Medicaid Cuts Remain Unknown So Far

by Tim Rowan | May 1, 2025 | CMS, Medicaid, Regulatory

by Tim Rowan, Editor Emeritus

"Life and Death"

Medicaid Cuts are Looming

We don’t need to cut benefits, and it really infuriates me to hear people here talking about that because it stresses people out. This is life and death for them. –Senator Bernie Moreno (R-OH)

Budget Reconciliation Threatens Medicaid

After last weeks HHS purge, all of Care at Home is on edge as the U.S. House and Senate negotiate differences in each body’s budget reconciliation bill. The same jitters are found among Medicaid-eligible citizens, especially those who hear more rumors than actual progress reports from Washington. All we know for sure this week are two things: Speaker Johnson has pushed his deadline for a vote on the bill, asking for $880 billion in cuts, from Memorial Day to Independence Day; and the parallel Senate budget bill, at this date, is quite different. Watching the reconciliation talks should be nerve-wracking but entertaining.

The House Version

As of May 1, it is too early to assign a dollar amount to the FY 2026 Medicaid budget. H.B. 1968, named “Full-Year Continuing Appropriations Act of 2025,” delegates specific cut decisions to committees. It first directs the House Energy and Commerce Committee, which oversees Medicaid and part of Medicare, to reduce the federal deficit by $880 billion over ten years. The Agriculture Committee, which oversees SNAP, is ordered to cut $230 billion over the same time period.

Medicaid Cuts: Per Capita Caps

The Energy and Commerce Committee is the oldest standing legislative committee in the House. It has broad jurisdiction over our nation’s energy, health care, telecommunications, and consumer product safety policies. In the 119th Congress, it is chaired by Brett Guthrie (R-KY), a West Point graduate with a degree in Public and Private Management from Yale.

Guthrie has advocated changes to Medicaid since his days as a Kentucky state legislator. He pushed for the $880 billion in cuts that found life in H.B. 1968. Guthrie’s solution to growing Medicaid costs is “per capita caps” which would give states a fixed maximum amount of money for each person on Medicaid. According to an analysis by Axios, published after interviewing Guthrie:

“The federal government now covers a percentage of states’ Medicaid costs, so the amount reimbursed goes up or down depending on how much a state spends on the program.
Per capita caps would likely result in less money for states, forcing them to make up the difference by raising taxes or cutting spending elsewhere.”

In His Own Words

Guthrie told Axios he saw how the Medicaid program affected state budgets firsthand while serving in the Kentucky Statehouse. “I dealt with it,” he told Axios. “That is why I care about this…It just overwhelmed state budgets. What I’ve learned is, as we keep subsidizing health care, the price keeps going up. So, my idea with per capita allotments has always been that it will control costs.”

People might “fall off” Medicaid. “I’ve talked to a lot of providers, other groups, and they’re concerned. I’m not saying they’re not, but I think we can do it in a way that people get service.”
(202) 225-3501; (202) 225-3501

Brett Guthrie

Chairman, Energy and Commerce Committee

SNAP Cuts

Glenn Thompson (R-PA) chairs the Agricultural Committee, which will be asked to make cuts to SNAP. Prior to being elected to Pennsylvania’s Fifteenth District, Thompson spent 28 years as a therapist, rehabilitation services manager, and a licensed nursing home administrator.
(202) 225-5121; (814) 353-0215

Strange Bedfellows in the Senate

Along with every Democrat, at least two conservative Republicans have expressed uncertainty about putting budget savings on the backs of Medicaid beneficiaries. Senators Bernie Moreno of Ohio and Josh Hawley of Missouri both warned in interviews with newsmagazine Semafor that proposals to cut the federal government’s share of the costs in states that have expanded Medicaid, and to otherwise cap Medicaid expansion spending, could lead to coverage losses. Moreno bluntly told Semafor that both ideas amount to “cutting benefits.”

“There’s not 50 votes for any kind of cuts in benefits. That’s just a fact,” Moreno said.

Just A Skosh of A Difference to Negotiate

A detailed analysis by the Geiger Gibson Program in Community Health at the Milken Institute School of Public Health at George Washington University compares the House and Senate versions side by side. Their analysis points out that the Senate outline for its bill calls for at least $1 billion in Medicaid spending reductions over the 10-year budget window. As already noted, the House wants its committees to find at least $880 billion over the same window.

