholds, including how UnitedHealth determines APK limits, whether facilities are penalized for exceeding thresholds, and five years of documentation on bonus payments to nursing homes.
Advance directive policies, including training materials for end-of-life conversations, the mortality risk assessment tool used, and who participates in those discussions with residents.
Marketing and enrollment practices for I-SNP plans at contracted nursing homes.
Federal oversight and compliance, including any CMS sanctions or enforcement actions in the past five years.

Wyden Warren UnitedHealth Group Heightened Alarm

Failure to Respond

Without adding details, the letter states that should UnitedHealth Group fail to respond it full, they will seek answers to their questions using “all tools at the Committee’s disposal.”

This is an ongoing inquiry/investigation and story. The Rowan Report will continue to provide updates as they become available.

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

LEAD Replaces REACH

by Kristin Rowan | Jan 9, 2026 | CMS, Hospice

by Kristin Rowan, Editor

LEAD Replaces REACH

CMS Launches 10-Year Model Test

LEAD replaces REACH in new 10-year CMS model. The Long-term Enhanced ACO Design (LEAD) model is scheduled to launched at the end of 2026, following the end of ACO Realizing Equity, Access, and Community Health (REACH). LEAD is a voluntary model that will run January 1, 2027 thorugh December 31, 2036, the longest CMS has ever run a test.

Key Takeaways

CMS provides the following information:

Problem: Many health care providers have not historically participated in or dropped out of ACOs because of financial and administrative obstacles to success.
Solution: LEAD is designed to address such barriers to support both established and newly created ACOs by providing them enhanced, flexible cash flow payments; and greater freedom and tools to support spending time with and meeting patient needs, including those with specialized care needs.
Outcomes: Through ACOs, health care providers will be empowered to deliver coordinated, accountable care and preventive services — keeping patients healthier and helping to reduce health care costs and unnecessary emergency room visits and hospitalizations.
Strategy: LEAD advances the Innovation Center’s commitment to 1) building opportunities for independent health care providers and practices to be rewarded for delivering better care, 2) promoting and empowering patient choice in both coverage and sites of care, and 3) making it easier for health care providers and patients to engage in preventive care that supports healthier living.

LEAD Goals

According to CMS, the LEAD Model will improve care coordination among a broad range of healthcare providers, including hospices. The model will also appeal to providers with specialized patients and those who are newer to ACOs like small, independent, or rural-based practices. The LEAD model intends to incentivize providers downstream such as home health agencies, palliative care, and hospices, to engage with the providers upstream. It is particularly aimed at complex patients with high needs.

CMS has outlined a 3-part framework for its goals:

Increase the scope of ACOs to include rural, small, and independent providers and health centers
Enhance evidence-based prevention and care coordination for more patients
Empower patient choice and encourage patient participation in care

Planning Phase

The LEAD Model will begin its planning stage in March of 2026 and run through December of 2027. During that time, CMS will identify two states to partner with for developing the framework for Medicaid partnerships. The framework will include how ACOs and Medicaid organizations can share data and coordinate care.

CARA

Among the more prominent changes in the LEAD Model is the CMS Administered Risk Arrangements (CARA). CMS will assist LEAD ACOs in designing episode-based risk payment arrangments with other health care providers. According to CMS, CARA will facilitate stronger preferred provider relationships. Building these strong care networks and partnerships between ACOs and hospice and palliative care providers will improve care for high-needs patients.

Hospice and palliative care organizations will need to demonstrate partnership value to ACO organizations by supporting smooth care transitions, reducing unnecessary hospitalizations, and ensuring patients receive the right care at the right time, according to a statement from The Alliance.

Final Thoughts

This new model may provide some opportunities for hospice agencies. It may also pave the way for a reimbursement model for palliative care. Although the statements from CMS focus on hospice and palliative care, there may be opportunities for home health agencies as well. These opportunities may become more apparent once the model demonstration begins in 2027. If they are not immediately apparent, we have 10 years to figure them out.

Applications for participation will open in March. To stay connected and receive updates from CMS, join the LEAD Model List or contact the LEAD Model team.

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Overtime Ruling Upheld

by Kristin Rowan | Jan 9, 2026 | Legal

by Kristin Rowan, Editor

Ruling Upheld

Agencies must pay minimum wage and overtime

A District Court of Pennsylvania ruled in favor of the Secretary of Labor against the WiCare Home Care Agency. The parties engaged in a lawsuit alleging the agency failed to pay minimum wage and overtime.

