Government Shutdown

Medicaid

by Kristin Rowan | Oct 9, 2025 | Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Government Shutdown Threatens Care at Home

Lawmakers on opposite sides of the aisle failed to come to a budget agreement by the deadline. This causes an immediate cease to all non-essential government functions and many government employees aren’t being paid.

The Disagreement

Reporters and spokespoeople from both sides of the debate have suggested various reasons for the shutdown. Equally, both sides claim they are not the holdouts. What we do know for sure is that one of the primary points of contention is the continuation of subsidies for Affordable Care Act Marketplace Insurance plans. One group wants an extension written into the current budget while the other says it’s not necessary since the subsidies currently run through the end of the calendar year.

Push to Extend

The lawmakers who are pushing to get the subsidy issue resolved believe that marketplace users are not going to sign up for insurance in November and do it again in January when the subsidies are fixed. Instead, insurance commissioners warn that without the subsidies, many people will opt not to have insurance at all and others will select substandard plans based on affordability. They will be priced out of the plans they want without the subsidies in place.

Priced Out

In 2025, even with the subsidies, the average family was paying $800 per month on health insurance through the marketplace. When the subsidies expire, those same families will see their existing plan rates jump to $3,000 per month. KFF, the nonpartisan health research organization, estimates that most users will have a 114% rate increase.

Photo Credit – The New York Times

Counter

According to ND insurance commissioner Jon Godfread, lawmakers who oppose the subsidies are actually opposing the cost of health care and insurance across the board. They insist the subsidies aren’t necessary if healthcare and insurance costs drop instead. Proponents of the subsidies agree, but say that is a longer discussion that will take a lot of time to resolve and the subsidies provide an immediate solution to a bigger problem. They are urging the holdouts to include the subsidies in the budget and tackle the rising cost of healthcare later.

Open Enrollment

The clock is ticking. Open enrollment for 2026 begins November first in every state except Idaho, where open enrollment starts next week. Insurers have already locked in their 2026 premium rates, which will likely cause sticker shock for most marketplace users. Most insurers have prepared subsidy and non-subsidy rates, but without the extension, we will only see the much higher non-subsidy rates. These rates are unlikely to change before enrollment starts and the only hope for marketplace buyers is for Congress to extend the subsidies.

Care at Home Impact

There are several ways in which the shutdown and the loss of the subsidy may impact care at home.

Payment delays are the most pressing risk. Government officials have promised no delay for some essential services like SNAP and WIC. It is likely Medicare and Medicaid payments will be delayed. While those payments will come through eventually, care at home agencies have to operate without payment or hope the

payers will process payments locally while waiting on the government to reopen. The longer the shutdown lasts, the more likely it is that payments will be delayed. The 6th Senate budget vote failed today, sending the shutdown to day 8.

The longer term impact for care at home will come if the subsidies are not renewed. If insurance rates increase by more than 100% on November 1, users will opt for lower priced coverage, which may no longer include care at home benefits. Fewer patients seeking care at home means less money for agencies. Long-term, it also means higher hospital and ER usage and costs, which increases government spending and usually leads to additional care at home cuts to offset the costs.

National Alliance for Care at Home has identifed current and potential implications of the shutdown. Read their analysis here.

This is an ongoing story and we will continue to provide additional information as it happens.

# # #

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

Can This New Software Eliminate Fraud and Billing Errors?

Admin

by Tim Rowan | Oct 9, 2025 | Admin, Medicaid, Product Review

by Tim Rowan, Editor Emeritus

Software Eliminates Fraud and Errors

Like so many Home Care providers, Aspen Home Care in Kansas City, Missouri was drowning in paper. Two hundred caregivers turned in weekly timesheets every Friday. A large office staff had to go through them, looking for errors, omissions, and unauthorized visits and shifts. Submitting erroneous claims, of course, leads to payment denials, even fines. When an agency submits too many bad claims every week over a long period, a surveyor will soon be knocking at their door.

The Hurdles

On a good week, Aspen completed all necessary payroll and billing tasks and had bills ready to submit by end of business on the following Thursday. Slowing down the process were the usual errors — forgotten check-outs, more hours worked than authorized, and late timesheet submission. Caregivers grew weary of the weekly phone calls asking for clarification, even when the error was their fault. Aspen did have a basic billing system, but paper timesheets fed it too. Electronic Visit Verification was possible, but only via a patient’s landline, using punched-in identification codes.

Then... the call came

“After years of software design, we have completed our replacement for your billing and EVV system. We would like you to switch from the basic system we sold you a few years ago and beta test our better one.”

– Henry (Hank) Schwab, Owner, Compliance Plus

Beta testing is a risky venture, but both owner Ahmed Jara and Office Manager Mohammed Mohammed* trusted Hank and agreed to give it a try. After all, the agency was drowning in paper, they reminded each other.

Dramatic Process Improvements

We took part in a demo of the Compliance Plus system before speaking with Mohammed and hearing Aspen’s experience. We saw a comprehensive, user-friendly system, with a color-coded user interface, that includes scheduling, EVV, and billing for Medicaid, Managed Care, and all other payers an agency contracts with.

Time Tracking

Caregivers clock in and out with an app that is GPS-enabled down to exact longitude and latitude coordinates. Should a patient live in an internet dead zone, caregivers can use their landline. If there is no landline, Aspen will install a “smart fob” in the home. Aspen does not require specific visit start times, but once a check-in is recorded, the app knows the patient’s authorized hours and automatically alerts the caregiver when it is time to clock out.

Verification

Mistakes do happen, of course, but fixing them is not difficult. When the Compliance Plus back end sees a 14-hour visit, it assumes the caregiver forgot to check out. The visit flashes red on the screen, indicating it is not ready to bill, and displays the difference between authorized and recorded hours. The office employee managing exceptions simply calls the caregiver for verification and then manually edits the end time, and compliance is maintained.

Caregiver Feedback

Mohammed told us his caregiving staff is thrilled with the app, though he did say the transition was hard at first. “They learn to use it in about 30 minutes,” he said. “Check-in and check-in take a few seconds and now they are happy to be done with paper forever, not to mention no longer having to deliver paper timesheets to the office.” He added that fake check-ins from the car on the way to a patient’s home have been completely eliminated.

Most importantly, the three-person office staff now completes payroll and billing for 200 caregivers by midday on Tuesday instead of late on Thursday.

The "Plus" of Compliance Plus

Certainly, procedural efficiencies are important, and many scheduling and EVV systems force caregivers to check in and check out in the presence of the patient and alert office staff when a caregiver arrives late or is a no-show. What we saw during our demo, however, we have not seen elsewhere. Compliance Plus automates the tedious task of rooting out EVV, billing, and payroll errors so efficiently, payment denials, aggregator rejections, and incorrect paychecks are virtually eliminated.

