Vision for CMS

by Kristin Rowan | Apr 24, 2025 | CMS, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Vision for CMS from Dr. Oz

Last week, Dr. Mehmet Oz issued a statement on his vision for the future of CMS. Dr. Mehmet Oz is a cardiothoracic surgeon and former host of his own TV show. Under the Department of Health and Human Services, CMS has a $1.7 trillion budget and oversees the health outcomes of more than 160 million people.

“I want to thank President Trump and Secretary Kennedy for their confidence in my ability to lead CMS in achieving their vision to Make America Healthy Again. Great societies protect their most vulnerable. As stewards of the health of so many Americans – especially disadvantaged youth, those with disabilities, and our seniors, the CMS team is dedicated to delivering superior health outcomes across each program we administer. America is too great for small dreams, and I’m ready to get work on the President’s agenda.”

Dr. Mehmet Oz

Administrator of CMS, Department of Health and Human Services

Make America Healthy Again

With HHS Secretary Kennedy, Oz is throwing his support behind Make America Healthy Again, under direction from President Trump. Senator Kennedy says that, under the leadership of Dr. Oz, CMS will work to modernize Medicare, the Marketplaces, and Medicaid. The goal is to get Americans the care they want, need, and deserve. The agenda includes:

Empowering the American People with personalized solutions with which they can better manage their health and navigate the complex health care system. As a first step, CMS will implement the President’s Executive Order on Transparency to give Americans the information they need about costs.
Equipping health care providers with better information about the patients they serve and holding them accountable for health outcomes, rather than unnecessary paperwork that distracts them from their mission. For example, CMS will work to streamline access to life-saving treatments.
Identifying and eliminating fraud, waste, and abuse to stop unscrupulous people who are stealing from vulnerable patients and taxpayers.
Shifting the paradigm for health care from a system that focuses on sick care to one that fosters prevention, wellness, and chronic disease management. For example, CMS operates many programs that can be used to focus on improving holistic health outcomes.

Letter to Medicaid

Following the vision statement, Dr. Oz released a letter to state Medicaid Agencies outlining the use of Medicaid dollars during his tenure as Administrator. The two-page letter, citing recent studies on gender dysphoria, directed Medicaid agencies to eliminate gender reassignment surgery from covered procedures, opting instead for psychotherapy. Hormonal interventions will be reserved for exceptional cases.

“My top priority is protecting children and upholding the law. Medicaid dollars are not to be used for gender reassignment surgeries or hormone treatments in minors – procedures that can cause permanent, irreversible harm, including sterilization. We have a duty to ensure medical care is lawful, necessary, and truly in the best interest of patients. CMS will not support services that violate this standard or place vulnerable children at risk.”

Read the full letter here.

Final Thoughts

We believe this will be the first of many changes made to Medicare and Medicaid rules under Dr. Oz. We will continue to share updates from the CMS newsdesk.

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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

Industry Update

by Kristin Rowan | Apr 24, 2025 | Admin, Advocacy, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Industry Update with Dr. Steve Landers

At last week’s New England Home Care & Hospice Conference, Dr. Steve Landers, President of The National Alliance for Care at Home (The Alliance) gave the keynote address and offered some industry insights and updates.

A Heartfelt Introduction

Ken Albert, Chairman of the Board at The Alliance introduced Dr. Landers before his address. After reading Dr. Landers’s official biography, Albert offered his own thoughts on the first few months of Landers’ tenure.

Last year, five colleagues from organizations across the country sat in D.C. interviewing candidates. While interviewing Landers, I was remarkably engaged by someone who is deeply passionate about care at home. Steve describes hospice care as a national treasure, and I don’t disagree. More than just his passion for care at home, Dr. Landers is savvy in navigating the political paradigms driving policy. He artfully combines data and stories to navigate relationships with policy makers. What I see every day is someone who roles up his sleeves for the patients we take care of with tremendous respect for the caregivers who are in the patients’ homes.

Ken Albert

Chairman of the Board, The National Alliance for Care at Home

Industry Changes, Advancements, and Ongoing Advocacy Efforts

Dr. Landers attributes much of the positive changes in D.C. to the efforts of volunteer leaders looking to move the industry forward. Care at home needs to become more streamlined, more efficient, and with a better voice.

His vision for the care at home industry is an America where everyone can access high-quality care wherever they call home.

