Industry Update

Admin

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.

# # #

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

That’s a No-No

Admin

by Elizabeth E. Hogue, Esq. | Apr 24, 2025 | Admin, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

by Elizabeth E. Hogue, Esq.

No-no # 1

“No-No” may seem like something you would say to a toddler, but there is a list of things agency owners do that they should not do. Many of these are things providers may not often consider. This article focuses on the use of private duty services by hospice and home health patients, and what hospices and home health agencies cannot do with regard to aide services.

Aide Services

Both home health and hospice services are usually intermittent and provided in patients’ homes. Patients and their families may elect to utilize the services of private duty/home care companies for additional assistance. At the same time, hospice and home health patients may receive aide services from hospices and home health agencies.

Conditions of Participation

According to Medicare Conditions of Participation (CoPs), hospice and home health aides can only provide personal care services, including bathing. Aides provided by private duty/home care companies may also provide personal care. Unlike aides provided by hospices and home health agencies, however, they can provide additional services; such as laundry, food preparation, light housekeeping, shopping, and running errands.

Private Duty Services

When patients use private duty services, they are often paying for these services out of their own pockets. Even if they have long-term care insurance, patients still bear the financial burden of paying for private duty services. Longterm care insurance often costs thousands of dollars that patients probably paid for themselves. Patients usually pay by the hour for these services.

That's a No-No

Patients may, of course, utilize private duty/home care services to perform any of the services described above. It seems, however, that hospices routinely tell patients who have private duty/home care that they will not provide aide services because private duty/home care aides are able to provide personal care for patients.

Breaking it Down

Here is an example: A hospice admitted a bedridden patient with urinary and fecal incontinence. The patient and caregiver requested aide services from the hospice five days a week to bathe him. He paid for a few hours of private duty/home care services each day. The hospice refused to provide aide services five days a week to bathe him because he had private duty/home care services. No-no!

Compelled to Provide Care

ospices must provide aide services consistent with patients’ needs related to their terminal illnesses. In the example above, the patient clearly had a need for aide services five days a week. If patients and their caregivers state that they prefer to use private caregivers for personal care, then hospices must document the refusal of hospice aide services offered, consistent with applicable standards of care. Then hospices are not required to provide aide services.

Profiteering

When hospices deny aide services that are consistent with applicable standards of care and require patients and caregivers to use private duty/home care services, hospices are shifting the cost of aide services onto patients and their families. Patients and their families may have to pay for additional private duty/home care services to meet patients’ needs. The result for hospices is that they do not incur the costs of aide services, thereby increasing their profits at the expense of patients and their families.

If hospice staff members who refuse to provide aide services to patients and require patients and their families to use private duty/home care services instead are compensated in any way based on the financial performance or profitability of the hospices, let’s hope they look good in orange jumpsuits!

Intent to Defraud

If the private duty/home care services are being paid for by any federal or state health care program; such as Medicaid, Medicaid waiver, VA, or TriCare; then both home health agencies and hospices have engaged in fraudulent conduct by shifting costs that they should have incurred onto other federal government programs.

God forbid that the hospice also owns the company from which patients receive private duty/home care services! Then hospices are limiting their costs while profiting from patients and their families.

Dig Deep and Find Your No-No's

Now is the time for all home health agencies and hospices especially to audit patients’ records to make certain that all patients have been offered services that they are required to provide. If patients and their families choose to use private duty/home care aides instead, documentation must show that they were offered the services but chose to use private duty/home care aides.

No-No's Final Thoughts

The bottom line is that hospices and home health agencies must always provide services needed by patients. Patients may choose to pay for services that are paid for by the Medicare hospice or home health benefits. Patients cannot be required to pay for services privately that hospices and home health agencies must provide. Unacceptable!

This article is the first in a series of “No-no” items for agency owners.

# # #

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

No portion of this material may be reproduced in any form without the advance written permission of the author.

©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

Mass Layoffs in HHS “Overhaul”

CMS

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.

# # #

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

©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

CDPAP Overhaul Under Scrutiny

Medicaid

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.

# # #

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

©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

Relief for Providers

Admin

by Elizabeth E. Hogue, Esq. | Apr 11, 2025 | Admin, Audits, CMS, Medicare, Regulatory

by Elizabeth E. Hogue, Esq.

Relief for Providers from Devastating Penalties?