Denials are Rare

Mohammed confirmed what we saw in the demo. The file that includes hours, authorizations, patient demographics, and pre-arranged pay rates is prepared and perfected in advance. Then, the system uploads the same corrected file to the aggregator and to state and other payers. “If we need to fix hours or a bill, we do it before uploading to all entities,” he said. “We rarely get rejections from the aggregator or denials from payers.”

Aggregated Data

One of the requirements of payers and EVV aggregators is that all patient and caregiver names and other information must be in their respective databases in advance. Compliance Plus finds missing data and removes a bill from the file before it is uploaded, notifying the user with a red flag. Mohammed added, “We have to make sure all patient data is in system, but that is easy to do.”

Implementation and Training

In every home care agency, there is always a measure of trepidation among the staff when switching from familiar paper to automation. Aspen Home Care was no different when owner Ahmed Jara announced that he had accepted Hank’s invitation to join a beta test. Mohammed told us that his staff’s time from implementation to software expertise took a little less than three months. Compliance Plus customer relationship manager Sara Moore conducted online training of key office staff, a service that is included in Aspen’s monthly fee. Mohammed and a couple others trained the rest of the staff on the full system and then caregivers on the use of the app.

“After a short while, the new system became our normal workflow,” Mohammed commented. “The only speed bump is when they upload new features. We need to spend a little time learning them, but ultimately, the new features improve our workflow. Our caregivers pick up the app in about 30 minutes, including new hires.”

Favorite Features

He added that his 200 caregivers like checking in and out on the app better than the legacy ANI system, which used the patient’s landline for automatic number identification. “English is a second language for some of our caregivers, and they sometimes had trouble with the ANI prompts spoken by the computerized voice,” he explained. “GPS verification is the best feature. If a caregiver checks in from too far away, we see their distance from the patient’s home on a map, and we gently ‘re-educated’ them and it does not happen again. In the past, they would sometimes get away with asking a family member to check in for them from the patient’s landline. Those days are gone.”

He also told us that Aspen does not insist on specific start times. What matters is that visit length matches authorized hours over a billing period. This is especially helpful for waiver and HCBS plans when the caregiver lives in the home. In those arrangements, checking in or out used to be easily forgotten. “I take care of her all day, how do I know when I start and stop?” The Compliance Plus app rings its cell phone loudly to remind visiting and live-in caregivers to check in and then to check out after the authorized number of hours have been reached.

Simplifying Complex Billing

Presently, Aspen exclusively serves Medicaid beneficiaries, though that can mean several managed care payers. With varying reimbursement rates from payers, combined with different caregiver hourly rates, getting a bill to match an authorization used to be a challenge for Office Manager Mohammed and his team.

It's Complicated

In the case of an agency employed family caregiver, there are often days when the family member will spend one hour toileting and feeding, the next hour doing reimbursable homemaking chores, and the third hour running care-related errands. Not only might those tasks be paid at different rates, but they can, and often are, reimbursed by different payers.

Patient Profiles

Mohammed emphasized that the way Compliance Plus handles these situations saves considerable time and reduces payer and aggregator rejections. Like in a Venn diagram, every combination of patient, payer, task type, and caregiver creates a “patient profile.” The user created most profiles in advance, based on known payer rates, etc. Occasionally, a patient’s profile is unique, but a user can easily enter the specifics into the system manually. Once a profile is built, the system calculates all of the billing accurately without additional user supervision.

Task Rates

If a payer’s rate for a task changes, Mohammed or another office staffer makes the change one time for all affected patients. In that scenario where the live-in caregiver performs three different tasks in one day, he or she checks in and out only once, before the first task and after the last, and designates each task performed. Compliance Plus does the rest.

Company Prospects

Hank Schwab told us that he is confident, after 100 successful beta customers, that Compliance Plus is ready for general release. At $10 to $12 per patient per month, he believes that supplementing word-of-mouth with a modest marketing effort will help him replace paper and strengthen the bottom line for many Medicaid and Personal Care agencies. Hank’s plan is to begin that effort as soon as he identifies an investor or two and hires a marketing director. “I already manage a team of coders and personally pay all the bills,” he laughed. “I’m ready for someone else to take on a few of my jobs.”
https://complianceplus.com/

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Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.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

MACPAC Rate Setting

CMS

by Rowan Report | Sep 25, 2025 | CMS, Medicaid, Medicare, Medicare Advantage, Partner News

FOR IMMEDIATE RELEASE

Contact: Elyssa Katz
571-281-0220
communications@allianceforcareathome.org

MACPAC Rate Setting

The Alliance Expresses Concerns Regarding MACPAC Approach to HCBS Rate Setting

Alexandria, VA, and Washington, DC, September 18, 2025. The National Alliance for Care at Home (the Alliance) released the following statement in response to the Medicaid and CHIP Payment and Access Commission’s (MACPAC) discussion regarding home- and community-based services (HCBS) rate-setting held during today’s September MACPAC meeting.

The Alliance appreciates MACPAC’s interest in addressing issues related to worker pay in HCBS. These workers should receive higher wages and benefits as they are the backbone of the long-term care system in our country. They are dedicated professionals who provide essential services that promote the community integration, independence, and positive health and social outcomes of older adults and people with disabilities.

Unfortunately, we are concerned about the draft recommendation MACPAC discussed during today’s meeting. Rather than seeking to address the root-cause of low worker wages, MACPAC’s recommendation instead focuses on collecting

additional information that would further describe the issue. This approach increases administrative burden on states and providers without actually proposing solutions to this problem.

MACPAC Rate Setting Report

MACPAC’s report acknowledges that rate studies and wage data are insufficient to address chronically underfunded Medicaid HCBS programs. To create meaningful change, state administrations and state legislators must be held accountable to fund services at levels that enable improved wages for workers. Sixty years of Medicaid program history have demonstrated that such wholesale changes to state actions are only achieved through new and strengthened Federal requirements. We urge MACPAC and its Commissioners to be bold and recommend structural changes to Federal Medicaid law and regulations that mandate payment policies ensuring access to HCBS through livable wages for direct care workers. The Centers for Medicare & Medicaid Services (CMS) should be given the authority to require states to:

Perform comprehensive rate studies no less frequently than every five years that:
- Use generally accepted accounting practices to develop a payment methodology that assures continued adequacy of each component of the rate model; and
- Establish a rate model that includes individualized components for core provider cost drivers as well as a livable wage for workers.
Submit a copy of the rate review report and recommendations with any waiver renewal or state plan amendment and make the report publicly available on their website; and
Require states to justify any variance between the report recommendations and the actual established payment rates.