Strong Admonition for CMS

Dr. Landers noted positive movement in some areas. However, he became passionately adamant that a payment update is not an increase if it doesn’t keep up with inflation or pay increases. “The Alliance represents providers delivering high-quality, person-centered care to million of individuals in the home, and they deserve to be recognized and compensated for the work they do,” he said.

Our Aging Nation

It should come as no surprise that older adults have a strong preference for aging at home. They prioritize living where they feel in control and connected. They want to be in familiar surroundings and to maintain their routines.

The U.S. population over the age of 85 is expected to triple from 2020-2060 to more than 19 million people. Despite medical advances, only 1/3 of those over the age of 85 say they are free of disability or free of difficulty with daily living.

With the rising number of older individuals, caregiver to patient ratios are falling nearly everywhere across the country. Dr. Landers and The Alliance urge policymakers to make promoting the dignity and independence of our aging population one of their highest health policy priorities. The Alliance will continue to tell anyone and everyone who will listen that care at home offers the win-win solution that policymakers are looking for.

Changes at the Top

We’ve already seen numerous and sometimes drastic changes at the federal level. Dr. Landers points out that eight years ago the “Trump 1.0 Administration” developed the PDGM framework and signed hospice reform legislation. On the campaign trail, President Trump stated he would not be making cuts to Medicare. The “Trump 2.0” care at home priorities are not yet clear, but The Alliance will continue to emphasize cost savings and the preference to age in place.

Secretary Kennedy, head of HHS, placed his emphasis on the chronic disease epidemic, launching Making America Healthy Again. He has stated a preference for community-based solutions and patient-centered care.

New CMS Administrator Dr. Oz seems to be supportive of Medicare Advantage, but did have some critique of the program during senate hearings. Dr. Oz has a stated focus of finding and eliminating fraud, waste, and abuse.

Changes Near the Top

At the congressional level, The Alliance lost a few key supporters with the last election, but many care at home advocates remained. Of the returning members of the Senate and House, care at home advocates include:

Senators Collins (R-ME), Hassan (D-NH), Tillis (R-NC), Barrasso (R-WY), Blackburn (R-TN), CortezMasto (D-NV), and Rosen (D-NV)
Representatives: Adrian Smith (R-NE), Sewell (D-AL) Van Duyne (R-TX), Panetta (D-CA), Guthrie (RKY), and Carter (R-GA)

The support in Congress leaves us hopeful. Large Reconciliation Packages dominate the current conversation. Many questions remain as to what is at risk for care at home and what Medicaid’s future might hold.

Later this year, The Alliance sees opportunities for care at home outside of reconciliation. These include Home Health PDGM reform, hospice reform, the telehealth extension, revocation of the Medicaid HCBS 80/20 rule, tax credits, and long term care insurance.

Public Policy Priorities

As The Alliance moves forward, several key issues will remain priorities:

Access to Care at Home

PDGM Implementation
Telehealth Extension
Medicare Advantage Dynamics
Care for High Needs Beneficiaries

Quality Care at Home

Special Focus Program Implementation
DEA Telehealth Provisions
HOPE tool implementation?

Eliminating Fraud and Abuse in Care at Home

Hospice Concurrent Care
Hospice and Medicare Advantage
Medicaid 80/20 Rule
Caregiver Tax Credits / LTCI

Growing the Care at Home Workforce

Supply is simply not meeting demand
Strengthened rates, incentives, and educational opportunities will attract and retain a qualified workforce

Follow Up

I spoke with Dr. Landers after the keynote address to ask him why lone worker safety was not among the top priorities of The Alliance. He assured me that there is a position within The Alliance who, among other tasks, is focusing on lone worker safety. I urged him to make it a higher priority and will follow up to get the contact information for the position he mentioned.

# # #

Mass Layoffs in HHS “Overhaul”

by Kristin Rowan | Apr 11, 2025 | CMS, Regulatory

by Kristin Rowan, Editor

Mass Layoffs at HHS

HHS Secretary Robert F. Kennedy Jr. announced more than 10,000 position cuts within the department this week. The layoffs impact employees at the FDA, the CDC, the National Institute for Occupational Safety and Health, and CMS, among others.

The 10,000 layoffs come after 10,000 additional employees left the department this year through retirement and deferred resignation programs. The HHS overall staff is currently at around 75% of its previous numbers.