A judge in the Northern District of Texas recently decided that even the minimum penalties mandated under the False Claims Act (FCA) violate the Eighth Amendment’s Excessive Fines Clause [see U.S. ex rel. Taylor v. Healthcare Associates of Tex. (N.D. Tex. Feb. 26, 2025)]. The FCA punishes providers for submission of information that is not true in order to get paid by the federal government.

Life Threatening Penalties

The penalties assessed against providers under the FCA may be described as “life threatening.” That is, it may be difficult for providers’ businesses to survive payment of such severe penalties. The minimum penalty increased from $13,946 to $14,308 in 2025. The maximum penalty per claim increased from $27,894 to $28,619.

Ex Post Facto

These increased penalties will be assessed for violations that occurred prior to the change, but that are assessed after they are in effect. These penalties certainly make it clear why it is difficult for providers to survive violations of the FCA.

False Claims

In the Taylor case above, for example, the defendants allegedly submitted false claims as follows:

As “incident to” a physician’s care without proper documentation
For services by providers who were not eligible to bill the Medicare Program
For services performed by medical assistants instead of qualified practitioners

FCA Math Doesn't Add Up

The jury found that one of the defendants, a primary care medical group practice, submitted 21,944 false claims for $2,753,641.86 in actual damages. After trebling the damages as required by the FCA, the Court said it would enter judgement against the defendant for approximately $8 million. The Court acknowledged, however, that penalties under the FCA are fines subject to the Eighth Amendment of the U.S. Constitution.

Grossly Disproportional to the Gravity

The Court then applied the following four factors to decide whether the “fine was grossly disproportional to the gravity of the offense” under the Eighth Amendment:

The essence of the defendant’s crime and its relationship to other criminal activity
Whether the defendant was within the class of people for whom the statute of conviction was principally designed
The maximum sentence, including the fine that could have been imposed
The nature of the harm resulting from the defendant’s conduct

Fraud...or a Reporting Error?

With regard to the first factor, the Court emphasized that the defendant’s misconduct involved violations of Medicare billing rules, but did not include billing for services that were not provided. In fact, the Court said that even though the defendant violated Medicare billing rules, the misconduct was “closer in gravity to something like a ‘reporting offense.’” There was, said the Court, no evidence that the defendant’s conduct was “related to other criminal or fraudulent activity.

Magnitude of Harm

The Court also focused attention on the fourth factor. The defendant’s harm was certainly significant, but the harm, according to the Court, did not necessitate a penalty “two orders of magnitude greater than the actual financial harm,” especially when the actual damages were substantial, i.e., one hundred times the amount of actual damages. That ratio was “grossly out of alignment with the ratios in other similar cases.” The Court imposed a civil penalty of $8,260,925.58 that represents less than 3% of the statutory minimum.

Final Thoughts

Whether other Courts follow the Taylor case described above remains to be seen, but it is quite clear that providers need relief from the penalties of the FCA.

# # #

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

No portion of this material may be reproduced in any form without the advance written permission of the author.

©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

Dr. Oz Nomination Advances to Full Senate

Admin

by Tim Rowan | Mar 31, 2025 | Admin, CMS, Regulatory

by Tim Rowan, Editor Emeritus

Dr. Oz Nomination Advance to Senate

“Given your close ties to the industry that you would regulate, if you are confirmed, the public would have reason to question your impartiality and commitment to serving the public’s interest.” — Senator Elizabeth Warren, letter to Dr. Mehmet Oz

Reuter’s Ahmed Aboulenein reported on March 12 that “Warren called on Oz to divest from his financial holdings related to industries regulated by the agency and commit to strong ethics safeguards.” Oz, of course, is President Donald Trump’s nominee for CMS Administrator, the agency most important to Home Health and Hospice providers.

Across the aisle, Missouri Senator Josh Hawley peppered Oz with questions about his position on transgender therapy. “You previously praised trans surgeries for minors and supported the use of puberty blockers for children. You discussed transgender therapy on your TV program and hosted transgender children.”

Hawley also questioned Dr Oz’s previous comments on abortion, adding: “I hope he’s changed his views to match President Trump! We need the Trump agenda at CMS.”

It goes without saying that a nominee who encounters challenges from the left and the right is facing an uphill battle toward Senate confirmation, especially when nominees this year can only afford to lose three votes from the majority party. What exactly has Dr. Oz said or done over his long career that may put his nomination in jeopardy?

