Public Comments on Proposed Federal Rules
Here's a look at public comments on proposed Federal Register rules
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National Shooting Sports Foundation Urges Clarification on Design Features That Classify Suppressors as Military-Grade for Export Controls
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
August 24, 2026
Office of Defense Trade Controls Policy
Directorate of Defense Trade Controls
U.S. Department of State
2401 E. Street, N.W.
Washington, DC 20226
RE: Comments on RIN 1140-AG11; Docket No. DOS-2026-0760; International Traffic in Arms Regulations: USML Category I Firearm Suppressors
Dear Sir or Madam,
On behalf of the National Shooting Sports Foundation (NSSF), the Firearm Industry Trade Association, ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. August 24, 2026 Office of Defense Trade Controls Policy Directorate of Defense Trade Controls U.S. Department of State 2401 E. Street, N.W. Washington, DC 20226 RE: Comments on RIN 1140-AG11; Docket No. DOS-2026-0760; International Traffic in Arms Regulations: USML Category I Firearm Suppressors Dear Sir or Madam, On behalf of the National Shooting Sports Foundation (NSSF), the Firearm Industry Trade Association,I am writing to submit comments regarding the above-referenced Interim Final Rule (the "IFR"), which was published for comment on July 23, 2026 (FR Doc. 2026-14943). This IFR proposes amendments to the International Traffic in Arms Regulations ("ITAR") U.S. Munitions List (USML) to remove firearm silencers, mufflers, and sound suppressors for non-automatic and semi-automatic firearms from USML Category I.
NSSF fully supports this regulatory change and agrees that such devices no longer provide a critical military or intelligence advantage, but are instead widely used in hunting and competitive sport shooting activities and are a proven method of preventing hearing loss from gunshots. These devices are legal products that are widely available on the commercial market for retail purchase both here in the U.S., and in many other parts of the world.
However, we note that DDTC states in the IFR "that silencers, mufflers, and sound suppressors specially designed for fully automatic firearms provide a critical military or intelligence advantage. Such items have design properties that enable them to enhance the utility of fully automatic firearms (e.g., increased heat dissipation to handle multiple rounds) and, given the inherent military nature of those weapons, have limited non-military use cases. Consequently, the Department is retaining those items on the USML." (emphasis added)
While many suppressors that are manufactured for both the commercial and defense markets may be advertised or marketed by manufacturers as "full-auto rated" or using similar terminology, there is no consensus within the industry as to what such a designation means. Accordingly, NSSF requests that DDTC provide further clarity about precise design features that DDTC will consider in determining whether a device is "designed for fully automatic firearms."
1 91 Fed. Reg. 46280.
In relation to suppressor product currently available in the marketplace, NSSF understands that some manufacturers may use a "full-auto" rating of a suppressor to communicate to the customer how many rounds of sustained fire a suppressor can handle before a required or recommended cool-down period to ensure safe operation and prevent damage to the device. These firing intervals can be very short, limited to as little as 50 or 100 rounds. Therefore, the designation of a suppressor as "full-auto rated" by its manufacturer does not always mean that it is capable of sustained full-auto fire.
The presence of such limitations on the use of a device with full-auto firearms does not give the article a critical military advantage because the device would not be suitable for use with full-auto firearms in the manner typically employed by military operators. Therefore, such designations by a manufacturer should not be used by DDTC in determining whether a device is "specially designed for defense articles described in paragraph (b) or (d)" (i.e. for full auto firearms and shotguns). Such language simply means that the suppressor has some ability to sustain limited full-auto fire but it may not be suitable for normal military use in the field.
This does not mean that there are no suppressor products in the marketplace that are "specially designed" for use with full-auto firearms. However, such devices generally have particular design features that render them suitable for such use, such as: construction of heavy-duty materials such as Inconel or stainless steel, reinforced blast chambers, advanced baffle designs, or heat-resistant coatings. These features specifically allow the suppressor to maintain structural integrity under extreme thermal stress which does provide a critical military advantage related to sustained use under full-auto conditions.
Therefore, to ensure that suppressors are not improperly over-classified based on marketing material or other representations as opposed to objective design features rendering them particularly suitable for use with full-auto firearms specifically, we respectfully request that DDTC provide further clarification on the precise design features that would qualify a suppressor as being "specially designed" for continuous full-auto fire, thereby providing a critical military advantage, and requiring an export license from DDTC.
We appreciate your consideration of our comments. We would be happy to respond to any questions or concerns, or provide additional information as may be helpful.
Sincerely,
Lawrence G. Keane
*
Original text of letter here: https://www.regulations.gov/comment/DOS-2026-0760-0017
August 24, 2026
Office of Defense Trade Controls Policy
Directorate of Defense Trade Controls
U.S. Department of State
2401 E. Street, N.W.
Washington, DC 20226
RE: Comments on RIN 1140-AG11; Docket No. DOS-2026-0760; International Traffic in Arms Regulations: USML Category I Firearm Suppressors
Dear Sir or Madam,
On behalf of the National Shooting Sports Foundation (NSSF), the Firearm Industry Trade Association, ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. August 24, 2026 Office of Defense Trade Controls Policy Directorate of Defense Trade Controls U.S. Department of State 2401 E. Street, N.W. Washington, DC 20226 RE: Comments on RIN 1140-AG11; Docket No. DOS-2026-0760; International Traffic in Arms Regulations: USML Category I Firearm Suppressors Dear Sir or Madam, On behalf of the National Shooting Sports Foundation (NSSF), the Firearm Industry Trade Association,I am writing to submit comments regarding the above-referenced Interim Final Rule (the "IFR"), which was published for comment on July 23, 2026 (FR Doc. 2026-14943). This IFR proposes amendments to the International Traffic in Arms Regulations ("ITAR") U.S. Munitions List (USML) to remove firearm silencers, mufflers, and sound suppressors for non-automatic and semi-automatic firearms from USML Category I.
NSSF fully supports this regulatory change and agrees that such devices no longer provide a critical military or intelligence advantage, but are instead widely used in hunting and competitive sport shooting activities and are a proven method of preventing hearing loss from gunshots. These devices are legal products that are widely available on the commercial market for retail purchase both here in the U.S., and in many other parts of the world.
However, we note that DDTC states in the IFR "that silencers, mufflers, and sound suppressors specially designed for fully automatic firearms provide a critical military or intelligence advantage. Such items have design properties that enable them to enhance the utility of fully automatic firearms (e.g., increased heat dissipation to handle multiple rounds) and, given the inherent military nature of those weapons, have limited non-military use cases. Consequently, the Department is retaining those items on the USML." (emphasis added)
While many suppressors that are manufactured for both the commercial and defense markets may be advertised or marketed by manufacturers as "full-auto rated" or using similar terminology, there is no consensus within the industry as to what such a designation means. Accordingly, NSSF requests that DDTC provide further clarity about precise design features that DDTC will consider in determining whether a device is "designed for fully automatic firearms."
1 91 Fed. Reg. 46280.
In relation to suppressor product currently available in the marketplace, NSSF understands that some manufacturers may use a "full-auto" rating of a suppressor to communicate to the customer how many rounds of sustained fire a suppressor can handle before a required or recommended cool-down period to ensure safe operation and prevent damage to the device. These firing intervals can be very short, limited to as little as 50 or 100 rounds. Therefore, the designation of a suppressor as "full-auto rated" by its manufacturer does not always mean that it is capable of sustained full-auto fire.
The presence of such limitations on the use of a device with full-auto firearms does not give the article a critical military advantage because the device would not be suitable for use with full-auto firearms in the manner typically employed by military operators. Therefore, such designations by a manufacturer should not be used by DDTC in determining whether a device is "specially designed for defense articles described in paragraph (b) or (d)" (i.e. for full auto firearms and shotguns). Such language simply means that the suppressor has some ability to sustain limited full-auto fire but it may not be suitable for normal military use in the field.
This does not mean that there are no suppressor products in the marketplace that are "specially designed" for use with full-auto firearms. However, such devices generally have particular design features that render them suitable for such use, such as: construction of heavy-duty materials such as Inconel or stainless steel, reinforced blast chambers, advanced baffle designs, or heat-resistant coatings. These features specifically allow the suppressor to maintain structural integrity under extreme thermal stress which does provide a critical military advantage related to sustained use under full-auto conditions.
Therefore, to ensure that suppressors are not improperly over-classified based on marketing material or other representations as opposed to objective design features rendering them particularly suitable for use with full-auto firearms specifically, we respectfully request that DDTC provide further clarification on the precise design features that would qualify a suppressor as being "specially designed" for continuous full-auto fire, thereby providing a critical military advantage, and requiring an export license from DDTC.
We appreciate your consideration of our comments. We would be happy to respond to any questions or concerns, or provide additional information as may be helpful.
Sincerely,
Lawrence G. Keane
*
Original text of letter here: https://www.regulations.gov/comment/DOS-2026-0760-0017
LeadingAge Raises Concerns Over Proposed Medicare Home Health Payment Cuts and Enrollment Policies
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
August 31, 2026
The Honorable Mehmet Oz, MD
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201
Subject: CMS-1844-P Calendar Year 2027 Home Health Prospective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the Expanded HH Value-Based Purchasing Model; Medicare Provider Enrollment, ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. August 31, 2026 The Honorable Mehmet Oz, MD Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services 200 Independence Ave. SW Washington, DC 20201 Subject: CMS-1844-P Calendar Year 2027 Home Health Prospective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the Expanded HH Value-Based Purchasing Model; Medicare Provider Enrollment,Durable Medical Equipment (DME), and DME, Prosthetics, Orthotics, and Supplies (DMEPOS) Policies
Submitted electronically via https://www.regulations.gov
Dear Administrator Oz,
LeadingAge, together with our state partners, represents more than 5,300 nonprofit and mission-driven aging services providers serving older adults and touching millions of lives every day. From our national headquarters in Washington, DC, and in collaboration with state partners whose members are active in 50 states, the District of Columbia, and Puerto Rico, we use advocacy, education, applied research, and community building to make America a better place to grow old. Our membership encompasses the entire continuum of aging services, including skilled nursing, assisted living, memory care, affordable housing, retirement communities, adult day programs, hospice, Programs of All-Inclusive Care for the Elderly (PACE), and home-based care including Medicare home health agencies.
On behalf of these members, LeadingAge is pleased to offer the following comments in response to the CY2027 Home Health Prospective Payment System Proposed Rule.
We wish to thank the administration for taking into consideration our comments on the CY2026 Home Health Proposed Rule regarding the calculation of the permanent and temporary adjustments required by the Bipartisan Budget Act of 2018. The resulting reduction of overall permanent and temporary adjustments was crucial to keeping our nonprofit, mission-driven home health agencies open to serve the most vulnerable Medicare beneficiaries. However, as we detail below, the proposed cuts and outstanding temporary adjustments should also be eliminated completely. Continuing to implement these cuts in any form or manner, beyond being methodologically incorrect, will have a disastrous effect on older adults who rely on these services.
The combined impact of the proposed payment changes and proposed Medicare provider enrollment changes may lead to more closures of home health agencies and the inability of providers that remain to take on new referrals.
With regard to the Medicare provider enrollment provisions of this rule, LeadingAge is deeply concerned that the expanded authority CMS is seeking has the potential to introduce significant uncertainty and impose excessive burdens on providers. This concern applies not only to the collection and submission of excessive information on staff and affiliations, but also to the due diligence required to prevent unintended affiliations that could jeopardize a provider's enrollment. We strongly believe that CMS should address its Medicare provider enrollment proposals in a separate rulemaking that targets the provider community more broadly and that properly accounts for the costs and benefits of these proposals.
Contents
General Comments on Fee-for-Service Home Health Care ................................. 4
Proposed CY2027 Home Health Payment Rate Updates .......................................................... 5
Methodological Errors in the Behavioral Adjustment Assumptions ..................................... 7
Forecasting Error Correction .................................................................................................... 9
Fixed Dollar Loss Ratio ............................................................................................................ 10
Request for Information on the Construction of a Home Health Specific Wage Index ........ 11
Palliative Care Services as Home Health Services .................................................................. 15
Home Health Quality Reporting Program (HH QRP) ................................................................ 19
Proposal To Revise HH QRP Data Submission Deadlines Beginning with the CY 2027 HH QRP ........................................................................................................................................... 19
Proposal To Revise the OASIS & HHCAHPS Annual Payment Update Reporting Timeframe and Regulation Text Related to Reconsiderations ................................................................ 20
HQRP Measure Concepts Under Consideration for Future Years-Request for Information (RFI) ...................................................................................................................... 20
The Expanded Home Health Value Based Purchasing ............................................................. 22
Provider Enrollment ..................................................................................................................... 24
General Comments on Enrollment Proposals ...................................................................... 24
Requests for Clarifications ......................................................................................................... 25
Modifications of Current Revocation and New Revocation Provisions .............................. 27
Abuse of Billing Privileges 424.535(a)(8)(ii) ....................................................................... 27
False or Misleading Information Sec. 424.535(a)(4) and Sec. 424.530(a)(4) ............................ 28
Extension of Revocations Sec. 424.535(i) ............................................................................... 29
High-Risk Enrollments (Sec. 424.535(a)(24)) ......................................................................... 30
Retroactive Revocations ........................................................................................................ 31
Claim Submission After Revocation .................................................................................... 32
Modification to Current Denial Reasons and New Denial Reasons ................................ 33
Debt Sec. 424.530(a)(6), Payment Suspension Sec. 424.530(a)(7), and Other Program Terminations/Suspensions Sec. 424.530(a)(14) .................................................................... 33
Same Suite (Sec. 424.530(a)(19)) ............................................................................................ 34
Hospice Medical Directors and Administrators (Sec. 424.530(a)(20)) ................................. 35
Misuse of Identity Sec. 424.530(a)(21) .................................................................................... 36
Reapplication Bar (Sec. 424.530(f)) ......................................................................................... 36
Changes in Majority Ownership (CIMOS) ........................................................................ 37
Temporary Moratoria (Sec. 424.570) ...................................................................................... 37
Hospice Reactivations (Sec. 424.540(b)(3)) ........................................................................... 39
Definition of "Operational" and "Signage" ........................................................................ 39
Retention and Furnishing of Documentation (Sec. 424.516) .................................................. 40
Managing Employees (Sec. 424.502) ......................................................................................... 41
Affiliations (Sec. 424.502) ........................................................................................................ 43
Conclusion ................................................................................................................................. 45
General Comments on Fee-for-Service Home Health Care
Despite the role home health agencies play in improving care for Medicare fee-for-service (FFS) beneficiaries and reducing total system costs, CMS's own monitoring data bears out our fears that home health use is in decline and continued long-term reductions will destabilize this critical setting. Information provided in the CY2027 Home Health Proposed Rule reviews the utilization trends between the simulated CY2018 and CY2019 30-day episodes and all episodes following the implementation of the Patient Driven Groupings Model (PDGM). The initial goals of PDGM were to better measure the case mix of home health care beneficiaries, minimize the potential for patient selection, and better align provision of services with patient needs. However, according to the Medicare Payment Advisory Commission's (MedPAC) Congressionally mandated report on the implementation of the PDGM, the payment change:
Was not associated with a higher probability of FFS home health care use. This is at a time when the vast majority of older adults, 93%, live in their own homes and want to maintain that independence.
Resulted in fewer visits per FFS stay. MedPAC found this drop in visits was similar for most groups, and across all disciplines, not just therapy, signaling that the goal of aligning service provision with patient needs was not necessarily obtained. There were also fewer visits among beneficiaries who are dual eligibles or receiving the low-income subsidy who are groups that are highly in need of services.
Did not substantially improve the quality of care for beneficiaries. MedPAC's analysis offered a mixed picture of quality, with fewer preventable hospitalizations but worse post-discharge outcomes.
Did not substantially impact FFS Medicare margins. While we do not agree with margins alone as an indicator of payment adequacy, this was undoubtedly a key rationale for changing the payment system given the misuse of therapy thresholds. However, MedPAC's analysis found only a 0.6-percentage-point decrease in FFS margins.
This table illustrates our continued concerns regarding the decline in use of home health services:
1
Parker, K., & Menasce Horowitz, J. (2026, February 26). Most older adults who live at home want to age in place, but they aren't entirely confident they'll get to. Pew Research Center. https://www.pewresearch.org/short-reads/2026/02/26/most-older-adults-who-live-at-home-want-to-age-in-place-but-they-aren't-entirely-confident-theyll-get-to/
5
Based on this information from MedPAC's analysis and CMS's monitoring data, LeadingAge would argue that PDGM is not having the intended effect on services and in fact is leading to a decrease in access to home health services. As we have stated in previous years' comment letters, there is not just a noticeable decline in unique beneficiaries and visits but also a decline in the number of home health agencies. For the past three years, MedPAC has acknowledged that all growth in new home health agencies has been concentrated in Los Angeles County, California.
2
Proposed CY2027 Home Health Payment Rate Updates
We are grateful for CMS's consideration of the public comments in the CY2026 Home Health Final Rule, which allowed CMS to use their time and manner authority to not apply permanent adjustments to the CY2023 or CY2024, and subsequently in this year's rule, the CY2025 data. We strongly agree with CMS's determination that behavior changes in these years were not attributable strictly to the change in payment to PDGM and a 30-day unit of payment.