Background

The battle on overtime wages for home health aides continues to create more questions than answers. The FLSA in 1974 extended overtime coverage for all domestic service workers with two exceptions: companion services and live-in employees. In 2013, the Department of Labor published a rule that created an exception to the exceptions: third-party employers, such as home care agencies and staffing agencies, cannot use the exception. This forced most home health and personal care agencies to pay minimum wage and overtime rates. Courts upheld this rule, applying deference to the DOL interpretation of the FLSA. This is in keeping with the Chevron Doctrine, which has since been overturned.

In July of 2025, the DOL proposed a rule that would revert back to the 1974 interpretation of the exceptions. Later that month, the Wage and Hour Division (WHD) of the DOL stated it would no longer uphold the 2013 change for new and existing cases. The DOL used the overturning of the Chevron case in support of the proposed rule.

Arguing Deference

WiCare lost the first case and the court ordered them to pay more than $1 million in back wages and damages. WiCare filed an appeal and argued that the DOL does not have standing to change the parameters of FLSA. The agency argued that government agencies should not be shown deference in their interpretation of a statute (Chevron Deference). They also argued that the DOL does not have the authority to override the exceptions for companion and live-in caregivers.

Court Unpersuaded

The opinion was filed by some but not all of the court of appeal judges. The court held that it is “well established” that agencies have the authority to give meaning to statutory terms. The decision upholds the now overturned Chevron Deference and conflicts with the 2025 statement from the WHD that it would not uphold the rule.

What it all Means

The proposed rule to undo the 2013 rule and revert to the 1974 rule is still undecided. This means that the existing FLSA rule remains intact. That rule requires overtime pay from an agency or other third-party employer.

This ruling on appeal is unlikely to impact other Chevron Defense cases. The court stated that the DOL has the express right to establish meaning and would have that right with or without Chevron. This ruling may, however, influence the proposed rule that would eliminate overtime requirements. The industry is split on support for this change and advocates continue to argue on both sides. This ruling may be used in attempts to stop the proposed rule from being finalized.

Final Thoughts

Until there is a clear change to the FLSA overtime and minimum wage exemptions and exceptions, individual employers and agencies should continue to ensure caregivers are paid both minimum wage and overtime wages in accordance with the existing exemptions.

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

2025 Caregiver Survey: An Interview with Stephen Vaccaro

by Kristin Rowan | Dec 18, 2025 | Caring for the Caregiver, Clinical, Vendor Watch

by Kristin Rowan, Editor

2025 Caregiver Survey

An Interview with Stephen Vaccaro

The end of the year seems like a good time to see where caregivers fall on questions about technology, training, management support, career motivations, and other relevant and pressing topics. Some of the results of the HHAeXchange caregiver survey are not surprising. Others, you may not expect.

The Rowan Report spoke with HHAeXchange President Stephen Vaccaro this week to discuss the survey.

Key Takeaways

Here are a few of the key takeaways from the 2025 Caregiver Survey:

Just over 65% of respondents said they are comfortable with technology, up from 55.65% just two years ago
Caregivers find technology supports them most with managing shifts and schedules
70% said they would spend an extra 3-5 minutes documenting client observations if it improves care
Higher pay is still the #1 complaint of caregivers
A desire for additional training and flexibility increased to 21.7% and 28.2%, respectively

Read theHHAeXchange survey press release.

In His Own Words

The Rowan Report:

Stephen, thank you for talking with me today. It’s good to see you again. It’s been quite a year or so of changes for HHAeXchange.

Stephen Vaccaro:

Thanks, Kristin. 2025 has been truly transformational for HHAeXchange. State Medicaid and Medicaid managed care plans have been very positive with the change. We’re now in a position to invest at scale.

RR:

It’s been fascinating watching. I can’t wait for what’s next. The answers you received in the 2025 Caregiver Survey had some significant changes to the answers this year. What can you tell me about this year’s survey?

HHAeXchange 2025 Caregiver Survey Vaccaro

Stephen:

We are connected to close to 3 million caregivers on the personal side. The past couple of years, we’ve done the caregiver survey. 2025 is the third year. It’s interesting to see the evolution of it. In the beginning there was a lot of fear around EVV technology. Now, the level of adoption is increasing and they’re starting to see that it’s a value add to their job. This year, 65% had positive feedback on technology in the home.