Further, CMS should be given the authority to disapprove rate methodologies that do not clearly account for all statutory and regulatory requirements of delivering services as well as demonstrating that the rates are sufficient to support a livable wage for workers.

Our members are committed to improving the lives and livelihoods of direct care workers because beneficiaries depend on them. We call on MACPAC to ensure that states and the federal government are equal partners in this critical endeavor.

# # #

About the National Alliance for Care at Home

The National Alliance for Care at Home (the Alliance) is the leading authority in transforming care in the home. As an inclusive thought leader, advocate, educator, and convener, we serve as the unifying voice for providers and recipients of home care, home health, hospice, palliative care, and Medicaid home and community-based services throughout all stages of life. Learn more at www.AllianceForCareAtHome.org.

© 2025. This press release originally appeared on the National Alliance for Care at Home website and is reprinted here with permission. For more information or to request permissions, please see the contact information above.

Bill Dombi Presents

Advocacy

by Kristin Rowan | Sep 18, 2025 | Advocacy, Home Health, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Bill Dombi Presents...

It has become almost customary for the President/CEO of The Alliance, and previously NAHC, to give the keynote address at state association and software user group meetings. The 2025 Kantime event, Passport to Success, was no exception. Dr. Steve Landers was scheduled to speak first thing Tuesday morning. But, Dr. Landers is in D.C. speaking to members of Congress and CMS for Advocacy Week, trying to convince anyone who will listen of the needed changes in Care at Home.

When Kantime asked Bill Dombi, former President of NAHC, to take Landers’s place, they asked him not to give his customary “vanilla” talk about the state of the industry. According to Dombi, Kantime gave him a bit of a license to step outside the traditional industry address. He took that license and ran with it, regaling the audience with stories of his school days, being educated (and tortured) by KCatholic nuns in full habits, his road to both the law and care at home, and his thoughts on the future of the industry.

“I shouldn’t be here. I’m retired! I should have no shoes in, wearing shorts, or maybe still sleeping, waking up just in time to catch Let’s Make a Deal or the Price is Right, have lunch, take a nap, and then watch a movie or mow my lawn. I had retirement dreams of lounging on a two-person hammock by the beach. My hammock is in the basement. And the guitar I bought myself as a retirelment present, with dreams of coming back here with my band, remains unopened in my living room. It has never been out of its case.”

Bill Dombi

President Emeritus, National Alliance for Care at Home

“But, one of my jobs is to make my successor a success. So, here I am.”

This led Bill to his first topic, Passion: Powering Health Care at Home. He invited the audience to think not of his story, but of their own what lead to their passion for care at home. If you’ve ever heard Bill Dombi speak about care at home and his wish to in his lifetime see the industry become what he has advocated for and imagined for more than 50 years, then you know how spirited and passionate he is. He has fought against injustice since the 6th grade and fought for radical improvement in care at home since college.

Bill spoke openly about the fraud, waste, and abuse that has plagued home health and hospice since before most of us knew what home care was. He lamented the continued need for advocacy at both state and federal levels with each new administration, bill, and MedPAC recommendation since before the Reagan era. He recalled the advent of Medicare and Medicaid when care at home was limited and underused. And he warned of the disasterous idea of rolling Hospice care into Medicare Advantage. In true “Bill Dombi style,” he managed to do all of this in a way that left an air of hope in the room rather than doom.

What's in Store for Care at Home?

Bill talked about the progress his successor has made, including his current work on The Hill for Advocacy week. According to Bill, the advocacy focus for the National Alliance for Care at Home is:

PDGM
Hospice Carve-in
HCBS OBBA Risks
HCBS 80/20 rule
Medicare Advantage
Workforce Improvement

Final Thoughts - Dombi's Care at Home Forecast

The scope of Health care at home will continue to expand. There will continue to be technology and artificial intelligence advances in care at home. The provide design and delivery of care model will evolve. Consolidation and competition are definitely in play. And the workforce is a common denominator for success.

# # #

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

Advocacy Week

Advocacy

by Rowan Report | Sep 18, 2025 | Advocacy, Home Health, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

Advocacy Week

FOR IMMEDIATE RELEASE

Contact: Elyssa Katz
communications@allianceforcareathome.org
571-281-0220

Over 240 Advocates Rally in DC for the Future of Care at Home

National Alliance for Care at Home Hosts Inaugural Advocacy Week on Capitol Hill

Alexandria, VA and Washington, D.C., September 12, 2025.

More than 240 care at home care advocates from across the country met with over 275 congressional offices this week to discuss key legislative and regulatory priorities for expanding access to home-based care services. The meetings were part of the 2025 National Alliance for Care at Home’s inaugural Advocacy Week.

Alliance Advocacy Week brings together leaders, advocates, and supporters to unite as one voice for care at home, driving positive legislative change and shaping the future of care to ensure broader access to the life-changing home care services for all Americans.

Advocates focused on four key issues during their congressional meetings:

Protecting home health care by preventing dangerous payment cuts
Safeguarding the Medicare Hospice Benefit by ensuring hospice remains a separate holistic managed care model outside of Medicare Advantage
Expanding telehealth access across many care at home services
Supporting robust Medicaid HCBS funding to strengthen community-based care

Advocacy Week National Alliance for Care at Home

In addition to Wednesday’s congressional meetings, Alliance Advocacy Week featured strategy sessions, beginner advocate training featuring a panel discussion with Congressional staffers, and in-depth policy briefings. On Thursday, the Alliance’s Assembly of State Associations – a network of leaders of state home care and hospice organizations – came together for a robust conversation.

The Alliance celebrates the achievements of this inaugural Advocacy Week on behalf of home-based care providers nationwide and will continue engaging in critical policy dialogue to support and expand access to essential care at home services.

# # #

About the National Alliance for Care at Home

The National Alliance for Care at Home (the Alliance) is the leading authority in transforming care in the home. As an inclusive thought leader, advocate, educator, and convener, we serve as the unifying voice for providers and recipients of home care, home health, hospice, palliative care, and Medicaid home and community-based services throughout all stages of life. Learn more at www.AllianceForCareAtHome.org.

©2025. This press release originally appeared on the National Alliance for Care at Home website and is reprinted here with permission. For questions or to request permission to use, please see press contact information above.

Medicare Advantage Excess Payments

CMS

by Kristin Rowan | Sep 4, 2025 | CMS, Hospice, Medicaid, Medicare Advantage

by Kristin Rowan, Editor

Medicare Advantage Excess Payments

Investigational Study

Researchers from the Department of Health Services, Policy and Practice at Brown Universchool of Public Health and the Department of Geriatrics and Palliative Medicine at Icahn School of Medicine published an original investigative study on spending versus payments in Medicare Advantage under the hospice carve-out model.

