Literature Review

Medicare Advantage plan spending and payments under the hospice carve-outJAMA Network Open; by Meghan Bellerose, Andrew M Ryan, Claire K Ankuda, David J Meyers; 8/25In 2021, the Centers for Medicare & Medicaid Services implemented a Value-Based Insurance Design (VBID) model to test the impact of including hospice services in the Medicare Advantage (MA) benefits package. In December 2024, the VBID was ended following widespread dissatisfaction ... Under the carve-out model, after an MA enrollee elects hospice, health care related to their terminal illness is paid for by fee-for-service (FFS) Medicare. MA plans stop receiving the inpatient and outpatient portions of that enrollee's capitated payment but continue to receive premium and rebate payments. In this cross-sectional study, MA plans received high premium and rebate payments for beneficiaries enrolled in hospice despite low health care spending after enrollees elected hospice. To reduce excess payments, the Centers for Medicare & Medicaid Services could require MA plans to submit information on enrollees' use of supplemental benefits and adjust payments made after election of hospice to align with spending.

Home health agency sues HHS over $34m Medicare payment recoupment Home Health Care News; by Morgan Gonzales; 9/8/25 Infinity Home Care of Lakeland, a Florida-based home health provider and affiliate of Amedisys, has sued the U.S. Department of Health and Human Services over Medicare recoupments. The Florida-based home health agency alleged that HHS completed “shoddy expert work” that led the agency to conclude that Medicare overpaid Infinity by $34 million for services from 2014 to 2016. According to the lawsuit, a contractor, Zone Program Integrity Contractors (ZPIC), reviewed 72 of the agency’s claims in 2017 and denied all 72 on the basis of errors with the face-to-face encounter documentation, that home health services were not medically reasonable and necessary or a lack of medical records. 

Nursing homes can disrupt ‘rehabbed to death’ cycle with PDPM-based palliative care Skilled Nursing News; by Kristin Carroll; 9/7/25 ... Skilled nursing facilities can leverage the Patient Driven Payment Model (PDPM) to provide more palliative care to people near the end of life, helping to drive value-based care goals while improving the patient experience. However, much more needs to be done on the policy level to disrupt the current status quo, in which people commonly go through several care transitions near the end of life, driving up costs across the health care system while patients receive services that are not aligned with their own goals. Enabling concurrent SNF and hospice care is one change that could lead to improvement. These are assertions in the recent article “Rehab and Death: Improving End-Of-Life Care for Medicare Skilled Nursing Facility Beneficiaries,” published in the Journal of the American Geriatrics Society.

CMS: Annual Change in Medicaid Hospice Payment Rates—ACTIONCMS, Department of Health and Human Services; email from Rory Howe, director; 9/5/25The Centers for Medicare and Medicaid Services (CMS) has released the Medicaid hospice rates for FY 2026. They are slightly different than the Medicare rates and should be used when billing for Medicaid hospice patients. This memorandum contains the Medicaid hospice payment rates for federal fiscal year (FY) 2026. The rates reflect changes made under the final Medicare hospice rule published on August 1, 2025 (CMS-1835-F). Please inform your staff and all state agencies in your jurisdiction of these new payment rates, which are effective October 1, 2025. We expect state agencies to share the Medicaid hospice payment rates for FY 2026 with the hospice providers in their state.

Bipartisan home health legislation introduced to protect Medicare beneficiaries and lower Medicare costs National Alliance for Care at Home, Alexandria, VA and Washington, DC; Press Release; 9/4/25 The National Alliance for Care at Home (the Alliance) issued the following statement today in response to the introduction of the Home Health Stabilization Act of 2025. This bipartisan legislation, introduced by Representatives Kevin Hern (R-OK) and Terri Sewell (D-AL), would protect home health care by pausing the devastating payment cuts proposed in the Centers for Medicare & Medicaid Services’ (CMS) CY 2026 Home Health Prospective Payment System proposed rule. 

Protecting Florida's seniors: Fighting fraud and financial exploitation Targeted News Service; 8/29/25 The Senate Special Committee on Aging released the following testimony by Brandy Bauer, director of the Senior Medicare Patrol Resource Center, from an Aug. 7, 2025, field hearing entitled "Protecting Florida's Seniors: Fighting Fraud and Financial Exploitation": Chairman Scott, thank you for inviting me here today on behalf of the Senior Medicare Patrol program. The nation's 54 Senior Medicare Patrol, or SMP, programs are managed by the U.S. Administration for Community Living, with the mission to help empower and assist people to prevent, detect, and report Medicare fraud, errors, and abuse. ...