Pulling Back the Curtain

Becker’s Hospital Review summarized Oz’s history as well as his answers to questions during his three-hour Senate hearing on March 14.

“The former TV personality answered questions about potential Medicaid cuts, the focus of the House’s February budget instruction that the Energy and Commerce Committee cut $880 billion over 10 years. Medicare and Medicaid are the largest programs under the committee’s oversight. (A March 5 Congressional Budget Office report said the only way to reach the $880 billion saving goal over the next decade, without raising taxes, would be through Medicaid or CHIP cuts.)”

While Dr. Oz did not directly respond to questions or reveal his stance regarding Medicaid cuts, he did have a prepared non-answer for the Senators. “I commit to doing whatever I can, working tirelessly to ensure that CMS provides Americans with superb care. Especially Americans who are most vulnerable. Our young, our disabled and our elderly.”

On March 25, the Senate Finance Committee voted to advance Oz’s nomination to the full Senate. The panel voted 14 to 13, along party lines.

Vision Statement

Prior to facing the challenging questions thrown at him from both sides of the aisle, Dr. Oz used his opening statement to outline a vision focused largely on modernizing CMS’s systems; addressing waste, fraud and abuse; and incentivizing Americans to make healthier lifestyle choices.

In the past, Oz had endorsed privatizing Medicare through a change that would essentially result in something that might be called “Medicare Advantage for All.” In his Senate hearing answers, Oz pivoted to the opposite argument. He cited problems of overpayments to Medicare Advantage plans, the need to limit prior authorizations, and emphasized the need to halt the practice of “upcoding” where providers or plans bill for treating patients as sicker than they actually are.

In 2010, Dr Oz hosted a 15-minute segment on his show called “Transgender Kids: Too Young to Decide?” in which he spoke to transgender children, their parents and a doctor who provided gender-affirming care.

Outlook

Considering the slim Republican majority in the Senate, Ox can afford to lose only three Republican votes in his bid to become the next CMS administrator.

# # #

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

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

MedPAC Comments on CY 2026

CMS

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.

# # #

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

©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

Dementia Care Model Test

Clinical

by Rowan Report | Mar 21, 2025 | Clinical, CMS, Partner News

FOR IMMEDIATE RELEASE

Contacts: PocketRN
William Leiner
Chief Operating Officer
will.leiner@pocketrn.com

Daughterhood
Becca Dittrich
becca@daughterhood.org

PocketRN and Daughterhood Announce a National Strategic Partnership to Test Medicare Dementia Care Model Developed by Centers for Medicare & Medicaid Services

Guiding an Improved Dementia Experience (GUIDE) Model, a Centers for Medicare & Medicaid Services Innovation Program, Aims to Increase Care Coordination, Support for Caregivers

WASHINGTON, D.C., MARCH 18, 2025 – Today, PocketRN, a leader in virtual nursing, and Daughterhood, a leading non-profit organization empowering family caregivers with community and resources, announced they will form a National Strategic Partnership to test the Centers for Medicare & Medicaid Services (CMS) alternative payment model designed to support people living with dementia and their caregivers.

Under CMS’ Guiding an Improved Dementia Experience (GUIDE) Model, PocketRN will be one of almost 400 participants building Dementia Care Programs (DCPs) across the country, working to increase care coordination and improve access to services and supports, including respite care, for people living with dementia and their caregivers.

Launched on July 1, 2024, the GUIDE Model will test a new payment approach for key supportive services furnished to people living with dementia, including: comprehensive, person-centered assessments and care plans; care coordination; 24/7 access to an interdisciplinary care team member or help line; and certain respite services to support caregivers. People with dementia and their caregivers will have the assistance and support of a Care Navigator to help them access clinical and non-clinical services such as meals and transportation through community-based organizations.

“We couldn’t be more thrilled to bring our revolutionary nurse-led care model to the millions of dementia patients and families who need it most. With PocketRN, patients and families get unwavering support from a Nurse for Life as they navigate the complexities of managing dementia at NO cost to them. Nurses are hands-down the best clinicians to be the ‘glue’ for patients and their families throughout their dementia journey–they’ve been doing so forever, and it’s high-time their work is valued by our system.”

Jenna Morgenstern-Gaines

CEO, PocketRN

“We are so excited to embark on this partnership that will bring invaluable expertise and resources to the dedicated dementia caregivers in our Daughterhood community. Dementia caregiving is a uniquely complex and deeply emotional journey—one that requires not only knowledge and support but also compassion and resilience. This partnership will further empower caregivers with the tools, guidance, and encouragement they need to navigate this journey with confidence, connectivity, and care.”