Carve-out to VBID to Carve-out

In 2021, CMS started a Value-Based Insurance Design (VBID) to test the impact of adding hospice services to Medicare Advantage benefits. By December of 2024, CMS ended the program due to widespread upset. CMS returned to the hospice carve-out model. Under this model, when an MA beneficiary chooses hospice, any health care expenses related to the terminal illness is paid on a fee-for-service (FFS) basis. MA no longer receives inpatient and outpatient payments, but continues to receive premiu, and rebate payments.

Carve-out Hospice Benefit

Once an MA enrollee enrolls in hospice, MA is no longer responsible for payments. Under the carve-out model, hospice services are paid by Medicare. MA plans are still responsible for paying for services that are not related to hospice care. These services can include inpatient, outpatient, physician, skilled nursing facility, home health care, and prescription drug expenses.

Medicare Advantage Spending and Payments

The study spanned 12 months and looked at 314,087 MA beneficiaries. In that period, 80.5% of enrollees had no spneding unrelated to their terminal illness. MA was not responsible for any healthcare related payments, but continued to receive $120 per enrollee per month. Estimated spending from MA on hospice enrollees was $57-70 per month.

In the 12 months following an enrollee electing hospice, MA plans netted $50-60 per month per enrollee. If half of the rebate payments received pay for supplemental benefits, MA receives excess payments to the tune of $68,808,924 over three years. If no rebate payments go toward supplemental benefits, MA receives $174,185,112 in excess payments over three years. The care a hospice enrollee receives uses the fee-for-service model. Medicare Advantage providers are seemingly paid on a fee-for-no-service model.

Medicare Advantage plans do not currently report the actual amount of rebate payments used to pay supplemental benefits.

Study Conclusion

The researchers conclude that MA receives excess payments under the hospice carve-0ut model. They also note that there is no accountability for spending after hospice election from MA plans to CMS. The researchers suggest that CMS could require MA plans to report actual spending on supplemental services after hospice election and pay premiums and rebates only to cover the amount spent.

I have a different recommendation….MA plans should not receive any additional premium payments or rebates following hospice election. MA plans should be required to report total payments and spending from enrollment date to election date. The balance, less the same 8% average margin of home and health and hospice agencies, should be used to pay for hospice services from election to passing. Any remaining balance after the patient’s passing should be returned to the beneficiary’s family.

# # #

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: CMS Changes AHEAD

CMS

by Rowan Report | Sep 4, 2025 | CMS, Medicaid, Medicare

From cms.gov

CMS Changes AHEAD

CMS Announces Changes to Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model to Improve Quality, Promote Transparency, and Decrease Costs

September 2, 2025

What's New

The CMS Innovation Center announced new policy and operational changes, as well as a new end date, to the Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model to help states achieve their total cost of care (TCOC) targets, while advancing the Center’s commitment to promote choice and competition, increase prevention, empower patients, and protect taxpayer dollars.

Why it Matters

Participating states now have more tools to manage Medicare costs (designed to support sustainable growth) and improve quality of care and population health outcomes

What to Expect

Changes will be implemented across all cohorts beginning in January 2026. AHEAD’s end date for all cohorts is now December 31, 2035.

The Big Picture

Changes made to the model will help to advance the CMS Innovation Center’s strategic pillars of: 1) choice and competition, with states implementing at least two policies focused on promoting choice and competition in their health care markets and 2) prevention, with a new Population Health Accountability Plan focused on preventive care, including chronic disease prevention.

Additional Details

CMS is also introducing payment reforms through AHEAD for patients with Original Medicare and establishing new transparency requirements around TCOC and primary care investment targets. For the first time ever, AHEAD will bring total cost of care accountability to all Original Medicare beneficiaries in AHEAD regions through geographic attribution of beneficiaries not attributed to other CMS accountable care organization programs. This novel framework will offer risk-bearing Geographic Entities additional tools and enhanced flexibilities to improve health outcomes and lower spending for their patients while receiving shared payments (or losses) through two-sided risk arrangements. In return, patients may receive additional beneficiary incentives while enjoying existing protections under the Original Medicare program.

Total Cost of Care Model

The AHEAD Model is a state total cost of care (TCOC) model that seeks to drive state and regional health care transformation and multi-payer alignment, with the goal of improving the total health of a state population and lowering costs. Under a TCOC approach, a participating state uses its authority to assume responsibility for managing health care quality and costs across all payers, including Medicare, Medicaid, and private coverage. States also assume responsibility for ensuring health providers in their state deliver high-quality care, improve population health, offer greater care coordination, and promote healthier living for all people participating in the model. The AHEAD Model provides participating states with funding and other tools to address rising health care costs and improve health outcomes.

More Information

# # #

Medicare Prior Authorization

CMS

by Kristin Rowan | Sep 4, 2025 | CMS, Medicare, Regulatory

by Kristin Rowan, Editor

Medicare Prior Authorization

Wasteful and Inappropriate Service Reduction Model

The Centers for Medicare and Medicaid Services (CMS) is launching a pilot program in six states to combat what they deem to be unnecessary treatments. Dubbed the Wasteful and Inappropriate Service Reduction (WISeR) Model, the voluntary program will launch in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington beginning January 1, 2026 and ending December 31, 2031. The program will use Artificial Intelligence (AI) and Machine Learning (ML) alongside human clinical review to “ensure timely and appropriate Medicare payment for select items and services.”

The Problem

According to CMS, health care waste harms patients and comprises 25% of healthcare spending. “Low-value” services provide little effectiveness, do not align with specific health conditions, and can lead to additional complications and more wasteful services.

Medicare Prior Authorization Solution

The new WISeR Model is designed to reduce unsupported care. Participating care providers will outsource authorization of a pre-selected list of services to reviewers using technology to “expedite and improve the review process.” These services are those that CMS designated as vulberable to fraud, waste, and abuse.

Reasoning

CMS suggests that the fee-for-service model used in traditional Medicare incentivizes unnecessary treatments, tests, and other care. According to CMS, these items provide little to no benefit for some patients. These include:

Skin and tissue substitutes
Electrical nerve stimulator implants for obstructive sleep apnea and incontinence
knee arthroscopy for knee osteoarthritis
Cervical fusion
Epidural steroid injections
Vertebral augmentation
Image-guided lumbar decompression
deep brain stimulation for Parkinson’s and essential tremor

Strategy and Outcomes

The WISeR Model is supposed to ensure patients get the most appropriate care for the best outcomes. It is also supposed to lower costs and administrative burden on providers. Patients are supposed to partner with their health care providers to decide on the most appropriate care plan. Eliminating “unnecessary” services and procedures is supposed to save taxpayer dollars and decrease fraud, waste, and abuse. Care providers are supposed to focus on providing care that has the most impact on the well-being of Medicare beneficiaries.