Additionally, there is evidence that CMS's decision to reevaluate the behavioral adjustments without CY2023, CY2024, and now CY2025 has contributed to some stabilization in the home health negative margin projections and therefore, continuing to make changes to stabilize the FFS payment system is critical to maintaining home health access. In a yearly appendix to the 2026
2
Medicare Payment Advisory Commission. (2024, 2025, 2026). Report to the Congress: Medicare payment policy.
6
Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, the CMS Office of Actuary states that in 2024 36% of HHAs had negative total all payer margins. This finding is consistent with their analysis from 2025.
3
However, the updated analysis estimates that by 2040, that number will rise to only 41% instead of the 57% estimated in 2025. That is a 16-percentage-point decrease in the number of agencies that could have negative total margins by 2040. We believe this provides strong evidence that FFS margins are critical to the stability of the home health sector.
Since Medicare Advantage (MA) enrollment has only continued to increase from 34 million beneficiaries in 2025 to 35 million in 2026, it is unlikely that MA payment changes influenced any of the stabilization. Based on our members' experiences with MA payments, we have no reason, and unfortunately no empirical evidence, that MA payments for home health services are improving. However, as with last year, the memo states that "Over the long range, however, the simulations suggest that absent other modifications, significant financial pressures will arise for providers, increasing the possibility of access and quality of care issues for Medicare beneficiaries." This is a clear indication that the Trustees of the Medicare Trust Funds, along with the CMS Office of the Actuary, believe it is their obligation to look at the overall financial pressure faced by providers as it relates to potential effects on Medicare beneficiaries' access and quality of care.
LeadingAge continues to believe that the government needs to work on ensuring rate adequacy across all payers before disrupting overall access to care through further cuts to FFS Medicare. CMS must evaluate payment adequacy across all payers under federal jurisdiction, including Medicaid and Medicare Advantage. LeadingAge offers our support to advocate for additional authority required by CMS to ensure rate adequacy across payers.
3
Centers for Medicare & Medicaid Services. (2026).
Simulations of Affordable Care Act Medicare payment update provisions: Part A provider financial margins. https://www.cms.gov/files/document/simulations-affordable-care-act-medicare-payment-update-provisions-part-provider-financial-margins.pdf-0
7
Methodological Errors in the Behavioral Adjustment Assumptions
Neither CMS nor MedPAC can disaggregate behavior caused by PDGM from other factors:
As we previously stated, we appreciate CMS's acknowledgement of the difficulties in attributing behavioral changes directly to the PDGM in 2023 through 2025. And, subsequently, based on those challenges, CMS's decision not to propose any permanent adjustments for CY2027. In the CY2026 Home Health Final Rule, CMS noted several policy changes which made calculating permanent adjustments for 2023 and beyond difficult and therefore reversed those permanent adjustments.
However, we maintain that these difficulties also existed in 2020, 2021, and 2022. CMS also has clearly indicated that the fraud present in the program starting in 2020 cannot be precisely distinguished from other behavioral changes. In addition to CMS's difficulty in attributing behaviors to the change in payment, MedPAC struggled to determine the behavioral changes related to PDGM vs. patient behaviors associated with COVID-19. As we will illustrate below, we believe based on CMS's rationale to eliminate the permanent adjustments applied in CY2023-CY2025, the same rationale applies to CY2020-CY2022.
Fraudulent Behaviors: LeadingAge has repeatedly requested that CMS evaluate the impact of fraudulent activity on the calculation of the aggregate adjustments since the implementation of PDGM and the expanded Home Health Value Based Purchasing (HHVBP) model. From 2019 (before COVID flexibilities and the implementation of PDGM) to 2024, the total number of home health agencies in Los Angeles County increased from 781 to 1,588, or a 103% increase in providers. This means there are currently 18.7 HHAs per 10,000 FFS beneficiaries in LA County. Additionally, CMS's data shows 44% of all home health payments in California in 2024 went to HHAs in LA County despite the average number of users per agency in LA was lower than the state as a whole. LA County also accounted for 9% of all home health FFS payments nationally in 2024. We know CMS is focused on Los Angeles County from an enforcement perspective, especially as it relates to home health and hospice. CMS has also implemented a six-month moratorium on new home health enrollments. While we supported the moratorium as a short-term measure, it is clear CMS is focused on additional enforcement mechanisms and therefore, a moratorium will no longer be necessary. We see CMS applying this logic in the durable medical equipment space (DME) where the moratorium was lifted after 6 months on August 27.
4
In a letter to CMS Administrator Oz, Senator Susan Collins (R-ME) requested that CMS analyze the impact of alleged fraudulent behavior in LA County on the aggregate behavioral adjustment for home health. In a letter responding to the request, CMS states they "cannot precisely distinguish agencies that engage in abusive coding and other behaviors from all others."
5
Notably, this response underscores that CMS cannot disaggregate behaviors like fraudulent activity from PDGM related activities.
4
Golinghorst, D., & Wallace, M. (2026, August 28). CMS Medicare DMEPOS supplier enrollment moratorium expires: Suppliers may submit new initial enrollment applications. JD Supra. https://www.jdsupra.com/legalnews/cms-medicare-dmepos-supplier-enrollment-9731633/
5
Dr. Mehmet Oz, Administrator, Centers for Medicare & Medicaid Services to the Honorable Senator Susan Collins. Washington, DC. (July 20, 2026).
8
CY2022 Case-Mix Weights Recalibration: As we stated in our CY2026 comment letter, we believe that the changes in case mix weights in CY2022 influenced provider behavior and, therefore, that the calculation of permanent adjustments was not attributable strictly to the change to PDGM and a 30-day episode. In the CY2022 Home Health Final Rule, and every subsequent year since, CMS has recalibrated the PDGM case-mix weights. The recalibration for CY2022 produced significant shifts in case-mix weights. While we understand CMS's position that "the impact of any reduction in resource use caused by the COVID-19 PHE on the calculation of the case-mix weight would be minimal since the impact would be accounted for both in the numerator and denominator of the formula used to calculate the case-mix weight", there is an additional consideration that CMS has not accounted for in their previous rule comments. The case-mix weights had not been recalibrated for two consecutive years, meaning the shifts in the rates were more significant and could have an outsized effect on provider behavior. The changes in weights ranged from +16% to -26% across case-mix groups compared to CY 2020. While the changes made to case-mix due to practice patterns during COVID-19 may have been mitigated, changes in payments at the case-mix group level after two full years of locked changes ultimately influenced how agencies structured service delivery to remain viable.
2020 and 2021 COVID-19 Impacts: We have stated our concerns before regarding the calculation of COVID-19 claims and their outsized impact on the aggregate behavioral adjustment methodology. However, previously we have focused on the role of COVID-19 in changing practice patterns that influenced case-mix. After further review, we believe COVID-19 had a much larger impact on the rate of LUPA payments than any other time before or since the implementation of PDGM. These impacts on LUPA rates were outside the provider's control due to individual choices to deny access to home health staff, forcing the agency to take a LUPA payment instead of the full case-mix payment. In the CY2023 Home Health Final Rule, when CMS discussed their decision to not adjust LUPA payments for CY2022 they stated:
However, in contrast, [to the impact on case-mix weight adjustments] the LUPA thresholds are based on the number of overall visits in a particular case-mix group (the threshold is the 10th percentile of visits or 2 visits, whichever is greater) instead of a relative value (like what is used to generate the case-mix weight) that would control for the impacts of the COVID-19 PHE. We noted that visit patterns and some of the decrease in overall visits in CY 2020 may not be representative of visit patterns in CY 2022. Therefore, to mitigate any potential future and significant short-term variability in the LUPA thresholds due to the COVID-19 PHE, we finalized the proposal to maintain the LUPA thresholds finalized and displayed in Table 17 in the CY 2020 HH PPS final rule with comment period (84 FR 60522) for CY 2022 payment purposes.
The impact of COVID-19 on home health services in 2020 and 2021 was considerable. While CMS has accounted for some aspects of the impact as part of the case-mix distributions, it has not accounted for other factors such as the increased LUPA rate. Additionally, MedPAC noted that it was unable to determine behavior changes related to PDGM versus other factors in its analysis.
6
Specifically, MedPAC:
Medicare Payment Advisory Commission. (2026). The impact of recent changes to the home health payment system. In Report to the Congress: Medicare payment policy (Chap. 14). Medicare Payment Advisory Commission. https://www.medpac.gov/wp-content/uploads/2026/03/Mar26_Ch14_MedPAC_Report_To_Congress_SEC.pdf
9
noted declines in the use of HHA services due, as we noted, to beneficiaries' reluctance to allow HHA staff into their homes during the early months of the pandemic. MedPAC also noted a decline in elective surgeries during this time that would have resulted in post-acute home health referrals. The behavioral adjustments required by statute focus specifically on provider behaviors and, to our knowledge, CMS has not considered adjustments for patient behaviors that could have impacted the implementation of PDGM including an increase in LUPA rates seen in 2020 and 2021.
For all of these reasons, CMS should remove all permanent adjustments applied previously (including CY2020-CY2022) and correct the home health 30-day payment rate for CY 2027. CMS should not finalize the -3.0% temporary adjustment for CY2027 as the removal of the permanent adjustments in CY2020-CY2022 would eliminate the $4.9 billion estimated overpayments which are attributable to the current assumptions.
Forecasting Error Correction
LeadingAge would like to take this opportunity to again stress the compounding nature of market basket forecasting errors. As we stated in our CY2026 Home Health Proposed Rule comments, the accuracy of annual payment updates is an essential piece of the payment structure for home health agencies and critical for ensuring that payments keep pace with rising costs, especially those related to labor and resources necessary to provide patient care. Each year, CMS provides an annual update to home health payments based on forecasts of market basket increases for the upcoming payment year because actual measures of price growth are not available until after rulemaking must be completed. While we understand that these forecasting errors have been a result of economic uncertainty and the health care sector specifically, the impact to providers is no less pronounced. For yet another year, the forecast fell short of actual price growth.
According to our review of the Office of the Actuary's summary of market basket history and forecasts 7 compared to finalized market basket rates from CY2021 to CY2025 (the most recent year of complete data), the home health market basket has had a cumulative forecast error of -7.3% points as illustrated below.
7
Centers for Medicare & Medicaid Services. Office of the Actuary, July 15, 2026, 2025 Four-Quarter Moving Average Percent Change data. https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-program-rates-statistics/market-basket-data
MB Forecast Error Impact
CY2021
CY2022
CY2023
CY2024
CY2025 Cumulative
Projected Market Basket (Final Rules)
2.30%
3.10%
4.10%
3.30%
3.20%
16.62%
Actual Market Basket
3.90%
6.20%
4.70%
4.00%
3.80%
23.95%
Percent Point Difference
-1.60%
-3.10%
-0.60%
-0.70%
-0.60%
-7.3%
We remain concerned that, unless corrected, this forecast error remains in the payment rates contributing to the chronic underfunding of the home health benefit resulting from combined policies to cut payments. CMS stated in response to comments in the CY2026 Home Health Final Rule, that any changes in a market basket error recalculation "would require careful consideration of the statutory and regulatory frameworks specific to the HH PPS, and any changes deemed necessary would be proposed through notice and comment rulemaking." This is an indication that CMS has the appropriate authority to make one-time adjustments to the market basket forecasting errors. However, CMS did not propose any one-time adjustments in the market basket to account for the compounding errors.
LeadingAge recommends that CMS adjust the final market basket for CY2027 payment to account for a one-time forecast error correction and increase the base payment rate to account for the underestimated market basket for CY 2021 through CY 2025.
Fixed Dollar Loss Ratio
In each calendar year update for home health payments since the implementation of the PDGM, CMS has included a monitoring report which includes all the critical changes to the yearly payment rules and how they impact utilization of services. However, CMS has never included data on the impact of changes to the Fixed Dollar Loss (FDL) Ratio or outlier payment. The intent of this payment is to incentivize home health agencies to accept more difficult and costly patients and to avoid "cherry-picking" of patients. Over the last several years, CMS has continued to decrease the FDL ratio, which we believe is counterintuitive to the purpose of the outlier payment. In our analysis of the consecutive years of decreases to the FDL ratio, we see a pattern of continued decline in visits consistent with the decrease in the FDL ratio.
We have concerns that the ratio is not working as intended and instead of incentivizing care for costly patients, it is creating an unintended incentive to provide fewer visits to avoid exceeding case-mix costs and actually qualifying for an outlier payment. In addition to the FDL ratio, there is an overall 10% cap on fee-for-service payments for outliers, meaning agencies cannot have more than 10% of their revenue come from outlier payments. If that happens, then agencies cannot earn any more outlier payments for the remainder of the calendar year unless their overall payments 11 increase and reduce the 10% of revenue from outliers. From the data available to LeadingAge, we found that only 6.8% of agencies hit the 10% cap on outlier payments in 2025. Of those, 20% were agencies with total FFS payments under $50,000 and 40% had FFS payments between $1,000,000 and $2,000,000. This seems to suggest that the majority of agencies are not incentivized to serve more costly patients, but we believe CMS should gather more data on this.
LeadingAge requests CMS conduct a thorough analysis of how the FDL ratio is functioning including which patients are receiving outlier payments, the characteristics of the agencies hitting the 10% cap on overall outlier payments, and if there is a correlation between the FDL ratio decreases and average visits.
Request for Information on the Construction of a Home Health Specific Wage Index
LeadingAge conceptually supports the development of an independent home health wage index as we did for other provider settings we represent in the FY2027 Hospice Wage Index and FY2027 Skilled Nursing Facility (SNF) Prospective Payment System Proposed Rule. We appreciate CMS' willingness to seek additional feedback from stakeholders and we hope that CMS continues to publish additional information and seek feedback in the coming comment cycles before any implementation of a new home health specific wage index.
As with hospices and SNFs, home health and hospitals are vastly different settings, employing different mixes of workers and utilizing them in different ways making the use of the Inpatient Prospective Payment System (IPPS) wage index less responsive to the needs of home health providers. As LeadingAge has noted in previous rulemaking cycles, the IPPS wage index also includes several exceptions when determining the wage index for hospitals which are not granted to other provider types and create inaccuracies. These exceptions include reclassifications, floors, outmigration, and a low-wage exception. Due to the statutory nature of these exceptions, the most appropriate course forward to accurately account for labor costs is creating new wage indices for post-acute settings.
Incorporating a home health-specific labor mix offers a more accurate representation of the occupational categories actually found in home health settings, improving the relevance of the data in comparison to the current wage index which is based on hospital occupational mix. This data also has the potential to be more recent wage data, allowing for wage index calculations to better reflect the current labor market instead of the two-year lag time with hospital-based cost reports.
The cross-industry data available through the BLS dataset is also much larger than only hospital data.
We therefore encourage CMS to seek data sources that provide the most accurate representation of the costs of labor in home health agencies. Recognizing that data sources like Medicare Cost Reports and Bureau of Labor Statistics data each have both advantages and limitations,
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LeadingAge provides the following comments on a potential new home health wage index. There are several significant concerns with using a wage index methodology similar to that employed in the End-Stage Renal Disease (ESRD) setting, which is based on Bureau of Labor Statistics (BLS). These issues require resolutions as discussed below.
Data Sources for Home Health Wage Index
First, we want to express concerns with any potential labor mix methodology and how cost reports are incorporated. The use of unaudited cost report data introduces the risk of inaccurate allocations and potential data manipulation. As we have made clear, LeadingAge remains deeply concerned regarding home health fraud across the country and the easy manipulation of cost report data for profit. If CMS pursues a new wage index, they must regularly audit the cost reports.
Unlike hospices, home health agencies report full-time employment on their cost reports, which will ease calculation of staff.
Second, using hourly wage rates for home health aides from the BLS "Home Health and Personal Care Aides" category (31-1120) should be revisited as home health aides have specialized training for health-related tasks (e.g., monitoring vitals, assisting with the administration of medication, simple wound dressing changes, etc.) that personal care aides are not qualified to perform, under the direction and supervision of a nurse. Additionally, home health agencies often compete with other occupations, like food service and retail, for entry-level home health aides, and these categories of wages should be considered in constructing a wage index.
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Occupational Mix for Home Health
The BLS-based wage indices implemented and proposed for ESRD and hospice respectively included a weighting methodology for occupations which raise concerns for LeadingAge. In this rule's "Monitoring the Effects of the Implementation of the PDGM", CMS looks at visits by discipline. While overall CMS raises concerns about the decrease in the total number of visits, for the purpose of developing a wage index methodology for home health, we would like to point out concerns about the consistent decreases in visits for disciplines beyond the qualifying services of nursing and therapy.
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U.S. Government Accountability Office. (2021). Health care workforce: Key issues, challenges, and the path forward (GAO-21-72). https://www.gao.gov/assets/gao-21-72.pdf
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Home health agencies per regulations (42 CFR 484.105(f)(1)) are only required to provide skilled nursing services and at least one other therapeutic service. As evidenced by the decreasing visits associated with non-qualifying services (social work and home health aides), we are concerned that agencies which provide access to all services under the benefit may be put at a disadvantage if CMS establishes a national occupational mix consistent with current visit trends. Agencies who do not provide the full scope of services under this home health would benefit from a wage that more accurately matches their costs while those providing home health aide and social work services would struggle to maintain staffing that is not representative of national trends but unquestionably invaluable to the beneficiaries receiving the services. In our analysis of home health services using data on Care Compare (which is based not on cost reports or claims but survey data), we found that many agencies did not offer social work or home health aide services.
