Non-Compliance Notifications & HOPE Training

by Kristin Rowan | Jul 24, 2025 | CMS, Hospice

by Kristin Rowan, Editor

Hospice Non-Compliance Notifications

On July 21, 2025, the CMS Hospice QRP Announcements page added an update titled “Hospice Quality Reporting Program: Non-Compliance Notifications.”

The Update Reads:

The Centers for Medicare & Medicaid Services (CMS) is providing notifications to hospices that were determined to be out of compliance with Hospice Quality Reporting Program (HQRP) requirements for calendar year (CY) 2024…. This will affect their fiscal year (FY) 2026 Annual Payment Update (APU). The Medicare Administrative Contractors (MACs) will distribute Non-compliance notifications and place them into hospices’ Certification and Survey Enhanced Reporting (CASPER) folders in QIES on July 21, 2025. Hospices that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 26, 2025. If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notification and on the Reconsideration Requests webpage.

Details

Any reconsiderations containing protected health information (PHI) will not be processed. All PHI must be removed for a reconsideration to be reviewed.

Additionally, all submissions must be less than 20 MB overall (email message and attachments). Submissions that are greater than 20 MB in size cannot be processed.

HOPE Training

As the implementation date for the HOPE tool drew nearer, advocacy groups and hospice agencies expressed concern over it’s readiness. On June 6, 2025, The Rowan Report shared that three of the largest organizations urged CMS to delay the tool. The groups asked for proper information, education, and training.

CMS Response

As of now, CMS is not delaying the implementation of the HOPE tool. They have, however, published training tools for hospice providers. The first series of videos is Didactic Training. They cover an introduction to the tool, admin information, preferences and active diagnoses, health conditions, skin conditions, and medications.

On July 21, 2025, CMS announced the opening of registration for live HOPE training. “Hospice Outcomes and Patient Evaluation (HOPE) National Implementation Virtual Training Program Course 2: Coding Workshop.” CMS recommends completing The Didactic Training as a prerequisite to the Coding Workshop.

The Centers for Medicare & Medicaid Services (CMS) is offering a live coding workshop on August 5, 2025…. It will provide coding practice for items that are new for HOPE, as well as the existing and updated items carried over from the Hospice Item Set (HIS).

Find the Didactic Recorded Training Series here.

Data Collection Starts Soon

The HOPE tool begins data collection on October 1, 2025. Key items hospice providers should understand:

More Frequent Assessments: HOPE introduces up to four assessment points per patient, capturing care from multiple angles during the first 30 days and at discharge.
Real-Time Data Capture: Unlike the retrospective nature of HIS, HOPE assessments are completed during live patient encounters, providing richer and more immediate insights.
Higher Stakes for Compliance: To avoid a reimbursement cut of up to 4%, agencies must ensure that at least 90% of HOPE assessments are submitted on time—a notable increase from the previous 2% penalty under HIS.
Public Reporting Timeline: While HIS data has been publicly available, HOPE data will not be released for public comparison until fiscal year 2028 or later, giving providers time to adapt.

*from the SimiTree blog: Understanding the Transition from HIS to HOPE

As the implementation of the HOPE tool gets closer, we will continue to share training information from CMS and other sources as it becomes available. If you need a referral to a hospice consultant to navigate the transition, please reach out to The Rowan Report.

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

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

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

Impact of H.R. 1: The Homebound and Overlooked

by Tim Rowan | Jul 24, 2025 | Medicaid, Regulatory

Analysis by Tim Rowan, Editor Emeritus

The Impact of H.R. 1

Homebound and Overlooked

In early 2025, the Republican-led Congress introduced its proposed budget for FY2026 and beyond, a sweeping legislative effort aimed at curbing federal expenditures and restructuring entitlement programs. Medicaid, one of the largest healthcare safety nets in the United States, faces major revisions under this bill. Central to the proposed changes is the shift toward block grants or per-capita caps on federal funding. The legislation also rolls back incentives enacted into law by the Affordable Care act, including those that supported Medicaid expansion. The reconciliation bill, signed into law on July 4, also eliminates financial support for optional services such as home and community-based services (HCBS). A new set of work requirements in the new law will expand the paperwork burden for beneficiaries.

Risks for Home- and Community-Based Care

The figure below presents a visual from the Commonwealth Fund showing their projection of over $100 billion in cumulative federal Medicaid cuts by 2035. These reductions are expected to disproportionately affect non-mandated programs like HCBS, which are many times more economical than residential care. With diminished federal support, states will face pressure to reallocate limited resources, often at the expense of these optional, yet critical, programs. ¹

For nearly eight million elderly Americans, Medicaid-funded HCBS has helped reduce hospital admissions, extend independence, and relieve stress on long-term care facilities. However, the new budget cuts destabilize these programs. Barbara Merrill, CEO of ANCOR, expressed concern, stating, “When you cut federal Medicaid dollars, even for optional services, states have to make tough decisions about who gets care and when.”² Experts anticipate that approval delays, extended waitlists, and even termination of services could follow as states struggle to maintain existing infrastructure.