Anne Tumlinson

Founder, Daughterhood

PocketRN and Daughterhood’s partnership in delivering the GUIDE Model will help people living with dementia and their caregivers have access to the education, supports, and services they need to feel more empowered and less alone in their journey – including unique “circle” community groups, podcasts, educational videos, and other curated resources. The GUIDE Model also provides respite services for certain people, enabling caregivers to take temporary breaks from their caregiving responsibilities. Respite is being tested under the GUIDE Model to assess its effect on helping caregivers continue to care for their loved ones at home, preventing or delaying the need for facility care.

More information on CMS’ GUIDE Model

# # #

About Daughterhood

Daughterhood is a 501(c)(3) organization that fosters community that empowers individuals to navigate the practical and emotional complexity of caregiving. Its unique blend of “circle” community groups, blogs, podcasts, and curated partner resources gives family caregivers emotional relief along with real, practical, and tangible solutions to navigate the stress, overwhelm, and confusion they often face – and to do so with the support of others on a similar path. For more information, visit https://daughterhood.org/ or engage with Daughterhood on LinkedIn, Facebook, and Instagram.

About PocketRN

PocketRN gives patients, families, and caregivers a Nurse for Life. Its mission is to close the gap between home and healthcare by: enabling nurses to care proactively and continuously at the top of their license, enabling caregivers with peace of mind and the confidence to support others, and enabling patients to access whole-person, trusted, empathetic care when and where they want it. PocketRN is the glue that holds together fragmented experiences in care so that partners, clinicians, patients, and families get back more of what they need: quality time. For more information, visit www.pocketrn.com or engage with PocketRN on LinkedIn, Facebook, and Instagram.

Alliance Statement on Congressional Budget

Advocacy

by Rowan Report | Mar 21, 2025 | Advocacy, CMS, Partner News, Regulatory

FOR IMMEDIATE RELEASE

Contacts: Tom Threlkeld
202-547-7424
Email

Elyssa Katz
571-281-0220
Email

The Alliance Comments on Recent Congressional Budget and Reconciliation Activity

ALEXANDRIA, VA and WASHINGTON, DC, March 5, 2025 – The National Alliance for Care at Home (the Alliance) released the following statement regarding recent legislative developments that may impact the Medicaid program. These include the passage of the House Budget Bill and the reconciliation framework that includes instructions for the House Energy and Commerce Committee to find $880 billion in reductions to programs under its jurisdiction; passage of the Senate Budget framework that does not include such drastic reductions; and comments by Speaker of the House Johnson (R-LA) that any changes to Medicaid will not include caps on federal funding or changes to the state matching formulas.

“The Alliance is reassured by affirmations that the congressional majority will not pursue some of the most drastic proposals previously discussed as options for reducing federal expenditures. Our members will not support any policies that reduce access to essential home and community-based services for eligible individuals. As Congress continues to assess options to reduce federal spending, we encourage leaders to continue to look favorably on high-value services that reduce costs and improve participant satisfaction.

“Care in the home is a proven model that reduces costs and is preferred by patients and families. An independent evaluation of Money Follows the Person, a grant program that transitioned individuals from institutional settings to the community, found that total spending on older adults decreased by 20 percent during the first year and 27 percent during the second year following their move to the community.[1] If Congress wishes to seek opportunities to reduce spending, we recommend they advance care models that provide cost-effective care without limiting access to services.

“We also recognize that there are opportunities to strengthen program integrity and reduce instances of fraud, waste, and abuse in the health care sector. The Alliance supports actions that reduce fraud, waste, and abuse from bad actors without placing unnecessary burdens or unfairly punishing providers and beneficiaries who are acting in good faith. We look forward to working with Congress to advance policies that strengthen federal health care program oversight.

“Medicaid is a complex program and changes to one part of the statute may have unanticipated negative outcomes on other aspects of services, financing, or reimbursements. We encourage Congress to be extremely careful to avoid making changes that could lead to unintended outcomes. We stand ready to provide our expertise to help strengthen Medicaid for all individuals and providers.”

# # #

About the National Alliance for Care at Home

The National Alliance for Care at Home (the Alliance) is a new national organization representing providers of home care, home health, hospice, palliative care, and other health care services mainly delivered in the home. The Alliance brings together two organizations with nearly 90 years of combined experience: NAHC and NHPCO. NAHC and NHPCO have combined operations to better serve members and lead into the future of care offered in the home. Learn more at www.AllianceForCareAtHome.org.   