RR:

To what do you attribute this change in response?

Stephen:

It’s a very meaningful change. The first round of technology was different. There were promises, delays, and a lot of pepople who didn’t think it would ever happen. It has gone from “We’d like to see you use it” to “you have to use it.” There’s a certain level of expectation. And now, it’s pushing down to managed care plans. Providers are cooperating now because it’s not okay not to. Sometimes it’s the consumers that are convincing the caregiver to use the technology.

RR:

Do you think there’s any tie in to the average age of the caregiver?

Stephen:

I think that helps, certainly. I think when new caregivers come in, they are starting mobile first. It’s part of the orientation. It’s how the job is done. But it’s also the impact the technology makes.

More than 61% ranked the positive impact on the client as the most important thing that they do. Having the app is bringing them in to the care team. Nurses and NPs are collaborating with caregivers and seeing that the observations of the caregiver are important, even when they seem small.

So, as we start to look at different care needs, we have to design programs accordingly, and that also has impacted the the change. Caregivers want support to get the training they need to do their job the best they can. They want resources, tools, and information. Advanced training is important, but the technology to be able to see the patient records, notes, and observations is key and that necessitates the technology.

RR:

What are the top reasons a caregiver leaves an agency?

Stephen:

Well, salary of course is the number one challenge. But more training and more flexibility rank pretty high on the list.

2025 Caregiver Survey Vaccaro HHAexchange

RR:

What do you see coming in 2026 and beyond?

Stephen:

I think there will be a big focus on technology. It will be the year we truly step into mobile first as a standard.

I also think we will continue to see the evolution of the caregiver as part of the care team. We will start leveraging the caregiver as the untapped asset that they are. We will see increased continuity of care, especially for integrated dual eligible patients.

RR:

And, what’s next for HHAeXchange?

Stephen:

We will continue looking for ways to innovate and bring value to the industry and the ecosystem. In the home care economy, all the players are involved. The patient, the caregiver, the doctor, and the payor. But, also the training vendors, food suppliers, transportation providers, and so many more. We will be looking at ways to involve all of the players from a patient’s home ecosystem into the care plan.

RR:

Stephen, it’s always a pleasure talking with you. Thank you, again for sharing your 2025 Caregiver Survey with us and for your always valuable insights. Happy Holidays.

Stephen:

Thank you for having me. Happy Holidays

Final Thoughts

Caregivers are embracing technology not for themselves, but for their clients. The desire to help and make a positive impact on their clients’ health and well-being is the core drive for caregivers, so it’s not surprise that they want better access to information and training. Non-medical supportive care at home has more contact hours and indiidual time with clients and are an invaluable untapped resource for home health and hospice. With the technology finally catching up to the motivation, we can tune in to that resource and provide better care across the board.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

House Passes Health Care Reform Bill

by Kristin Rowan | Dec 18, 2025 | Regulatory

by Kristin Rowan, Editor

House to Vote on Health Care Plan

Discharge Petition Forces Vote

Since the temporary appropriations passed to reopen the government last month, the House and the Senate have been playing chicken with the health care plan for 2026. The lack of consensus threatens both Affordable Care Act (ACA) subsidies to keep health insurance rates down and the extension of the additional subsidies needed to keep the government open after January 30.

Today, four GOP members broke rank and sided with their Democrat counterparts on a discharge petition that would force a vote on the House floor on extending the subsidies. The House quickly called for an expedited vote on the Democratic-backed bill to extend the subsidies for three years without any changes.

In an uncommon move that Democrats decried as “outrageous,” House Leader Johnson closed the vote while some House members were still trying to vote. The vote against the bill passed 204-203. There are 435 voting members of the House. The subsequent vote for the Republican-backed plan passed 213-209. With 15 missing votes, the discharge petition vote may have passed.

House Speaker Johnson said it is “inevitable” that the discharge petition will come up for a vote when the House reconvenes in January.

Multiple Plans

Both Republicans and Democrats want votes on their own House bills.

The Democratic-backed bill from Leader Hakeem Jeffries is a straight forward extension to the existing ACA subsidies with no policy changes.