Comparing the 2005 Budget Bill to the Affordable Care Act

Compared to the Affordable Care Act (ACA), the Republican budget bill marks a significant policy reversal. The ACA expanded Medicaid eligibility and incentivized states to develop non-institutional care models. It emphasized preventive care and home-based treatment options, helping shift care away from costly institutional settings. By contrast, the new bill eliminates such incentives and introduces fiscal and operational barriers. According to data from Medicaid.gov and the Kaiser Family Foundation, Medicaid enrollment, which rose steadily during the ACA years, is projected to drop by 10% nationwide once the budget bill is implemented³. This decline reflects both tightening eligibility and retreat from HCBS programs.

Healthcare providers will need to brace for substantial ripple effects. With fewer patients accessing home care, hospitals and emergency departments may see an uptick in acute episodes related to unmanaged chronic conditions. Providers may also encounter staffing shortages and reduced reimbursements, undermining service quality and sustainability. Richard Edwards, policy director at Amivie Home Health, warned, “If states cut home care services, many patients have no other choice but to enter a skilled nursing facility. That’s not just a shift in care—it’s often a worse outcome at a higher cost.” ⁴ These operational challenges could exacerbate pressure on an already strained healthcare workforce.

Scope and Severity of Coming Changes

Today, over eight million seniors rely on Medicaid-funded HCBS, with an average annual cost per recipient of $29,000. Thirty-three states use HCBS waivers to administer these services, yet the average state waitlist already exceeds 3,000 applicants. Institutional care costs remain 57% higher than home care, making HCBS not only more humane but more fiscally prudent. Despite that, projected federal cuts of $100 billion by 2035 threaten to replace HCBS with nursing home care. Meanwhile, a national enrollment drop of 10% would leave millions at risk of losing coverage and care.

Richard Edwards, policy director at Amivie Home Health, explains, “If states cut home care services, many patients have no other choice but to enter a skilled nursing facility. That’s not just a shift in care—it’s often a worse healthcare and social outcome at a higher cost.” ⁴

8 million elderly rely on Medicaid HCBS
$29,000/year average cost per Medicaid home care recipient
33 states use HCBS waivers
Average state waitlist for HCBS exceeds 3,000 applicants
Institutional care costs 57% more than home care
Estimated federal Medicaid cuts by 2035: $100 billion
Projected national enrollment drop: 10%

Implications for Care at Home: Next Steps

To mitigate these risks, policy experts are advocating for pragmatic alternatives, knowing that implementation depends entirely on the direction in which political winds blow. Federal stabilization grants could offer targeted relief to states with high HCBS enrollment, preserving continuity of care. Streamlining waiver approvals would reduce bureaucratic delays and ease access for both providers and patients. Retaining key ACA incentives could help maintain momentum in home-based care innovation. States would also benefit from flexible financing rules, including reformed provider tax policies, to better manage Medicaid funds under new constraints.

Final Thoughts

Ultimately, the new budget, passed with no Democratic votes, may reshape eldercare delivery for years to come. With states facing hard choices, the healthcare community must prepare for transitions that could disrupt care and deepen inequities. Advocacy for vulnerable populations, investment in alternatives, and ongoing engagement in policy reform will be essential to ensure seniors receive the care they deserve in the setting they prefer.

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¹ Congressional Budget Office, Federal Healthcare Outlook 2025–2035
² Barbara Merrill, ANCOR Policy Brief, March 2025
³ Kaiser Family Foundation, Medicaid Enrollment Tracker, April 2025
⁴ Amivie Health, Testimony to House Budget Committee, June 2025

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

Fraud, Waste, and Abuse

by Kristin Rowan | Jul 10, 2025 | Clinical, CMS, Home Health, Legal, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Fraud, Waste, and Abuse

DOJ, HHS False Claims Act

Fraud, Waste, and Abuse has become something of a mantra within the Department of Health and Human Services (HHS). Secretary Kennedy has committed to combatting fraud, waste, and abuse within the federal healthcare system. The Department of Justice (DOJ) and HHS have a long history of working together to combat healthcare frauding under the False Claims Act (FCA).

Working Group

In furtherance of their goal to combat healthcare fraud, HHS and DOJ have formed the DOJ-HHS False Claims Act Working Group. The Working Group will include leadership from the HHS Office of General Counsel, CMS Center for Program Integrity, the Office of Counsel for the OIG, and the DOJ Civil Division.