Kennedy Promises no Cuts to Essential Services

Despite the 25% reduction in workforce, Secretary Kennedy insists that no essential services will be cut. Native American tribes across the Southwest disagree with that statement and met with Kennedy to discuss the support they need. Kennedy left those meetings saying, “We are all going back with a long laundry list of tasks that we need to perform. And I’m going to give you my commitment today that I am available and listening to you.” Kennedy promised to look into cuts that disrupted scientific research and reinstate them.

Mass Layoff Impact to Care at Home

Of the 10,000 layoffs, approximately 300 of them came from within CMS. The agency lost roughly 4% of its total workforce. The administration pointed to “minor duplication” across the agency that the layoffs will eliminate.

The Administration for Children and Families (ACF), Assistant Secretary for Planning and Evaluation (ASPE), and CMS will share critical programs within the Administration for Community Living (ACL) that support older adults and people with disabilities.

Long-Term Goals

Multiple departments within HHS are consolidating, removing overlapping positions, research, and efforts. The stated goal of the department is to implement Make America Healthy Again, aimed at ending the chronic disease epidemic.

Make America Healthy Again

From the office of the President, Make America Healthy Again focuses on combatting rising rates of mental health disorders, obesity, diabetes, and other chronic diseases. According to the Presidential Action, agencies should prioritize gold-standard research, work with farmers to ensure food is the healthiest and most affordable possible, and ensure the availability of treatment options and the flixibility for health insurance coverage to provide benefits that support healthy lifestyles and disease prevention.

Final Thoughts

The current upheaval and overhaul within HHS does not seem to be impacting CMS or Medicare and Medicaid services at this time. The 4% reduction is staff is negligible and there have been no cuts to services or programs within CMS. Word from HHS is that no additional cuts are planned and their next focus will be on streamlining efficiency. The new Assistant Secretary for Enforcement position to combat waste, fraud, and abuse will oversee the Office of Medicare Hearings and Appeal. We will continue to follow this story as it develops.

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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 .She also has a master’s degree in business administration and marketing and 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

CDPAP Overhaul Under Scrutiny

by Kristin Rowan | Apr 11, 2025 | Medicaid, Regulatory

by Kristin Rowan, Editor

CDPAP Overhaul in NY Medicaid Program

New York State Department of Health issued a comprehensive plan to overhaul the state’s Medicaid program. The state’s program, Consumer Directed Personal Assistance Program (CDPAP), allows patients to hire the caregiver of their choice. Eligible participants like the program for its autonomy. The redesign of the program’s execution reduces payment processors from more than 600 to just one company: Public Partnerships, LLC of Georgia.

The Need for the CDPAP Overhaul

New York Governor Kathy Hochul points to waste, fraud, and abuse in the Medicaid program as the drivers of the change. According to the Department of Health and Human Services (HHS), the cost for CDPAP rose from $2.5B in 2019 to $12B in 2025. Despite drawing national criticism, Hochul maintains that the program needs stronger oversite to ensure adequate care. Additionally, the state’s Medicaid program has recently suffered more than $143 million in clawbacks from kickbacks and improperly claimed reimbursements.

Brakes Applied

Last week, a judge issued a temporary restraining order (TRO) blocking the consolidation of the payer system down to a single entity. The TRO was issued following a lawsuit filed on behalf of individuals and independent living centers. The parties claim that the transition to Public Partnerships LLC has been delayed by technical challenges. The delays threaten to remove beneficiary access to home health services. The litigants also cited failure on the part of the state to serve notice and to allow for a fair hearing to challenge the change.

A judge has extended that TRO through April 14th, blocking additional changes. Beneficiaries who have already switched to the new payer are not impacted by the TRO. HHS Secretary Robert F. Kennedy Jr. stated there will be a 90-day review period to assess whether the change complies with federal law.

Hit From Both Sides

For or against the transition to a single payer, lawmakers on both sides of the aisle are in agreement on one thing: Public Partnership LLC should not be that single payer. The company has a history of financial mismanagement, no experience working in New York, and may have engaged in bid rigging.

Dubious Reassurances

The NY Department of Health issued a public service announcement saying access to home health care will remain intact and that members will be able to keep their current caregiver. Following the review period from HHS and the pending lawsuits, residents of New York may experience familiar disappointments.