The Republican-backed bill does not extend the subsidies or address them at all. Instead, it appropriates funds to pay for cost-sharing reductions that would decrease overall subsidies, lower premiums for some, and raise premiums for others.

Some moderates disagree with their own party’s leadership. Fitzpatrick (R-Pa) and Golden (D-Maine) introduced their own bill that extends the subsidies for two years and includes some eligibility changes. In addition, Gottenheimer (D- NJ) introduced a separte bill with Kiggans (R-VA) that extends the subsidies for one year and includes modest eligibility reforms. Neither petition has near enough support to force a vote.

Second Vote Today

Despite the moderates’s support of Jeffries’s bill, the House voted today on the Republican-backed bill from Miller-Meeks (R-IA). This bill also includes reform of Pharmacy Benefit Managers and provide more control for small business owners through Association Health Plans.

The vote for Lower Health Care Premiums for All Act was 213-209 (some reports say 216-211) and the bill will advance to the Senate. It is unlikely the Senate will vote on the bill before the end-of-year recess, leaving the bill undecided until the Senate returns on January 5th.

End of the Year

Both the House and the Senate will start their end-of-year recess this week. The House of Representatives is scheduled to close their session on December 18th. The Senate will conclude on December 19th. They will return to session on January 6th and January 5th, respectively.

With only two days left on the Senate calendar, they are unlikely to vote on the House bill this session. Most experts predict the bill is unlikely to pass regardless of when the vote is scheduled.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Subsidies Undecided

by Kristin Rowan | Dec 12, 2025 | Medicaid, Medicare, Regulatory

by Kristin Rowan, Editor

Subsidies Undecided

Senate cannot agree

The record-breaking government shutdown centered around one issue: extending the COVID-era Affordable Care Act supplemental subsidies. The subsidies were an additional discount for Americans within a certain income bracket. They helped make healthcare insurance through the ACA marketplace more affordable during and after COVID. The subsidies have been extended multiple times and expire at the end of the year. Senate Republicans are not willing to extend them again. Senate Democrats won’t vote in favor of any health care proposal that doesn’t include them.

Time is Running Out

Not only do the subsidies expire at the end of the year, but anyone enrolling in a marketplace plan has to apply by December 15th, leaving precious few days to find a way forward. Senate Democrats proposed a straight three-year extension of the subsidies, which failed. Senate Republicans proposed using the subsidy money to contribute to HSAs for bronze or “catastrophic” plans. That proposal also failed.

A hybrid compromise is in the works. Details have not been released but it will likely include income caps and eligibility restrictions on the subsidies as well as some HSA flexibility. Without an extension on the subsidies, premiums are expected to increase an average of 26% in 2026, although some analyses suggest premiums could go up by 73-90%.

Another Shutdown?

The 43-day shutdown that ended in November did not finalize the 2026 budget. It merely passed enough appropriations to temporarily fund some departments through January 30, 2026 and a few essential departments for longer. If the Senate and House cannot agree on the subsidy issue, we face another shutdown in February. Every shutdown impacts Medicare & Medicaid payments, approvals, and renewals.

Experts indicate nearly 50% of people buying marketplace plans are ages 50-64. Most, if not all of them, are looking at lower cost (and lower benefit) plans or dropping insurance altogether in 2026. If insurance costs remain high, this group of

people will enter Medicare with poorer health, which will cost the Medicare program and tax payers more in the long run. It will cause a vicious circle of higher Medicare costs, leading to higher taxes, lower subsidies, higher premiums, fewer people being covered, and finally higher Medicare costs again.

This is an ongoing story and The Rowan Report will continue to bring you the latest news on the subsidies and the impending expiration of the temporary government funding as we head into 2026.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

CMS Proposed Changes

by Kristin Rowan | Dec 12, 2025 | Advocacy, CMS, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

CMS is Making Changes

Good or Bad?

CMS is making changes across Medicare and Medicare Advantage. From Star Ratings to Prescription Drug Prices to the Hospice benefit, CMS is embracing Make America Healthy Again. Will these initiatives benefit Medicare and Medicare Advantage recipients or the insurance companies who provide the plans?

Drug Payment Model

In early November, CMS announced a plan to lower prescription drug costs for Medicaid recipients. State Medicaid programs can opt in to the GENErating cost Reductions fOr U.S. Medicaid Model (GENEROUS). The pilot program is using the most-favored-nation pricing that was recently negotiated and announced by President Trump. Most-favored-nation pricing requires prescription drug manufacturers to charge the same low rate paid in other countries.

