CMS Proposed Changes

by Kristin Rowan | Dec 12, 2025 | Advocacy, CMS, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

CMS is Making Changes

Good or Bad?

CMS is making changes across Medicare and Medicare Advantage. From Star Ratings to Prescription Drug Prices to the Hospice benefit, CMS is embracing Make America Healthy Again. Will these initiatives benefit Medicare and Medicare Advantage recipients or the insurance companies who provide the plans?

Drug Payment Model

In early November, CMS announced a plan to lower prescription drug costs for Medicaid recipients. State Medicaid programs can opt in to the GENErating cost Reductions fOr U.S. Medicaid Model (GENEROUS). The pilot program is using the most-favored-nation pricing that was recently negotiated and announced by President Trump. Most-favored-nation pricing requires prescription drug manufacturers to charge the same low rate paid in other countries.

Limited Pilot

Beginning in 2026, CMS will negotiate with manufacturers of select drugs for lower pricing. Participating states will start using uniform, transparent coverage criteria. This is not criteria for inital coverage in Medicaid, but for standardizing access to high-cost medications.

Manufacturers are not required to participate in the GENEROUS Model, but can voluntarily apply. Participating manufacturers agree NOT to seek additional supplemental rebates or discounts outside the model price.

New Medicare Advantage Policies

CMS has proposed updates to the Medicare Advantage and Medicare Part D programs. The new plan would begin in CY 2027 and includes major changes to the Star Ratings system. CMS is also seeking feedback on new ways to modernize MA.

Star Rating Changes

The proposed changes are supposed to incentivize plans to improve care. CMS suggests removing 12 unique measures that look at administrative processes and those that don’t highlight differences between plans. Star Rating measurements of care, outcomes, and patient experience will remain.

Request for Feedback

CMS is seeking feedback on Medicare Advantage changes, including improving competition, refining risk adjustment, and aligning quality incentives to deliver greater value. CMS is open to either a limited model test or program-wide changes. Interested parties can submit feedback through January 26, 2026. Read the Proposed Rule here. Submit your comments.

Expanding Technology-Enabled Care

CMS may finally be recognizing what we’ve been promoting for 25 years: Care improves with technology support.

CMS Proposed Changes<br />
Technology-based Care

The ACCESS model tests a new payment approach in original Medicare to expand access to technology-supported care options. CMS aims to increase technology-supported care options to improve health and prevent and manage chronic diseases. More than two-thirds of Medicare beneficiaries are dealing with high blood pressure, diabetes, chronic musculoskeletal pain, and depression.

An interest form is now available for the 10-year Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model test. The model test begins July 1, 2026. The application to participate must be received by April 1, 2026.

Impact

As these programs roll out between now and 2029, the impact on insurance plans, payors, beneficiaries, and taxpayers will unfold. Will lower cost prescriptions and technology-based care lower insurance rates? Payor reform may be necessary to change out-of-pocket costs. Regulations may have to further incentivize payors to increase care when costs go down, particularly with value-based care models.

Please take a few minutes to read the details on each of these proposals, add your comments, and sign up to participate. The industry needs reform and our aging family members deserve better.

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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

MedPAC Proposes Drastic Cut

by Kristin Rowan | Dec 12, 2025 | Clinical

by Kristin Rowan, Editor

MedPAC Proposes Drastic Cuts

Five Year Decrease Not Enough

The onset of PDGM and the recalculations of payments in 2020 have led to an overall decrease in Medicare reimbursement rates for home health by approximately 12%. CMS continues to calculate budget neutrality with flawed formulas. The Alliance, along with several other advocacy groups as well as agencies and individuals, continues to fight against the formula and the pay cuts, estimating that nearly half of all home health agencies will be losing money in order to stay open.

Industry Report

Despite the continual decrease in payment rates, MedPAC recommends additional steep cuts. Highlights from the MedPAC report include:

97% of beneficiaries have access to 2 or more HHAs
The total number of HHAs declined 1% in 2024 (excluding CA)
Only 7.9% of beneficiaries used HH in 2024
Number of 30-day periods per beneficiary increased 2.6%
The overall profit margin for Traditional Medicare is 21.2%
The overall profit margin for all payers is 5%
Anticipated profit margin for 2026 is 19% for Traditional Medicare (3% overall)

Less than 0

The Traditional Medicare profit margin in 2026 is projected at 19%. This is offset by the negative profit margin from Medicare Advantage and private insurance plans. It may not be realistic or fair for the taxpayer to offset poor policies in Medicare Advantage and private insurance plans, but that has been the reality for years. Medicare Advantage plans yield high profits for insurance payors, and negative margins for HHAs. With an overall profit margin of 3%, lowering the Medicare reimbursement rate by more than 3% will put all HHAs in the red.