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Additionally, CMS must consider how to incorporate Low Utilization Payment Adjustment (LUPA) visits into the calculation of any wage index. While LUPA visits remain a small portion of overall 30-day periods - and like other visits are trending down - the visits by discipline are not distributed in the same way as average 30-day period visits according to CMS' own data in this proposed rule. This will need to be accounted for in the weighting of visits as well.
Mismatch of Provider Location and Service Delivery Location
By definition, home health is a home-based service and there is a potential mismatch between where home health agencies pay for labor (provider location) and where services are delivered (beneficiary location). Especially, in rural and rural-adjacent areas, agencies may be pulling employees from more expensive suburban and urban areas but only are reimbursed the wage index associated with the rural area where the patient is receiving care. This creates a disincentive for agencies to serve rural areas where wage indices are considerably lower than urban or suburban areas.
Incorporation of Contract Labor
The exclusion of contract labor costs from BLS data fails to account for a significant portion of home health labor expenses, undermining the completeness and accuracy of the wage index.
Home health agencies per regulations (42 CFR 484.105(f)(1)) are only required to provide one of the qualifying services directly but the second required service and any additional services can be provided by contract. While the home health cost reports do capture contract labor, those costs 85% 81% 78% 72% 67% 76%
Nursing
PT
OT
SLP
SW
HHA
Percent of HHAs with Service
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can vary widely based on the provider location and the scarcity of contract labor which can drive up costs. When we spoke with our members, a significant number struggled with attracting speech-language pathologists and many are relying on contracted labor to provide that service. Any future methodology must accurately capture the cost of average contracts with the occupational mix identified for the wage index.
Transparent Implementation Process
Consistent with our comments on the FY2027 Hospice Wage Index Proposed Rule, implementation of any changes to wage indices should be approached with careful consideration to ensure stability and transparency, including publicly publishing the methodology and resulting wage index values before notice and comment rulemaking to allow all providers to share feedback. This includes being transparent about the wage index values produced using the BLS-based approach before and after the application of the 5% cap on wage index decreases.
During the transition period from using the hospital wage index to a BLS-based wage index for home health, several protections should be put in place. These include implementing a Fixed Dollar Loss cap hold-harmless provision to prevent significant reductions in overall payments if a home health agency were to exceed their FDL cap due to an increase in their wage index, which is beyond their control. Additionally, CMS should carefully address the disproportionate effects of the BLS-based approach, limiting decreases to no more than 0.5% per year in any region to avoid destabilizing home health care in affected areas. It is also important to assess the potential impact on state Medicaid budgets, as states must statutorily base Medicaid payment rates on the Medicare rates. Additionally, the revised methodology must be transparent, replicable, and capable of being validated by home health providers. Ample lead time before any changes to the home health wage index are implemented is critical for agencies to effectively plan, adjust budgets, modify staffing strategies, and ensure continued access to quality care without disruption.
Palliative Care Services as Home Health Services
As we noted in our response to the palliative care request for information in the hospice proposed rule (CMS-1851-P), certified home health agencies are uniquely positioned to support palliative care needs of Medicare beneficiaries, particularly if the current structure of the payment and quality incentives are changed. We applaud your guidance that palliative care needs are skilled needs and that home health can provide care to patients with serious illness under the existing regulatory guidelines. We look forward to seeing the updated Medicare Benefit Policy Manual that CMS releases after the final rule is published later this year. We have included some examples of palliative care patients that could be incorporated into these updates to ensure patients receive the care that is afforded to them.
We would like to take this opportunity to provide additional feedback on the role of palliative care services in home health and the barriers agencies currently face to support patients needing these services. As CMS outlines in this rule, a significant portion of Medicare beneficiaries dealing with serious illness meet the homebound and skilled need requirements of home health eligibility.
However, most agencies struggle to serve these patients or purposefully avoid these individuals due to the mismatched incentives in the current home health payment and quality structure.
Finally, given some of the narrative in this section of the proposed rule, to clarify that LeadingAge does not believe home health agencies are the sole place where community-based palliative care is acceptable in the Medicare program. Many of our mission-driven, nonprofit members who are not home health agencies serve palliative care patients through outpatient, clinic-based, or home-based palliative care programs. The statutory requirements of home health eligibility, homebound status and skilled need, also restrict the patients who can access these services, making other forms of palliative care necessary to meet the needs of the whole Medicare population. We firmly believe, given CMS's requests for information in other payment rules that it is CMS's intention in providing clarification around home health and palliative care was not to imply that home health is the only appropriate setting for community-based palliative care but rather clarify that services should not be denied for individuals whose needs are predominantly palliative in nature. We request CMS clarify their position in the final rule.
Payment and Billing Barriers Solutions for Home Health Palliative Care
Payments to home health agencies have decreased over the last five years since the implementation of the Patient Driven Groupings Model (PDGM). This has led to the shortening of home health stays and decreases in the number of visits overall. It is difficult to adequately address all the issues associated with the interdisciplinary needs of a palliative care patient with this limited reimbursement. In this rule, CMS states "The structure of the PDGM allows, in general, for palliative care services to be most appropriately grouped into the medication, management, teaching, and assessment (MMTA) clinical group." This seems to imply that MMTAs are the only clinical groupings that would be eligible for palliative care services under the home health benefit. We strongly disagree with this assessment and believe that any additional guidance should include all clinical groupings under PDGM as eligible for palliative services. In our examples below we provide several scenarios of patients outside the MMTA clinical groupings that present strong cases for palliative care service needs.
There are also issues with the HCPCS codes available to home health agencies to bill in the bundle for telephonic services of social workers (such as the HCPCS G0155, REV 0569 in hospice). Additionally, there is a lack of coding for the delivery of a nurse focused maintenance program which would be essential to offer for palliative care patients. Currently, there are HCPCS codes for therapy-based maintenance programs (G0159, G0160, G0161) but, as was required by the Jimmo v. Sebelius settlement, maintenance extends to not only therapy but nursing supports.
To address these issues and encourage more palliative care services in home health, LeadingAge makes the following recommendations:
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Enhance the payment structure for palliative care patients to incentivize greater coordination between the certifying clinicians as well as incentivize use of more disciplines from the home health benefit.
If CMS develops a Part B billing model for palliative care which separates the palliative care assessment from the palliative care billing, a certifying clinician could bill for the assessment and formally establish through that assessment the palliative nature of the home health orders. Especially in more rural areas community-based palliative care might be difficult to obtain but a certifying clinician with palliative training could establish a home health plan of care with palliative goals supported through the home health interdisciplinary team and offer additional benefits including spiritual care through the Part B billing available to the clinician.
Additionally, if a Part B billing structure is created for palliative care, CMS should consider how to layer home health with Part B palliative care to ensure components of palliative care like spiritual care could be offered to home health beneficiaries via the certifying plan of care.
Due to the restrictive payments, social work and home health aide services are deeply underutilized in home health writ large and clearly would have beneficial impacts on this segment of the home health population. Additional support through increased payment could better support these services. As we note in this letter, there has been a downward trend in utilization in aide and social work services in home health, especially since the implementation of PDGM. We believe additional funding to ensure adequate support for these services would have to come through Congress.
Nursing services are most common which can support the physical needs of palliative care patients such as medication adherence and evaluation.
More clearly established coding for nursing-based maintenance programs and coding for social work education of families and social work telephonic based outreach are also needed.
Quality Barriers and Solutions for Home Health Palliative Care
Quality reporting creates even more disincentives to support palliative care patients due to the exclusive focus on improvement in function. Despite the Jimmo settlement, nearly all home health quality measures focus on the improvement of function for patients. This diminishes the real ability of home health agencies to support maintenance of function and support of symptom management, which may not improve functioning but is essential for quality of life. For many palliative care patients at the beginning of their serious illness trajectory, this maintenance is far more important than improvement and is a truer metric of the quality of care they receive.
To address these issues and encourage more palliative care services in home health, LeadingAge makes the following recommendations:
Create a distinction for patients in home health who receive rehabilitative services vs. maintenance/palliative services.
This distinction would be established by the certifying clinician on their orders for home health.
CMS should add an item to the OASIS indicating which type of home health service is being delivered (rehabilitative, maintenance, or palliative) based on the certifying clinician's orders or assessments and adjust which OASIS items need to be responded to and how quality measures would be calculated from the responses.
While not endorsed by the Consensus Building Entity, CMS already has measure specifications for stabilization built into OASIS.
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Examples of Palliative Care Patients Served by Home Health
In order to support CMS's efforts to better define the palliative care population in home health, we offer the following patient examples which are outside of the MMTA category but meet the eligibility requirements for homebound and skilled-need requirements and require palliative-based supports rather than rehabilitative supports. As CMS considers updates to the Medicare Benefit Policy Manual we hope that these types of patients can be included.
Patient A:
A 78-year-old patient with end-stage heart failure and a non-healing Stage 4 sacral pressure ulcer receives home health under the Wound/Skin grouping. Skilled nursing provides complex dressing changes and pain management to prevent infection and control symptoms. The Medicare Administrative Contractor (MAC) may deny claims, arguing that dressing changes are maintenance care that a family caregiver can perform, overlooking the clinical complexity of managing a deteriorating palliative wound and breakthrough pain.
Patient Profile
Condition: Stage 4 sacral pressure ulcer, end-stage heart failure, severe chronic pain.
Grouping: Wound/Skin Management.
Goal: Palliation, symptom control, and wound stabilization rather than healing or functional recovery.
Patient B:
A 74-year-old patient with an advanced, progressive ischemic stroke (recurrent) and vascular dementia maps to the Neuro/Stroke Rehabilitation clinical grouping.
The patient is receiving skilled physical and speech therapy under a skilled maintenance program alongside nursing for palliative symptom management. Because the patient has reached a plateau and is in slow neurological decline, a Medicare Administrative Contractor (MAC) looking through a traditional restorative lens sees a high denial risk. Lack of restorative progress, and the expectation that a caregiver could be trained to provide custodial support (vs a skilled need) would be typical.
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Centers for Medicare & Medicaid Services. (n.d.). Home health outcome measures table: OASIS-E 2025 [Data table]. https://www.cms.gov/files/document/home-health-outcome-measures-table-oasis-e2025.pdf
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Patient Profile
Primary Diagnosis (ICD-10): I69.398 (Other sequelae of cerebral infarction) paired with F01.511 (Vascular dementia with behavioral disturbance).
PDGM Grouping: Neuro/Stroke Rehabilitation.
Clinical Picture: Severe left-sided hemiplegia, profound dysphagia, neurogenic bowel/bladder, and aphasia. The patient is bedbound and requires maximum assistance for all transfers.
Care Plan Focus: Palliative maintenance therapy. This includes establishing a safe positioning routine to prevent aspiration, physical therapy to prevent debilitating joint contractures, and nursing to manage neurogenic pain and terminal agitation.
We recommend CMS issue the following guidance for MACs in addition to an illustrative example in the Medicare Benefit Policy Manual:
CMS should provide clear guidance to the MACs that denials should not be based on any standard of decline, i.e., with how quickly a patient declines or how slowly they decline. By the nature of the benefit, home health is time limited and does not adequately account for the full trajectory of an individual's decline.
CMS should provide clear guidance to the MACs that training and support for family caregivers to provide palliative care including dressing changes and complex symptom management supports are grounds for home health service.
Home Health Quality Reporting Program (HH QRP)
LeadingAge strongly supports CMS's efforts to better align the HH QRP program with the Expanded Home Health Value Based Purchasing (HHVBP) model as well as creating more consistency between the reporting standards for the calendar year payment updates and the Annual Payment Updates (APU). Additionally, we provide considerations for future measures that look at advance care planning and the role of home health agencies in the process.
Proposal To Revise HH QRP Data Submission Deadlines Beginning with the CY 2027 HH QRP
In the CY2026 Home Health Proposed Rule, CMS solicited feedback on reducing the OASIS assessment data submission deadline from 4.5 months to 45 days. Generally, commenters were supportive of the change including LeadingAge who recommended 60 days instead of 45 days to align with the expectations of the current Conditions of Participation. Generally, LeadingAge supported the change which would shorten the amount of time it takes for quality measure data to be posted publicly on Care Compare. We did note concerns that a 60-day timeline may be more appropriate for home health due to the reporting requirements of OASIS. In this rule, CMS provides additional detail on the proposed 45-day timeline which better explains the purpose of aligning to this standard instead of the 60-day standard due to aligning the reporting with calendar quarters. LeadingAge supports CMS's proposal to reduce the OASIS assessment data submission deadline from 4.5 months to 45 days.
Proposal To Revise the OASIS & HHCAHPS Annual Payment Update Reporting Timeframe and Regulation Text Related to Reconsiderations
The current OASIS and HHCAHPS annual payment update (APU) reporting timeframe differs from that used by other major CMS payment updates. Notably, the expanded HHVBP Model annual payment adjustment and the HH PPS updates are both based on a calendar year timeline. To improve alignment between HH payment policies and OASIS QRP reporting requirements, CMS is proposing to revise the OASIS and HHCAHPS APU data reporting timeframe to reflect a January 1 through December 31 reporting timeframe, or the calendar year. CMS believes this update would provide clarity to HH payment updates and facilitate the alignment of the HH pay-for-reporting policies with other HH payment policies.
As stated above, LeadingAge supports CMS's work to align the data submission expectations of the program with the calendar year nature of the rule instead of a federal fiscal year. To that end, LeadingAge supports revisions to both the OASIS and HHCAHPS Annual Payment Update Reporting Timeframes as well as the corresponding regulatory text revisions to implement the changes.
HQRP Measure Concepts Under Consideration for Future Years-Request for Information (RFI)
CMS requested feedback on the importance, relevance, appropriateness, and applicability of the quality measure concepts related to advance care planning in home health. In part, this comes from CMS's efforts during the Measures Under Consideration process to include a measure in the HH QRP that would look at the percentage of patients 18 and older with one inpatient encounter who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record. This was tied to a record being available at the time of hospital discharge despite being proposed for the home health setting.
While LeadingAge agrees with CMS that in post-acute care (PAC) settings, where patients recover from acute illness, injury, or major procedures, their needs and goals may evolve as their condition changes, we do not necessarily agree that holding PAC providers accountable to a measure of documenting advance care planning is effective. We agree that patient priorities can shift over the course of recovery, especially if the recovery is difficult and not meeting the expectations of the patient or certifying clinician. We agree that regular reassessment and transparent communication 21 is essential to maintaining personcentered care, however, high-quality advance care planning is essential to achieve goal-concordant care.
While LeadingAge strongly supports advance care planning with Medicare beneficiaries in other settings, due to the continuing decrease in visits and the intermittent and temporary nature of home health services, lack of evidence-based advance care planning interventions in home health, and current clear regulatory barriers, LeadingAge does not believe it is either appropriate, relevant, or applicable to develop advance care planning measures for home health agencies.
CMS was clear that evidence-based outcomes are prioritized in determining which aspects of advance care planning are appropriate for home health. In our review of the existing, limited research on advance care planning in home health, there is limited research on the most common conditions seen by home health agencies, including cardiovascular and pulmonary disease and in general more research is needed on the role home health agencies play in these discussions.
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Many of the studies had very limited sample size, often restricted to a single agency, and while some of the goal conflicts between family members was mitigated by a home health agency's intervention in the planning conversation, there were no statistically significant differences found in perceptions of collaboration and readiness for advanced care planning in the population.
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When we discussed this effort with our members, all members shared that they comply with the requirements of 42 CFR 489.102(a) to provide written information about patient rights with regards to advance care planning, requirements to document in the medical record if the patient has an advance directive and having written policies and procedures regarding advance directives.
Additionally, the regulations clearly state:
(i) In the case of a home health agency, in advance of the individual coming under the care of the agency. The HHA may furnish advance directives information to a patient at the time of the first home visit, as long as the information is furnished before care is provided.
This seems to imply that home health agencies should not engage in advance care planning while providing care to the patient. While many of our members shared they attempt to address changing needs of patients and communicate those needs to the referring/certifying clinician, they have limited time with patients and in many cases do not have long term relationships with patients like other providers would. Many members felt like additional education to support staff to have an effective advance care planning conversation would be welcome; however, one study from the UK found limited evidence for the effectiveness of advanced care training for care home workers and despite the call for additional research few studies exist.
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10
Bigger, S., & Haddad, L. (2019). Advance Care Planning in Home Health: A Review of the Literature. Journal of Hospice & Palliative Nursing, 21(6), 518-523. https://doi.org/10.1097/NJH.0000000000000591
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Tay, D. L., Ellington, L., Towsley, G. L., Supiano, K., & Berg, C. A. (2020). Evaluation of a collaborative advance care planning intervention among older adult home health patients and their caregivers. Journal of Palliative Medicine, 23(9), 1214-1222. https://doi.org/10.1089/jpm.2019.0521
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Gleeson, A., Noble, S., & Mann, M. (2021). Advance care planning for home health staff: A systematic review. BMJ Supportive & Palliative Care, 11(2), 209-216. https://doi.org/10.1136/bmjspcare-2018-001680
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The Expanded Home Health Value Based Purchasing
LeadingAge appreciates CMS's update on the Expanded HHVBP program in this year's rule. In particular, we are grateful CMS took our recommendations from CY2026 and did not make any changes to the HHVBP program this calendar year. Since the implementation of the program there have been multiple changes in the measurement baselines and quality measures, continually moving the goalposts for home health agencies. We are eager to have a year with no changes to measures, baselines or otherwise to work with members to improve their performance.
We also appreciate CMS bringing to the attention of the HHVBP Technical Expert Panel (TEP) changes recommended by LeadingAge to scoring rules associated with accurate data submission.