Limited Pilot

Beginning in 2026, CMS will negotiate with manufacturers of select drugs for lower pricing. Participating states will start using uniform, transparent coverage criteria. This is not criteria for inital coverage in Medicaid, but for standardizing access to high-cost medications.

Manufacturers are not required to participate in the GENEROUS Model, but can voluntarily apply. Participating manufacturers agree NOT to seek additional supplemental rebates or discounts outside the model price.

New Medicare Advantage Policies

CMS has proposed updates to the Medicare Advantage and Medicare Part D programs. The new plan would begin in CY 2027 and includes major changes to the Star Ratings system. CMS is also seeking feedback on new ways to modernize MA.

Star Rating Changes

The proposed changes are supposed to incentivize plans to improve care. CMS suggests removing 12 unique measures that look at administrative processes and those that don’t highlight differences between plans. Star Rating measurements of care, outcomes, and patient experience will remain.

Request for Feedback

CMS is seeking feedback on Medicare Advantage changes, including improving competition, refining risk adjustment, and aligning quality incentives to deliver greater value. CMS is open to either a limited model test or program-wide changes. Interested parties can submit feedback through January 26, 2026. Read the Proposed Rule here. Submit your comments.

Expanding Technology-Enabled Care

CMS may finally be recognizing what we’ve been promoting for 25 years: Care improves with technology support.

CMS Proposed Changes<br />
Technology-based Care

The ACCESS model tests a new payment approach in original Medicare to expand access to technology-supported care options. CMS aims to increase technology-supported care options to improve health and prevent and manage chronic diseases. More than two-thirds of Medicare beneficiaries are dealing with high blood pressure, diabetes, chronic musculoskeletal pain, and depression.

An interest form is now available for the 10-year Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model test. The model test begins July 1, 2026. The application to participate must be received by April 1, 2026.

Impact

As these programs roll out between now and 2029, the impact on insurance plans, payors, beneficiaries, and taxpayers will unfold. Will lower cost prescriptions and technology-based care lower insurance rates? Payor reform may be necessary to change out-of-pocket costs. Regulations may have to further incentivize payors to increase care when costs go down, particularly with value-based care models.

Please take a few minutes to read the details on each of these proposals, add your comments, and sign up to participate. The industry needs reform and our aging family members deserve better.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

MedPAC Proposes Drastic Cut

by Kristin Rowan | Dec 12, 2025 | Clinical

by Kristin Rowan, Editor

MedPAC Proposes Drastic Cuts

Five Year Decrease Not Enough

The onset of PDGM and the recalculations of payments in 2020 have led to an overall decrease in Medicare reimbursement rates for home health by approximately 12%. CMS continues to calculate budget neutrality with flawed formulas. The Alliance, along with several other advocacy groups as well as agencies and individuals, continues to fight against the formula and the pay cuts, estimating that nearly half of all home health agencies will be losing money in order to stay open.

Industry Report

Despite the continual decrease in payment rates, MedPAC recommends additional steep cuts. Highlights from the MedPAC report include:

97% of beneficiaries have access to 2 or more HHAs
The total number of HHAs declined 1% in 2024 (excluding CA)
Only 7.9% of beneficiaries used HH in 2024
Number of 30-day periods per beneficiary increased 2.6%
The overall profit margin for Traditional Medicare is 21.2%
The overall profit margin for all payers is 5%
Anticipated profit margin for 2026 is 19% for Traditional Medicare (3% overall)

Less than 0

The Traditional Medicare profit margin in 2026 is projected at 19%. This is offset by the negative profit margin from Medicare Advantage and private insurance plans. It may not be realistic or fair for the taxpayer to offset poor policies in Medicare Advantage and private insurance plans, but that has been the reality for years. Medicare Advantage plans yield high profits for insurance payors, and negative margins for HHAs. With an overall profit margin of 3%, lowering the Medicare reimbursement rate by more than 3% will put all HHAs in the red.

The Math Isn't Mathing

The numbers are there. HHAs earn 5% now, 3% next year. MedPAC recommends that CMS reduce the 2026 rate by an additional 7%.

NET PROFIT MARGIN -4%

Conclusion from MedPAC: This will not impact care; providers will still be willing to treat Traditional Medicare beneficiaries.