NMDOJ charges ‘imposter nurse’ who treated hospice patients in Albuquerque KRQE News, Albuquerque, NM; by Fallon Fischer; 8/28/25 A certified nurse assistant in Albuquerque is facing charges for allegedly stealing the identities of three nurses and illegally providing care to hospice patients, and in one case, almost causing one patient to die via a morphine overdose, according to the New Mexico Department of Justice. This week, a Bernalillo County grand jury issued an indictment against April Guadalupe Hernandez, 26, for 19 counts of misconduct including identity theft, nursing without a license, fraud totaling approximately $40,000, abuse of a resident, violations of the Nursing Practice Act and more. “To exploit trusting patients in their most vulnerable moments is unconscionable,” Attorney General Raúl Torrez stated in part, in a news release. 

Social workers’ role in improving hospice live discharge processes Hospice News; by Holly Vossel; 8/26/25 A lack of standardized care coordination is challenging the ability for patients and families to receive support following a live discharge from hospice. Deeper integration of social work services may help address the issue. This is according to findings from a recent study published in the Journal of Gerontological Social Work, which examined different methodologies for preparing patients, family caregivers and providers for hospice-initiated live discharges from social worker perspectives. 

HHS launches committee to shape Medicare, MedicaidBecker's Payer Issues; by Andrew Cass; 8/22/25HHS and CMS are establishing a panel of experts tasked with providing recommendations on how to “improve how care is financed and delivered” across Medicare, Medicaid, the Children’s Health Insurance Program and the ACA’s exchanges... “This committee will help us cut waste, reduce paperwork, expand preventive care, and modernize CMS programs with real-time data and accountability, all while keeping patients at the center,” Dr. Oz said in the release.Publisher's note: Click here for additional information or to apply to particiate on this Technical Expert Panel.

Navigating the Wage Index: Insights from industry experts Teleios Collaborative Network (TCN); podcast by Chris Comeaux with Annette Kiser and Judi Lund Person; 8/20/25 The healthcare landscape is transforming before our eyes, shifting away from hospital-centered care toward home-based models.  This fundamental change raises urgent questions about Medicare's outdated reimbursement systems, particularly for Hospice providers facing a mere 2.6% rate increase while battling significant inflation. Join us in this illuminating conversation and in-depth discussion with industry experts Annette Kiser, Chief Compliance Officer with Teleios, and Judi Lund Person, Principal, Lund Person & Associates LLC, as they sit down with Chris and explore the complexities of the final 2026 Hospice Wage Index and its impact on Hospice organizations.

The Medicare Advantage, ACA and No Surprises Act lawsuits to watch Modern Healthcare; by Bridget Early; 8/18/25 Legal challenges to Medicare Advantage marketing, health insurance exchange regulations and the No Surprises Act are working their way through the courts with major implications for the healthcare sector. Here are some key cases that could change how health insurance companies sell Medicare plans, how insurers and providers resolve out-of-network billing disputes, how consumers sign up for health insurance exchange plans, and how preventive healthcare is covered. 

Hospice claim denial remanded to ALJ in absence of explanation, (Aug 4, 2025) VItalLaw; by Leah S. Poniatowski, JD; 8/4/25 ... A hospice provider that was denied Medicare reimbursement for two patients was granted remand to the administrative law judge (ALJ) because the ALJ’s decision was without any reasoned discussion, which impaired review and suggested that the ALJ had used her lay assessment of the medical record, the federal district court in Delaware ruled (Seasons Hospice & Palliative Care of Delaware, LLC v. Kennedy, No. 24-175-GBW-LDH (D. Del. July 31, 2025)).

Governor creates new LTC oversight board, pledges to fill surveyor openings by year’s end McKnights Long-Term Care News; by Jessica R. Towhey; 8/12/25 A new politically appointed Nursing Home Oversight and Accountability Advisory Board is being proposed as a way to strengthen facility oversight in a state that has a 42% vacancy rate among its public inspectors. Gov. Glenn Youngkin (R) called for the board, which will consist of members appointed by the state Secretary of Health, in an executive order issued Monday. Both LeadingAge Virginia and the Virginia Health Care Association / Virginia Center for Assisted Living applauded the overall goals of the executive order but cautioned that resources to implement the directives are needed. Guest Editor's Note, Judi Lund Person: The Virginia governor, Glenn Youngkin, has taken steps to address surveyor vacancies and strengthen oversight for nursing homes in the state, calling on partnerships with other states for training. Advocates cited the state, as in many other states, is hampered by flatline funding from federal partners and the lack of clinical staff willing to fill surveyor roles.