The Math Isn't Mathing

The numbers are there. HHAs earn 5% now, 3% next year. MedPAC recommends that CMS reduce the 2026 rate by an additional 7%.

NET PROFIT MARGIN -4%

Conclusion from MedPAC: This will not impact care; providers will still be willing to treat Traditional Medicare beneficiaries.

That statement may be true. However, in order for HHAs to survive, they will have to drop all MA plans. More than 50% of Medicare beneficiaries are on MA plans. 40% of MA patients use HH care after hospitalization. Medicare Advantage will survive through hospitals and physicians, but the Home Health benefit won’t have any providers.

Hospice Tie-In

CMS is currently weighing the option of the hospice carve-in to Medicare Advantage plans. The pilot plan failed miserably and yet rolling this out across all plans is an option, somehow. CMS and MedPAC must not be able to see what has happened to Home Health under MA plans. Hospice will suffer the same fate through the carve-in. It is irresponsible and destructive to add Hospice to MA. For that matter, it is irresponsible and destructive NOT to remove Home Health from MA. Move it all back to Traditional Medicare where at least the profit margin is above 0.

May Cooler Heads Prevail

From the proposed rule in July to the final rule in November, CMS lessened the permanent rate cut by about 5%, finally hearing the concerns of advocates who told them HHAs would go out of business. We certainly hope CMS will keep that in mind when considering the MedPAC recommendation.

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BREAKING NEWS: Home Health Final Rule

by Kristin Rowan | Nov 29, 2025 | Breaking News, CMS, Home Health, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

BREAKING NEWS

Home Health Final Rule

While most of us were still recovering from our Thanksgiving feast overload, CMS quietly released the CY 2026 Home Health Prospective Payment System Final Rule (HH Final Rule). In past years, CMS published the HH Final Rule on or about November 1. The HH Final Rule was delayed this year due to the government shutdown.

Payment & Policy Updates

The payment rate for 2026 will change based on multiple factors:

HH payment update of +2.4%
The final permanent rate adjustment of -0.9%
The final temporary adjustment of -2.7%
Fixed-dollar loss ratio for outlier payments update of -0.1%

The aggregated payment update for 2026 is a net decrease of 1.3%

Read the CMS Fact Sheet

Face-to-Face

The CARES Act allows Nurse Practitioners, Certified Nurse Specialists, and Physicians Assistants to order and certify eligibility for Medicare HH and establish a plan of care. CMS has updated face-to-face encounters to now allow NPs, CNSs, PAs and physicians to perform face-to-face encounters whether or not they were the certifying practitioner or one who cared for the patient prior to home health care.

Home Health VBPM

Effective in April 2026, the HHCAHPS survey will undergo changes. CMS is removing these three survey-based measures:

Care of Patients
Communications between Providers and Patients
Specific Care Issues

CMS is adding four measures to them measure set. These include three measures related to bathing and dressing and the Medicare Spending per Beneficiary setting measure. These changes also prompted alterations to the weights of each measure and measure category.

The expanded model has built-in criteria for the removal of any quality measure. CMS is adding an additional criteria to the list of factors. Factor 9 reads that CMS may remove a quality measure if it is not feasible to implement the measure specificiations.

Medicare Provider Enrollment Revocation

Currently, any provider must enroll and be approved to become a Medicare provider. CMS has the authority to both approve and revoke provider Medicare enrollment. When CMS revokes a provider’s Medicare enrollment, the revocation is effective 30 days after CMS mails notification to the provider. In certain circumstances, CMS can revoke enrollment retroactively to the first date of non-compliance and consequently collect any money paid to that provider back to the retroactive date. CMS is adding to the allowable grounds for retroactive revocation.

If an enrolled physician or practitioner has not ordered or certified services for 12 consective months
If a beneficiary attests that a provider did not actually perform the services they billed

Additional Changes

CMS is recalibrating case-mix weights under PDGM and LUPA thresholds.

DMEPOS accreditation regulations will now require suppliers to be resurveyed and reaccredited annually. Additionally, CMS is increasing the amount and frequency of data accrediting organizations (AOs) submit, expanding their ability to monitor AOs, and strengthening their ability to address poorly performing AOs.

The DMEPOS Competitive Bidding Program will change, but we are still waiting for the finalized improvements. CMS will begin paying for all continuous glucose monitors and insulin infusion pumps.