This is an ongoing story and we will provide updates as the story develops.

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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. She also has a master’s degree in business administration and marketing and 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

MedPAC Comments on CY 2026

by Kristin Rowan | Mar 22, 2025 | CMS, Editorial, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

MedPAC Comments on CY 2026

MedPac Sends Recommendations to Congress

MedPAC makes recommendations to Congress and HHS on issues affecting the Medicare program. The March report for 2025 includes recommendations for hospice, home health, and SNFs, in addition to in-patient and out-patient hospital services.

Hospice

Using the exact terminology from the 2024 report, MedPAC recommends that Congress eliminate the update to the 2025 Medicare base payment rates for hospice. MedPAC pointed to a number of statistics to support the evaluation:

The number of hospice providers increased in 2023
Some of the growth in hospice providers occurred in states where CMS has concerns over program integrity
The percentage of patients using hospice increased by .8 percent nationwide, as did the days of care and visits per week
Medicare payments exceeded marginal costs by 14 percent

Opinion

The population of the U.S. is aging as more and more Baby Boomers qualify for Medicare; there is an increased need for hospice agencies to accommodate the volume of patients
Whether there are more hospices in states where program integrity is questioned does not impact the need for hospice care; program integrity reform changes this, not reimbursement rates
The rise in use, length of stay, and days of care explain the increase in the number of hospice; need, not profitability drives this growth
The average markup in 2022 was 72 percent above marginal cost

Marginal Cost

Marginal cost is the cost of adding one more unit of production. In simple terms, that would be the overall costs of adding one hour of care for a hospice patient. This would include scheduling, hourly wage, and other operational costs. MedPAC believes that if an agency adds one hour of care and make 14 percent more than their costs, that is sufficient.

Home Health

Keeping with tradition, MedPAC used the same language again from 2024 to recommend that Congress reduce the 205 Medicare base payment rate for home health agencies by 7 percent.

The number of HHAs participating in Medicare increased by 3.4 percent.
Most of the growth in HHAs was in LA County. Outside LA County, the number of HHAs decreased by 2.8 percent.
The number of 30-day episodes per beneficiary decreased by 1.8 percent, but is still higher than in prepandemic years
MedPAC was unable to compute the marginal profit for 2023
Quality of care (percent discharged to community) increased by 1.3 percent
The all-payer margin in HHAs was 8.2 percent, attracting investors
The projected Medicare payment margin for 2025 is 19 percent

Image of letters spelling health and wealth

Opinion

LA County has more HHAs, but the rest of the country has fewer. We believe if you ask The National Alliance for Care at Home, Bill Dombi, or any number of prior HHA owners, low reimbursement rates forced them out of business

Pandemic numbers skewed the need for care at home because everyone was at home; if you only look at prepandemic numbers compared with 2023 numbers, the need for home health is increasing
HHAs keep patients out of the hospital, which accounts for more Medicare payments and higher costs
Again, the average margin across the U.S. is 72 percent, but MedPAC somehow believes 8 percent will attract investors and buyers; volume is attracting buyers, not margins
The projected 2025 margin is 19 percent and MedPAC recommends lowering it to 14 percent, matching hospice, and is 58 percent lower margins than the average industry

One Point of Parity

Surprisingly, there is an overlap in thinking between providers and MedPAC. In the February 2025 comment on the CMS notice of proposed rulemaking for 2026, MedPAC addressed the coding intensity and increased Medicare Advantage payments.

Last summer, Editor Emeritus Tim Rowan reported on the inflated health conditions filed by payers. Medicare Advantage payers also routinely deny care that traditional Medicare plans would cover. MA payers are collecting on both the front and back ends of the “Bank of CMS.” According to the Center for Economic Policy Research, upcoding by MA plans costs CMS 106 percent of traditional Medicare costs. Quality bonus payments add an additional 2 percent. Operating surplus from enrolling healthier beneficiaries adds another 11 percent. Payments to MA plans are 19 percent higher. MedPAC agrees and urges CMS to further investigate coding intensity from MA payers.

Point of Contention

Although we agree with MedPAC’s assessment of MA coding intensity, that is where the similarity ends. Let’s take that recommendation one step further and require that MA plans pay hospice and home health providers a higher percentage of their risk-assessment adjustment and let the payers make their profits elsewhere.