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CMS confirmed LeadingAge's findings that 14% of the highest performing HHVBP agencies (those receiving a +5% adjustment) also received an annual payment adjustment penalty of 2% for missing their quality reporting expectations and the majority were in Los Angeles, CA. We are grateful to the TEP for understanding our concerns and seeing CMS's proposals to address the issue as "intuitive and long overdue." The TEP did request CMS conduct further analysis of the potential impacts to providers and we hope CMS will propose changes to this particular scoring rule in future rulemaking cycles to preserve the integrity of the Expanded HHVBP model.
While CMS did not propose any changes to the Expanded HHVBP model, we wish to convey our previous recommendation on the program specifically, expanding the number of cohorts. The original demonstration of the Home Health Value Based Purchasing (HHVBP) model, which occurred in only nine states, was highly positive and correlated with considerable savings and improved quality of services. In the initial demonstration, cohorts were organized by states, not sizes of agencies. Generally, this allowed participants to compare themselves against agencies with similar client populations, regulatory burden from states, and allowed for a fair distribution of sizes. The expanded model created two simple cohort sizes: the small-volume cohort, which includes agencies with fewer than 60 unique beneficiaries in the baseline year, and the large-volume cohort, which includes agencies with 60 or more unique beneficiaries in the baseline year.
Our initial recommendation to CMS was to consider redefining cohort sizes based on average daily census or OASIS episodes during the baseline year. And while we still believe this is a valid redevelopment, the calculations necessary to redefine cohorts by patient size could be more cumbersome for CMS as well as agencies. However, if CMS were to define a third cohort to be large-volume agencies with less than 40 returned surveys in the baseline year which would prevent the calculation of CAHPS measures, this would create a more equitable distribution of cohorts and allow each to be compared based on available data. Currently, large-volume cohort agencies
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Abt Global. (2026). 2025 Technical Expert Panel meeting: Home Health Quality Reporting Program and Expanded Home Health Value-Based Purchasing Model summary report. Centers for Medicare & Medicaid Services. https://www.cms.gov/priorities/innovation/files/hhvbp-tep-summary-report.pdf
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LeadingAge. (n.d.). LeadingAge expresses concerns on Medicare home health benefit, HHVBP. https://leadingage.org/leadingage-expresses-concerns-on-medicare-home-health-benefit-hhvbp/
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without 40 returned surveys are not assessed a score for CAHPS measures. In LeadingAge's analysis of the CY2024 performance data, we found that, of the top 10 percent of large-volume achieving agencies (those receiving some percentage increase) 85% had "No or insufficient data available" for CAHPS scores to be included in their calculations. We argue this provides agencies who do not obtain enough returned surveys an advantage over those agencies with 40 or more completed returned surveys as those agencies with CAHPS scores have more data to be compared against their achievement and improvement thresholds.
Changing the cohort sizes would not only make the program more equitable, but it would also work to eliminate the earlier concerns regarding missing HH CAHPS data, as agencies that are of a smaller size in the larger-volume cohort struggle to get 40 returned surveys despite their compliance with HH QRP requirements.
We request CMS evaluate the creation of a third cohort which would bifurcate the current large-volume cohort into two: one cohort would include HHAs who had sufficient data to calculate CAHPS measures during the baseline year and a second cohort which did not have sufficient data to calculate CAHPS measures during the baseline year.
Provider Enrollment
General Comments on Enrollment Proposals
LeadingAge fundamentally supports CMS's efforts to protect the Medicare Trust Fund and Medicare beneficiaries from fraud, waste, and abuse. Enrollment policies are critical to prevent unqualified and potentially fraudulent individuals and entities from inappropriately billing the Medicare program and harming beneficiaries through subpar care delivery. The authorities currently conveyed to CMS allow for the denial and removal of these individuals and entities who engage in fraudulent or abusive behaviors.
We wish to make abundantly clear that LeadingAge has consistently supported the administration's targeted actions against fraud and has encouraged CMS's efforts to detect, prevent, and deter fraud, waste, and abuse in the Medicare program as evidenced by our numerous letters regarding our concerns.
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We are not opposed to stronger fraud enforcement. Rather, we believe that CMS should continue to target bad actors without creating a provider-enrollment regime in which broad discretion, undefined standards, third-party conduct, or simple technical compliance failures can produce disproportionate consequences for legitimate providers.
Our central concern is that the proposed rule significantly expands CMS's enrollment denial, revocation, reporting, and related enforcement authorities while simultaneously removing or failing to establish objective standards and procedural safeguards. The result could be severe and lasting enrollmen
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Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2311-0370
August 31, 2026
The Honorable Mehmet Oz, MD
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201
Subject: CMS-1844-P Calendar Year 2027 Home Health Prospective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the Expanded HH Value-Based Purchasing Model; Medicare Provider Enrollment, ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. August 31, 2026 The Honorable Mehmet Oz, MD Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services 200 Independence Ave. SW Washington, DC 20201 Subject: CMS-1844-P Calendar Year 2027 Home Health Prospective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the Expanded HH Value-Based Purchasing Model; Medicare Provider Enrollment,Durable Medical Equipment (DME), and DME, Prosthetics, Orthotics, and Supplies (DMEPOS) Policies
Submitted electronically via https://www.regulations.gov
Dear Administrator Oz,
LeadingAge, together with our state partners, represents more than 5,300 nonprofit and mission-driven aging services providers serving older adults and touching millions of lives every day. From our national headquarters in Washington, DC, and in collaboration with state partners whose members are active in 50 states, the District of Columbia, and Puerto Rico, we use advocacy, education, applied research, and community building to make America a better place to grow old. Our membership encompasses the entire continuum of aging services, including skilled nursing, assisted living, memory care, affordable housing, retirement communities, adult day programs, hospice, Programs of All-Inclusive Care for the Elderly (PACE), and home-based care including Medicare home health agencies.
On behalf of these members, LeadingAge is pleased to offer the following comments in response to the CY2027 Home Health Prospective Payment System Proposed Rule.
We wish to thank the administration for taking into consideration our comments on the CY2026 Home Health Proposed Rule regarding the calculation of the permanent and temporary adjustments required by the Bipartisan Budget Act of 2018. The resulting reduction of overall permanent and temporary adjustments was crucial to keeping our nonprofit, mission-driven home health agencies open to serve the most vulnerable Medicare beneficiaries. However, as we detail below, the proposed cuts and outstanding temporary adjustments should also be eliminated completely. Continuing to implement these cuts in any form or manner, beyond being methodologically incorrect, will have a disastrous effect on older adults who rely on these services.
The combined impact of the proposed payment changes and proposed Medicare provider enrollment changes may lead to more closures of home health agencies and the inability of providers that remain to take on new referrals.
With regard to the Medicare provider enrollment provisions of this rule, LeadingAge is deeply concerned that the expanded authority CMS is seeking has the potential to introduce significant uncertainty and impose excessive burdens on providers. This concern applies not only to the collection and submission of excessive information on staff and affiliations, but also to the due diligence required to prevent unintended affiliations that could jeopardize a provider's enrollment. We strongly believe that CMS should address its Medicare provider enrollment proposals in a separate rulemaking that targets the provider community more broadly and that properly accounts for the costs and benefits of these proposals.
Contents
General Comments on Fee-for-Service Home Health Care ................................. 4
Proposed CY2027 Home Health Payment Rate Updates .......................................................... 5
Methodological Errors in the Behavioral Adjustment Assumptions ..................................... 7
Forecasting Error Correction .................................................................................................... 9
Fixed Dollar Loss Ratio ............................................................................................................ 10
Request for Information on the Construction of a Home Health Specific Wage Index ........ 11
Palliative Care Services as Home Health Services .................................................................. 15
Home Health Quality Reporting Program (HH QRP) ................................................................ 19
Proposal To Revise HH QRP Data Submission Deadlines Beginning with the CY 2027 HH QRP ........................................................................................................................................... 19
Proposal To Revise the OASIS & HHCAHPS Annual Payment Update Reporting Timeframe and Regulation Text Related to Reconsiderations ................................................................ 20
HQRP Measure Concepts Under Consideration for Future Years-Request for Information (RFI) ...................................................................................................................... 20
The Expanded Home Health Value Based Purchasing ............................................................. 22
Provider Enrollment ..................................................................................................................... 24
General Comments on Enrollment Proposals ...................................................................... 24
Requests for Clarifications ......................................................................................................... 25
Modifications of Current Revocation and New Revocation Provisions .............................. 27
Abuse of Billing Privileges 424.535(a)(8)(ii) ....................................................................... 27
False or Misleading Information Sec. 424.535(a)(4) and Sec. 424.530(a)(4) ............................ 28
Extension of Revocations Sec. 424.535(i) ............................................................................... 29
High-Risk Enrollments (Sec. 424.535(a)(24)) ......................................................................... 30
Retroactive Revocations ........................................................................................................ 31
Claim Submission After Revocation .................................................................................... 32
Modification to Current Denial Reasons and New Denial Reasons ................................ 33
Debt Sec. 424.530(a)(6), Payment Suspension Sec. 424.530(a)(7), and Other Program Terminations/Suspensions Sec. 424.530(a)(14) .................................................................... 33
Same Suite (Sec. 424.530(a)(19)) ............................................................................................ 34
Hospice Medical Directors and Administrators (Sec. 424.530(a)(20)) ................................. 35
Misuse of Identity Sec. 424.530(a)(21) .................................................................................... 36
Reapplication Bar (Sec. 424.530(f)) ......................................................................................... 36
Changes in Majority Ownership (CIMOS) ........................................................................ 37
Temporary Moratoria (Sec. 424.570) ...................................................................................... 37
Hospice Reactivations (Sec. 424.540(b)(3)) ........................................................................... 39
Definition of "Operational" and "Signage" ........................................................................ 39
Retention and Furnishing of Documentation (Sec. 424.516) .................................................. 40
Managing Employees (Sec. 424.502) ......................................................................................... 41
Affiliations (Sec. 424.502) ........................................................................................................ 43
Conclusion ................................................................................................................................. 45
General Comments on Fee-for-Service Home Health Care
Despite the role home health agencies play in improving care for Medicare fee-for-service (FFS) beneficiaries and reducing total system costs, CMS's own monitoring data bears out our fears that home health use is in decline and continued long-term reductions will destabilize this critical setting. Information provided in the CY2027 Home Health Proposed Rule reviews the utilization trends between the simulated CY2018 and CY2019 30-day episodes and all episodes following the implementation of the Patient Driven Groupings Model (PDGM). The initial goals of PDGM were to better measure the case mix of home health care beneficiaries, minimize the potential for patient selection, and better align provision of services with patient needs. However, according to the Medicare Payment Advisory Commission's (MedPAC) Congressionally mandated report on the implementation of the PDGM, the payment change:
Was not associated with a higher probability of FFS home health care use. This is at a time when the vast majority of older adults, 93%, live in their own homes and want to maintain that independence.
Resulted in fewer visits per FFS stay. MedPAC found this drop in visits was similar for most groups, and across all disciplines, not just therapy, signaling that the goal of aligning service provision with patient needs was not necessarily obtained. There were also fewer visits among beneficiaries who are dual eligibles or receiving the low-income subsidy who are groups that are highly in need of services.
Did not substantially improve the quality of care for beneficiaries. MedPAC's analysis offered a mixed picture of quality, with fewer preventable hospitalizations but worse post-discharge outcomes.
Did not substantially impact FFS Medicare margins. While we do not agree with margins alone as an indicator of payment adequacy, this was undoubtedly a key rationale for changing the payment system given the misuse of therapy thresholds. However, MedPAC's analysis found only a 0.6-percentage-point decrease in FFS margins.
This table illustrates our continued concerns regarding the decline in use of home health services:
1
Parker, K., & Menasce Horowitz, J. (2026, February 26). Most older adults who live at home want to age in place, but they aren't entirely confident they'll get to. Pew Research Center. https://www.pewresearch.org/short-reads/2026/02/26/most-older-adults-who-live-at-home-want-to-age-in-place-but-they-aren't-entirely-confident-theyll-get-to/
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Based on this information from MedPAC's analysis and CMS's monitoring data, LeadingAge would argue that PDGM is not having the intended effect on services and in fact is leading to a decrease in access to home health services. As we have stated in previous years' comment letters, there is not just a noticeable decline in unique beneficiaries and visits but also a decline in the number of home health agencies. For the past three years, MedPAC has acknowledged that all growth in new home health agencies has been concentrated in Los Angeles County, California.
2
Proposed CY2027 Home Health Payment Rate Updates
We are grateful for CMS's consideration of the public comments in the CY2026 Home Health Final Rule, which allowed CMS to use their time and manner authority to not apply permanent adjustments to the CY2023 or CY2024, and subsequently in this year's rule, the CY2025 data. We strongly agree with CMS's determination that behavior changes in these years were not attributable strictly to the change in payment to PDGM and a 30-day unit of payment.
Additionally, there is evidence that CMS's decision to reevaluate the behavioral adjustments without CY2023, CY2024, and now CY2025 has contributed to some stabilization in the home health negative margin projections and therefore, continuing to make changes to stabilize the FFS payment system is critical to maintaining home health access. In a yearly appendix to the 2026
2
Medicare Payment Advisory Commission. (2024, 2025, 2026). Report to the Congress: Medicare payment policy.
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Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, the CMS Office of Actuary states that in 2024 36% of HHAs had negative total all payer margins. This finding is consistent with their analysis from 2025.
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However, the updated analysis estimates that by 2040, that number will rise to only 41% instead of the 57% estimated in 2025. That is a 16-percentage-point decrease in the number of agencies that could have negative total margins by 2040. We believe this provides strong evidence that FFS margins are critical to the stability of the home health sector.
Since Medicare Advantage (MA) enrollment has only continued to increase from 34 million beneficiaries in 2025 to 35 million in 2026, it is unlikely that MA payment changes influenced any of the stabilization. Based on our members' experiences with MA payments, we have no reason, and unfortunately no empirical evidence, that MA payments for home health services are improving. However, as with last year, the memo states that "Over the long range, however, the simulations suggest that absent other modifications, significant financial pressures will arise for providers, increasing the possibility of access and quality of care issues for Medicare beneficiaries." This is a clear indication that the Trustees of the Medicare Trust Funds, along with the CMS Office of the Actuary, believe it is their obligation to look at the overall financial pressure faced by providers as it relates to potential effects on Medicare beneficiaries' access and quality of care.
LeadingAge continues to believe that the government needs to work on ensuring rate adequacy across all payers before disrupting overall access to care through further cuts to FFS Medicare. CMS must evaluate payment adequacy across all payers under federal jurisdiction, including Medicaid and Medicare Advantage. LeadingAge offers our support to advocate for additional authority required by CMS to ensure rate adequacy across payers.
3
Centers for Medicare & Medicaid Services. (2026).
Simulations of Affordable Care Act Medicare payment update provisions: Part A provider financial margins. https://www.cms.gov/files/document/simulations-affordable-care-act-medicare-payment-update-provisions-part-provider-financial-margins.pdf-0
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Methodological Errors in the Behavioral Adjustment Assumptions
Neither CMS nor MedPAC can disaggregate behavior caused by PDGM from other factors:
As we previously stated, we appreciate CMS's acknowledgement of the difficulties in attributing behavioral changes directly to the PDGM in 2023 through 2025. And, subsequently, based on those challenges, CMS's decision not to propose any permanent adjustments for CY2027. In the CY2026 Home Health Final Rule, CMS noted several policy changes which made calculating permanent adjustments for 2023 and beyond difficult and therefore reversed those permanent adjustments.
However, we maintain that these difficulties also existed in 2020, 2021, and 2022. CMS also has clearly indicated that the fraud present in the program starting in 2020 cannot be precisely distinguished from other behavioral changes. In addition to CMS's difficulty in attributing behaviors to the change in payment, MedPAC struggled to determine the behavioral changes related to PDGM vs. patient behaviors associated with COVID-19. As we will illustrate below, we believe based on CMS's rationale to eliminate the permanent adjustments applied in CY2023-CY2025, the same rationale applies to CY2020-CY2022.
Fraudulent Behaviors: LeadingAge has repeatedly requested that CMS evaluate the impact of fraudulent activity on the calculation of the aggregate adjustments since the implementation of PDGM and the expanded Home Health Value Based Purchasing (HHVBP) model. From 2019 (before COVID flexibilities and the implementation of PDGM) to 2024, the total number of home health agencies in Los Angeles County increased from 781 to 1,588, or a 103% increase in providers. This means there are currently 18.7 HHAs per 10,000 FFS beneficiaries in LA County. Additionally, CMS's data shows 44% of all home health payments in California in 2024 went to HHAs in LA County despite the average number of users per agency in LA was lower than the state as a whole. LA County also accounted for 9% of all home health FFS payments nationally in 2024. We know CMS is focused on Los Angeles County from an enforcement perspective, especially as it relates to home health and hospice. CMS has also implemented a six-month moratorium on new home health enrollments. While we supported the moratorium as a short-term measure, it is clear CMS is focused on additional enforcement mechanisms and therefore, a moratorium will no longer be necessary. We see CMS applying this logic in the durable medical equipment space (DME) where the moratorium was lifted after 6 months on August 27.
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In a letter to CMS Administrator Oz, Senator Susan Collins (R-ME) requested that CMS analyze the impact of alleged fraudulent behavior in LA County on the aggregate behavioral adjustment for home health. In a letter responding to the request, CMS states they "cannot precisely distinguish agencies that engage in abusive coding and other behaviors from all others."