Editorial Comment

I am not a Medicare recipient, but I have many close friends and family who are. I am not a nurse or home health expert, but I am a patient and by my count, I have a PCP and 6 specialists that I see on a regular basis. However, I am now, or will be in the near future, in need of:

Electrical nerve stimulator
Cervical fusion
Steroid injections
Lumbar decompression

Personal Experiences

I am already at the mercy of my health insurance provider for pre-authorizations for everything that is not routine visits with my primary care provider. I know first-hand the hoops and red tape my provider(s) go through. Already this year, I have filed two requests to review denials, more than 10 rescheduled visits because my pre-authorization had not been received, and at least one interview that my PCP had to attend with an “expert” who had previously decided that my regularly scheduled follow-up cancer scan was unnecessary.

Predicted Results

Adding prior authorization approval requirements for care and treatment will delay beneficiaries from getting the care they need, prolong the pain they experience daily, and cost more in wasted time and money than it can possibly save in wasted procedures. I sincerely hope there are enough voluntary participants in this experiment to document the additional time, money, and resources required. I also hope these participants send regular surveys to their Medicare beneficiaries to ask whether they feel like getting pre-authorizations for routine procedures has made them feel like they are getting better care.

# # #

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

OASIS-E2

CMS

by Kristin Rowan | Aug 28, 2025 | CMS, OASIS, Regulatory

OASIS-E2

by Kristin Rowan, Editor

OASIS-E2 Instruments and Change Table draft are available from The Centers for Medicare & Medicaid Services (CMS). They are available for download here. The draft proposes an off-cycle implementation date of April 1, 2026

Change Table

Changes include:

Transportation listing changed from A1250 to A1255
Hearing (B0200) and Vision (B1000) added to ROC
Sex (A0810) replaces Gender (M0069)
COVID vaccination up to date removed
Language (A1110) added to ROC
Minor changes to replace outdated item numbers with updated ones (ex: all instances of A1250 changed to A1255)

Change Timeline

The Changes are effective April 1, 2026. However, the changes are not final pending approval from the Office of Management and Budget (OMB). Agencies are able to use the draft form for training purposes, but should look for the final form that includes the OMB control number and expiration date.

Implications

OASIS accuracy is linked to PDGM payments and quality outcomes. Prepare early for the off-cycle April 1, 2026 changes to ensure a smooth transition to E2 requirements and continued reporting accuracy.

Resources

Draft versions of the instruments are on the CMS website in a ZIP file. You can download the file here.

The PRA package, which includes four separate documents, is available for download here.

Submit comments to CMS about OASIS-E2 or any other item in the Home Health Prospective Payment System Rate Update for CY 2026 here and here.

Eleos Navigates Eligibility Risk

Admin

by Rowan Report | Aug 21, 2025 | Admin, Artificial Intelligence, Clinical, Home Health, Hospice, Medicaid, Partner News

Eleos Navigates Eligibility Risk

FOR IMMEDIATE RELEASE

Contact: Amanda Wells

awells@sloanepr.com

Eleos Launches AI Scanner to Navigate Medicaid Eligibility Risk in Real Time

The new OBBBA AI scanner uses Eleos’ ambient AI technology to alert providers of patient eligibility changes, preserving revenue and ensuring care continuity amid sweeping Medicaid policy changes

BOSTON, MA, Aug. 20, 2025 — Eleos, the leading AI platform in post-acute care, today announced the launch of the OBBBA (One Big Beautiful Bill Act) AI scanner, the first real-time tool to proactively detect potential changes to Medicaid eligibility during client sessions. The OBBBA AI scanner uses Eleos’ purpose-built ambient AI scribing technology to inform providers about changes that may impact coverage, giving them time to act before Medicaid coverage lapses. The tool was launched in response to sweeping Medicaid funding cuts and eligibility rule changes.

Eligibility Check

Providers can select Medicaid-related “themes” to track such as housing status, diagnosis updates, or life events like marriage or aging out of eligibility. The OBBBA scanner captures contextual clues that could trigger changes in coverage. Providers use this information to take action to prevent eligibility loss, reduce care disruption and maintain treatment continuity. For care organizations, this means fewer denials and greater revenue stability, as well as better client support.

The OBBBA AI scanner arrives at a critical moment: new Medicaid rules introduce shorter retroactive coverage windows, semi-annual (versus annual) redeterminations and narrowed eligibility criteria — all of which lead to a higher risk of churn, especially for vulnerable groups such as people with serious mental illness and those experiencing housing instability.

“We’re hearing from leaders across the country that Medicaid redetermination changes are already causing confusion and fear among clients and providers alike. The OBBBA AI scanner gives providers the earliest possible warning via real-time insights so they can protect coverage and avoid treatment disruptions, ensuring clients continue to receive necessary and life-saving care. This kind of provider-first technology is at the core of Eleos.”

Alon Joffe

Co-founder and CEO, Eleos

Embedded seamlessly within the Eleos Documentation experience, the tracker works in tandem with providers’ existing workflows, requiring no additional software or manual data entry.

Industry leader sees Eleos scanner as critical tool

“OBBBA has created significant uncertainty for the behavioral health sector, and organizations need every possible advantage to navigate it. Properly deployed, purpose-built AI tools help organizations navigate an ever-changing landscape while also promoting the health and well-being of clients and communities.”

Chuck Ingoglia

President and CEO, National Council for Mental Wellbeing

Rationale

The OBBBA AI scanner builds on Eleos’ mission to free care providers from administrative burdens and enable better, more data-informed care. Deployed in over 200 organizations in 30-plus states, Eleos is the most-used AI solution in behavioral health, substance use disorder (SUD) treatment and post-acute care. Its suite of AI-powered documentation and compliance solutions has been proven to reduce documentation time by more than 70%, double client engagement and drive 3-4x better treatment outcomes.

For more information about the OBBBA AI scanner or to request a demo, visit www.eleos.health.

# # #

About Eleos

Eleos is the leading AI platform for behavioral health, substance use disorder, home health and hospice. At Eleos, we believe the path to better care is paved with provider-focused technology. Our purpose-built AI platform streamlines documentation, simplifies revenue cycle management and surfaces deep care insights to drive better client outcomes. Created using the industry’s largest database of real-world sessions and fine-tuned by our in-house clinical experts, our AI tools are scientifically proven to reduce documentation time by more than 70%, boost client engagement by 2x and improve symptom reduction by 3-4x. With Eleos, post-acute care providers are free to focus less on administrative tasks and more on what got them into this field in the first place: caring for their clients.