Working Group Priorities to Combat Fraud, Waste, and Abuse

1. HHS will refer potential False Claims Act violations to the DOJ that are in line with the Working Group priority enforcement areas:

Medicare Advantage
Drug, device, or biologics pricing
- arrangements for discounts, rebates, service fees, and formulary placement and pricing reporting
Barriers to patient access to care
- violations of network adequacy requirements
Kickbacks related to drugs, medical decives, DME, and other products paid for by federal healthcare programs
Materially defective medical devices that impact patient safety
Manipulation of Electronic Health Records systems to drive inappropriate utilization of Medicare covered products and services

2. The Working Group will maximize collaboration to expedite investigations and identify new leads. They will leverage HHS resources using data mining and assessment of findings.

3. The Working Group will discuss implementing payment suspension according to the CMS Medicare Program Code of Federal Regulations¹

4. The Working Group will discuss whether DOJ will dismiss a whistleblower case under the U.S. Code for Civil actions for False Claims, pursuant to the DOJ Manual for Civil Fraud Litigation²

Report Fraud, Waste, and Abuse

The Working Group encourages whistleblowers to report violations of the False Claims Act within the priority areas. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to HHS at 800-HHS-TIPS (800-447-8477). Similarly, the Working Group encourages healthcare companies to identify and report such violations.

²DOJ Dismissal of a Civil Qui Tam Action. When evaluating a recommendation to decline intervention in a qui tam action, attorneys should also consider whether the government’s interests are served, in addition, by seeking dismissal pursuant to 31 U.S.C. § 3730(c)(2)(A).

¹Suspension of payment. The withholding of payment by a Medicare contractor from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists, or until the resolution of an investigation of a credible allegation of fraud.

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Planned Parenthood Cut Halted

by Kristin Rowan | Jul 10, 2025 | CMS, Legal, Medicaid, Regulatory

by Kristin Rowan, Editor

Part of Big Beautiful Bill Halted

Medicaid Cuts to Planned Parenthood Blocked

The tax and immigration bill, dubbed “One Big Beautiful Bill,” signed by President Trump on July 4th, included removing all Medicaid payments to any nonprofit organization that provides medical services, received more than $800,000 in federal funding in 2023, and also provides abortions.

On Monday, July 7th, the first business day after the bill was signed into law, U.S. District Judge Indira Talwani granted a temporary halt to Medicaid funding cuts to Planned Parenthood.

Planned Parenthood Claims Unfavorable Treatment

The portion of the bill in question does not specifically name Planned Parenthood. The bill cuts Medicaid funding to groups “primarily engaged in family planning services, reproductive health, and related medical care” that also provide abortions and abortion education. According to the lawsuit, however, because of the federal funding threshold of $800,000, Planned Parentood locations comprise almost all of the impact.

[It’s a] “naked attempt to leverage the government’s spending power to attack and penalize Planned Parenthood and impermissibly single it out for unfavorable treatment.”

Planned Parenthood

Immediate Decision

The decision came before the federal government responded. Judge Talwani ruled within hours and provided no explanation other than a brief note stating that Planned Parenthood showed good cause for immediate intervention.

Decision Unlikely to Stand

The decision came within hours of the lawsuit filing
Congress is generally lawfully allowed to make determinations on spending
This was an egregious judicial usurpation of legislative power
This makes her court look like a fast food drive-through
The House could initiate impeachment proceedings against the judge for this decision

These are just a few of the statements made in opposition to the injunction, mostly claiming that the judge did not have the authority to make the decision. Talwani set a hearing for July 21 to hear from both Planned Parenthood and the agencies named in the lawsuit, HHS, and CMS.

Precedent

A previous ruling from the Supreme Court in June of this year provides that any state can remove any provider from the list of “Qualified Providers” using its own Medicaid criteria. The court further ruled that, although patients have the right to choose their own provider, patients do not have the right to sue based on who those qualified providers are.

This lawsuit is the first against the tax and immigration bill, but it is most likely not the last. We will continue to report on this and other lawsuits as they arise.

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CMS Home Health Proposed Rule 2026

by Kristin Rowan | Jul 2, 2025 | Advocacy, CMS, Home Health, Regulatory

by Kristin Rowan, Editor

CMS Home Health Proposed Rule 2026

June 30th, 2025, the Centers for Medicare & Medicaid Services issued its proposed rule with updates to Medicare payment policies and rates for home health agencies under the Home Health Prospective Payment System Proposed Rule for calendar year 2026.