Read the Final Rule and additional Documents

Final Thoughts

A decrease in pay of any amount is unfortunate. However, we applaud CMS for listening to the feedback. CMS stated, “…commenters raised concers that behavior change after CY 2022 might [attribute] to factors unrelated to…PDGM.” Changes since 2020 include the introduction of OASIS-E, the expansion of value-based purchasing, and the large increase in the percentage of Medicare Advantage enrollees.

Whatever the reason, The Rowan Report joins the National Alliance for Care at Home in commending CMS for adjusting its payment calculations. The permanent pay adjustment for 2026 is listed as the final adjustment, a positive for HH moving forward. The proposed rule issued mid-year had a net -6.4% decrease in payments for a net decrease of more than $1 billion dollars. The final rule payment adjustment has a net decrease of $220 million. Still a decrease, but much more palatable.

CMS will continue to assess the need for temporary payment adjustments for several more years. Additional adjustments (read decreases) to the payment rate will impact patient access to care. The Alliance will continue to advocate and educate members of Congress and HHS to lower or eliminate they reductions. Your advocacy and support is needed to ensure the future of Care at Home. The Rowan Report will continue to support the Alliance and other advocacy groups and share with you opportunities for advovacy.

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Hospice Carve-In is Out

by Rowan Report | Nov 25, 2025 | Advocacy, Hospice, Medicare, Medicare Advantage, Partner News, Regulatory

FOR IMMEDIATE RELEASE

Contact: Hannah Kristan
communications@allianceforcareathome.org
202-355-1647

Sen. Marshall and Sen. Whitehouse Issue Letter to Senate Leadership Expressing Bipartisan Support for Policies that Preserve Medicare’s Hospice Benefit Under Original Medicare

Alexandria, VA and Washington, D.C., November 24, 2025. On November 20, Senator Roger Marshall (R-KS) and Senator Sheldon Whitehouse (D-RI) sent a letter to Senate leadership expressing strong bipartisan support for policies that preserve the Medicare Hospice Benefit under Original Medicare, including for Medicare Advantage (MA) beneficiaries, which has protected their access to high-quality, timely end-of-life care for nearly three decades.

Repeal Special Rule

As Congress considers potential reforms to the MA program, the letter urges Senate leadership to maintain this critical safeguard and oppose any proposals that would include hospice in the Medicare Advantage program, including repeal or alteration of the Special Rule for Hospice (the Special Rule), also known as hospice carve-in.

Hopice in MA

Despite years of attempts from Congress, the Alliance strongly opposes efforts to integrate hospice into Medicare Advantage (MA). Past attempts have revealed challenges such as administrative burdens, difficulty creating networks, and delayed payments for claims. Bringing hospice under Medicare Advantage would undermine patient choice, adversely impact timely access to care, and fragment the hospice experience for patients and families at a highly vulnerable time.

View the full letter here.

Excerpt

“MA enrollees who elect hospice currently retain the freedom to choose any Medicare-certified hospice provider, free from network limitations or prior authorization requirements. More than half of hospice beneficiaries pass away within 14 days of election, making delays in care both harmful and unacceptable. Integrating the hospice benefit into MA plan design would jeopardize this access by layering additional managed care terms (or policies) on top of an already managed and coordinated benefit.”

Marshall and Whitehouse

U.S. Senators

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“The Alliance thanks Sen. Marshall and Sen. Whitehouse for listening to the concerns of the care at home community and taking action to protect our nation’s most vulnerable patient population by defending the Hospice Benefit under original Medicare,” said Scott Levy, Chief Government Affairs Officer at the Alliance. “The Alliance will continue to lead on this important public policy priority for hospice providers nationwide by advocating to preserve this sacred promise established by Congress and kept on behalf of the American people for over four decades.”

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About the National Alliance for Care at Home

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

© 2026. This press release originally appeared on the National Alliance for Care at Home Website and is published with permission. For additional information or for permission to print, please see press contact above.

Medicare Advantage Reform

by Kristin Rowan | Nov 25, 2025 | CMS, Editorial, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Medicare Advantage Reform

Background

Traditional Medicare is available to any U.S. citizen over the age of 65 or with a qualifying disability. Part A covers hospital care, skilled nursing facility care, hospice care, and some medically necessary home health care while Part B covers doctor visits and outpatient care. Medicare is billed through and paid by the federal government.