DOJ Settles with UnitedHealth and Amedisys

Legal

by Kristin Rowan | Aug 21, 2025 | Legal, M&A, Medicare, Medicare Advantage

by Kristin Rowan, Editor

DOJ Settles with UnitedHealth and Amedisys

Judge to Weigh In

DOJ settles with UnitedHealth and Amedisys after almost nine months of negotiations. The Department of Justice (DOJ) initially blocked the proposed merger between UnitedHealth and Amedisys, citing concerns over eliminating competition in home health and hospice services in some areas of the U.S. After the most recent settlement hearing, the merger seems to be back on track.

Public Comment Period and Judicial Review

Now that the DOJ hurdle has been passed, there is a public comment period. Following the public comment period, the U.S. District Court for the District of Maryland will enter final judgement. From the Justice Department website:

As required by the Tunney Act, the proposed settlement, along with a competitive impact statement, will be published in the Federal Register. Any interested person should submit written comments concerning the proposed settlement within 60 days following the publication to Jill Maguire, Acting Chief, Healthcare and Consumer Products Section, Antitrust Division, U.S. Department of Justice, 450 Fifth Street NW, Suite 4100, Washington, DC 20530.

Antitrust Division Statement

“In no sector of our economy is competition more important to Americans’ well-being than healthcare. This settlement protects quality and price competition for hundreds of thousands of vulnerable patients and wage competition for thousands of nurses. I commend the Antitrust Division’s Staff for doggedly investigating and prosecuting this case on behalf of seniors, hospice patients, nurses, and their families.”

Abigail Slater

Assistant Attorney General, Justice Department Antitrust Division

Divestiture Agreement

According to the new agreement, UnitedHealth will sell 164 home health and hospice locations across 19 states. In addition to the sale, the agreement provides the buyers of these locations with assets, personnel, and relationships to help them compete with remaining UnitedHealth locations. Also included are protections to deter UnitedHealth from interfering with the new owners’ ability to compete.

BrightSpring Health Services and Pennant Group will acquire the 164 locations. Slater said the settlement, which includes the largest ever divestiture of outpatient healthcare, protects quality and price competition patients as well as wage competition for nurses. However, antitrust specialist Robin Crauthers, a partner with McCarter & English, says it doesn’t go far enough. According to Crauthers, the settlement agreement does not address all of the markets that would have less competition and that the DOJ accepted less than they wanted in the agreement.

Additionally, critics argue the divestiture moves 164 home health and hospice agencies from one large player to two other large players in the space. Arguably, rather than preserve competition, this divestiture agreement will only serve to strengthen the largest players in the market, giving them a substantial advantage over smaller agencies in these areas.

UnitedHealth Amedisys divestiture locations

Not the Only Concern

Vertical Integration

Joe Widmar, Director of M&A at West Monroe consulting firm, says that the number of home health and hospice agencies is not the tipping factor in competition. Rather, it is UnitedHealth’s vertical integration. A health insurance company that also owns nearly 2,700 subsidiaries, including pharmacies, home health and hospice, behavioral health, consulting for healthcare organizations, surgery centers, hospitals, mental health, managed care for Medicaid and Medicare, and specialty care. Virtually any referral from a PCP to any other health professional puts more money into the health care giant’s pockets. The lack of competition is across all forms of healthcare, leaving patients no choice buy to support UnitedHealth Group in areas where all local healthcare providers are subsidiaries. I 2024, UnitedHealth insurance paid $150.9 million to its subsidiaries for care. These provider companies are not counted in the profit caps placed on insurance companies.

Upcoding

In addition to side-stepping profit caps, vertical integration aids in upcoding. Upcoding is the practice of digging into a patient’s life to find (or create) additional patient needs. Insurers add as many codes as possible for the greatest reimbursement rates. According to a recent study, UnitedHealthcare overbilled Medicare Advantage by $14 billion through upcoding.

In-home health risk assessments and patient reviews, often offered to beneficiaries as a free service, result in an average risk score 7% higher than in patients seen in medical practices and hospitals. UnitedHealth generates more income from patient review diagnoses than any other MA insurer. The Department of Justice is currently investigating UnitedHealth’s Medicare billing practices.

Final Thoughts

If you own a home health, hospice, or palliative care agency in any of the states shown in the graphic above, write to Jill Maguire with comments and concerns. Our primary objective is providing quality care to patients in their homes. We know that home care is less expensive for the patient and government-funded insurance. But not when all the home care agencies in an area are owned by only a few of the largest home health agencies in the country. And not when the insurer is adding diagnostic codes to pad their bill.

# # #

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

HIS to HOPE Help

Admin

by Rowan Report | Aug 21, 2025 | Admin, Clinical, CMS, Hospice

by Curantis Solutions

HIS to HOPE Help

HOPE visit types

The HOPE (Hospice Outcomes & Patient Evaluation) model introduces a new rhythm to hospice documentation, one that centers on the patient’s evolving experience of care. To meet HOPE’s standards with confidence, it’s critical to understand the different visit types and their timing.

Let’s break down the three visit types defined by HOPE: INV, HUV, and Symptom Follow-Ups, so your team knows exactly what’s required, when, and why it matters.

INV

Initial Nursing Visit

What it is: The first clinical touchpoint in the HOPE timeline. The INV marks the beginning of structured data collection and sets the baseline for all subsequent updates.

When it’s due: As soon as possible after admission, ideally within the first day.

What it captures:

Key demographic and clinical data
Initial symptom impact ratings
Observations that may trigger a future follow-up

HUV

HOPE Update Visits

HOPE requires two follow-up check-ins to capture how the patient’s condition is changing over time. These are called HOPE Update Visits—HUV1 and HUV2.

HUV1

When it’s due: Days 6–15 after admission
Purpose: Reassess symptoms and update the patient’s status.

HUV2

When it’s due: Days 16–30 after admission
Purpose: Continue tracking trends and changes, especially as patients stabilize or begin to decline.

Pro tip: Even if the visit wasn’t originally intended as a HOPE Update Visit, clinicians can update their response at visit close ensuring the right file is created.

Symptom Follow-Up Visits

What they are:
Special visits required when certain symptoms (e.g., pain, shortness of breath, anxiety) are rated as having a moderate or severe impact on the patient’s well-being.

When they’re due:
Time-sensitive, must occur within days of the symptom being flagged.

Why they matter:
These follow-ups are the heart of HOPE’s patient-centered approach. They ensure that care plans are adapted quickly and that patients don’t suffer in silence.