“The Senate bill also authorizes the Budget Committee to adjust the targets for the purpose of “protecting the Medicaid program,” which may include “strengthening and improving” Medicaid (undefined) in a deficit-neutral fashion. The Senate measure thus effectively prioritizes protections for Medicaid over other potential policy aims to be achieved through the reconciliation process. The House bill, by contrast, calls for scaling back tax relief if the spending reduction targets are not met, thereby placing additional pressure on the $880 billion floor.

The House and Senate now must reconcile two extremely different measures before the reconciliation process actually proceeds, the university report concludes. “Although it is unclear whether the House will proceed with a legislation to achieve reconciliation in advance of a final agreement.”

$779 billion is a lot of reconciling...

One final independent analysis may draw this discussion to a close that speaks directly to our industry’s concerns. The Commonwealth Fund, in a March 25 “Issue Briefing,” looked at the long-term consequences of deep Medicaid cuts. In its executive summary, the briefing says:

Key Findings and Conclusions

Combined losses from proposed Medicaid and SNAP cuts would reach $1.1 trillion over a decade, including a $95 billion loss of federal funding in 2026 alone. State gross domestic products (GDPs) would be $113 billion lower, exceeding federal budget savings. About 1.03 million jobs would be lost nationwide in health care, food-related industries, and other sectors. State and local governments would lose $8.8 billion in state and local tax revenues. Not extending the enhanced health insurance premium tax credits that are scheduled to expire after December 2025 would lead to an additional 286,000 jobs lost in 2026, for a combined total of more than 1.3 million jobs lost in the United States.

Stay tuned. We at the Rowan Report are committed to keeping a close eye on developments in this bi-partisan battle.

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

©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

Vision for CMS

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

by Kristin Rowan, Editor

Vision for CMS from Dr. Oz

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

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

Dr. Mehmet Oz

Administrator of CMS, Department of Health and Human Services

Make America Healthy Again

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

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

Letter to Medicaid

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

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

Read the full letter here.

Final Thoughts

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

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

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

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

CDPAP Overhaul Under Scrutiny

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

by Kristin Rowan, Editor

CDPAP Overhaul in NY Medicaid Program

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

The Need for the CDPAP Overhaul

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

Brakes Applied

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

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

Hit From Both Sides

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

Dubious Reassurances

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

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

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

Alliance Statement on Congressional Budget

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

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

by Kristin Rowan, Editor

Underlying Causes of Health Issues

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

Guidance Rescinded

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

Opposition

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

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

Underlying Causes of Health Issues Andrey Ostrovsky

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

Damon Terzaghi

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

On the Other Hand

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

Final Thoughts

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

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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

Update on Public Participation in Rule Making

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

by Kristin Rowan, Editor

Update

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

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

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

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

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

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

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

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

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

# # #

Below is the original article, published March 6, 2025

Public Participation Rescinded

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

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

Robert F. Kennedy, Jr.

Secretary, Department of Health and Human Services

What it Means

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

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

Public Participation in Medicare Rules

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

Public Participation in Medicaid and CHIP rules

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

Department of Veterans Affairs

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

Final Thoughts

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

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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

BREAKING NEWS: Kennedy Rescinds Public Participation in Rule Making

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

by Kristin Rowan, Editor

Public Participation Rescinded

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

Robert F. Kennedy, Jr.

Secretary, Department of Health and Human Services

What it Means

Public Participation in Medicare Rules

Public Participation in Medicaid and CHIP rules

Department of Veterans Affairs

Final Thoughts

# # #

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

Treatment in Place from Emergency Medical Services

by Elizabeth E. Hogue, Esq. | Feb 14, 2025 | Clinical, Medicare Advantage, Regulatory

by Elizabeth E. Hogue, Esq.

Treatment in Place

Providers of services to patients in their homes are anecdotally familiar with situations in which patients need help at home, but do not qualify for home health services and have not arranged for or are unable to afford home care/private duty services. These patients need assistance, but do not need transport.

The Problem

The problem for Emergency Medical Services (EMS) is nonpayment for services if patients are not transported for services.

Can EMS Charge Without Transport

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has weighed in on whether local EMS can meet this need and bill patients’ insurance for treatment in place (TIP) services. The OIG has “blessed” the provision and billing of these services in Advisory Opinion No. 24-09 issued on November 21, 2024.