Medicare Advantage (originally Medicare+Choice) is Medicare coverage offered by private insurance companies who are then reimbursed by the government. The goal was to create competition and lower costs. It has done neither. Medicare Advantage plans are supposed to provide all of the coverage from Parts A, B, & D except hospice care. That is still handled by traditional Medicare.

Hospice Carve-in Plan

Despite the epic failure of the recent hospice carve-in experiment, House representative Schweikert (R-AZ) introduced H.R. 3467 to reform the Medicare Advantage program and included a requirement for hospice care. The goal, according to Schweikert, is to eliminate waste and fraud and stop MA insurance companies from making billions in profits by upcoding. The solutions, outlined in H.R.3467, include requiring MA recipients to stay on the same plan for at least three years and permanently including the hospice benefit in MA plans.

Eight New Bills

On November 19, 2025, Representative Mark Pocan (D-WI), with the support of 12 other members of the House, introduced eight separate bills aimed at Medicare Advantage reform and strengthening traditional Medicare. The eight bills include:

1. Disincentives for delaying and denying lifesaving care due to prior authorization requirements
2. Automatic appeals for any denial of care
3. Visually and audibly disclosing delay and denial rates in advertising
4. Banning participation in MA for any company convicted of defrauding the government
5. Lowering MA reimbursement rates to at or below traditional Medicare rates
6. Limiting the number of MA plans a company can offer to 3 per year
7. Prohibiting MA from being the default option
8. Creating a website listing all doctors by plan

Commentary

In addition to the package cosponsors and six endorsing organizations, Rep Pocan received industry expert support for his bill package.

“Big Insurance has long pitched Medicare Advantage as a key tool to lowering health care costs and delivering better care, but like so much of their rhetoric, this is nothing but bold-faced lies. The truth is, Medicare Advantage is neither Medicare nor an advantage. And it certainly doesn’t exist to lower costs. It exists to help Big Insurance make sky-high profits and enrich shareholders. It is long past time Congress stepped in and protected patients. The legislative package Congressman Pocan is introducing is the most comprehensive plan ever introduced to rein in Medicare Advantage and protect patients. Congress should pass these bills without delay.”

– Wendell Potter, President, The Center for Health and Democracy

“Medicare Advantage insurers profit from withholding medically necessary care, and can withhold care with near impunity. So, people enrolling in corporate MA plans are forced to gamble with their health and with their lives. They can’t avoid the bad actors. It’s time Congress protected older Americans and people with disabilities from bad actor Medicare Advantage insurers, as Congressman Pocan’s MA Bill package would do.”

– Diane Archer, President and Founder, Just Care

Rep. Pocan’s bills do not include the hospice carve-in and would leave hospice care under traditional Medicare.

Faulty Logic?

Medicare Advantage plan payors have been accused of upcoding, fraud, overbilling, delays in care, and denials that circumvent the rule that MA must cover everything traditional Medicare does. It may be naive to assume that passing these bills will force unscrupulous companies to suddenly have integrity.

MA enrollees pay the standard Part B premium and might pay an additional MA premium depending on their income, geographic locations, and/or additional plan benefits. Rep. Pocan’s bill lowers what MA charges the government (aka tax payers) but does not address what the plans charge enrollees. If MA plans are required to lower reimbursement rates by 10%, for example, won’t they just increase premiums, deductibles, and copays or remove additional benefits? Sure, the government spends less, but out-of-pocket costs increase and quality of care drops.

The “Seniors Choice” bill limiting the number of plans to three is unclear in its direction. A 2019 rule removed the meaningful difference requirement for MA plans. This bill seeks to reinstate that requirement, but changes the term to “significantly different” in premiums, benefits, and cost-sharing. There are too many variables in health insurance to limit the choices to three. Three choices per company lessens the competitive need to keep prices low.

Not so Hidden Agenda

Medicare Advantage reform is sorely needed. MA is largely fraudulent, misleading, and costly both in spending and health. Chipping away at some of these pieces is for the good of the enrollees on their surfaces. But dig just a little deeper and the goal is clear.

Overwhelmingly, the organizations in support of this bill package are proponents of a single payer system. The prior authorizations disincentive is termination of the entire contract for the year. The disallowing participation bill includes all companies and individuals convicted of any crime, misdemeanor or greater, in any way connected to healthcare, all financial misconduct in or out of healthcare, and all acts of fraud, kickbacks, and misrepresentation of material fact. Any plan charging more than its traditional Medicare counterpart will be eliminated. Given these restrictions, it will not take long for every Medicare Advantage plan to be eliminated entirely.

