Medicare policy changes, hospice benefit updates, billing guidance, and the free tool that helps families understand exactly which care their loved one qualifies for — and what Medicare will cover.
The Patient-Driven Groupings Model (PDGM) continues to evolve. The FY2026 home health prospective payment system final rule brings a net aggregate payment adjustment that varies significantly by agency type, case mix, and geography. Agencies with high LUPA rates are facing continued scrutiny as CMS monitors whether PDGM created incentives to underprovide care.
The simultaneous push on home health value-based purchasing means that quality metrics are increasingly tied to payment — agencies need to be tracking both their OASIS accuracy and their outcome data with the same urgency as their billing compliance. The two are no longer separable in the CMS payment framework.
OIG and CMS audit activity in the hospice space has increased significantly. The primary target: whether patients enrolled in hospice meet the six-month prognosis requirement and whether clinical documentation supports terminal certification. Agencies with high rates of long-stay patients face elevated risk.
CMS extended several telehealth flexibilities for home health agencies originally implemented during the public health emergency. The extension comes with updated documentation requirements for virtual visits and new guidance on what services can be delivered remotely vs. in-person.
Low utilization payment adjustments (LUPAs) continue to represent significant revenue risk for home health agencies under PDGM. The threshold varies by HIPPS code. Agencies should be auditing their LUPA rate by clinical group and identifying which case types are generating outlier patterns.
Several states with significant HCBS waiver expansion are creating new opportunities for Medicaid-certified home health agencies. The expansion populations — seniors aging in place and younger adults with disabilities — require different care coordination models than traditional Medicare home health.
Home health aide and hospice aide shortages are among the most acute in healthcare — more severe than nursing homes in many markets. Agencies reporting waitlists for hospice admissions due to aide availability, not clinical capacity, in rural markets particularly.
OASIS-E has been live for over a year, but clinical teams at many agencies still report uncertainty on specific items that affect PDGM grouping. The highest-impact OASIS-E item errors continue to center on Section GG functional assessment and the new social determinants items.
Medicare covers skilled home health care when a patient is homebound and needs skilled nursing, physical therapy, or speech therapy. What it does NOT cover: custodial care (bathing, dressing) unless combined with skilled need, non-homebound patients, or extended-term personal care. Most families misunderstand the benefit until they're already in the situation.
Traditional Medicare hospice requires patients to forgo curative treatment for their terminal diagnosis. But the CARE Act demonstration and ongoing policy evolution around concurrent/simultaneous care represents a significant shift in how hospice is delivered — especially for pediatric hospice populations.
General Inpatient (GIP) hospice billing — the highest intensity and highest reimbursed hospice level of care — is the primary target of CMS and OIG hospice audits. Documentation of unmanageable symptom burden must be explicit and complete. Generic "pain not controlled" language is no longer sufficient.
The two most misunderstood Medicare benefits in home care. Answer four questions and get a clear, honest explanation of what your loved one qualifies for and what Medicare will cover.
This is a general educational guide. Eligibility for Medicare home health or hospice must be certified by a physician. Coverage decisions are made by Medicare based on clinical documentation and medical necessity. Always consult with your healthcare team and a Medicare counselor (SHIP) for your specific situation.
The two most important distinctions in home-based care. Getting these right saves families from expensive surprises.
What it covers: Skilled nursing visits, physical/occupational/speech therapy, medical social work, home health aide visits (only when combined with skilled need). 100% covered with no copay when criteria are met.
Requirements: Patient must be homebound (leaving requires considerable effort). Care must be ordered by a physician. A skilled need must exist. A certified home health agency must provide care.
What it doesn't cover: Custodial care only (bathing, dressing, meals without skilled need). 24-hour care. Non-homebound patients.
What it covers: Everything related to the terminal diagnosis — nursing, aide care, medications, medical equipment, social work, chaplain, counseling, and bereavement support for family. 100% covered with very minimal copay for medications.
Requirements: Two physicians must certify a prognosis of 6 months or less if the disease runs its normal course. Patient must choose comfort care over curative treatment for the terminal diagnosis.
What it doesn't cover: Treatment intended to cure the terminal diagnosis. Unrelated medical conditions are still covered by regular Medicare.
Medicare policy, billing updates, regulatory changes, and workforce data — delivered daily. Read by HHA administrators, hospice clinical directors, and industry executives.