That statement may be true. However, in order for HHAs to survive, they will have to drop all MA plans. More than 50% of Medicare beneficiaries are on MA plans. 40% of MA patients use HH care after hospitalization. Medicare Advantage will survive through hospitals and physicians, but the Home Health benefit won’t have any providers.

Hospice Tie-In

CMS is currently weighing the option of the hospice carve-in to Medicare Advantage plans. The pilot plan failed miserably and yet rolling this out across all plans is an option, somehow. CMS and MedPAC must not be able to see what has happened to Home Health under MA plans. Hospice will suffer the same fate through the carve-in. It is irresponsible and destructive to add Hospice to MA. For that matter, it is irresponsible and destructive NOT to remove Home Health from MA. Move it all back to Traditional Medicare where at least the profit margin is above 0.

May Cooler Heads Prevail

From the proposed rule in July to the final rule in November, CMS lessened the permanent rate cut by about 5%, finally hearing the concerns of advocates who told them HHAs would go out of business. We certainly hope CMS will keep that in mind when considering the MedPAC recommendation.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Appeals Court Filing

by Kristin Rowan | Dec 4, 2025 | Advocacy, Clinical, CMS, Hospice, Legal

by Kristin Rowan, Editor

Appeals Court Filing

Hospice ALJ

A hospice claim may fall under review either before or after the claim has been paid. A hospice agency with a denied claim must file appeals until the claim is approved or the appeals are exhausted. First, they file a written request to reconsider. Then, they file an appeal to a Qualified Independent Contractor (QIC) who employs medical professionals to assess the case. Next, they file an appeal to an Administrative Law Judge (ALJ).

The ALJ is meant to review the documentation to determine whether it satisfies Medicare requirements. That’s all. There are two sets of criteria: the Medicare requirements and the patient record. If they match, the claim is paid. However, a recent ALJ decision and subsequent challenge suggests that the ALJ ignored expert testimony and decided independently that the patient did not qualify for hospice care.

Request to File

The hospice agency in this case filed suit against the ALJ, arguing that physician expertise should be shown deference in these cases. The National Alliance for Care at Home (the Alliance), joined by the American Academy of Hospice and Palliative Medicine (AAHPM), represented by William A. Dombi of Arnall Golden Gregory (AGG), has requested the right to file an amicus brief. An amicus brief provides extra information in a court case from an individual or group that is not part of the lawsuit, but has a vested interest in the outcome.

The Dispute

The Alliance puts at the heart of the case several issues, including:

Predicting death is inherently difficult
Physicians are the experts and their opinion should carry more weight
Oversight from non-qualified third parties add confusion, increase costs, and limit care

The Argument

The wording in multiple parts of the hospice benefit recognizes the expertise and importance of the physician. It is the physician who determines terminal illness. Physicians must have a face-to-face for continued eligibility. And it is the physician’s clinical judgment makes these determinations based on a patient’s individual circumstances, not an arbitrary set of standards.

If an ALJ, or any non-medical person, can overrule the treating physician’s assessment of a patient, they are effectively usurping the role of the doctor in providing a treatment plan. Medical care is subjective, which is why CMS has repeatedly considered and rejected defined criteria that would overrule a physician.

Broader Implications

The brief argues that medical professionals are better able to make care determinations. Further, the brief includes the complexity of health care prognosis, particularly in terminal illnesses. Previous court decisions have noted that “clinical judgments must be tethered to a patient’s valid medical records….” which already eliminates the need for this oversight. The Alliance stated a high probability that the decision in this case will carry substantial weight and influence both in the Sixth Circuit and in courts nationwide.

In fact, the implications may be farther reaching than that. Payors in and out of hospice deny claims deemed “unnecessary” regularly. Claims denials range from about 19% in the ACA Marketplace to as much as 49% from private payers. Even though about 80% of appeals are later accepted, only about 1% of denied claims are appealed.

Not only could this case help more patients get the hospice care they need, it could also lay the groundwork to require insurance companies to rely more heavily on the treating physician’s recommendation. We could see lower denials from prior authorization requests, unconventional treatment plans, VA benefits, and more.