Payment Adjustments

The Facts, as Listed by CMS

A permanent prospective adjustment to home health payments of -4.059% (not applied to LUPAs)
- Reasoning: the impact of implementing PDGM
A temporary adjustment of -5.0% (not applied to LUPAs)
- Reasoning: to recoupe retrospective overpayments
Updates Fixed-Dollar Loss (FDL) adjustment of -0.5%
Payment Update Percentage of 2.4%
Quality data decrease of 2%, offset by the update percentage yields a 0.4% adjustment
Net changes in payment rate from 2025 to 2026 with quality reporting data is -6.40%

Contradictory Facts, as Listed by CMS

The finalized methodology used to calculate the impact of PDGM yielded the need for a -7.85% permanent adjustment
In CY 2023, 2024, and 2025, CMS implemented permanent adjustments of -3.925%, -2.890%, and -1.975%, respectively
The total permanent adjustment made in the last three years is -8.790% (0.940% more than the calculated adjustment need)
CMS has now determined that Medicare is still paying more under PDGM than it did under the old system and is proposing an additional permanent adjustment of -4.059%
This yields a combined -12.849% permanent adjustment over four years
The CMS analysis of estimated aggregate expenditures lead them to propose an additional temporary adjustment of -5.0%

HHCAHPS Survey Changes

Added Questions

Whether the care provided helped the patient take care of their health.
Whether the patient’s family/friends were given sufficient information and
instructions.
Whether the patient felt the staff cared about them “as a person.”

Removed Questions - Medication

Whether someone asked to see all the prescription and over-the-counter medicines
the patient was taking.
Whether the patient is taking any new prescription medicines or whether the patient’s
medicines have changed.
Whether home health providers talked to the patient about the purpose for taking new
or changed prescription medicines.
Whether home health providers talked to the patient about when to take the
medicines.

Removed Questions - Other

Which type of staff served the patient – nurse, PT/OT, or home care aide
Whether the patient got information about what care and services they would get when they first started home health care
Removal of the proposed changes to include questions on SDOH
Minor text changes to clarfiy some existing questions and response options

Other Changes

CMS recommends additional changes in various categories:

Recalibration of the PDGM case-mix weights
- Update low utilization payment adjustment (LUPA) thresholds
- Update functional impairment levels
- Update comorbidity adjustment subgroups
- Update the fixed-dollar loss (FDL) for outlier payments
Change the face-to-face encounter policy by adding physicians to the list of who can perform the face-to-face
Removal of the “Up-to-date” on the COVID-19 vaccine percentage
Changing the Final Data Submissions Deadline Period from 4.5 months to 45 days
Adding a Termination Clause for DME, prosthetics, orthotics, and supplies competitive bidding program

Requests for Information and Feedback

CMS has issued the following RFI:

Request for Information related to Executive Order 14192 – Unleashing Prosperity Through Deregulation of the Medicare Program

CMS is seeking feedback on the proposed rule through

August 29th, 2025

Feedback on the digital quality measurement transition
Feedback on the final data submission deadline from 4.5 months to 45 days
Feedback on tools that promote healthy eating habits, exercise, nutrition, and physical activity
Feedback on the current state of health IT use, including EHRs
Feedback on the proposed changes to DMEPOS

Submit comments, feedback, and documentation to CMS

The Alliance Responds

“We are alarmed by the negligent proposed payment update, which deepens a heartless pattern of insufficient adjustments that have already led providers to close their doors and reduce services, and now threatens to further diminish care access by compelling more HHAs to take similar actions.”

Dr. Steve Landers

CEO, The National Alliance for Care at Home

You can read the entire Proposed Rule HERE. Read the Fact Sheet HERE.

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PocketRN SYNERGY HomeCare Partner

by Rowan Report | Jun 20, 2025 | Partner News

FOR IMMEDIATE RELEASE

Contacts: Melissa Drake
Imagine Productions
Melissa@imagineprstrategy.com
(732) 236-1569

William Leiner
PocketRN
will.leiner@pocketrn.com

PocketRN, SYNERGY HomeCare Partner for Dementia Care

This partnership will operate under CMS’s Guiding an Improved Dementia Experience (GUIDE) Model

Tempe, AZ, June 16, 2025. PocketRN, a provider of virtual nursing care, and SYNERGY HomeCare, a homecare company, announced they will form a national partnership to test the Centers for Medicare & Medicaid Services (CMS) alternative payment model designed to support people living with dementia and their family caregivers.

SYNERGY HomeCare Speaks

“This is an exciting collaboration that amplifies and elevates the services both PocketRN and SYNERGY HomeCare bring to their clients,” said Rich Paul, chief operating officer for SYNERGY HomeCare. “As the fastest growing homecare franchise in a relatively young industry, we have a tremendous opportunity to positively impact a large number of people affected by dementia. SYNERGY HomeCare has a long history of aligning with a wide array of national partners, health plans and third-party payers to create a highly diversified referral base and extend services to a greater pool of clients. Our partnership with PocketRN is another excellent example of our ability to survey the evolving homecare landscape and find meaningful ways to deliver even more value through strategic partnerships.”

GUIDE Model

Under CMS’s 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 family caregivers. This partnership allows for integration of medical and non-medical care in the home.

According to the CMS, many people with dementia do not consistently receive high-quality, coordinated care, despite its prevalence. As a result, they experience poor outcomes, including high rates of hospitalization, emergency department visits and post-acute care utilization. They also experience high rates of depression, behavioral and psychological symptoms of dementia and poor management of other co-occurring conditions.