It Could be Worse

Given the recent upheaval in D.C. and the fear that Medicare, Medicare Advantage, Medicaid, Social Security, and other benefits would be done away with completely, we are relieved to see the House Budget Bill passing without the drastic reductions to care at home.

From the Alliance

Following the passing of the House Budget Bill, The National Alliance for Care at Home issued a response statement. We’ve published the full response here for you.

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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. She also has a master’s degree in business administration and marketing and 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

Underlying Causes of Health Issues

by Kristin Rowan | Mar 13, 2025 | Advocacy, CMS, Outcomes, Regulatory

by Kristin Rowan, Editor

Underlying Causes of Health Issues

Underlying causes of health issues are common. Not all health issues come directly from infections, medical conditions, or genetics. Lifestyle, environmental factors, and social determinants can cause and/or increase the severity of health issues. Beginning in the winter of 2023, the Centers for Medicare and Medicaid Services posted guidance on approving coverage for these social needs, acknowledging that they contribute to poor health outcomes. CMS named the social needs that could be covered by Medicaid, CHIP, Section 1115, and Home and Community Based Services. These include help finding new housing, one-time moving costs, eviction prevention, respite care, sober centers, home improvements, meals, and case management.

Guidance Rescinded

CMS referred to both the 2023 and 2024 documents as “Center Informational Bulletins” (CIB) meant as guidance, not rule of law. The 2024 document provided updates and clarifications to the 2023 document. According to the statement from CMS, dated March 4, 2025, they have rescinded both CIBs “to evaluate policy options consistent with Medicaid and CHIP progam requirements and objectives.” Moving forward, CMS will consider each application to cover these services on a case-by-case basis using the Social Security Act, not the HRSN Framework or the CIBs.

Opposition

Former chief medical officer of the US Medicaid program Andrey Ostrovsky, MD, FAAP said that removing coverage for social determinants of health will harm patients and taxpayers.

Sen Ron Wyden (D, Oregon) agrees, stating that addressing the underlying causes of health issues is key to keeping America healthy.

Underlying Causes of Health Issues Andrey Ostrovsky

“It’s unlikely we see an easy, smooth approval process for such services moving forward….I think that the bar to getting it approved will be higher. States are going to have to make individualized decisions around where their priorities are and where they want to continue to focus on expansion — and maybe focus a little bit more on cost constraint and financially effective services under the new administrative priorities.”

Damon Terzaghi

Senior Director of Medicaid Advocacy, National Alliance for Care at Home

On the Other Hand

Despite the opposition to this change, there does seem to be some validity to the move. There should be some discussion about where Medicaid services should end and another department begins. The question here is whether a different federal program should be providing coverage for these social determinants of health. According to Terzaghi, this could be the beginning of an improvement to the system, rather than the dismantling of it.

Final Thoughts

The changes coming out of D.C. recently seem to be coming like rapid fire. See this weeks related press release on the continuing resolution passed by Congress. As with most of these edicts, executive orders, and other changes, the long-term impact and the eventual goal remain to be seen. We will continue to follow these and other stories as new information becomes available.

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Update on Public Participation in Rule Making

by Kristin Rowan | Mar 13, 2025 | Advocacy, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Update

Last week, we reached out to some of our contacts for responses to this change.

Former President of NAHC and current Senior Counsel at Arnall Golden Gregory Bill Dombi said:

It is difficult to discern the impact of the rescission of the waiver. One concern is whether the administration considers Medicaid a grant or benefit program thereby exempting it from APA public notice and comment rulemaking.

With respect to Medicare, if it is considered a benefit, there is still a Medicare statutory requirement of public notice and opportunity for comment through formal rulemaking that should effectively nullify the practical impact of the rescission of the waiver. All that said, we will need to see more before being to judge the impact.

Frequent guest author and Fellow, American Health Law Association, Elizabeth E. Hogue, Esq. had this to say:

Recission of the Richardson Waiver is not good news for providers.

Many federal agencies voluntarily committed to give notice and comment for actions that otherwise would be exempt. The US Department of Health and Human Services was one of the federal agencies that adopted this policy in October, 1970, in a memorandum commonly referred to as the “Richardson Waiver.” This policy was published in the Federal Register in 1971. HHS did not, however, promulgate the Waiver through notice and comment rulemaking.