Symptom follow-ups should be:

Automatically evaluated after each visit
Clearly flagged with alerts across the system
Auto-documented into the HOPE record upon completion and QA

HOPE Hub

To support you every step of the way, Curantis Solutions has created the HOPE Hub—a dedicated resource center designed to guide your team through a seamless transition to HOPE-based documentation. For more HOPE Resources, visit here.

# # #

About Curantis Solutions

Curantis Solutions was born from a desire to put hospice and palliative care first. With a genuine culture of caring, our team is dedicated to creating a refreshingly simple software experience that utilizes emerging technology, smart design and a cloud-native/serverless architecture to create an experience that is congruent with the technology you utilize in your everyday life. It’s time for hospice and palliative care software to make life easier vs creating arduous workarounds and added frustration. It’s time you experience Curantis Solutions!

Medicaid Enrollees Sent to ICE

Legal

by Kristin Rowan | Aug 21, 2025 | Legal, Medicaid, Regulatory

by Kristin Rowan, Editor

UPDATE

The Rowan Report originally published this article on August 7, 2025. This update is as of August 15, 2025.

After HHS began providing access to personal data on Mediciad enrollees to the Department of Homeland Security (DHS), 20 states filed to sue the department for violating privacy laws. Shortly thereafter, CMS entered into a new agreement to give DHS daily access to view the same data.

Federal Judge Vince Chhabria of California ordered HHS to stop giving DHS access to personal information. The ruling grants a preliminary injunction, stopping HHS from sharing Medicaid data with ICE in the 20 states that participated in the lawsuit. The injunction will last until 14 days after the two agencies complete and submit a reason for the decision to share information. The reasoning must comply with the Administrative Procedure Act. The injunction can also end if litigation is concluded (a formal hearing and decision).

Chhabria noted that there is no formal law preventing government agencies from sharing information, he cited agency policy as his reasoning for the injunction. ICE has a well-publicized policy against using Medicaid data for immigration enforcement. Judge Chhabria wrote in his ruling:

“Given these policies, and given that the various players in the Medicaid system have relied on them, it was incumbent upon the agencies to carry out a reasoned decisionmaking process before changing them. The record in this case strongly suggests that no such process occurred.”

August 7, 2025

Associated Press Confirms

Enrollee Information Given to ICE

In a surprise announcement on July 17, 2025, investigative reporter Kimberly Kindy and reporter Amanda Seitz filed a report. They uncovered information confirming Medicaid enrollee information given to ICE from CMS. ICE will use this to find “aliens” across the country. The health and personal information disclosed includes home addresses, birth dates, Social Security numbers, and ethnicities.

Department of Homeland Security Responds

DHS Assistant Secretary Tricia McLauglin said, “…CMS and DHS are exploring an intitiative to ensure that illegal aliens are not receiving Medicaid benefits….”

DHS Spokesperson Andrew Nixon said, “With respect to the recent data sharing between CMS and DHS, HHS acted entirely within its legal authority—and in full compliance with all applicable laws….”

Opposing Viewpoints

Senator Adam Schiff (D-CA) said, “The massive transfer of the personal data of millions of Medicaid recipients should alarm every American. This massive violation of our privacy laws must be halted immediately. It will harm families across the nation and only cause more citizens to forego lifesaving access to health care.”

Similarly, CA Governor Gavin Newsom said, “This potential data transfer brought to our attention by the AP is extremely concerning, and if true, potentially unlawful….”

HHS and DHS Sued

State Attorneys General from 20 states, led by California Attorney General Rob Bonta have filed suit. They are suing the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), HHS Secretary Robert F. Kennedy Jr., and DHS Secretary Kristi Noem.

The Associated Press found a Medicaid internal memo and emails. Subsequently, the AP reported that Medicaid officials tried to stop the data transfer due to legal and ethical concerns. The objection was unsuccessful. CMS had 54 minutes to comply with an order coming from two advisors within Secretary Kennedy Jr’s camp.

Disclosure Focuses on Violation of Laws

Current laws provide that states can create their own health plans, eligibility standards, and coverage, as long as the plan follows federal criteria. Medicaid laws also provide for emergency coverage for non-citizens. Seven states and D.C. started programs that offer full Medicaid coverage to non-citizens.

Four of the seven states, New York, Oregon, Minnesota, and Colorado, never submitted identifiable information about Medicaid recipients to CMS. The data shared with ICE came from the remaining three states; California, Illinois, & Washington State; and Washington D.C.

Map of U.S. States Compromised by CMS and DHS

The Allegation

The lawsuit was filed in the U.S. District Court for the Northern District of California. It alleges that the federal government is allowing the personal data of Medicaid recipients to be used for purposes unrelated to the Medicaid program.

Further, the coalition of states alleges that the disclosures violate several federal data privacy laws. These include Health Insurance Portability and Accountability Act (HIPAA), Federal Information Security Modernization Act (FISMA), and the Privacy Act.

Additionally, the Attorneys General state that the disclosures are contrary to the Social Security Act and a violation of the Spending Clause.

The lawsuit calls upon the court to bar CMS from sending additional PII to DHS and to bar DHS from using any of the information it has already received.

“In the seven decades since Congress enacted the Medicaid Act to provide medical assistance to vulnerable populations, federal law, policy, and practice has been clear: the personal healthcare data collected about beneficiaries of the program is confidential, to be shared only in certain narrow circumstances that benefit public health and the integrity of the Medicaid program itself.”

Attorneys General

Coalition of States

Final Thoughts

This lawsuit is the latest of many against the current administration. The Rowan Report will continue to update this and other stories impacting care at home as the lawsuits continue.

# # #

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

Alliance Responds to Hospice Final Rule

Advocacy

by Kristin Rowan | Aug 7, 2025 | Advocacy, CMS, Hospice, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

The Alliance Responds to CMS Hospice Final Rule

CMS Issues FY 2026 Hospice Final Rule

On August 1, 2026, CMS issues the FY 2026 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Programs Requirements Final Rule. Here are the high-level changes in this year’s final rule:

Rate Setting Changes
- A 3.3% inpatient hospital market basket percentage increase
- A 0.7% productivity adjustment (read decrease)
- Statutory cap increases from $34,465.34 to $35,361.44
Hospice Care Admission
- The physician member of the interdisciplinary group (IDG) may recommend admission to hospice care
Face-to-Face Attestation
- Signature and date requirements restored
- Eliminated requirement for attestation to be a separate and distinct document
- Attestation requirement can be a section or addendum to recert form, or part of a signed and dated clinical note
Hospice Quality Reporting Program

The HOPE tool will replace the HIS tool on October 1, 2025, despite comments to delay implementation
CMS published a HOPE Technical Information webpage ,an HQRP training library, and a Requirements and Best Practices webpage
CMS recognized the error in their HOPE burden calculations. The burden is 21.1% higher than initially reported. The difference will be “taken into consideration” in the next PRA package submission.
The separate reporting tool (QIES) and reports tool (CASPER) will sunset and iQIES will replace both tools.