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Notably, this response underscores that CMS cannot disaggregate behaviors like fraudulent activity from PDGM related activities.
4
Golinghorst, D., & Wallace, M. (2026, August 28). CMS Medicare DMEPOS supplier enrollment moratorium expires: Suppliers may submit new initial enrollment applications. JD Supra. https://www.jdsupra.com/legalnews/cms-medicare-dmepos-supplier-enrollment-9731633/
5
Dr. Mehmet Oz, Administrator, Centers for Medicare & Medicaid Services to the Honorable Senator Susan Collins. Washington, DC. (July 20, 2026).
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CY2022 Case-Mix Weights Recalibration: As we stated in our CY2026 comment letter, we believe that the changes in case mix weights in CY2022 influenced provider behavior and, therefore, that the calculation of permanent adjustments was not attributable strictly to the change to PDGM and a 30-day episode. In the CY2022 Home Health Final Rule, and every subsequent year since, CMS has recalibrated the PDGM case-mix weights. The recalibration for CY2022 produced significant shifts in case-mix weights. While we understand CMS's position that "the impact of any reduction in resource use caused by the COVID-19 PHE on the calculation of the case-mix weight would be minimal since the impact would be accounted for both in the numerator and denominator of the formula used to calculate the case-mix weight", there is an additional consideration that CMS has not accounted for in their previous rule comments. The case-mix weights had not been recalibrated for two consecutive years, meaning the shifts in the rates were more significant and could have an outsized effect on provider behavior. The changes in weights ranged from +16% to -26% across case-mix groups compared to CY 2020. While the changes made to case-mix due to practice patterns during COVID-19 may have been mitigated, changes in payments at the case-mix group level after two full years of locked changes ultimately influenced how agencies structured service delivery to remain viable.
2020 and 2021 COVID-19 Impacts: We have stated our concerns before regarding the calculation of COVID-19 claims and their outsized impact on the aggregate behavioral adjustment methodology. However, previously we have focused on the role of COVID-19 in changing practice patterns that influenced case-mix. After further review, we believe COVID-19 had a much larger impact on the rate of LUPA payments than any other time before or since the implementation of PDGM. These impacts on LUPA rates were outside the provider's control due to individual choices to deny access to home health staff, forcing the agency to take a LUPA payment instead of the full case-mix payment. In the CY2023 Home Health Final Rule, when CMS discussed their decision to not adjust LUPA payments for CY2022 they stated:
However, in contrast, [to the impact on case-mix weight adjustments] the LUPA thresholds are based on the number of overall visits in a particular case-mix group (the threshold is the 10th percentile of visits or 2 visits, whichever is greater) instead of a relative value (like what is used to generate the case-mix weight) that would control for the impacts of the COVID-19 PHE. We noted that visit patterns and some of the decrease in overall visits in CY 2020 may not be representative of visit patterns in CY 2022. Therefore, to mitigate any potential future and significant short-term variability in the LUPA thresholds due to the COVID-19 PHE, we finalized the proposal to maintain the LUPA thresholds finalized and displayed in Table 17 in the CY 2020 HH PPS final rule with comment period (84 FR 60522) for CY 2022 payment purposes.
The impact of COVID-19 on home health services in 2020 and 2021 was considerable. While CMS has accounted for some aspects of the impact as part of the case-mix distributions, it has not accounted for other factors such as the increased LUPA rate. Additionally, MedPAC noted that it was unable to determine behavior changes related to PDGM versus other factors in its analysis.
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Specifically, MedPAC:
Medicare Payment Advisory Commission. (2026). The impact of recent changes to the home health payment system. In Report to the Congress: Medicare payment policy (Chap. 14). Medicare Payment Advisory Commission. https://www.medpac.gov/wp-content/uploads/2026/03/Mar26_Ch14_MedPAC_Report_To_Congress_SEC.pdf
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noted declines in the use of HHA services due, as we noted, to beneficiaries' reluctance to allow HHA staff into their homes during the early months of the pandemic. MedPAC also noted a decline in elective surgeries during this time that would have resulted in post-acute home health referrals. The behavioral adjustments required by statute focus specifically on provider behaviors and, to our knowledge, CMS has not considered adjustments for patient behaviors that could have impacted the implementation of PDGM including an increase in LUPA rates seen in 2020 and 2021.
For all of these reasons, CMS should remove all permanent adjustments applied previously (including CY2020-CY2022) and correct the home health 30-day payment rate for CY 2027. CMS should not finalize the -3.0% temporary adjustment for CY2027 as the removal of the permanent adjustments in CY2020-CY2022 would eliminate the $4.9 billion estimated overpayments which are attributable to the current assumptions.
Forecasting Error Correction
LeadingAge would like to take this opportunity to again stress the compounding nature of market basket forecasting errors. As we stated in our CY2026 Home Health Proposed Rule comments, the accuracy of annual payment updates is an essential piece of the payment structure for home health agencies and critical for ensuring that payments keep pace with rising costs, especially those related to labor and resources necessary to provide patient care. Each year, CMS provides an annual update to home health payments based on forecasts of market basket increases for the upcoming payment year because actual measures of price growth are not available until after rulemaking must be completed. While we understand that these forecasting errors have been a result of economic uncertainty and the health care sector specifically, the impact to providers is no less pronounced. For yet another year, the forecast fell short of actual price growth.
According to our review of the Office of the Actuary's summary of market basket history and forecasts 7 compared to finalized market basket rates from CY2021 to CY2025 (the most recent year of complete data), the home health market basket has had a cumulative forecast error of -7.3% points as illustrated below.
7
Centers for Medicare & Medicaid Services. Office of the Actuary, July 15, 2026, 2025 Four-Quarter Moving Average Percent Change data. https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-program-rates-statistics/market-basket-data
MB Forecast Error Impact
CY2021
CY2022
CY2023
CY2024
CY2025 Cumulative
Projected Market Basket (Final Rules)
2.30%
3.10%
4.10%
3.30%
3.20%
16.62%
Actual Market Basket
3.90%
6.20%
4.70%
4.00%
3.80%
23.95%
Percent Point Difference
-1.60%
-3.10%
-0.60%
-0.70%
-0.60%
-7.3%
We remain concerned that, unless corrected, this forecast error remains in the payment rates contributing to the chronic underfunding of the home health benefit resulting from combined policies to cut payments. CMS stated in response to comments in the CY2026 Home Health Final Rule, that any changes in a market basket error recalculation "would require careful consideration of the statutory and regulatory frameworks specific to the HH PPS, and any changes deemed necessary would be proposed through notice and comment rulemaking." This is an indication that CMS has the appropriate authority to make one-time adjustments to the market basket forecasting errors. However, CMS did not propose any one-time adjustments in the market basket to account for the compounding errors.
LeadingAge recommends that CMS adjust the final market basket for CY2027 payment to account for a one-time forecast error correction and increase the base payment rate to account for the underestimated market basket for CY 2021 through CY 2025.
Fixed Dollar Loss Ratio
In each calendar year update for home health payments since the implementation of the PDGM, CMS has included a monitoring report which includes all the critical changes to the yearly payment rules and how they impact utilization of services. However, CMS has never included data on the impact of changes to the Fixed Dollar Loss (FDL) Ratio or outlier payment. The intent of this payment is to incentivize home health agencies to accept more difficult and costly patients and to avoid "cherry-picking" of patients. Over the last several years, CMS has continued to decrease the FDL ratio, which we believe is counterintuitive to the purpose of the outlier payment. In our analysis of the consecutive years of decreases to the FDL ratio, we see a pattern of continued decline in visits consistent with the decrease in the FDL ratio.
We have concerns that the ratio is not working as intended and instead of incentivizing care for costly patients, it is creating an unintended incentive to provide fewer visits to avoid exceeding case-mix costs and actually qualifying for an outlier payment. In addition to the FDL ratio, there is an overall 10% cap on fee-for-service payments for outliers, meaning agencies cannot have more than 10% of their revenue come from outlier payments. If that happens, then agencies cannot earn any more outlier payments for the remainder of the calendar year unless their overall payments 11 increase and reduce the 10% of revenue from outliers. From the data available to LeadingAge, we found that only 6.8% of agencies hit the 10% cap on outlier payments in 2025. Of those, 20% were agencies with total FFS payments under $50,000 and 40% had FFS payments between $1,000,000 and $2,000,000. This seems to suggest that the majority of agencies are not incentivized to serve more costly patients, but we believe CMS should gather more data on this.
LeadingAge requests CMS conduct a thorough analysis of how the FDL ratio is functioning including which patients are receiving outlier payments, the characteristics of the agencies hitting the 10% cap on overall outlier payments, and if there is a correlation between the FDL ratio decreases and average visits.
Request for Information on the Construction of a Home Health Specific Wage Index
LeadingAge conceptually supports the development of an independent home health wage index as we did for other provider settings we represent in the FY2027 Hospice Wage Index and FY2027 Skilled Nursing Facility (SNF) Prospective Payment System Proposed Rule. We appreciate CMS' willingness to seek additional feedback from stakeholders and we hope that CMS continues to publish additional information and seek feedback in the coming comment cycles before any implementation of a new home health specific wage index.
As with hospices and SNFs, home health and hospitals are vastly different settings, employing different mixes of workers and utilizing them in different ways making the use of the Inpatient Prospective Payment System (IPPS) wage index less responsive to the needs of home health providers. As LeadingAge has noted in previous rulemaking cycles, the IPPS wage index also includes several exceptions when determining the wage index for hospitals which are not granted to other provider types and create inaccuracies. These exceptions include reclassifications, floors, outmigration, and a low-wage exception. Due to the statutory nature of these exceptions, the most appropriate course forward to accurately account for labor costs is creating new wage indices for post-acute settings.
Incorporating a home health-specific labor mix offers a more accurate representation of the occupational categories actually found in home health settings, improving the relevance of the data in comparison to the current wage index which is based on hospital occupational mix. This data also has the potential to be more recent wage data, allowing for wage index calculations to better reflect the current labor market instead of the two-year lag time with hospital-based cost reports.
The cross-industry data available through the BLS dataset is also much larger than only hospital data.
We therefore encourage CMS to seek data sources that provide the most accurate representation of the costs of labor in home health agencies. Recognizing that data sources like Medicare Cost Reports and Bureau of Labor Statistics data each have both advantages and limitations,
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LeadingAge provides the following comments on a potential new home health wage index. There are several significant concerns with using a wage index methodology similar to that employed in the End-Stage Renal Disease (ESRD) setting, which is based on Bureau of Labor Statistics (BLS). These issues require resolutions as discussed below.
Data Sources for Home Health Wage Index
First, we want to express concerns with any potential labor mix methodology and how cost reports are incorporated. The use of unaudited cost report data introduces the risk of inaccurate allocations and potential data manipulation. As we have made clear, LeadingAge remains deeply concerned regarding home health fraud across the country and the easy manipulation of cost report data for profit. If CMS pursues a new wage index, they must regularly audit the cost reports.
Unlike hospices, home health agencies report full-time employment on their cost reports, which will ease calculation of staff.
Second, using hourly wage rates for home health aides from the BLS "Home Health and Personal Care Aides" category (31-1120) should be revisited as home health aides have specialized training for health-related tasks (e.g., monitoring vitals, assisting with the administration of medication, simple wound dressing changes, etc.) that personal care aides are not qualified to perform, under the direction and supervision of a nurse. Additionally, home health agencies often compete with other occupations, like food service and retail, for entry-level home health aides, and these categories of wages should be considered in constructing a wage index.
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Occupational Mix for Home Health
The BLS-based wage indices implemented and proposed for ESRD and hospice respectively included a weighting methodology for occupations which raise concerns for LeadingAge. In this rule's "Monitoring the Effects of the Implementation of the PDGM", CMS looks at visits by discipline. While overall CMS raises concerns about the decrease in the total number of visits, for the purpose of developing a wage index methodology for home health, we would like to point out concerns about the consistent decreases in visits for disciplines beyond the qualifying services of nursing and therapy.
8
U.S. Government Accountability Office. (2021). Health care workforce: Key issues, challenges, and the path forward (GAO-21-72). https://www.gao.gov/assets/gao-21-72.pdf
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Home health agencies per regulations (42 CFR 484.105(f)(1)) are only required to provide skilled nursing services and at least one other therapeutic service. As evidenced by the decreasing visits associated with non-qualifying services (social work and home health aides), we are concerned that agencies which provide access to all services under the benefit may be put at a disadvantage if CMS establishes a national occupational mix consistent with current visit trends. Agencies who do not provide the full scope of services under this home health would benefit from a wage that more accurately matches their costs while those providing home health aide and social work services would struggle to maintain staffing that is not representative of national trends but unquestionably invaluable to the beneficiaries receiving the services. In our analysis of home health services using data on Care Compare (which is based not on cost reports or claims but survey data), we found that many agencies did not offer social work or home health aide services.
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Additionally, CMS must consider how to incorporate Low Utilization Payment Adjustment (LUPA) visits into the calculation of any wage index. While LUPA visits remain a small portion of overall 30-day periods - and like other visits are trending down - the visits by discipline are not distributed in the same way as average 30-day period visits according to CMS' own data in this proposed rule. This will need to be accounted for in the weighting of visits as well.
Mismatch of Provider Location and Service Delivery Location
By definition, home health is a home-based service and there is a potential mismatch between where home health agencies pay for labor (provider location) and where services are delivered (beneficiary location). Especially, in rural and rural-adjacent areas, agencies may be pulling employees from more expensive suburban and urban areas but only are reimbursed the wage index associated with the rural area where the patient is receiving care. This creates a disincentive for agencies to serve rural areas where wage indices are considerably lower than urban or suburban areas.
Incorporation of Contract Labor
The exclusion of contract labor costs from BLS data fails to account for a significant portion of home health labor expenses, undermining the completeness and accuracy of the wage index.
Home health agencies per regulations (42 CFR 484.105(f)(1)) are only required to provide one of the qualifying services directly but the second required service and any additional services can be provided by contract. While the home health cost reports do capture contract labor, those costs 85% 81% 78% 72% 67% 76%
Nursing
PT
OT
SLP
SW
HHA
Percent of HHAs with Service
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can vary widely based on the provider location and the scarcity of contract labor which can drive up costs. When we spoke with our members, a significant number struggled with attracting speech-language pathologists and many are relying on contracted labor to provide that service. Any future methodology must accurately capture the cost of average contracts with the occupational mix identified for the wage index.
Transparent Implementation Process
Consistent with our comments on the FY2027 Hospice Wage Index Proposed Rule, implementation of any changes to wage indices should be approached with careful consideration to ensure stability and transparency, including publicly publishing the methodology and resulting wage index values before notice and comment rulemaking to allow all providers to share feedback. This includes being transparent about the wage index values produced using the BLS-based approach before and after the application of the 5% cap on wage index decreases.
During the transition period from using the hospital wage index to a BLS-based wage index for home health, several protections should be put in place. These include implementing a Fixed Dollar Loss cap hold-harmless provision to prevent significant reductions in overall payments if a home health agency were to exceed their FDL cap due to an increase in their wage index, which is beyond their control. Additionally, CMS should carefully address the disproportionate effects of the BLS-based approach, limiting decreases to no more than 0.5% per year in any region to avoid destabilizing home health care in affected areas. It is also important to assess the potential impact on state Medicaid budgets, as states must statutorily base Medicaid payment rates on the Medicare rates. Additionally, the revised methodology must be transparent, replicable, and capable of being validated by home health providers. Ample lead time before any changes to the home health wage index are implemented is critical for agencies to effectively plan, adjust budgets, modify staffing strategies, and ensure continued access to quality care without disruption.
Palliative Care Services as Home Health Services
As we noted in our response to the palliative care request for information in the hospice proposed rule (CMS-1851-P), certified home health agencies are uniquely positioned to support palliative care needs of Medicare beneficiaries, particularly if the current structure of the payment and quality incentives are changed. We applaud your guidance that palliative care needs are skilled needs and that home health can provide care to patients with serious illness under the existing regulatory guidelines. We look forward to seeing the updated Medicare Benefit Policy Manual that CMS releases after the final rule is published later this year. We have included some examples of palliative care patients that could be incorporated into these updates to ensure patients receive the care that is afforded to them.
We would like to take this opportunity to provide additional feedback on the role of palliative care services in home health and the barriers agencies currently face to support patients needing these services. As CMS outlines in this rule, a significant portion of Medicare beneficiaries dealing with serious illness meet the homebound and skilled need requirements of home health eligibility.
However, most agencies struggle to serve these patients or purposefully avoid these individuals due to the mismatched incentives in the current home health payment and quality structure.
Finally, given some of the narrative in this section of the proposed rule, to clarify that LeadingAge does not believe home health agencies are the sole place where community-based palliative care is acceptable in the Medicare program. Many of our mission-driven, nonprofit members who are not home health agencies serve palliative care patients through outpatient, clinic-based, or home-based palliative care programs. The statutory requirements of home health eligibility, homebound status and skilled need, also restrict the patients who can access these services, making other forms of palliative care necessary to meet the needs of the whole Medicare population. We firmly believe, given CMS's requests for information in other payment rules that it is CMS's intention in providing clarification around home health and palliative care was not to imply that home health is the only appropriate setting for community-based palliative care but rather clarify that services should not be denied for individuals whose needs are predominantly palliative in nature. We request CMS clarify their position in the final rule.