Treatment in Place Requirements to Bill Insurance

Specifically, the OIG says that EMS may provide services to patients in their homes or TIP services and bill Patients’ insurers if the following requirements are met:

Charges to patients’ insurers would be limited for emergency responses only.
Charges for TIP services must be based on the level of care furnished to patients and cannot exceed amounts currently claimed for payment for the same levels of care furnished in connection with ambulance transports.
Charges are made regardless of whether patients are enrolled in commercial insurance plans or federal health programs.
EMS accepts payment for TIP services from patients’ health insurances as payment in full.
Patients will not be billed for any cost-sharing amounts under patients’ health insurance, including federal health care programs for covered TIP services, regardless of whether they are residents or nonresidents of the county where TIP services are provided.
EMS cannot later claim cost-sharing amounts waived as bed debts for payments under federal health care programs or otherwise shift the burden of cost-sharing waivers onto federal health care programs, other payors, or individuals by, for example, balance billing.

Cost-Sharing

In light of the above, the OIG first acknowledged that the prohibition on waivers of cost-sharing under the federal anti-kickback statute (AKS) is applicable and that the requirements of a safe harbor that addresses waivers of cost-sharing amounts for municipally owned ambulances are not met by the proposed arrangement. The OIG also said that the proposed arrangement would result in remuneration in the form of cost-sharing waivers for TIP services and TIP services provided at no charge to patients. Consequently, remuneration provided implicates both the AKS and the Beneficiary Inducements CMP.

Risk

Nonetheless, the OIG concluded that the arrangement involves a low risk of fraud and abuse. In addition to the above requirements, the OIG concluded that neither Medicare Part B nor the State Medicaid Program currently covers TIP services; only a handful of Medicare Advantage Plans and some Medicaid Programs currently cover TIP services. This means that, in most circumstances, the arrangement will result in no costs to federal health care programs and, in fact, may reduce costs by avoiding ambulance transport or subsequent hospital care. Patients may also receive care more quickly and efficiently, and at more appropriate levels of care when they receive TIP services.

Treatment in Place Cost-sharing Waivers

Finally, according to the OIG, waivers of cost-sharing for TIP services or the provision of free TIP services are unlikely to affect patients’ decisions to use future emergency ambulance services reimbursed by federal health care programs.

Providers are increasingly aware that patients need a variety of services in their homes. The OIG has opened another door!

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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.

Is Medicaid Down for the Count?

by Kristin Rowan | Feb 6, 2025 | Breaking News, Regulatory

by Kristin Rowan, Editor

Medicaid Payment System Goes Dark

On Monday, January 27, President Trump, through the Office of Management and Budget, announced a temporary freeze on federal spending while his newly designated head of the Department of Government Efficiency ensures all spending follows the executive orders the President has signed. The memo was vague and caused widespread confusion across government departments. Almost immediately after the memo was circulated, Medicaid programs could not access the Payment Management Services web portal, the entity responsible for paying Medicaid claims.

The Memo

The language used in the memo on federal spending was broad and overreaching. As such, many federal organizations were unclear as to whether the memo applied to them. The message in the memo was that the administration intended to curb any spending that does not improve the day-to-day lives of the people. Throughout the day Monday, the White House sent clarifications about what programs would not be impacted. Among them were food assistance programs like SNAP, WIC, and Meals on Wheels, and Medicaid. The medicaid payment portal went down, despite this clarification.

Exclusions

Multiple state and federal agencies reached out to the White House for clarification following the release of the memo. Explicitly excluded from the freeze are direct benefit plans like Social Security and Medicare. In addition to the programs named in the memo, clarification on additional programs that would not be impacted included Medicaid. Despite the temporary website outage, claims were still being processed and payments were still being made.

Immediate Lawsuits

Almost simultaneously with the distribution of the memo, several non-profit organizations filed suit against the federal government. They called Trump’s action an “unlawful and unconstitutional” act, even temporarily. The pause on federal spending was set to go into effect at 5 p.m. ET on Tuesday. Minutes before, U.S. District Judge Loren L. AliKhan put a pause on the pause.

Temporary Freeze on the Temporary Freeze

To allow both sides time to construct an argument, the judge stayed the funding freeze until Monday, February 3. That morning, the judge will hear arguments and consider the issue. After the stay, attorneys general from 22 states and D.C. filed their own lawsuit to permanently block the freeze and prevent any future attempts to cut off already approved federal funding.

Then Comes the Thaw

If the judge allows the freeze to move forward, Trump has given every agency until February 10 to account for and explain all spending programs within their departments. Once the accounting has been reviewed, likely the OMB and the Department of Government Efficiency will determine which federal spending programs can resume operation.