New Approach

The GUIDE Model, which launched July 2024, is testing a new payment approach for supportive services for 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 family caregivers. People living with dementia and their family 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.

“This is an exciting collaboration that amplifies and elevates the services both PocketRN and SYNERGY HomeCare bring to their clients. Our partnership with PocketRN is [an] excellent example of our ability to survey the evolving homecare landscape and find meaningful ways to deliver even more value through strategic partnerships.”

Rich Paul

COO, SYNERGY HomeCare

Partners

SYNERGY HomeCare’s partnership with PocketRN is rooted in the fact that a significant portion of its client base has a dementia diagnosis. The company’s locations nationwide provide in-home memory care support for people living with Alzheimer’s and other forms of dementia, as well as respite care for their family caregivers.

PocketRN Speaks

“We couldn’t be more thrilled to partner with SYNERGY HomeCare to bring our revolutionary Nurse for Life model to the millions of dementia patients and families who need it most,” said PocketRN CEO Jenna Morgenstern-Gaines. “With PocketRN, patients and families get unwavering support from a dedicated, trusted nurse as they navigate the complexities of managing dementia at NO cost to them. Nurses are a critical part of the care continuum across all health fields and even more so as they provide a cohesive ‘glue’ for patients and their families throughout their dementia journey.”

Access to Care by Referral

PocketRN’s partnership with SYNERGY HomeCare to deliver the GUIDE Model will help people living with dementia and their family caregivers have access to education and support, such as training programs on best practices for caring for a loved one living with dementia. The GUIDE Model also provides respite services for certain people, enabling family caregivers to take temporary breaks from their caregiving responsibilities.

Under this partnership, PocketRN will refer families in need of respite care to local SYNERGY HomeCare agencies. 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. Similarly, SYNERGY HomeCare can refer their clients to PocketRN in the event they would benefit from 24/7 access to virtual clinical support.

For more information on CMS’ GUIDE Model, visit: cms.gov/priorities/innovation/innovation-models/guide.

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About SYNERGY HomeCare

SYNERGY HomeCare is the fastest-growing national franchisor in the home care industry with over 240 franchises operating in more than 550 territories across the U.S. The company provides a broad range of non-medical in-home services including personal care, companion care, memory care and specialized care for individuals who are living with physical or developmental disabilities, chronic health conditions or recovering from illness or surgery. No matter what each person’s circumstances are, SYNERGY HomeCare steps in with effective, comforting, life-affirming care that moves people emotionally and physically forward. For more information visit SYNERGYHomeCare.com or find an in-home care location near you.

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.

Medicaid Cuts Still Looming

by Tim Rowan | Jun 20, 2025 | Clinical, Medicaid, Regulatory

by Tim Rowan, Editor Emeritus

Medicaid Cuts Looming

Terminal Prognosis

Let me tell you about my brother. In his early 30’s, Tom was diagnosed with a rare disorder, one of the 25 versions of Ataxia. A disorder that is sometimes genetic, sometimes of unknown cause. It damages the part of the brain stem that controls balance, eye-hand coordination, and speech. He was supposed to be confined to a wheelchair by age 45 and not make it to 60.

Medicaid to the Rescue

Tom will celebrate his 71st birthday next week. Some years back, an experimental drug appeared that happened to be effective with his variation of Ataxia. That medication, administered intravenously in his home, is ridiculously expensive. If not for Medicare and Medicaid, those early prognoses would have come true. With the treatments, the disorder does still progress, though much more slowly. During my visits to his home — yes, he still manages on his own for now — he and I talk about the Assisted Living or Skilled Nursing Facility that looms in his future. Always with his head low and a sigh, he says he knows that day will come.

One in 71 Million

The 20 percent of American citizens who qualify for Medicaid are as nervous as Tom is about a bill making its way through Congress. As of May 22, 2025, H.R. 1 passed the House of Representatives by one vote. Today, it is still under debate in the Senate, where several amendments are being considered.

Medicaid Pays More than Medicare

In a February report, the Kaiser Family Foundation explained it this way:

Four in ten adults incorrectly believe that Medicare is the primary source of coverage for low-income people. For those who need nursing or home care, Medicaid is the primary payer. Medicaid covered two-thirds of all home care spending in the United States in 2022. With House Republicans considering $2.3 trillion in Medicaid cuts over 10 years, the availability of home care could be affected in future years. Home care cannot afford the loss of almost one-third of the entire Medicaid budget.

Medicaid Cuts Impact

The February report indicates that H.R 1 could fundamentally change how Medicaid financing works. This would consequently impact enrollees’ access to care. The authors assert that “cuts of this magnitude would put states at financial risk, forcing them to raise new revenues or reduce Medicaid spending by eliminating coverage for some people, covering fewer services, and/or cutting rates paid to home care workers and other providers.”