Payment and Billing Barriers Solutions for Home Health Palliative Care
Payments to home health agencies have decreased over the last five years since the implementation of the Patient Driven Groupings Model (PDGM). This has led to the shortening of home health stays and decreases in the number of visits overall. It is difficult to adequately address all the issues associated with the interdisciplinary needs of a palliative care patient with this limited reimbursement. In this rule, CMS states "The structure of the PDGM allows, in general, for palliative care services to be most appropriately grouped into the medication, management, teaching, and assessment (MMTA) clinical group." This seems to imply that MMTAs are the only clinical groupings that would be eligible for palliative care services under the home health benefit. We strongly disagree with this assessment and believe that any additional guidance should include all clinical groupings under PDGM as eligible for palliative services. In our examples below we provide several scenarios of patients outside the MMTA clinical groupings that present strong cases for palliative care service needs.
There are also issues with the HCPCS codes available to home health agencies to bill in the bundle for telephonic services of social workers (such as the HCPCS G0155, REV 0569 in hospice). Additionally, there is a lack of coding for the delivery of a nurse focused maintenance program which would be essential to offer for palliative care patients. Currently, there are HCPCS codes for therapy-based maintenance programs (G0159, G0160, G0161) but, as was required by the Jimmo v. Sebelius settlement, maintenance extends to not only therapy but nursing supports.
To address these issues and encourage more palliative care services in home health, LeadingAge makes the following recommendations:
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Enhance the payment structure for palliative care patients to incentivize greater coordination between the certifying clinicians as well as incentivize use of more disciplines from the home health benefit.
If CMS develops a Part B billing model for palliative care which separates the palliative care assessment from the palliative care billing, a certifying clinician could bill for the assessment and formally establish through that assessment the palliative nature of the home health orders. Especially in more rural areas community-based palliative care might be difficult to obtain but a certifying clinician with palliative training could establish a home health plan of care with palliative goals supported through the home health interdisciplinary team and offer additional benefits including spiritual care through the Part B billing available to the clinician.
Additionally, if a Part B billing structure is created for palliative care, CMS should consider how to layer home health with Part B palliative care to ensure components of palliative care like spiritual care could be offered to home health beneficiaries via the certifying plan of care.
Due to the restrictive payments, social work and home health aide services are deeply underutilized in home health writ large and clearly would have beneficial impacts on this segment of the home health population. Additional support through increased payment could better support these services. As we note in this letter, there has been a downward trend in utilization in aide and social work services in home health, especially since the implementation of PDGM. We believe additional funding to ensure adequate support for these services would have to come through Congress.
Nursing services are most common which can support the physical needs of palliative care patients such as medication adherence and evaluation.
More clearly established coding for nursing-based maintenance programs and coding for social work education of families and social work telephonic based outreach are also needed.
Quality Barriers and Solutions for Home Health Palliative Care
Quality reporting creates even more disincentives to support palliative care patients due to the exclusive focus on improvement in function. Despite the Jimmo settlement, nearly all home health quality measures focus on the improvement of function for patients. This diminishes the real ability of home health agencies to support maintenance of function and support of symptom management, which may not improve functioning but is essential for quality of life. For many palliative care patients at the beginning of their serious illness trajectory, this maintenance is far more important than improvement and is a truer metric of the quality of care they receive.
To address these issues and encourage more palliative care services in home health, LeadingAge makes the following recommendations:
Create a distinction for patients in home health who receive rehabilitative services vs. maintenance/palliative services.
This distinction would be established by the certifying clinician on their orders for home health.
CMS should add an item to the OASIS indicating which type of home health service is being delivered (rehabilitative, maintenance, or palliative) based on the certifying clinician's orders or assessments and adjust which OASIS items need to be responded to and how quality measures would be calculated from the responses.
While not endorsed by the Consensus Building Entity, CMS already has measure specifications for stabilization built into OASIS.
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Examples of Palliative Care Patients Served by Home Health
In order to support CMS's efforts to better define the palliative care population in home health, we offer the following patient examples which are outside of the MMTA category but meet the eligibility requirements for homebound and skilled-need requirements and require palliative-based supports rather than rehabilitative supports. As CMS considers updates to the Medicare Benefit Policy Manual we hope that these types of patients can be included.
Patient A:
A 78-year-old patient with end-stage heart failure and a non-healing Stage 4 sacral pressure ulcer receives home health under the Wound/Skin grouping. Skilled nursing provides complex dressing changes and pain management to prevent infection and control symptoms. The Medicare Administrative Contractor (MAC) may deny claims, arguing that dressing changes are maintenance care that a family caregiver can perform, overlooking the clinical complexity of managing a deteriorating palliative wound and breakthrough pain.
Patient Profile
Condition: Stage 4 sacral pressure ulcer, end-stage heart failure, severe chronic pain.
Grouping: Wound/Skin Management.
Goal: Palliation, symptom control, and wound stabilization rather than healing or functional recovery.
Patient B:
A 74-year-old patient with an advanced, progressive ischemic stroke (recurrent) and vascular dementia maps to the Neuro/Stroke Rehabilitation clinical grouping.
The patient is receiving skilled physical and speech therapy under a skilled maintenance program alongside nursing for palliative symptom management. Because the patient has reached a plateau and is in slow neurological decline, a Medicare Administrative Contractor (MAC) looking through a traditional restorative lens sees a high denial risk. Lack of restorative progress, and the expectation that a caregiver could be trained to provide custodial support (vs a skilled need) would be typical.
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Centers for Medicare & Medicaid Services. (n.d.). Home health outcome measures table: OASIS-E 2025 [Data table]. https://www.cms.gov/files/document/home-health-outcome-measures-table-oasis-e2025.pdf
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Patient Profile
Primary Diagnosis (ICD-10): I69.398 (Other sequelae of cerebral infarction) paired with F01.511 (Vascular dementia with behavioral disturbance).
PDGM Grouping: Neuro/Stroke Rehabilitation.
Clinical Picture: Severe left-sided hemiplegia, profound dysphagia, neurogenic bowel/bladder, and aphasia. The patient is bedbound and requires maximum assistance for all transfers.
Care Plan Focus: Palliative maintenance therapy. This includes establishing a safe positioning routine to prevent aspiration, physical therapy to prevent debilitating joint contractures, and nursing to manage neurogenic pain and terminal agitation.
We recommend CMS issue the following guidance for MACs in addition to an illustrative example in the Medicare Benefit Policy Manual:
CMS should provide clear guidance to the MACs that denials should not be based on any standard of decline, i.e., with how quickly a patient declines or how slowly they decline. By the nature of the benefit, home health is time limited and does not adequately account for the full trajectory of an individual's decline.
CMS should provide clear guidance to the MACs that training and support for family caregivers to provide palliative care including dressing changes and complex symptom management supports are grounds for home health service.
Home Health Quality Reporting Program (HH QRP)
LeadingAge strongly supports CMS's efforts to better align the HH QRP program with the Expanded Home Health Value Based Purchasing (HHVBP) model as well as creating more consistency between the reporting standards for the calendar year payment updates and the Annual Payment Updates (APU). Additionally, we provide considerations for future measures that look at advance care planning and the role of home health agencies in the process.
Proposal To Revise HH QRP Data Submission Deadlines Beginning with the CY 2027 HH QRP
In the CY2026 Home Health Proposed Rule, CMS solicited feedback on reducing the OASIS assessment data submission deadline from 4.5 months to 45 days. Generally, commenters were supportive of the change including LeadingAge who recommended 60 days instead of 45 days to align with the expectations of the current Conditions of Participation. Generally, LeadingAge supported the change which would shorten the amount of time it takes for quality measure data to be posted publicly on Care Compare. We did note concerns that a 60-day timeline may be more appropriate for home health due to the reporting requirements of OASIS. In this rule, CMS provides additional detail on the proposed 45-day timeline which better explains the purpose of aligning to this standard instead of the 60-day standard due to aligning the reporting with calendar quarters. LeadingAge supports CMS's proposal to reduce the OASIS assessment data submission deadline from 4.5 months to 45 days.
Proposal To Revise the OASIS & HHCAHPS Annual Payment Update Reporting Timeframe and Regulation Text Related to Reconsiderations
The current OASIS and HHCAHPS annual payment update (APU) reporting timeframe differs from that used by other major CMS payment updates. Notably, the expanded HHVBP Model annual payment adjustment and the HH PPS updates are both based on a calendar year timeline. To improve alignment between HH payment policies and OASIS QRP reporting requirements, CMS is proposing to revise the OASIS and HHCAHPS APU data reporting timeframe to reflect a January 1 through December 31 reporting timeframe, or the calendar year. CMS believes this update would provide clarity to HH payment updates and facilitate the alignment of the HH pay-for-reporting policies with other HH payment policies.
As stated above, LeadingAge supports CMS's work to align the data submission expectations of the program with the calendar year nature of the rule instead of a federal fiscal year. To that end, LeadingAge supports revisions to both the OASIS and HHCAHPS Annual Payment Update Reporting Timeframes as well as the corresponding regulatory text revisions to implement the changes.
HQRP Measure Concepts Under Consideration for Future Years-Request for Information (RFI)
CMS requested feedback on the importance, relevance, appropriateness, and applicability of the quality measure concepts related to advance care planning in home health. In part, this comes from CMS's efforts during the Measures Under Consideration process to include a measure in the HH QRP that would look at the percentage of patients 18 and older with one inpatient encounter who have an advance care planning document or documentation of an advance care planning discussion resulting in a documented decision in the electronic health record. This was tied to a record being available at the time of hospital discharge despite being proposed for the home health setting.
While LeadingAge agrees with CMS that in post-acute care (PAC) settings, where patients recover from acute illness, injury, or major procedures, their needs and goals may evolve as their condition changes, we do not necessarily agree that holding PAC providers accountable to a measure of documenting advance care planning is effective. We agree that patient priorities can shift over the course of recovery, especially if the recovery is difficult and not meeting the expectations of the patient or certifying clinician. We agree that regular reassessment and transparent communication 21 is essential to maintaining personcentered care, however, high-quality advance care planning is essential to achieve goal-concordant care.
While LeadingAge strongly supports advance care planning with Medicare beneficiaries in other settings, due to the continuing decrease in visits and the intermittent and temporary nature of home health services, lack of evidence-based advance care planning interventions in home health, and current clear regulatory barriers, LeadingAge does not believe it is either appropriate, relevant, or applicable to develop advance care planning measures for home health agencies.
CMS was clear that evidence-based outcomes are prioritized in determining which aspects of advance care planning are appropriate for home health. In our review of the existing, limited research on advance care planning in home health, there is limited research on the most common conditions seen by home health agencies, including cardiovascular and pulmonary disease and in general more research is needed on the role home health agencies play in these discussions.
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Many of the studies had very limited sample size, often restricted to a single agency, and while some of the goal conflicts between family members was mitigated by a home health agency's intervention in the planning conversation, there were no statistically significant differences found in perceptions of collaboration and readiness for advanced care planning in the population.
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When we discussed this effort with our members, all members shared that they comply with the requirements of 42 CFR 489.102(a) to provide written information about patient rights with regards to advance care planning, requirements to document in the medical record if the patient has an advance directive and having written policies and procedures regarding advance directives.
Additionally, the regulations clearly state:
(i) In the case of a home health agency, in advance of the individual coming under the care of the agency. The HHA may furnish advance directives information to a patient at the time of the first home visit, as long as the information is furnished before care is provided.
This seems to imply that home health agencies should not engage in advance care planning while providing care to the patient. While many of our members shared they attempt to address changing needs of patients and communicate those needs to the referring/certifying clinician, they have limited time with patients and in many cases do not have long term relationships with patients like other providers would. Many members felt like additional education to support staff to have an effective advance care planning conversation would be welcome; however, one study from the UK found limited evidence for the effectiveness of advanced care training for care home workers and despite the call for additional research few studies exist.
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Bigger, S., & Haddad, L. (2019). Advance Care Planning in Home Health: A Review of the Literature. Journal of Hospice & Palliative Nursing, 21(6), 518-523. https://doi.org/10.1097/NJH.0000000000000591
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Tay, D. L., Ellington, L., Towsley, G. L., Supiano, K., & Berg, C. A. (2020). Evaluation of a collaborative advance care planning intervention among older adult home health patients and their caregivers. Journal of Palliative Medicine, 23(9), 1214-1222. https://doi.org/10.1089/jpm.2019.0521
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Gleeson, A., Noble, S., & Mann, M. (2021). Advance care planning for home health staff: A systematic review. BMJ Supportive & Palliative Care, 11(2), 209-216. https://doi.org/10.1136/bmjspcare-2018-001680
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The Expanded Home Health Value Based Purchasing
LeadingAge appreciates CMS's update on the Expanded HHVBP program in this year's rule. In particular, we are grateful CMS took our recommendations from CY2026 and did not make any changes to the HHVBP program this calendar year. Since the implementation of the program there have been multiple changes in the measurement baselines and quality measures, continually moving the goalposts for home health agencies. We are eager to have a year with no changes to measures, baselines or otherwise to work with members to improve their performance.
We also appreciate CMS bringing to the attention of the HHVBP Technical Expert Panel (TEP) changes recommended by LeadingAge to scoring rules associated with accurate data submission.
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CMS confirmed LeadingAge's findings that 14% of the highest performing HHVBP agencies (those receiving a +5% adjustment) also received an annual payment adjustment penalty of 2% for missing their quality reporting expectations and the majority were in Los Angeles, CA. We are grateful to the TEP for understanding our concerns and seeing CMS's proposals to address the issue as "intuitive and long overdue." The TEP did request CMS conduct further analysis of the potential impacts to providers and we hope CMS will propose changes to this particular scoring rule in future rulemaking cycles to preserve the integrity of the Expanded HHVBP model.
While CMS did not propose any changes to the Expanded HHVBP model, we wish to convey our previous recommendation on the program specifically, expanding the number of cohorts. The original demonstration of the Home Health Value Based Purchasing (HHVBP) model, which occurred in only nine states, was highly positive and correlated with considerable savings and improved quality of services. In the initial demonstration, cohorts were organized by states, not sizes of agencies. Generally, this allowed participants to compare themselves against agencies with similar client populations, regulatory burden from states, and allowed for a fair distribution of sizes. The expanded model created two simple cohort sizes: the small-volume cohort, which includes agencies with fewer than 60 unique beneficiaries in the baseline year, and the large-volume cohort, which includes agencies with 60 or more unique beneficiaries in the baseline year.
Our initial recommendation to CMS was to consider redefining cohort sizes based on average daily census or OASIS episodes during the baseline year. And while we still believe this is a valid redevelopment, the calculations necessary to redefine cohorts by patient size could be more cumbersome for CMS as well as agencies. However, if CMS were to define a third cohort to be large-volume agencies with less than 40 returned surveys in the baseline year which would prevent the calculation of CAHPS measures, this would create a more equitable distribution of cohorts and allow each to be compared based on available data. Currently, large-volume cohort agencies
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Abt Global. (2026). 2025 Technical Expert Panel meeting: Home Health Quality Reporting Program and Expanded Home Health Value-Based Purchasing Model summary report. Centers for Medicare & Medicaid Services. https://www.cms.gov/priorities/innovation/files/hhvbp-tep-summary-report.pdf
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LeadingAge. (n.d.). LeadingAge expresses concerns on Medicare home health benefit, HHVBP. https://leadingage.org/leadingage-expresses-concerns-on-medicare-home-health-benefit-hhvbp/
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without 40 returned surveys are not assessed a score for CAHPS measures. In LeadingAge's analysis of the CY2024 performance data, we found that, of the top 10 percent of large-volume achieving agencies (those receiving some percentage increase) 85% had "No or insufficient data available" for CAHPS scores to be included in their calculations. We argue this provides agencies who do not obtain enough returned surveys an advantage over those agencies with 40 or more completed returned surveys as those agencies with CAHPS scores have more data to be compared against their achievement and improvement thresholds.
Changing the cohort sizes would not only make the program more equitable, but it would also work to eliminate the earlier concerns regarding missing HH CAHPS data, as agencies that are of a smaller size in the larger-volume cohort struggle to get 40 returned surveys despite their compliance with HH QRP requirements.
We request CMS evaluate the creation of a third cohort which would bifurcate the current large-volume cohort into two: one cohort would include HHAs who had sufficient data to calculate CAHPS measures during the baseline year and a second cohort which did not have sufficient data to calculate CAHPS measures during the baseline year.
Provider Enrollment
General Comments on Enrollment Proposals
LeadingAge fundamentally supports CMS's efforts to protect the Medicare Trust Fund and Medicare beneficiaries from fraud, waste, and abuse. Enrollment policies are critical to prevent unqualified and potentially fraudulent individuals and entities from inappropriately billing the Medicare program and harming beneficiaries through subpar care delivery. The authorities currently conveyed to CMS allow for the denial and removal of these individuals and entities who engage in fraudulent or abusive behaviors.
We wish to make abundantly clear that LeadingAge has consistently supported the administration's targeted actions against fraud and has encouraged CMS's efforts to detect, prevent, and deter fraud, waste, and abuse in the Medicare program as evidenced by our numerous letters regarding our concerns.
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We are not opposed to stronger fraud enforcement. Rather, we believe that CMS should continue to target bad actors without creating a provider-enrollment regime in which broad discretion, undefined standards, third-party conduct, or simple technical compliance failures can produce disproportionate consequences for legitimate providers.