The recent government shutdown centered around the ACA subsidies that are set to expire at the end of the year. The elimination of those subsidies could push healthcare insurance premiums to a level that few can afford, furthering the need for a single payer plan.

Final Thoughts

The White House has promised a health care proposal with much speculation but no facts. The proposal has yet to be released. Congress is still negotiating the extension of Covid-era subsidy increases with only a few weeks remaining before they adjourn for the holidays. ACA participants are having to renew their health insurance without knowing what the final cost will be and many believe the number of participants will drop significantly, leaving millions uninsured.

None of the proposed solutions will fix all the problems with healthcare. But, a temporary stay is better than losing access to healthcare altogether. This is an ongoing issue and The Rowan Report will continue to bring you the latest information as it becomes available.

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Alliance to Congress: STOP CUTS

by Kristin Rowan | Oct 30, 2025 | Advocacy, CMS, Home Health, Medicare

by Kristin Rowan, Editor

9% Cut Proposed

CMS proposed home health rule for 2026 includes disastrous cuts. A 3.2% market basket increase, a 0.8% productivity cut, a 5% reduction to recoup prior overpayments, and a 4.1% permanent reduction to prevent further overpayments. CMS proposed an additional 0.5% cut to account for high-risk outliers. In other words, CMS wants to pay less for all patients to make up for the small percentage of patients who need more care.

Deadline Looming

The mandatory comment period ended on August 29. Next, CMS reviews the submitted comments, responds to those comments (generally explaining why they are not going to listen), and then finalizes the 2026 rule. The final rule is due November 1, 2025. Although, that falls on a Saturday, so the deadline may extend to Monday. A good many of us will be in New Orleans for the Alliance annual conference and expo by then.

Group Effort

The National Alliance for Care at Home (Alliance) joined 150+ provider, patient, community, and advocacy groups to write a letter to Congress urging them to prevent the CMS proposed cut.

“The proposed payment reductions for home health pose a serious threat to the health and safety of Medicare beneficiaries and to the broader integrity of our healthcare system. With the 2026 payment rule under review and due by November 1, we urge you to promptly intervene and press CMS to stop the cuts and realign payments.”

Pattern of Payment Reduction

The letter, addressed to Senate Majority Leader John Thune, Senate Minority Leader Chuck Schumer, Speaker Mike Johnson, and House Minority Leader Hakeem Jeffries, asks Congress to look at the consecutive years of pay reductions and how they have impacted home health. Because of the cuts, agencies have gone out of business or downsized, leaving rural areas without care.

Home Health Costs Less

The letter also explains that cutting medicare payments actually costs more. When more patients have access to home health, CMS spends less on unplanned hospital visits and ER trips. Patients have fewer falls and accidents. Risk factors are identified earlier and preventative treatments are used before a patient’s condition requires hospitalization. Home health patients stay home years longer than those not receiving home health before entering a skilled nursing or assisted living facility.

What's at Risk

The Medicare Trust Fund, funded partially by payroll taxes, includes hospital insurance that pays for hospital (Medicare Part A) services. When these costs increase, the trust fund is at risk being insolvent and taxes are increased to put money back into the fund. Lowering home health payment rates and cutting off millions of people who depend on home health will impact tax payers as well.

“The cuts currently proposed to Medicare’s home health benefit are unsustainable and would be deeply harmful to those who depend on care at home. The Alliance will continue to work with policymakers and our stakeholder allies to oppose these harmful cuts and protect access to home health services for millions of older adults, individuals with disabilities, and their families.”

Dr. Steve Landers

CEO, National Alliance for Care at Home

The Alliance issued a press release with the highlights from the letter. You can read the full letter here.

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Government Shutdown

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

by Kristin Rowan, Editor

Government Shutdown Threatens Care at Home

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

UPDATE: Shutdown, Day 16

–As of October 16, 2025–

What it Means for Care at Home

After 10 attempts, the government is no closer to an agreement than they were on September 30th. The Senate is expected to break at the end of the day, leaving the next opportunity to negotiate until at least Monday.

Telehealth

The biggest impact on care at home during the government shut down is the ability to complete required face-to-face visits using telehealth appointments. Both home health and hospice have employed telehealth for face-to-face encounters since the COVID-era waiver, which has now been extended several times. The most recent extension, which we anticipated Congress to extend in this budget, expired on September 30th.

All face-to-face encounters occurring after October 1, 2025 must be in person.

According to home health expert Melinda A. Gaboury of Healthcare Provider Solutions says it is unlikely an extension would be retroactive even if Congress includes an extension in the finalized budget.