“Such difficult choices would have implications for home care because over half of Medicaid spending finances care for people ages 65 and older and those with disabilities, the enrollees most likely to use home care and related services.”

Mohamed, A.; Burns, A.; O'Malley Watts, M.

Authors, What is Medicaid Home Care (HCBS)?

Medicaid Cuts Proposals

The Center on Budget and Policy Priorities has been listening to Senate debates and reading proposed amendments. In a news release this week, CBPP offered a dismal assessment.

“The health provisions in the Senate Republican leaders’ plan are, alarmingly, even harsher and more damaging than the health provisions in [H.R. 1]. Under both plans, tens of millions of people would face substantially higher health care costs and millions would lose access to life-saving treatments, routine care, and medications they need.”

Higher Costs, Less Access

Home Care and the Work Requirement

There is much talk in Congress and in social media about able-bodied Medicaid beneficiaries who sit at home and play video games all day. Not only does this indicate a confusion between healthcare and welfare (you can’t eat or sleep in Medicaid), but it also tends to exaggerate the scope of this fraud/waste/abuse target.

As KFF points out, most Medicaid adults under age 65 are already working but are paid low enough that they still qualify. Many who are not working (12%) serve as caregivers for a family members. If they are removed from the home to go to a job, someone else would have to take over caregiving duties, probably a home care agency. Thus, there would be a net loss to the system.

Net Loss

The Congressional Budget Office found when examining the House version that work requirements would decrease federal spending by reducing the number of uninsured. However, in the same report, the CBO notes that there would be no increase in employment numbers.

On top of the uncertain benefit of the work requirement, the bill as it stands today would greatly increase reporting requirements. In place of “once qualified, always qualified,” Medicaid eligibility will require regular reporting to prove employment and annual re-qualification paperwork. The new red tape burdens will be especially difficult on seasonal workers or those who frequently change jobs.

Medicaid Cuts and Rural Hospitals

No one is quite sure what the impact on home care will be when Medicaid cuts force rural hospitals to close, as the CBO predicts. Longer journeys to receive hospital care and doctor visits may push more beneficiaries to home care while home care will be struggling to find caregiving staff.

Before the bill becomes law, rural hospitals are already in trouble. The American Hospital Association says that 48 percent of rural hospitals operated at a loss in 2023 and 92 closed their doors over the past 10 years. There are 16.1 million Medicaid beneficiaries living in rural communities, including 65 percent of nursing home residents. Can home care cover the losses if a portion of the estimated $800 billion in Medicaid cuts over 10 years hit home care just as hard?

Medicaid Support in Congress

There are home care champions on the Republican side of the House and Senate. Some of them have already expressed their doubts about whether cutting home care would decrease or increase overall spending. In the “strange bedfellow” category, conservative icon Josh Hawley of Missouri swore he would “tank any bill that cuts Medicaid benefits.”

Senate Republicans can afford to lose only three votes to get this bill passed and sent back to the House. Today would be the time for all of them to hear from the care at home industry. Call your Senator. All phone numbers start with 202-224-

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The Alliance Responds

by Kristin Rowan | Jun 13, 2025 | Advocacy, CMS, Hospice

by Kristin Rowan, Editor

The Alliance Responds to CMS Hospice Update

The Alliance responds to CMS-1835-P, the FY 2026 Hospice Wage Index, Conditions of Participation, and Quality Reporting Program Requirements updates. On June 10, 2025, in a 25 page letter to Dr. Mehemet Oz, CEO for The National Alliance for Care at Home Steve Landers, MD, MPH lays out the constraints and financial burdens hospice agencies will face if these updates are enacted.

Payment Rate Update

Increase Less than Inflation

In the rule for FY 2026, CMS proposes a 3.2 percent market basket increase and a .8 percent productivity decrease, yielding a 2.4 percent increase overall. According to the letter, inflation has raised medical care prices by 3.1 percent, leaving a shortfall of .7 percent. Hospices are also plagued by the same workforce shortage the rest of the medical industry faces. Workforce shortages result in fewer qualified people than there are available positions, which drives wages up. BLS data indicates the wage increase for 2025 was 4.4%. The Alliance argues that the 2.4% net increase falls well short of the actual expense increase.

Faulty Data

In a recent article, we outlined the process that CMS uses to determine the market basket update. The Alliance echos our information, showing the market basket forecast is well below actual increases. The Alliance further argues that the shortfall compounds, leaving the base rate increasingly smaller with each forecast. The current estimate is a 4.9% pay rate gap. CMS contends there is no way to adjust for forecast errors. The Alliance has a simple solution: manually adjust the payment rate every year when the finalized number are above the forecasted numbers BEFORE adding the next year’s payment rate increase.

Likewise, The Alliance concurs with The Rowan Report sentiment that productivity cannot increase in hospice like it does in less labor-intensive sectors. Landers also mentions the failure to consider travel costs, the wage differences in rural areas, and the lack of reclassification options in hospice care.