Our central concern is that the proposed rule significantly expands CMS's enrollment denial, revocation, reporting, and related enforcement authorities while simultaneously removing or failing to establish objective standards and procedural safeguards. The result could be severe and lasting enrollmen
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Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2311-0370
Home Care Association of New York State Opposes Proposed 3% Rate Reduction Threatening Home Health Access in New York
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
260 Washington Avenue Ext., Suite 100, Albany, NY 12203
P
518-426-8764
F 518-426-8888
E INFO@HCANYS.ORG WWW.HCANYS.ORG
August 31, 2026
U.S. Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1844-P P.O. Box 8013 Baltimore, MD 21244-8013
Re: File Code CMS-1844-P, Medicare Program; Home Health Calendar Year (CY) 2027 Prospective Payment System Rate Update & Wage Index ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. 260 Washington Avenue Ext., Suite 100, Albany, NY 12203 P 518-426-8764 F 518-426-8888 E INFO@HCANYS.ORG WWW.HCANYS.ORG August 31, 2026 U.S. Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1844-P P.O. Box 8013 Baltimore, MD 21244-8013 Re: File Code CMS-1844-P, Medicare Program; Home Health Calendar Year (CY) 2027 Prospective Payment System Rate Update & Wage IndexUpdate
To CMS Officials:
The Home Care Association of New York State (HCANYS) is a statewide not-for-profit organization representing approximately 100 home care and hospice providers, allied organizations, managed care providers and individuals committed to the advancement of quality home health and hospice care services in New York State.
On behalf of our certified home health agency (CHHA) members that serve many of the approximately 140,000 Medicare home health beneficiaries annually in New York, we appreciate the opportunity to provide comments on the U.S. Centers for Medicare and Medicaid Services (CMS) Medicare Program Home Health CY 2027 Prospective Payment System (PPS) Rate Update and Wage Index Update.
General Overview of CMS's CY 2027 Proposed Rule
CMS's proposed rule updates the Medicare home health payment rates for CHHAs serving Medicare beneficiaries in CY 2027.
In addition to the payment updates, the rule contains numerous proposed changes and updates that HCANYS is interested in providing comments and in some cases recommendations. These include the following:
A 3.0 percent reduction for CY 2027, that is equivalent to a 0.9700 temporary adjustment factor, to the CY 2027 national standardized payment rate to recoup approximately $500 million of the $4.9 billion in alleged overpayments from 2020-2025.
A market-basket increase of 2.1 percent based on an annual inflation update of 3.1 percent, reduced by a 1.0 percent productivity adjustment.
An updated CY 2027 Wage Index and a request for information (RFI) on the construction of a home health specific wage index.
A discussion regarding the provision of palliative care under the Medicare home health benefit and future sub-regulatory guidance.
Proposed provider enrollment changes aimed at addressing fraud, waste and abuse.
Proposed policy changes to better align the Home Health Quality Reporting Program (HHQRP) and the Home Health Value Based Purchasing (HHVBP) Model, including revisions to the data submission and correction timeframes.
HCANYS Strongly Opposes CMS's 3% Temporary Rate Reduction in the CY 2027 Proposed Rule
HCANYS writes in serious opposition to the 3.0% temporary adjustment that could jeopardize access to care at home, as the true cost of providing comprehensive, high-quality care continues to rise. The estimated total impact of this proposal is a $500 million decrease in funding to Medicare-certified home health agencies (CHHAs) in CY 2027. And while Medicare payments are proposed to increase in CY 2027, this is still a 3% cut to the 30-day rate that agencies will experience, on top of years of compounding permanent and temporary payment cuts.
The proposed reductions come in the wake of over 22% in funding cuts imposed by CMS from 2020 to 2026 that have already caused beneficiaries to lose access to home health care as CHHAs substantially reduce service areas or close altogether. According to CMS's own data, since 2019, 20 CHHAs have closed and approximately 188,000 Medicare enrollees needed but did not receive home health care between 2020-2025 here in New York. Simply put, the New York CHHA delivery system cannot sustain the temporary reduction set forth in the proposed rule, especially considering over 60% of the agencies in the state are already experiencing negative operating margins.
If finalized, the proposed temporary reduction will devastate the delivery system, leaving beneficiaries with essentially no viable option to receive skilled care in their homes and communities, and forcing them into higher-cost, higher-risk institutional settings at greater cost to the Medicare program.
HCANYS Comments
HCANYS and our colleagues at The National Alliance for Care at Home (The Alliance) have previously commented on the flaws in CMS's methodology for determining permanent and temporary rate adjustments to CHHA payment rates. We continue to have significant technical concerns with CMS's approach that relies on a simulation of payments under the pre-PDGM payment system to establish a budget neutrality target that effectively places an artificial limit on current PDGM payments.
CMS's approach is explicitly intended to replicate what payments would have been had the agency not implemented PDGM and the 30-day unit of payment. However, the approach fails to accurately do that but rather establishes an arbitrarily low limit on current payments. Critically, CMS fails to update aspects of its model to reflect routine changes that would have been made to the pre-PDGM payment system such as recalibration of the case mix weights and updates to LUPA thresholds. Other concerns relating to use of the data and the misalignment between the pre-PDGM simulation model and actual PDGM payments result in bias and estimation error that are compounded year after year as these adjustments are applied.
The proposed 3% negative temporary adjustment to the CY 2027 rate impacts home health's ability to compete for a limited pipeline of healthcare workers, limiting our ability to serve patients, meet community needs, and ultimately impacting patient access to care. A single positive year does not restore a base rate that has been subject to cuts for years and is reduced again by a temporary adjustment.
HCANYS Recommendations
For these reasons, we urge CMS to not finalize the proposed temporary adjustment in the Proposed Rule. Further, HCANYS implores CMS to refine its methodologies to make them consistent with Congressional intent. CMS's methodology contains critical flaws that overstate the previous permanent and temporary payment adjustments, incorrectly attributing them to provider behavior, when they are largely the result of unrelated policy changes and technical errors. In fact, the only behavioral changes of note that affect Medicare spending are:
An increased level of Low Utilization Payment Adjustments (LUPAs) that are significantly higher than CMS estimated, which decreases overall Medicare home health spending.
An increased functional domain scoring which is unknown as to the distribution of real versus nominal changes which increases Medicare home health spending.
Reduction in therapy visits triggered by changes in financial incentives under PDGM in contrast to the HHPPS incentives with therapy thresholds. We believe that CMS should not use CY 2020 through 2025 therapy utilization data to determine budget neutrality.
Simply put, CMS has overcorrected for any plausible behavior change as a result of the 30-day unit of payment and new case-mix adjustment methodology implemented on January 1, 2020, and should issue a positive permanent adjustment instead of a negative one.
HCANYS believes that Medicare payments should be accurate, predictable, and support access to high-quality home healthcare. However, based on the data and serious concerns presented in this comment letter, we believe that CMS policies result in a home health benefit that is failing patients, providers, and the Medicare program.
These rate cuts are not sustainable and will cause significant harm to the home health care delivery system and beneficiaries it serves, in Medicare fee-for-service, Medicare Advantage, and under CMS's innovation models that promote use of home care.
Lastly, CMS should also consider the impact home health had on reduced hospitalizations in Medicare and the overall savings to the Medicare program because of the Home Health Value Based Purchasing (HHVBP) program.
HCANYS's Concerns with the Proposed 2.1% CY 2027 Home Health Market Basket Update
By statute CMS is required to utilize the inpatient hospital market basket update (currently projected at 3.1% for CY 2027) less a productivity adjustment (currently estimated to be 1.0 percentage point for CY 2027) to arrive at the annual payment update for home health services. As a result, CMS projects the home health market basket update percentage for CY 2027 to be 2.1%.
This value may change if more recent data becomes available prior to publication of a final CY 2027 home health payment rule. The 2.1% update appears to be the lowest market basket update since the implementation of HHPPS in CY 2000. While we understand that CMS has limited discretion relative to calculation of the annual payment update, we are deeply concerned that the projected payment update for home health (as well as hospice) provider members will be inadequate to address the accelerating financial demands that home health has been facing over the course of the last five years. HCANYS' CHHA members have voiced numerous issues that are creating these financial strains, including:
Severe workforce shortages caused by caregiver burnout and higher pay in other healthcare sectors.
Increased costs related to management fees, outsourcing, recruitment, staff retention.
Need to offer sign-on bonuses or travel pay at increased rates in many cases, to attract and/or retain one's workforce.
Raising prices and other inflationary pressures such as the increased costs for gasoline, supplies, drugs, and other items essential to the delivery of high-quality home health care.
Continuation of the 2% Medicare Sequestration cut.
HCANYS Comments & Recommendations
We are very concerned that the market basket update factors are not sufficiently sensitive to appropriately reflect the rapid financial changes and challenges that home health and hospice providers have experienced over the past 5-6 years. While we understand that CMS has limited flexibility relative to the inputs it uses to calculate the market basket update, we strongly encourage you to explore all options available to address the financial strains that providers are undergoing, including the following:
Examine trends relative to HIS Global's forecasts to determine whether more recently available data than used for the final CY 2027 rule would result in a higher market basket update and determine whether additional updates could be made during the course of CY 2027 to provide additional support to home health and other providers.
Direct various divisions of CMS to examine potential options for home health regulatory relief, with a particular focus on policies that could help to address issues that contribute to the existing workforce crisis, including reductions in paperwork and more appropriate utilization of various clinical personnel.
Proposed CY 2027 Home Health Wage Index Update & RFI on Potential New Home Health Specific Wage Index
Background
As part of the CY 2023 Home Health final rule, CMS established a permanent approach to smooth year-to-year changes in providers' wage indexes by placing a 5 percent cap on all wage index decreases in future years, regardless of the reason for the decrease. Under this change, a geographic area's wage index would not be less than 95 percent of its wage index calculated in the prior FY.
CMS also finalized that if a geographic area's prior CY wage index is calculated based on the 5 percent cap, then the following year's wage index would not be less than 95 percent of the geographic area's capped wage index in the prior CY. The 5 percent cap will be implemented in a budget neutral manner and would be applied after the application of the hospice wage index floor. If there is a 5 percent decrease from the previous FY's wage index value after the application of the hospice wage index floor, then the 5 percent cap on wage index decreases would also be applied. CMS will be analyzing the effects of this policy on an ongoing basis in the future in order to assess its appropriateness.
For CY 2027, the proposed home health wage index would be based on the Fiscal Year (FY) 2027 hospital pre-floor, pre-reclassified wage index for hospital cost reporting periods beginning on or after October 1, 2022, and before October 1, 2023 (FY 2023 cost report data).
HCANYS Comments & Concerns
While HCANYS supports a cap on losses in wage index values, we believe that the CMS should consider lowering the cap to 2% in order to protect CHHAs who are already operating with negative or razor-thin operating margins and are still experiencing multiple negative consequences due to the COVID pandemic, such as increased costs and loss of staff.
HCANYS is encouraged that CMS is soliciting comments on whether the agency should consider using alternative data sources to construct a home health specific wage index for potential use in future years. Throughout the years, HCANYS has asked CMS to consider for wholesale revision and reform of the home health and hospice wage index. We believe the pre-floor, pre-reclassified hospital wage index is wholly inadequate for adjusting home health costs, particularly in states like New York, which has among the nation's highest labor costs and continues to increase.
While HCANYS believes using alternative data sources, such as the Bureau of Labor Statistics (BLS) data and home health specific Medicare cost reports would be potentially better than the pre-floor, pre-reclassified hospital wage index, we would like to see CMS provide more preliminary data from these two potential sources before we make a formal recommendation to CMS.
Palliative Care under the Medicare Home Health Benefit Discussion
In the proposed rule, CMS wants to expand access to community-based palliative care. Specifically, CMS states that because palliative care is a method of care delivery that is provided throughout the continuum of illness, it can be furnished under various Medicare benefits. CMS notes that palliative services are covered under home health if patients meet current home health skilled-care criteria, and an allowed practitioner determines the need for palliative care, regardless of prognosis, diagnosis, or treatment goals. Palliative care services can include skilled nursing, therapy, and social work, and the goals of care can be symptom management, functional support, and advance care planning needs, which allows palliative care to most appropriately fall within the Medication Management, Teaching, and Assessment (MMTA) clinical group under PDGM (for documentation and billing purposes). In line with its goal of encouraging community-based palliative care, CMS plans to add additional palliative care examples to its examples of skilled care in the Medicare Benefit Policy Manual and seeks further input on strategies to reach that goal.
HCANYS Comments
HCANYS appreciates CMS's proposal to clarify that palliative care is a skilled service under the Medicare home health benefit. As CMS acknowledges in the proposed rule, home health agencies are already serving patients with serious or chronic illness under the existing benefit through symptom relief, pain and medication management, coordination and caregiver support, and that's certainly the case here in New York.
As an association representing both Home Health Agencies and hospice providers that serve the same New York communities, we see this as a meaningful opportunity: broader, better-defined palliative care access can strengthen the continuum of serious illness care, helping patients transition smoothly to hospice should they become terminally ill. We encourage CMS to build this policy into a well-defined, formally recognized coverage pathway, consistent with the recommendations the National Alliance for Care at Home submitted on the parallel palliative care RFI in the FY2027 Hospice Rule (CMS-1851-P).
That same dual perspective also surfaces a question worth asking: our hospice members have raised open questions about how expanded, formally recognized palliative care under home health will affect referral timing and pathways into hospice. As CMS finalizes this clarification, we urge the Agency to consider how accompanying quality measures, documentation standards, and payment structures can be designed to support - rather than inadvertently discourage - timely, appropriate referral from palliative-focused home health care to hospice as a patient's condition progresses. New York's hospice and home health agency providers are well positioned to help CMS understand these referral dynamics in practice, and we welcome the opportunity to serve as a resource as the Agency develops implementing guidance, including any future updates to Chapter 7 of the Medicare Benefit Policy Manual. HCANYS encourages CMS to consider establishing a Technical Expert Panel (TEP) of home health agency representatives, and state and national associations experts to assist CMS going forward.
Medicare Provider Enrollment Proposals
CMS is proposing several new and revised provider enrollment provisions to build on current program integrity initiatives to crush fraud, waste, and abuse. These revisions apply to all Medicare provider types. The proposed provider enrollment enhancements outline various mechanisms to confirm that providers and suppliers are valid to bill Medicare for services and items furnished to the beneficiary. CMS is also proposing an expanded definition of "operational" that would define what the agency considers a valid provider. These new provisions are to "gatekeep" potential fraudulent and unqualified providers from entering the program.
Some of the most significant proposed requirements include the following areas:
Retroactive Revocations
Shortened Post-Revocation Claim Submission Period
Abuse of Billing Privileges
False or Misleading Information Revocations
High-Risk Enrollments
Misdemeanor Convictions
Changes in Majority Ownership
Payment Suspensions
Temporary Enrollment Moratoria
HCANYS' Comments & Concerns
HCANYS generally supports CMS's efforts to strengthen provider enrollment processes and enhance program integrity in the home health and hospice Medicare benefits. HCANYS also strongly supports CMS's goal of removing bad actors from the Medicare program and protecting the beneficiaries the program serves.
As CMS referenced in the proposed rule, our colleagues at The National Alliance for Care at Home (The Alliance) in collaboration with other state and national trade associations submitted detailed program integrity recommendations in December 2025 urging targeted, data-driven actions. HCANYS and the Alliance support program integrity measures that hold bad actors accountable through targeted, data-driven enforcement, without restricting patient access or harming the legitimate providers patients rely on.
However, we are concerned that several of these fraud, waste and abuse proposals in the rule do not distinguish bad actors from legitimate providers operating in good faith, and will ultimately impair care access for these beneficiaries. If finalized, CMS could effectively deny or revoke a legitimate provider's enrollment based on a neighbor's conduct, a shared address, a vendor relationship, or innocent mistakes in enrollment activity, none of which is fraudulent activity. Other proposals rely on standards that CMS does not define, raising questions and doubt among the provider community and ultimately threatening decreased investment in and access to care at home.
The consequences of these proposals in our industry are severe. A revocation or termination does not simply close a business. It ends the relationship that established agencies have built with their patients. For beneficiaries in a rural county served by a lone CHHA or hospice, there may be no alternative provider. An enforcement tool that does not distinguish between bad actors and legitimate providers operating in good faith ultimately reaches the very beneficiaries who depend on them. This is not in the best interest of the Medicare program.
HCANYS's Recommendations
HCANYS asks CMS to not finalize proposals of this scale without a proposal-specific assessment of the affected universe, estimated frequency of action, compliance and monitoring costs, implementation burden, and beneficiary access implications. CMS should also distinctly analyze the impact on rural and underserved communities, where one provider's removal or a multi-site organization's loss of enrollment can have significant consequences disproportionate to the alleged infraction. CMS should also solicit data on the number of existing shared location arrangements, the prevalence of shared vendors and management relationships, and the operational cost of identifying historic affiliations and newly reportable personnel.
Other Provider Enrollment Issues: Delays in processing provider enrollment applications and changes in information
HCANYS has heard from some of our CHHA members that the time frames for Medicare Administrative Contractors (MACs) to process enrollment applications, changes in ownership, and other updates to provider information have become increasingly lengthy. In some cases, MACs take many months to complete these transactions. Additionally, it is not unusual for MACs to request documentation that has already been submitted by the agency, creating unnecessary duplication and further delaying processing.
HCANYS Recommendations: CMS should:
Work with MACs to establish clear and reasonable processing timeframes for provider enrollment and change of ownership requests, with transparent tracking of progress.