FY 2026 Hospice Quality Reporting Program

National Alliance for Care at Home Statement

After CMS issued the final rule, the Alliance responds with a statement addressing the wage adjustment, HOPE tool implementation, and sttestation changes. Read the full press release here.

Wage Adjustment

The Alliance recognizes that the 2.6% wage update is higher than the proposed 2.4% adjustment issued earlier this year. However, The Alliance maintains its position that the update does not go far enough to offset the very high and very real operational costs that hospices across the country face.

Regulatory Relief

Both the physician member of the IDG recommending hospice admission and the inclusion of a clinical note to serve as attestation of a face-to-face were welcome changes to hospice regulations. The Alliance thanked CMS for these changes.

HOPE Tool Implementation

The Alliance was among the many commenters to CMS about the October 1, 2025 implementation date for the HOPE tool. Alliance CEO Dr. Steve Landers had this to say:

Despite responsiveness in other areas, the Alliance is deeply disappointed that CMS did not heed recommendations and delay the October 1, 2025 implementation of the Hospice Outcomes and Patient Evaluation (HOPE) tool nor waive the timeliness completion requirement for HOPE record submission. We expect providers to face a burdensome transition and urge CMS to remain responsive to real-world challenges, offering flexibility as providers navigate the change.

Dr. Steve Landers

CEO, National Alliance for Care at Home

The Alliance is committed to working with CMS to reduce spending and strengthen the Medicare hospice benefit. They also continue to support the CMS initiative to reduce fraud, waste, and abuse.

Final Thoughts

The Hospice Final Rule is not what we hoped for. The wage update was increase, but not by enough to make a real impact on the operational burden hospices face. CMS has provided technical training and education for the HOPE tool, but severely underestimated the financial burden connected to the transition. CMS continues to use outdated, incorrect, or faulty information in its calculations of wage rate updates and ignores the repeated comments from advocacy groups and hospice providers.

# # #

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

Tell CMS not to Kill Home Health

Advocacy

by Kristin Rowan | Aug 7, 2025 | Advocacy, CMS, Regulatory

by Kristin Rowan, Editor

The Alliance to Care at Home:

CMS needs your comments

CMS needs your comments on the home health proposed rule for FY 2026. Advocacy is a cornerstone of the mission of The National Alliance for Care at Home. From The Hill to the home, The Alliance fights for the future of the industry. But, they can’t do it alone.

Proposed Rule

The CMS proposed rule for FY 2026 has a net 6.4% decrease in payments to home health providers. Industry experts warn that this change will cause home health agencies to shutter their doors and it will leave many rural areas in a home health desert.

The Alliance Call to Action

At last week’s 2025 Financial Summit in Chicago, policy and industry experts provided ways to adjust how to write comments to CMS. According to Mary Carr, Vice President for Regulatory Affairs at National Alliance for Care at Home, it’s not enough for a few agencies and organizations to advocate for home health. Everyone has to submit comments about this. Carr says if done effectively, sending comments on proposed rules is one of the most powerful ways to stop these policy changes. The way you write your comment letters is important if you want them to have an impact.

Carr provided this guidance and tips on how to right an effective comment to CMS:

Remember that CMS is not looking for an agree/disagree statement

Provide good reasons for not keeping the proposed rule as is

Address very specific reasons why any part of the proposed rule is bad

Include the direct impact the proposal will have on your business, your staff, and your patients

Provide an alternative recommendation

Mention studies on how much less home health costs compared with SNFs and ALFs

Don’t let fear, anger, and anxiety detract from your message

Maintain professionalism and respect

Mention and thank CMS for any good aspects of the proposed rule

Include impact statements on reduction in services, delays to getting care, and areas that would be without any available home health care should the proposed rule stand

Mention the Other Side

No matter what side of the aisle you are usually on, we all must agree that care at home is an industry issue, not a Democrat or Republican issue. Hillary Loeffler, Vice President of policy and regulatory affairs at the Alliance, reluctantly mentions that the clawbacks, reductions, and methodology used to determine rates were put in place by the previous administration.

“It’s a new administration. I hate to say it, but I’m going to say, ‘This methodology was created by the Biden administration, and the Trump administration needs to do something about this.’ So, hopefully they take a fresh look at it.”

Hillary Loeffler

Vice President of Policy and Regulatory Affairs, National Alliance for Care at Home

Loeffler also suggests going directly to Congress with comments and letters in addition to CMS. The recent trend of lowering reimbursement rates causing fewer visits, less coverage, and longer wait times is untenable and complete reform of the home health benefit at the federal level is needed to ensure its survival, added Loeffler.

Illogical Arguments

Whether you are publishing comments on the home health proposed rule or writing a letter to your senators and representatives, steer clear of logical fallacies. These errors in reasoning are easy to fall prey to when you have an emotional investment in the issue at hand.

Ad Hominem

The very common Ad Hominem fallicy happens when the argument moves from the problem to the person. Blaming your representative or accusing CMS of hating home health rather than focusing on the impact of the pay cut will weaken our standing.

Slippery Slope

This fallicy involves stretching the consequences of an action beyond reality. Cutting home health payment rates will decrease care and increase start-of-care delays. It will not cause homelessness, mass hysteria, or a small pox outbreak.

Fallacy of Composition

If you’re familiar with standard contracts, you’ve read the clause that goes something like, “if any part of this contract is illegal, the rest is still intact.” The composition fallacy assumes that the whole of something matches its parts. The CMS proposed rule for FY 2026 has improvements, such as allowing physicians to do face-to-face appointments even if they are not the certifying physician. Don’t throw out the entire proposed rule. Rather focus on those parts that are clearly devastating to the industry.

Fallacy of Origin

Criticizing the rule based on its authors (CMS) as adversaries to care at home also negates the impact of our advocacy. CMS has been charged with maintaining government payments for health care in hospitals, physician groups, hospices, SNFs, and more. They have also been directed to cut costs, decrease spending, and maintain budget neutrality. The proposed rule is a death sentence for home health not because it came from CMS, but because of the flawed math. Address the calculations, the methodology, the assumption that care at home is more expensive than hospital or SNF care, and the number of people who will lose access to quality care.

CMS needs your comments now

Now that you know what issues to address and how to frame your argument, reach out. Contact CMS and your Congresspeople and submit your comments today. Comments are due by August 29th.

# # #

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