[1] https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/mfpfieldreport21.pdf

Underlying Causes of Health Issues

Advocacy

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.

# # #

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

©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

ATA Applauds Telehealth Inclusion

Advocacy

by Rowan Report | Mar 13, 2025 | Advocacy, CMS, Partner News, Regulatory, Telehealth

FOR IMMEDIATE RELEASE

Contact: Gina Cella
781-799-3137
gcella@americantelemed.org

ATA ACTION APPLAUDS INCLUSION OF MEDICARE TELEHEALTH FLEXIBILITIES IN DRAFT CONTINUING RESOLUTION, URGES CONGRESS TO REINSTATE PROVISIONS AS SOON AS POSSIBLE

WASHINGTON, D.C., MARCH 8, 2025 – ATA Action, the advocacy arm of the American Telemedicine Association, today praised Congress for including Medicare Telehealth Flexibilities and the Acute Hospital Care at Home Program in the draft Continuing Resolution (CR) released today by appropriators. These critical provisions, which were originally implemented under President Trump’s leadership in his first term, will now remain in place through September 30, 2025, ensuring that millions of Americans continue to have access to high-quality, convenient, and affordable care.

“We appreciate Congress taking action to prevent a lapse in these vital telehealth flexibilities. While we would have preferred a longer extension, this step ensures uninterrupted access to telehealth services for patients and clinicians, as we continue working toward permanent solutions that reflect the needs of modern healthcare.”

Kyle Zebley

Executive Director, ATA Action

“But there remains work to be done. The CR must still be passed by Congress, and its path forward remains uncertain,” Zebley noted. “However, we are encouraged that, this past week, we submitted a detailed letter to House and Senate Appropriations Committee leaders, expressing urgency in extending these essential provisions, and clearly Congress listened and is responding to the needs of patients and the healthcare community, for which we are deeply grateful.”

Eliminated Coverage

However, key provisions – including first-dollar coverage for High Deductible Health Plan-Health Savings Accounts (HDHP-HSA), telehealth as an excepted benefit, an expanded Medicare Diabetes Prevention Program (MDPP) that would include telehealth components, and expanded, in-home cardiopulmonary rehabilitation services – were once again left out of the final CR, as they were at the end of 2024. These essential provisions now remain expired, leaving millions of Americans without the telehealth coverage they need.

“We strongly urge Congress to reinstate these provisions as soon as possible,” Zebley said. “Every day these flexibilities remain lapsed is another day that patients cannot access the care they need, employers struggle to provide affordable coverage, and critical gaps in healthcare widen.

“Telehealth remains a bipartisan issue, and we deeply appreciate the longstanding leadership of President Trump, who put these provisions in place during his first term, as well as our policy champions in Congress,” Zebley added. “We will continue to work in earnest with the administration and lawmakers to solidify telehealth as a lasting pillar of American healthcare.”

# # #

About the ATA

As the only organization completely focused on advancing telehealth, the American Telemedicine Association is committed to ensuring that everyone has access to safe, affordable, and appropriate care when and where they need it, enabling the system to do more good for more people. The ATA represents a broad and inclusive member network of leading healthcare delivery systems, academic institutions, technology solution providers and payers, as well as partner organizations and alliances, working to advance industry adoption of telehealth, promote responsible policy, advocate for government and market normalization, and provide education and resources to help integrate virtual care into emerging value-based delivery models.

About ATA Action

ATA Action recognizes that telehealth and virtual care have the potential to transform the healthcare delivery system by improving patient outcomes, enhancing the safety and effectiveness of care, addressing health disparities, and reducing costs. ATA Action is a registered 501c6 entity and an affiliated trade organization of the American Telemedicine Association (ATA).

© 2025 This press release was submitted to The Rowan Report by ATA Action via prnewswire.com and is reprinted here with permission. For additional information, please see the contact information above.

Update on Public Participation in Rule Making

Advocacy

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 Healh 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.

# # #

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

©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

Humana Thyme Agreement

Clinical

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

©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

Prior Authorization Requirement Removed by UnitedHealthcare

Clinical

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.

# # #

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

©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: Kennedy Rescinds Public Participation in Rule Making

Advocacy

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 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.

# # #

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

©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