There is no indication yet as to whether Trump will extend the February 10 deadline, given the delay in the courts. By the time the judge rules on Monday, however, we hope the White House will have issued additional details and guidance to avoid additional disruption to essential services like Medicare and Medicaid.

Final? Ruling

Early Monday, Judge AliKhan said she was not convinced by the argument that nonprofit groups have no case against the funding freeze since the OMB rescinded the memo. The administration argued that a brief pause on funding to align federal spending is within the law. The administration also suggests that the courts have no standing to block it. AliKhan has indicated that she will likely grant a longer temporary order to stay the funding freeze.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

Care at Home Coming to Medicaid?

by Elizabeth E. Hogue, Esq. | Jan 16, 2025 | Advocacy, Regulatory

by Elizabeth E. Hogue, Esq.

Brown v D.C. Decision is Another Boost for Care at Home

In Olmstead v. L.C., the U.S. Supreme Court decided that unjustified segregation of disabled persons constitutes discrimination in violation of Title II of the Americans with Disabilities Act.

The Court said that public entities must provide community-based services to disabled persons when such services are:

- Appropriate;
- Unopposed by disabled persons; and
- Reasonable accommodations taking into account resources available to public entities and the needs of other disabled individuals receiving services from the entity.

This decision gave a tremendous boost to the provision of home and community-based services of all types. Since Olmstead was decided in 1999, there have been more court decisions that require services to be provided at home based on this opinion.

Support for Olmstead

One recent decision is Brown, et al v. District of Columbia (Brown v D.C.) that was decided on December 31, 2024. The Court decided that the District of Columbia violated the rights of D.C. residents with disabilities under the Americans with Disabilities Act (ADA) and the Rehabilitation Act. According to the Court, D.C. failed to inform nursing facility residents who receive Medicaid that they could leave nursing facilities and receive home health services in their communities and failed to assist them to do so. The D.C. government also failed to help them access community-based services and housing options needed to transition back to the community.

The Court recognized that individuals living in nursing facilities often need help learning about and applying for available community services to help them transition out of the institution and into their own homes. Even when residents learn about services, navigating the complicated Medicaid-funded long-term care program can cause confusion and anxiety that sometimes causes facility residents to lose hope that they can live in their own homes again.

Consequently, the decision applies to

“All persons with physical disabilities who, now or during the pendency of this lawsuit: (1) receive DC Medicaid-funded long-term care services in a nursing facility for 90 or more consecutive days; (2) are eligible for Medicaid-covered home and community-based long-term care services that would enable them to live in the community; and (3) would prefer to live in the community instead of a nursing facility but need the District of Columbia to provide transition assistance to facilitate their access to long-term care services in the community.”

Brown v D.C. Says That D.C. Must

- Develop and implement a working system of transition assistance for [nursing home residents that], at a minimum
  - informs DC Medicaid-funded residents, upon admission and at least every three months thereafter, about community-based long-term care alternatives to nursing facilities
  - elicits DC Medicaid-funded nursing facility residents’ preferences for community or nursing facility placement upon admission and at least every three months thereafter
  - begins DC Medicaid-funded nursing facility residents’ discharge planning upon admission and reviews at least every month the progress made on that plan
  - provides DC Medicaid-funded nursing facility residents who do not oppose living in the community with assistance accessing all appropriate resources available in the community
- Ensure sufficient capacity of community-based long-term care services for [residents] under the EPD, MFP, and PCA programs and other long-term care service programs, to serve [residents] in the most integrated setting appropriate to their needs, as measured by enrollment in these long-term care programs.
- …[D]emonstrate [its] ongoing commitment to deinstitutionalization by, at a minimum, publicly reporting on at least a semi-annual basis the total number of DC Medicaid-funded nursing facility residents who do not oppose living in the community; the number of those individuals assisted by [DC] to transition to the community with long-term care services [described above]; and the aggregate dollars [DC] saves (or fails to save) by serving individuals in the community rather than in nursing facilities.

Final Thoughts on Brown v D.C.

As indicated above, there continues to be a clear mandate for Medicaid Programs to provide services to individuals in the community, which is a significant impetus to provide services to patients in their homes. This mandate, however, does not directly address practical aspects of implementation, such as reimbursement at appropriate rates for providers or availability of staff to provide services at home. Nonetheless, the Olmstead and Brown cases provide an important basis for further development of in-home services of all types to meet the needs of disabled persons.

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