The open process of give and take between agencies and providers under the Richardson Waiver resulted in resolution of important issues relatively informally. Now it appears that only policies mandated by statute will go through the rulemaking process. In other words, opportunities to resolve issues without formal resolution will be compromised.

The recission of the Waiver may also make administration of both the Medicaid and Medicare programs more complicated and less effective, especially in view of US Supreme Court decisions that say everything that hasn’t gone through the notice and comment process is not binding on providers.

# # #

Below is the original article, published March 6, 2025

Public Participation Rescinded

The Administrative Procedure Act (APA) requires that an agency public a notice of proposed rulemaking in the Federal Register; allow sufficient time for public participation via written data, views, or arguments; and then publish a final rule. Matters relating to agency management, personnel, or public property; loans, grants, benefits, or contracts; and for “good cause” are exempt from the reporting requirements. The Richardson Waiver, adopted in 1971, waived the exemption and instructed agencies to use the good cause exemption sparingly. Effective immediately, the Richardson Waiver is rescinded.

“The policy waiving the statutory exemption…imposes on the Department obligations beyond the maximum procedural requirements specified by the APA, adds costs [that] are contrary to the efficient operation of the Department, and impedes the Department’s flexibility to adapt quickly to legal and policy mandates.”

Robert F. Kennedy, Jr.

Secretary, Department of Health and Human Services

What it Means

Public participation is now optional. Agencies and offices of the Department of HHS can, if desired, use the public notice and comment procedures for these matters, but are no longer required to do so. The Department will continue to follow these procedures in all circumstances in which they are required to do so.

Law firm Hogan Lovells, experts in healthcare law, wrote about the potential implications for the health care industry in a recent blog post. According to the firm, it is unclear how HHS will interpret the “benefits” portion of the exemption. HHS, and specifically CMS, currently uses the notice and comment procedure for various benefits programs, including Medicare and Medicaid. Secretary Kennedy’s statement clearly calls out the limitation in impacting any other law requiring notice and comment periods.

Public Participation in Medicare Rules

Hogan Lovells indicates that few if any policies written under the Medcare Act will be impacted by this change. The Medicare Act operates under additional rulemaking requirements under section 1871(a) of the SSA. Additionally, Azar v. Allina Health Services, 587 U.S. 566 (2019) confirms that Medicare rulemaking is independent from the APA. Some policies are currently exempt from the notice and comment obligations under the Medicare Act and will remain exempt.

Public Participation in Medicaid and CHIP rules

Medicare and CHIP fall under Title XIX of the SSA, which does not contain its own notice and comment requirements separate from the APA. HHS has used the APA notice and comment rules for many of the changes made to the Medicaid program. HHS could interpret the “benefits” clause as exempting Medicaid changes from the rule. Hogan Lovells states it is currently unclear whether HHS will take this route. They also purport the courts have not ruled on whether APA excludes Medicaid from the notice and comment requirements, and may not agree with that exclusion. Until the term “benefits” is better defined, Medicaid, CHIP, the insurance exchange marketplace, and TANF, among others, may be impacted.

Department of Veterans Affairs

A notable exception to these changes is the rulemaking in the Department of Veterans Affairs as it relates to the Veterans Health Care act of 1992. This program implemented Federal contractor requirements that established pricing and contracting standards for drug manufacturers. The VA policies and rules have historically been enacted using guidance letters, avoiding the rulemaking process altogether.

Final Thoughts

There is too much that is yet unknown regarding this change to understand its full impact. There will be immediate changes, court rulings, further changes, and likely a lot of advocacy from national organizations fighting for transparency for Medicare, Medicaid, and other “benefit” programs. This will be an ongoing story and The Rowan Report will bring updates as they happen.

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Humana Thyme Agreement

by Kristin Rowan | Mar 7, 2025 | Clinical, Hospice, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Palliative Care for Medicare Advantage Members

Cancer is one of the highest leading causes of death in the United States, second only to heart disease. The challenges for cancer patients are not only physical, but emotional and financial as well. The consequences of these challenges are often devastating to the patient and their families. Providing additional care, support, and pharmaceutical interventions through value-based care can improve patient outcomes and reduce out-of-pocket costs.