Payment Rate Recommendations

As any well-drafted response should, The Alliance provides actionable recommendations in each section. For payment rate updates, The Alliance recommends:

We recommend CMS examine closely more recent data and increase final payment rates for FY 2026.
We urge CMS to explore all available avenues to address the forecast error shortfall, such as through a one-time adjustment.
We encourage CMS to collaborate with stakeholders to address the shortcomings of relying upon hospital data to determine hospice payment rates, and ways to achieve parity across provider types with respect to geographic area wage adjustments.

HIS to HOPE Transition

Also addressed in the letter is opposition to the timeline of the HIS to HOPE transition. The Alliance restates much of what was in the joint letter to CMS urging the delay of the HOPE tool adoption. That letter was a joint venture between The National Alliance for Care at Home (The Alliance), LeadingAge, and the National Partnership for Healthcare and Hospice Innovation (NPHI).

The consequence of adverse outcomes cannot be understated. The risk of negative financial consequences for hospice providers is
largely dependent this year on the success of two transitions—iQIES and HOPE— neither of which are within their control.

Steve Landers, MD, MPH

CEO, National Alliance for Care at Home

HOPE Transition Recommendations

Considering the volatility inherent in a reporting transition of this magnitude and the lack of clear information provided to date, we respectfully request CMS waive the HOPE timeliness submission requirement for two calendar quarters post implementation.
We further respectfully request that CMS delay the HOPE implementation date until at least six months after CMS education and training, beyond that which is introductory and that is scheduled for spring/summer 2025, the final validation utility tool specifications are available and the application for iQIES access has been opened for hospices.

Digital and Future Hospice Measurements

Among the digital hospice measurements is an interoperability measurement. The Alliance supports interoperability and data exchange across medical care entities, but stresses to CMS that many hospices do not have digital EHR systems, cannot afford to maintain such systems, and have not received the federal financial support necessary to meet this objective.

The Alliance also objects, not in theory, but in practical application, to the nutrition measure noted in future hospice measures. Nutrition for a hospice patient is vastly different than for other patients and should be implemented as a process measure, rather than having specific goals for food intake and nutrition.

Similarly, the well-being measure is not designed for hospice care. In other sectors of healthcare, well-being incorporates measures for mental, social and physical health and focuses on curative plans. Hospice care focuses on person-centered care, emphasizing the desires of the patient as they are balanced against religious, cultural, and personal beliefs. The well-being measure must be curated to fit hospice care.

The Alliance - Conclusion

The Alliance values CMS’s ongoing commitment to enhancing hospice care quality,
ensuring program integrity, and improving patient outcomes. We appreciate your
consideration of our comments and look forward to ongoing dialogue to achieve these
shared objectives.

The Rowan Report - Conclusion

The Alliance has, as always, done an exemplary job at explaining the industry position on the CMS rule. Likewise, it has outlined each step CMS should take to view the updates through a hospice lens rather than a hospital lens. We commend and support The Alliance statement and position. As this is an ongoing topic until the final rule is implemented, we will continue to provide updates as they become available.

If you are a member of The Alliance, you can read the full 25 page letter here.

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Fraudsters Arrested, Oz Issues Warning

by Kristin Rowan | Jun 6, 2025 | CMS, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Fraudsters Arrested, Oz Issues Warning

Fraud in California

Fraudsters arrested in West Covina, CA this week were allegedly running a Medicare scheme. Authorities arrested hospice owner-operator Normita Sierra. They charged her with nine counts of health care fraud, one count of conspiracy, and four counts illegal remuneration (kick-backs) for health care referrals. The U.S. Attorney’s Office named co-conspirator Rowena Elegado. They also arrested her and charged her with one count of conspiracy and four counts of illegal remuneration for health care referrals.

Kickbacks

Sierra and Elegado worked together to pay marketers to recruit patients who did not have a hospice referral from their PCP and who were not terminally ill. Some of the kickbacks paid to marketers were as high as $1,300 per patient per month. After six months, the patients were referred out to Sierra’s home health company.

Medicare Claims

According to the U.S. Attorney’s Office, from 2018 to 2022, Sierra’s hospice agences submitted $4.8 million in fraudulent claims. Of those claims, Medicare paid approximately $3.8 million.

Dr. Oz Issues Warning

In a video statement, Dr. Oz explained how Medicare recipients are falling victim to scams. Sales people call, email, and even knock on your door, offering advice, free samples, and referrals. These marketers have one goal: get you sign a piece of paper. That paper signs you up for hospice care and agrees to allow a specific hospice agency to provide that care. The hospice agency then bills Medicare for services they never provide. Watch the video statement here.

