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

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

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

Can This New Software Eliminate Fraud and Billing Errors?

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

by Tim Rowan, Editor Emeritus

Software Eliminates Fraud and Errors

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

The Hurdles

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

Then... the call came

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

– Henry (Hank) Schwab, Owner, Compliance Plus

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

Dramatic Process Improvements

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

Time Tracking

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

Verification

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

Caregiver Feedback

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

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

The "Plus" of Compliance Plus

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

Denials are Rare

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

Aggregated Data

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

Implementation and Training

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

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

Favorite Features

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

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

Simplifying Complex Billing

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

It's Complicated

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

Patient Profiles

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

Task Rates

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

Company Prospects

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

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

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

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.

# # #

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.

# # #

About the National Alliance for Care at Home

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

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

Medicare Home Health Cuts: Survey Says

by Rowan Report | Sep 4, 2025 | Partner News

FOR IMMEDIATE RELEASE

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

70% of Americans Oppose Medicare Home Health Cuts, National Poll Finds

Alexandria VA, and Washington, DC, September 4, 2025– A new national poll by Fabrizio Ward, commissioned by the National Alliance for Care at Home (the Alliance), finds that seven in ten Americans oppose the Centers for Medicare & Medicaid Services’ (CMS) 2026 Medicare home health proposed rule, which would slash Medicare home health funding by an additional 9%, or $1.1 billion, next year. These cuts would put lifesaving home health care for millions of Americans at risk, particularly seniors and those with disabilities, while doing nothing to address fraud, waste, and abuse occurring in the home health payment system.

In one of the strongest bipartisan rebukes of Medicare home health cuts to date, the poll found overwhelming opposition across party lines. Large majorities of voters support targeting cost savings to eliminating waste and fraud rather than across-the-board cuts. Voters widely recognize that home health provides significant savings for taxpayers, that lack of access to home health due to recent cuts hurts Medicare patients, and that many more would be hurt if the proposed cuts go into effect.

“The results send a crystal-clear message: Americans want more home-based care, not less, and preserving access to care is critical. Cutting home health doesn’t save money – it hurts patients, worsens outcomes, and costs taxpayers more in the long run.”

Dr. Steve Landers

CEO, National Alliance for Care at Home

The poll reveals Americans see home health as essential to keeping patients safe at home, lowering costs, and easing pressure on already overburdened hospitals and emergency rooms.

Key findings:

70% of all voters oppose Medicare cutting home health services by an additional 9% next year.
91% of all voters believe it’s important that home health services be available when Medicare patients require extra medical support.
55% of all voters support President Trump taking steps to reverse the proposed Medicare home health cuts and ordering a crackdown on fraud in the system.
71% of all voters believe home care is the most affordable care option, compared to just 17% who believe hospital care is more affordable.
73% of all voters say that cutting Medicare home health harms patients and legitimate providers while failing to stop the fraudulent operators that scam hundreds of millions of dollars from the program each year is a good reason to oppose the cuts.

“With more than one out of every two voters either on Medicare, or with a parent on Medicare, voters are clear that people want treatment at home if it’s an option and that home medical care is less expensive than care provided at hospitals and nursing homes. Voters also see the folly in across-the-board cuts that harm everyone rather than focusing efforts to root out known fraud in the home health system. Across the political spectrum voters oppose cuts and support redoubling efforts to fight fraud.”

Tony Fabrizio

Partner, Fabrizio Ward

“These numbers should give every lawmaker pause,” Dr. Landers cautioned. “Patients want to recover where they’re safest – at home. It’s time for Congress to protect what’s working and stop the home-care bleeding. Lawmakers have an opportunity to protect a program that saves lives, lowers costs, enjoys overwhelming bipartisan support, and reflects the clear will of the American people.”

The Alliance is urging Congress and CMS not to finalize the proposed payment cuts and to work with providers to revise their approach and strengthen, not weaken, access to home-based care.

A memo of the poll findings can be found here.

###

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.

Medicare Advantage Excess Payments

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

by Kristin Rowan, Editor

Medicare Advantage Excess Payments

Investigational Study

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

Carve-out to VBID to Carve-out

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

Carve-out Hospice Benefit

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

Medicare Advantage Spending and Payments

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

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

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

Study Conclusion

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

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

# # #

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

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

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

BREAKING NEWS: CMS Changes AHEAD

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

From cms.gov

CMS Changes AHEAD

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

September 2, 2025

What's New

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

Why it Matters

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

What to Expect

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

The Big Picture

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

Additional Details

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

Total Cost of Care Model

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

More Information

# # #

DOJ Settles with UnitedHealth and Amedisys

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

by Kristin Rowan, Editor

DOJ Settles with UnitedHealth and Amedisys

Judge to Weigh In

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

Public Comment Period and Judicial Review

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

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

Antitrust Division Statement

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

Abigail Slater

Assistant Attorney General, Justice Department Antitrust Division

Divestiture Agreement

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

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

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

UnitedHealth Amedisys divestiture locations

Not the Only Concern

Vertical Integration

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

Upcoding

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

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

Final Thoughts

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

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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

Patients’ Right to Freedom of Choice

by Elizabeth E. Hogue, Esq. | Jul 24, 2025 | Admin, CMS, Home Health, Hospice, Medicaid, Medicare, Regulatory

by Elizabeth E. Hogue, Esq.