Thyme Care

Thyme Care is a Nashville-based cancer treatment center that operates in seven states. The centers provide not just treatment, but cancer care navigation, designed to work within the value-based framework, keeping the patient at the center of care. Thyme Care includes an oncology care team, a patient app with multiple resources and 24/7 access to support. Patient surveys track symptoms and reduce barriers to care. This approach combines cancer treatment and palliative care for whole-person cancer care support.

Palliative Care

Palliative care works alongside medical care to improve the quality of life for the patient, addressing physical, emotional, and spirtual needs. Strictly speaking, it is not medical care, and not specifically covered by most insurance plans. The out-of-pocket costs for palliative care can be extremely high, making this kind of care an inaccessible amenity for most patients.

Value-Based Care

Value-based care reimburses care providers partially based on patient outcomes and patient satisfaction. Providers also share the financial risk of care with health insurance companies. Care providers who can both improve outcomes and patient satisfaction can be reimbursed more through health insurance plans, which can cover the costs of palliative care, even when it is not explicitly covered by the plan.

Humana

Humana is a payer with plans for Medicare, Medicaid, and Individual/Family beneficiaries. The Medicare Advantage value-based care plans allow Humana to disperse payments for covered services in partnership with care provider teams across a patient’s care journey. The better the outcome and satisfaction, the more Humana can pay a provider for care. Better outcomes often means reduced hospital visits, a longer time at home before requiring skilled nursing facilities, and lower costs.

Humana Thyme Palliative Care Collaboration

The recently announced partnership between payer and provider will give eligible patients access to palliative care support as part of the whole-person cancer care navigation provided by Thyme. Humana patients can also receive, as needed, 24/7 virtual care, medication guidance, symptom management, chronic condition management, community-based resources, financial assistance, transportation, food assistance, and/or access to stable housing.

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. She also has a master’s degree in business administration and marketing and 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

Prior Authorization Requirement Removed by UnitedHealthcare

by Kristin Rowan | Mar 7, 2025 | Clinical, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Easier Access to Home Health

Prior authorization requirements can be cumbersome, delaying or even preventing care in some cases. Patients who need prior authorization to get he care they need also generally have form after form to fill out or to have completed by their PCP or hospital physician, who doesn’t have time for adequate visits, much less more paperwork.

As part of their ongoing efforts to reduce prior authorization volume by 10%, UnitedHealthcare has just announced a change in their home health services requirements.

Limits on Where Changes Apply

Beginning April 1, 2025, UHC will no longer require prior authorization or concurrent reviews for home health services managed by Home & Community (formerly naviHealth). This is the next step in an ongoing effort to modernize the authorization process and simplify health care for its members and providers.

These changes will apply to Medicare Advantage and Dual Special Needs Plan (D-SNP) beneficiaries in 36 states and the District of Columbia.

Alabama
Alaska
Arkansas
California
Colorado
Connecticut
Florida*
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas

Kentucky
Louisiana
Maine
Maryland
Massachusetts
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon

Pennsylvania
Rhode Island
South Carolina
Tennessee*
Texas
Utah
Virginia
Washington
Wisconsin
Wyoming
Washington, D.C.

*In Florida and Tennessee, the changes will not apply to D-SNP plans that are not managed by Home & Community.

Prior Authorization Additional Information

You should continue to request prior authorization and concurrent review through March 31, 2025. UHC reminds all providers that following CMS guidelines for providing home health care services is still required. And in states where a Medicare denial is required to get Medicaid prior authorizations, providers should submit their requests through the UHC provider portal.

The available information on this pending change is limited. We will provide updates should they become available. Please contact UHC directly through the provider portal if you have specific questions.

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BREAKING NEWS: Kennedy Rescinds Public Participation in Rule Making

by Kristin Rowan | Mar 7, 2025 | Advocacy, Breaking News, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Public Participation Rescinded

The Administrative Procedure Act (APA) requires that an agency publish a notice of proposed rulemaking in the Federal Register; allow sufficient time for public participation via written data, views, or arguments; and then publish a final rule. Matters relating to agency management, personnel, or public property; loans, grants, benefits, or contracts; and for “good cause” are exempt from the reporting requirements. The Richardson Waiver, adopted in 1971, waived the exemption and instructed agencies to use the good cause exemption sparingly. Effective immediately, the Richardson Waiver is rescinded.

Robert F. Kennedy, Jr.

Secretary, Department of Health and Human Services