Final Thoughts

The Rowan Report supports the Alliance’s efforts in this case and wholeheartedly agrees that a physician knows better the care his patient needs than a judge ever could. We are hopeful that Bill Dombi and his team at AGG will be successful in this case and that hospice providers can get back to the business of patient care. Read the statement from the Alliance here.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

BREAKING NEWS: Home Health Final Rule

by Kristin Rowan | Nov 29, 2025 | Breaking News, CMS, Home Health, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

BREAKING NEWS

Home Health Final Rule

While most of us were still recovering from our Thanksgiving feast overload, CMS quietly released the CY 2026 Home Health Prospective Payment System Final Rule (HH Final Rule). In past years, CMS published the HH Final Rule on or about November 1. The HH Final Rule was delayed this year due to the government shutdown.

Payment & Policy Updates

The payment rate for 2026 will change based on multiple factors:

HH payment update of +2.4%
The final permanent rate adjustment of -0.9%
The final temporary adjustment of -2.7%
Fixed-dollar loss ratio for outlier payments update of -0.1%

The aggregated payment update for 2026 is a net decrease of 1.3%

Read the CMS Fact Sheet

Face-to-Face

The CARES Act allows Nurse Practitioners, Certified Nurse Specialists, and Physicians Assistants to order and certify eligibility for Medicare HH and establish a plan of care. CMS has updated face-to-face encounters to now allow NPs, CNSs, PAs and physicians to perform face-to-face encounters whether or not they were the certifying practitioner or one who cared for the patient prior to home health care.

Home Health VBPM

Effective in April 2026, the HHCAHPS survey will undergo changes. CMS is removing these three survey-based measures:

Care of Patients
Communications between Providers and Patients
Specific Care Issues

CMS is adding four measures to them measure set. These include three measures related to bathing and dressing and the Medicare Spending per Beneficiary setting measure. These changes also prompted alterations to the weights of each measure and measure category.

The expanded model has built-in criteria for the removal of any quality measure. CMS is adding an additional criteria to the list of factors. Factor 9 reads that CMS may remove a quality measure if it is not feasible to implement the measure specificiations.

Medicare Provider Enrollment Revocation

Currently, any provider must enroll and be approved to become a Medicare provider. CMS has the authority to both approve and revoke provider Medicare enrollment. When CMS revokes a provider’s Medicare enrollment, the revocation is effective 30 days after CMS mails notification to the provider. In certain circumstances, CMS can revoke enrollment retroactively to the first date of non-compliance and consequently collect any money paid to that provider back to the retroactive date. CMS is adding to the allowable grounds for retroactive revocation.

If an enrolled physician or practitioner has not ordered or certified services for 12 consective months
If a beneficiary attests that a provider did not actually perform the services they billed

Additional Changes

CMS is recalibrating case-mix weights under PDGM and LUPA thresholds.

DMEPOS accreditation regulations will now require suppliers to be resurveyed and reaccredited annually. Additionally, CMS is increasing the amount and frequency of data accrediting organizations (AOs) submit, expanding their ability to monitor AOs, and strengthening their ability to address poorly performing AOs.

The DMEPOS Competitive Bidding Program will change, but we are still waiting for the finalized improvements. CMS will begin paying for all continuous glucose monitors and insulin infusion pumps.

Read the Final Rule and additional Documents

Final Thoughts

A decrease in pay of any amount is unfortunate. However, we applaud CMS for listening to the feedback. CMS stated, “…commenters raised concers that behavior change after CY 2022 might [attribute] to factors unrelated to…PDGM.” Changes since 2020 include the introduction of OASIS-E, the expansion of value-based purchasing, and the large increase in the percentage of Medicare Advantage enrollees.

Whatever the reason, The Rowan Report joins the National Alliance for Care at Home in commending CMS for adjusting its payment calculations. The permanent pay adjustment for 2026 is listed as the final adjustment, a positive for HH moving forward. The proposed rule issued mid-year had a net -6.4% decrease in payments for a net decrease of more than $1 billion dollars. The final rule payment adjustment has a net decrease of $220 million. Still a decrease, but much more palatable.

CMS will continue to assess the need for temporary payment adjustments for several more years. Additional adjustments (read decreases) to the payment rate will impact patient access to care. The Alliance will continue to advocate and educate members of Congress and HHS to lower or eliminate they reductions. Your advocacy and support is needed to ensure the future of Care at Home. The Rowan Report will continue to support the Alliance and other advocacy groups and share with you opportunities for advovacy.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com