Payments

Conflicting information on Medicare payments leave us unsure of the actual impact. Some reports say there will be no delay while others mention 10-day holds. It is unclear whether this is in addition to the standard 14-day hold. Either way, we are anticipating (and hoping for) minimal payment disruptions.

Surveys

Initial Medicare certification for home health and hospice as well as recertifications will be delayed. If ACHA, CHAP, or another accrediting body is conducting your survey, however, there should be no delay. These accrediting bodies are continuing without interruption. State agency surbveys will be delayed until after the budget is finalized and the shutdown ends.

Look for continued updates from The Rowan Report as the shutdown and negotiations continue.

–As of October 9, 2025–

The Disagreement

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

Push to Extend

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

Priced Out

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

Photo Credit – The New York Times

Counter

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

Open Enrollment

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

Care at Home Impact

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

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

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

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

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

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

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Can This New Software Eliminate Fraud and Billing Errors?

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

by Tim Rowan, Editor Emeritus

Software Eliminates Fraud and Errors

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

The Hurdles

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

Then... the call came

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

– Henry (Hank) Schwab, Owner, Compliance Plus

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

Dramatic Process Improvements

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

Time Tracking

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

Verification

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

Caregiver Feedback

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

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

The "Plus" of Compliance Plus

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

Denials are Rare

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

Aggregated Data

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

Implementation and Training

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

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

Favorite Features

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

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

Simplifying Complex Billing

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

It's Complicated

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

Patient Profiles

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

Task Rates

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

Company Prospects

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

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

What Can Providers Give to Patients, Pt 1

by Elizabeth E. Hogue, Esq. | Oct 9, 2025 | Admin, Legal, Marketing

by Elizabeth E. Hogue, Esq.

Providers Kickbacks

Keeping it Clean

Providers, including marketers, are tempted to give patients free items and services. But be careful! These activities may violate laws prohibiting providers that participate in state and federal health programs from giving free items and services to patients. Private insurers often impose the same prohibitions. This means that private duty agencies are not exempt from these fraud and abuse prohibitions if they participate in any state healthcare programs, such as Medicaid or Medicaid waiver programs, or accept payments from private insurers.

Provider Prohibitions

The government generally prohibits providers from giving free items and services to patients because it is concerned that such activities may:

Result in overutilization of services
Produce decisions concerning care that are not objective
Increase costs to the Medicare and Medicaid Programs and other state and federal healthcare programs

Consequences of Provider Kickbacks

Providers who violate prohibitions on what may be given to patients face criminal fines, civil money penalties, suspension or exclusion from the Medicare and Medicaid Programs and other state and federal healthcare programs, and jail time.

There are two applicable federal statutes:

The anti-kickback statute (AKS)
The civil monetary penalties law (CMPL)

Exceptions

The federal government says that providers have violated the federal False Claims Statute if referrals are obtained in a way that violates the AKS and providers submit claims for services provided to patients who were referred in violation of the AKS. Providers generally violate the False Claims Statute if they submit claims or cost reports to the government that include untrue information. When providers submit claims, they, according to enforcers, also promise that referrals were not received in ways that are prohibited. If referrals are received inappropriately by violating the anti-kickback statute, for example, then the claims are “false.” Giving free items or services to patients may also violate a federal statute: the civil money penalties law.

Promotions and Marketing

The CMPL prohibits providers from offering to give or actually giving items or services to patients or potential patients that are likely to influence receipt of services from particular providers. This prohibition is especially relevant to marketing activities. It applies to both direct and indirect promotional activities.

State-Specific Laws

Providers must also comply with applicable laws in all of the states in which they do business. State laws vary, of course, from state to state. Many states have anti-kickback statutes that are similar to the federal statute described above. State licensure statutes for physicians, nurses, therapists, social workers, and other types of providers may also include prohibitions on giving free or discounted items or services to patients, especially when they may induce patients to receive potentially unnecessary services.

Final Thoughts

Although providers may have good intentions when they give free items or services to patients and potential patients, before they are acted upon such intentions must be subjected to consideration of the prohibitions described above.

This is part 1 of a two-part series. Look for part 2 next week.

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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.

MACPAC Rate Setting

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

FOR IMMEDIATE RELEASE

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

MACPAC Rate Setting

The Alliance Expresses Concerns Regarding MACPAC Approach to HCBS Rate Setting

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

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

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

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

MACPAC Rate Setting Report

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

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

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

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

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About the National Alliance for Care at Home

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

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