HHS OIG Issues Consumer Alert

In a similar statement, HHS issued a consumer alert regarding DME companies. The alert warns that some DME companies are contacting Medicare beneficiaries. They claim to work for or on behalf of Medicare. Once they receive the patient’s Medicare number, they bill Medicare for unnecessary medical items. These items include urinary catheters, knee and back braces, orthotic braces, and prescription drugs, which may or may not ever be sent to the patient. HHS urges enrollees not to give their Medicare number to anyone. Further, they suggest regulary reviewing items charged to insurance, and refusing delivery of any medical supply not ordered by a physician.

Combating Waste, Fraud, and Abuse

Dr. Oz and CMS have spoken numerous times about combatting the waste, fraud, and abuse withing the Medicare and Medicaid systems. Originally a strong proponent for Medicare Advantage, Oz has promised to audit MA after discovering the government pays more for MA than traditional Medicare. Oz also promised to reduce the amount of prior authorization requests needed before a patient gets services. Oz responded to the Republican-backed House bill requiring more oversight on Medicaid eligibility. Oz indicated that some Medicaid patients are enrolled in more than one state and that Medicaid is paying for able-bodied patients. The waste, fraud and abuse across Medicare and Medicaid is costing the government between $1 and $10 billion and Dr. Oz plans to find it and make significant changes to the management of the system.

A Cautionary Tale for Hospice Providers

You may be thinking, “What does this have to do with me?” Unfortunately, even the most scrupulous hospice agencies can fall prey to marketers running schemes. There are legitimate referral resources in the market who can help your agency get more referrals and more clients. There are also underhanded marketers who know how the system works. These predators will promise new referrals (for a fee) and then enroll uneligible patients without your knowledge. If you are working with or looking for a referral partner for your hospice agency, use one that is referred by someone you trust, and/or do a lot of research on the company history before working with anyone. Be especially wary of the ones who promise much more than what most referral companies offer.

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Delay HOPE Tool

by Kristin Rowan | Jun 6, 2025 | Advocacy, CMS, Hospice, Regulatory

by Kristin Rowan, Editor

Advocacy Groups to CMS:

Delay HOPE Tool Implementation

“Delay HOPE Tool Implementation,” say multiple hospice advocacy groups. LeadingAge, the National Alliance for Care at Home (The Alliance), and the National Partnership for Healthcare and Hospice Innovation (NPHI) are urging CMS to delay the transition from HIS to HOPE. The three groups sent a joint letter to Dr. Mehmet Oz, CMS Administrator, earlier this week.

“Our associations remain fully committed to the [Hospice Quality Reporting Program (HQRP)], including the payment penalties for non-compliance, and recognize the critical importance of accurate, timely data submission to inform the delivery of high-quality hospice care. However, we have serious concerns about the potential for successful implementation of the HOPE tool.”

LeadingAge, The Alliance, NPHI

Hospice Advocacy

The concerns over agency readiness to implement the new tool center on the new reporting platform. Hospice agencies state they don’t have all the necessary information to develop a workable tool for submission. Therefore, the agencies have asked CMS to delay the implementation of the HOPE tool. They have called on CMS to wait until six months after agencies have access to education, training, and final validation specifications.

Hospice Rule Penalty

The hospice program through CMS requires substantial reporting for payment. Hospices that do not submit the required 90% of records, they receive an annual payment penalty of 4%. Combined with lower than sustainable payment increases, the 4% penalty results in a lower reimbursement rate over prior years. The associations worry that the lack of information and education will lead to lower reporting. In turn, the lower reporting lowers reimbursement rates. For hospices that are already struggling to survive, the penalty is devastating. The letter to CMS asked to waive the timeliness requirement for two quarters after implementation.

HOPE Tool Lacks Validation

CMS will have a Validation Utility Tool that agencies will need to use in order to ensure their software can successfully submit their data. CMS has not released the tool and indicates they may not until sometime in September. The HOPE tool is scheduled for implementation in October. There is not enough time between release of the validity tool and implementation of the HOPE tool for proper testing.

Hospice Agencies Lack Validation

In addition to validating data submission, hospice agencies have to enroll in the new submission portal, iQUIES. Enrollment requires a privacy security official and other staff. Additionally, it requires an application to access the system, background checks, and other actions. Thus far, hospice agencies do not have access to begin this process and there is no indication of how long it will take. The associations are concerned that the process may also involve significant financial cost to hospice agencies.

Resources

CMS released the Hospice Outcomes and Patient Evaluation (HOPE) Guidance Manual v1.01, a 138 page PDF, available here. The manual includes links to other resources for hospice agencies. Namely, a webpage with information on HOPE Data Submission Specifications has a “final” version of data specs available for download. Additionally, there are links to the Main Page here and technical information and updates here. The document urges vendors to register to get updates and important announcements.

Final Thoughts

There is no information yet as to a response to the letter from CMS. Thus far, CMS is still planning on keeping the October 1, 2025 HOPE implementation date. We will continue to report on updates from CMS and the advocacy groups.

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