Patient's Right to Freedom of Choice of Providers

U.S. Supreme Court Weighs In

Patient’s rights to freedom of choice of providers who will render care to them is currently based on four key sources:

Court decisions that establish the right of all patients, regardless of payor source and the setting in which services are rendered, to control treatment, including who provides it
Federal statutes for both the Medicare and Medicaid Programs that establish the right of patients whose care is paid for by these programs to choose providers to render care – Specifically, Section 1802 (42 U.S. C. 1395a) states as follows: “(a) Basic freedom of choice.- Any individual entitled to insurance benefits under this title may obtain health services from any institution, agency, or person qualified to participate under this title if such institution, agency or person undertakes to provide him such services.”
The Balanced Budget Act of 1997 (BBA), which currently requires hospitals to provide a list of home health agencies and hospices to patients. According to the BBA, the list must meet the following criteria: (a) Providers that render services in the geographic area in which patients reside, are Medicare-certified, and request to be included must appear on the list given to patients. (b) If hospitals have a financial interest in any provider that appears on the list, this interest must be disclosed on the list.
Conditions of Participation (COP’s) of the Medicare Program that are the same as the provisions of the BBA described above

Supreme Court Decision

The U.S Supreme Court has now issued a decision about the federal statute for the Medicaid Program described above in Medina v. Planned Parenthood South Atlantic, et al. [No, 23-1276 (June 26, 2025)]. This case involves the any-qualified-provider provision in the statute above that requires states to ensure that any individual eligible for medical assistance may obtain it from any provider qualified to perform the service who undertakes to provide it. The question is whether individual Medicaid beneficiaries may sue state officials under the above statute for failing to comply with the any-qualified-provider provision.

Exclusions on "any-qualified-provider" provision

The State of South Carolina excluded Planned Parenthood from the Medicaid Program. An enrollee in the Medicaid Program sued the State based on the above statute because she said that she wanted to receive Medicaid services from Planned Parenthood.

Federal enforcement; not private

The Court said that spending power statutes, such as Medicaid Programs, are especially unlikely to create the right for individuals to sue the states. The typical remedy for state noncompliance is federal funding termination. Private enforcement, such as suits by individuals, requires states to voluntarily and knowingly consent to private suits based on clear and unambiguous alerts from Congress to the states that private enforcement is a funding condition.

The Court concluded that the above statute does not permit individuals to sue the States for violation of their right to freedom of choice of providers.

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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.

OBBB Care at Home Adjustments

by Kristin Rowan | Jul 18, 2025 | Advocacy, CMS, Medicaid, Medicare, Regulatory

by Kristin Rowan, Editor

Care at Home Through Medicare and Medicaid

Adjustments from OBBB

Despite the passing and subsequent signing of the reconciliation bill, numerous lawsuits have paused its implementation in some areas. We will continue to report on those court decisions as they arise. In the meantime, the care at home industry can look at the few adjustments that will positively impact the industry.

Medicaid Waivers

Prior to this, the HHS Secretary could only approve Medicaid waivers to cover home and community-based services for beneficiaries who already met institutional level-of-care criteria. This bill provides additional flexibility to define waiver eligibility without the institutional level-of-care criteria.

For FY 2026, CMS has an additional $50 million to oversee the new waivers. There is an additional $100 million earmarked for FY 2027 to deliver HCBS under new and existing waivers. Although the expanded waivers and additional budget will not satisfy the more 700,000 on waiting lists for HCBS, it is a start.

Rural Health Transformation Program

For five years, beginning in 2026, states can apply for a portion of a $10 billion annual fund for rural health providers. To qualify, providers must submit a rural health care plan that includes technology adoption, local partnerships, using data-driven methods, and setting strategies for financial stability. This could provide an opportunity for care at home agencies to partner with rural hospitals to help provide care in rural settings.

Health Savings Accounts

Health Savings Accounts (HSAs) allow insurance beneficiaries to save money to pay for deductibles, copays, and other services not covered by insurance (such as non-medical supportive care and home health). Currently, people can only use HSAs if they have a high deductible health plan (HDHP). The bill allows for a plan to be considered an HDHP even if it covers telehealth and remote health services prior to meeting the deductible. Insurance companies can design new HDHPs that can be used with HSAs.

Another change to HSAs involves the type of plan that qualifies. Currently, bronze and catastrophic plans cannot be considered HDHPs because their out-of-pocket limits exceed IRS limits for HDHPs. The bill allows bronze and catastrophic plans to qualify as HDHPs and have access to HSAs.

Additionally, current regulations prohibit anyone with a Direct Primary Care (DPC) arrangement from contributing to our using HSAs. DPC is an arrangement with a flat monthly fee for services rather than using insurance for routine care. The bill removes the limitations, allowing people with DPC arrangements to contriute to HSAs and use them for DPC arrangements.

Adding telehealth/remote plans, bronze plans, and catastrophic plans to HSA eligibility could provide opportunities for care at home agencies to connect with beneficiaries of these plans who did not have expendable funds for non-covered services before, but can now use HSAs. Allowing patients with DPCs to use HSAs could provide yet another path to increasing patients by partnering with DPC offices.

Final Thoughts

As a whole, we are anticipating great disruption to Medicare and Medicaid stemming from the budget reconciliation bill. While we await the final word on legality from the U.S. Supreme Court on many of the provisions, we can look to the ones that may help brace the industry in the meantime.

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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