Require MACs to implement systems that prevent duplicate document requests and ensure that information already submitted is appropriately retained and applied to the pending file. This would reduce the administrative burden on CHHAs, minimize operational disruption, and help ensure that beneficiaries have uninterrupted access to care.
Home Health Quality Reporting Program (HHQRP) Proposed Policy to Better Align this Program and the Home Health Value Based Purchasing (HHVBP) Model, including revisions to the Data Submission Timeframes
CMS proposes to change the OASIS assessment data submission and correction timeframe from 4.5 months to, essentially, 45 days beginning with the CY2027 data. The 45th day would be the 15th day of the second month after the end of each calendar quarter. In situations where the 15th day falls on a Friday, weekend, or Federal holiday, the date is delayed until 11:59 p.m. EST on the next business day.
This change would affect the CY 2029 annual payment update year. Part of the reason for this change is to reduce the lag time between the end of the data collection period and when measures are publicly reported. There is currently a 9-month lag, and this change could reduce it by 3 months. In last year's proposed rule, CMS included an RFI about a change of this kind and industry feedback was supportive of the change as most providers are currently submitting their OASIS records within the 45-day window. In fact, CMS found that nearly all OASIS assessments, 99.27%, are already submitted within 45 days.
HCANYS Comments
HCANYS supports CMS's proposal to change the OASIS assessment data submission and correction timeframe from 4.5 months to, essentially, 45 days beginning with the CY2027 data, which would affect the CY 2029 HHVBP payment update. We believe CMS's determination that 99.27% of OASIS assessments are already submitted with 45 days nationally and that New York agencies would be in that general range as well.
Conclusion
HCANYS thanks CMS for this opportunity to submit comments and respectfully request CMS's consideration of our concerns and recommendations. I would be pleased to answer any questions or assist CMS staff in any way going forward and can be contacted at pconole@hcanys.org or (518) 810-0661.
Sincerely,
Patrick Conole, MHA Vice President, Finance & Management Home Care Association of New York State, Inc.
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2311-0304
260 Washington Avenue Ext., Suite 100, Albany, NY 12203
P
518-426-8764
F 518-426-8888
E INFO@HCANYS.ORG WWW.HCANYS.ORG
August 31, 2026
U.S. Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1844-P P.O. Box 8013 Baltimore, MD 21244-8013
Re: File Code CMS-1844-P, Medicare Program; Home Health Calendar Year (CY) 2027 Prospective Payment System Rate Update & Wage Index ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. 260 Washington Avenue Ext., Suite 100, Albany, NY 12203 P 518-426-8764 F 518-426-8888 E INFO@HCANYS.ORG WWW.HCANYS.ORG August 31, 2026 U.S. Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1844-P P.O. Box 8013 Baltimore, MD 21244-8013 Re: File Code CMS-1844-P, Medicare Program; Home Health Calendar Year (CY) 2027 Prospective Payment System Rate Update & Wage IndexUpdate
To CMS Officials:
The Home Care Association of New York State (HCANYS) is a statewide not-for-profit organization representing approximately 100 home care and hospice providers, allied organizations, managed care providers and individuals committed to the advancement of quality home health and hospice care services in New York State.
On behalf of our certified home health agency (CHHA) members that serve many of the approximately 140,000 Medicare home health beneficiaries annually in New York, we appreciate the opportunity to provide comments on the U.S. Centers for Medicare and Medicaid Services (CMS) Medicare Program Home Health CY 2027 Prospective Payment System (PPS) Rate Update and Wage Index Update.
General Overview of CMS's CY 2027 Proposed Rule
CMS's proposed rule updates the Medicare home health payment rates for CHHAs serving Medicare beneficiaries in CY 2027.
In addition to the payment updates, the rule contains numerous proposed changes and updates that HCANYS is interested in providing comments and in some cases recommendations. These include the following:
A 3.0 percent reduction for CY 2027, that is equivalent to a 0.9700 temporary adjustment factor, to the CY 2027 national standardized payment rate to recoup approximately $500 million of the $4.9 billion in alleged overpayments from 2020-2025.
A market-basket increase of 2.1 percent based on an annual inflation update of 3.1 percent, reduced by a 1.0 percent productivity adjustment.
An updated CY 2027 Wage Index and a request for information (RFI) on the construction of a home health specific wage index.
A discussion regarding the provision of palliative care under the Medicare home health benefit and future sub-regulatory guidance.
Proposed provider enrollment changes aimed at addressing fraud, waste and abuse.
Proposed policy changes to better align the Home Health Quality Reporting Program (HHQRP) and the Home Health Value Based Purchasing (HHVBP) Model, including revisions to the data submission and correction timeframes.
HCANYS Strongly Opposes CMS's 3% Temporary Rate Reduction in the CY 2027 Proposed Rule
HCANYS writes in serious opposition to the 3.0% temporary adjustment that could jeopardize access to care at home, as the true cost of providing comprehensive, high-quality care continues to rise. The estimated total impact of this proposal is a $500 million decrease in funding to Medicare-certified home health agencies (CHHAs) in CY 2027. And while Medicare payments are proposed to increase in CY 2027, this is still a 3% cut to the 30-day rate that agencies will experience, on top of years of compounding permanent and temporary payment cuts.
The proposed reductions come in the wake of over 22% in funding cuts imposed by CMS from 2020 to 2026 that have already caused beneficiaries to lose access to home health care as CHHAs substantially reduce service areas or close altogether. According to CMS's own data, since 2019, 20 CHHAs have closed and approximately 188,000 Medicare enrollees needed but did not receive home health care between 2020-2025 here in New York. Simply put, the New York CHHA delivery system cannot sustain the temporary reduction set forth in the proposed rule, especially considering over 60% of the agencies in the state are already experiencing negative operating margins.
If finalized, the proposed temporary reduction will devastate the delivery system, leaving beneficiaries with essentially no viable option to receive skilled care in their homes and communities, and forcing them into higher-cost, higher-risk institutional settings at greater cost to the Medicare program.
HCANYS Comments
HCANYS and our colleagues at The National Alliance for Care at Home (The Alliance) have previously commented on the flaws in CMS's methodology for determining permanent and temporary rate adjustments to CHHA payment rates. We continue to have significant technical concerns with CMS's approach that relies on a simulation of payments under the pre-PDGM payment system to establish a budget neutrality target that effectively places an artificial limit on current PDGM payments.
CMS's approach is explicitly intended to replicate what payments would have been had the agency not implemented PDGM and the 30-day unit of payment. However, the approach fails to accurately do that but rather establishes an arbitrarily low limit on current payments. Critically, CMS fails to update aspects of its model to reflect routine changes that would have been made to the pre-PDGM payment system such as recalibration of the case mix weights and updates to LUPA thresholds. Other concerns relating to use of the data and the misalignment between the pre-PDGM simulation model and actual PDGM payments result in bias and estimation error that are compounded year after year as these adjustments are applied.
The proposed 3% negative temporary adjustment to the CY 2027 rate impacts home health's ability to compete for a limited pipeline of healthcare workers, limiting our ability to serve patients, meet community needs, and ultimately impacting patient access to care. A single positive year does not restore a base rate that has been subject to cuts for years and is reduced again by a temporary adjustment.
HCANYS Recommendations
For these reasons, we urge CMS to not finalize the proposed temporary adjustment in the Proposed Rule. Further, HCANYS implores CMS to refine its methodologies to make them consistent with Congressional intent. CMS's methodology contains critical flaws that overstate the previous permanent and temporary payment adjustments, incorrectly attributing them to provider behavior, when they are largely the result of unrelated policy changes and technical errors. In fact, the only behavioral changes of note that affect Medicare spending are:
An increased level of Low Utilization Payment Adjustments (LUPAs) that are significantly higher than CMS estimated, which decreases overall Medicare home health spending.
An increased functional domain scoring which is unknown as to the distribution of real versus nominal changes which increases Medicare home health spending.
Reduction in therapy visits triggered by changes in financial incentives under PDGM in contrast to the HHPPS incentives with therapy thresholds. We believe that CMS should not use CY 2020 through 2025 therapy utilization data to determine budget neutrality.
Simply put, CMS has overcorrected for any plausible behavior change as a result of the 30-day unit of payment and new case-mix adjustment methodology implemented on January 1, 2020, and should issue a positive permanent adjustment instead of a negative one.
HCANYS believes that Medicare payments should be accurate, predictable, and support access to high-quality home healthcare. However, based on the data and serious concerns presented in this comment letter, we believe that CMS policies result in a home health benefit that is failing patients, providers, and the Medicare program.
These rate cuts are not sustainable and will cause significant harm to the home health care delivery system and beneficiaries it serves, in Medicare fee-for-service, Medicare Advantage, and under CMS's innovation models that promote use of home care.
Lastly, CMS should also consider the impact home health had on reduced hospitalizations in Medicare and the overall savings to the Medicare program because of the Home Health Value Based Purchasing (HHVBP) program.
HCANYS's Concerns with the Proposed 2.1% CY 2027 Home Health Market Basket Update
By statute CMS is required to utilize the inpatient hospital market basket update (currently projected at 3.1% for CY 2027) less a productivity adjustment (currently estimated to be 1.0 percentage point for CY 2027) to arrive at the annual payment update for home health services. As a result, CMS projects the home health market basket update percentage for CY 2027 to be 2.1%.
This value may change if more recent data becomes available prior to publication of a final CY 2027 home health payment rule. The 2.1% update appears to be the lowest market basket update since the implementation of HHPPS in CY 2000. While we understand that CMS has limited discretion relative to calculation of the annual payment update, we are deeply concerned that the projected payment update for home health (as well as hospice) provider members will be inadequate to address the accelerating financial demands that home health has been facing over the course of the last five years. HCANYS' CHHA members have voiced numerous issues that are creating these financial strains, including:
Severe workforce shortages caused by caregiver burnout and higher pay in other healthcare sectors.
Increased costs related to management fees, outsourcing, recruitment, staff retention.
Need to offer sign-on bonuses or travel pay at increased rates in many cases, to attract and/or retain one's workforce.
Raising prices and other inflationary pressures such as the increased costs for gasoline, supplies, drugs, and other items essential to the delivery of high-quality home health care.
Continuation of the 2% Medicare Sequestration cut.
HCANYS Comments & Recommendations
We are very concerned that the market basket update factors are not sufficiently sensitive to appropriately reflect the rapid financial changes and challenges that home health and hospice providers have experienced over the past 5-6 years. While we understand that CMS has limited flexibility relative to the inputs it uses to calculate the market basket update, we strongly encourage you to explore all options available to address the financial strains that providers are undergoing, including the following:
Examine trends relative to HIS Global's forecasts to determine whether more recently available data than used for the final CY 2027 rule would result in a higher market basket update and determine whether additional updates could be made during the course of CY 2027 to provide additional support to home health and other providers.
Direct various divisions of CMS to examine potential options for home health regulatory relief, with a particular focus on policies that could help to address issues that contribute to the existing workforce crisis, including reductions in paperwork and more appropriate utilization of various clinical personnel.
Proposed CY 2027 Home Health Wage Index Update & RFI on Potential New Home Health Specific Wage Index
Background
As part of the CY 2023 Home Health final rule, CMS established a permanent approach to smooth year-to-year changes in providers' wage indexes by placing a 5 percent cap on all wage index decreases in future years, regardless of the reason for the decrease. Under this change, a geographic area's wage index would not be less than 95 percent of its wage index calculated in the prior FY.
CMS also finalized that if a geographic area's prior CY wage index is calculated based on the 5 percent cap, then the following year's wage index would not be less than 95 percent of the geographic area's capped wage index in the prior CY. The 5 percent cap will be implemented in a budget neutral manner and would be applied after the application of the hospice wage index floor. If there is a 5 percent decrease from the previous FY's wage index value after the application of the hospice wage index floor, then the 5 percent cap on wage index decreases would also be applied. CMS will be analyzing the effects of this policy on an ongoing basis in the future in order to assess its appropriateness.
For CY 2027, the proposed home health wage index would be based on the Fiscal Year (FY) 2027 hospital pre-floor, pre-reclassified wage index for hospital cost reporting periods beginning on or after October 1, 2022, and before October 1, 2023 (FY 2023 cost report data).
HCANYS Comments & Concerns
While HCANYS supports a cap on losses in wage index values, we believe that the CMS should consider lowering the cap to 2% in order to protect CHHAs who are already operating with negative or razor-thin operating margins and are still experiencing multiple negative consequences due to the COVID pandemic, such as increased costs and loss of staff.
HCANYS is encouraged that CMS is soliciting comments on whether the agency should consider using alternative data sources to construct a home health specific wage index for potential use in future years. Throughout the years, HCANYS has asked CMS to consider for wholesale revision and reform of the home health and hospice wage index. We believe the pre-floor, pre-reclassified hospital wage index is wholly inadequate for adjusting home health costs, particularly in states like New York, which has among the nation's highest labor costs and continues to increase.
While HCANYS believes using alternative data sources, such as the Bureau of Labor Statistics (BLS) data and home health specific Medicare cost reports would be potentially better than the pre-floor, pre-reclassified hospital wage index, we would like to see CMS provide more preliminary data from these two potential sources before we make a formal recommendation to CMS.
Palliative Care under the Medicare Home Health Benefit Discussion
In the proposed rule, CMS wants to expand access to community-based palliative care. Specifically, CMS states that because palliative care is a method of care delivery that is provided throughout the continuum of illness, it can be furnished under various Medicare benefits. CMS notes that palliative services are covered under home health if patients meet current home health skilled-care criteria, and an allowed practitioner determines the need for palliative care, regardless of prognosis, diagnosis, or treatment goals. Palliative care services can include skilled nursing, therapy, and social work, and the goals of care can be symptom management, functional support, and advance care planning needs, which allows palliative care to most appropriately fall within the Medication Management, Teaching, and Assessment (MMTA) clinical group under PDGM (for documentation and billing purposes). In line with its goal of encouraging community-based palliative care, CMS plans to add additional palliative care examples to its examples of skilled care in the Medicare Benefit Policy Manual and seeks further input on strategies to reach that goal.
HCANYS Comments
HCANYS appreciates CMS's proposal to clarify that palliative care is a skilled service under the Medicare home health benefit. As CMS acknowledges in the proposed rule, home health agencies are already serving patients with serious or chronic illness under the existing benefit through symptom relief, pain and medication management, coordination and caregiver support, and that's certainly the case here in New York.
As an association representing both Home Health Agencies and hospice providers that serve the same New York communities, we see this as a meaningful opportunity: broader, better-defined palliative care access can strengthen the continuum of serious illness care, helping patients transition smoothly to hospice should they become terminally ill. We encourage CMS to build this policy into a well-defined, formally recognized coverage pathway, consistent with the recommendations the National Alliance for Care at Home submitted on the parallel palliative care RFI in the FY2027 Hospice Rule (CMS-1851-P).
That same dual perspective also surfaces a question worth asking: our hospice members have raised open questions about how expanded, formally recognized palliative care under home health will affect referral timing and pathways into hospice. As CMS finalizes this clarification, we urge the Agency to consider how accompanying quality measures, documentation standards, and payment structures can be designed to support - rather than inadvertently discourage - timely, appropriate referral from palliative-focused home health care to hospice as a patient's condition progresses. New York's hospice and home health agency providers are well positioned to help CMS understand these referral dynamics in practice, and we welcome the opportunity to serve as a resource as the Agency develops implementing guidance, including any future updates to Chapter 7 of the Medicare Benefit Policy Manual. HCANYS encourages CMS to consider establishing a Technical Expert Panel (TEP) of home health agency representatives, and state and national associations experts to assist CMS going forward.
Medicare Provider Enrollment Proposals
CMS is proposing several new and revised provider enrollment provisions to build on current program integrity initiatives to crush fraud, waste, and abuse. These revisions apply to all Medicare provider types. The proposed provider enrollment enhancements outline various mechanisms to confirm that providers and suppliers are valid to bill Medicare for services and items furnished to the beneficiary. CMS is also proposing an expanded definition of "operational" that would define what the agency considers a valid provider. These new provisions are to "gatekeep" potential fraudulent and unqualified providers from entering the program.
Some of the most significant proposed requirements include the following areas:
Retroactive Revocations
Shortened Post-Revocation Claim Submission Period
Abuse of Billing Privileges
False or Misleading Information Revocations
High-Risk Enrollments
Misdemeanor Convictions
Changes in Majority Ownership
Payment Suspensions
Temporary Enrollment Moratoria
HCANYS' Comments & Concerns
HCANYS generally supports CMS's efforts to strengthen provider enrollment processes and enhance program integrity in the home health and hospice Medicare benefits. HCANYS also strongly supports CMS's goal of removing bad actors from the Medicare program and protecting the beneficiaries the program serves.
As CMS referenced in the proposed rule, our colleagues at The National Alliance for Care at Home (The Alliance) in collaboration with other state and national trade associations submitted detailed program integrity recommendations in December 2025 urging targeted, data-driven actions. HCANYS and the Alliance support program integrity measures that hold bad actors accountable through targeted, data-driven enforcement, without restricting patient access or harming the legitimate providers patients rely on.
However, we are concerned that several of these fraud, waste and abuse proposals in the rule do not distinguish bad actors from legitimate providers operating in good faith, and will ultimately impair care access for these beneficiaries. If finalized, CMS could effectively deny or revoke a legitimate provider's enrollment based on a neighbor's conduct, a shared address, a vendor relationship, or innocent mistakes in enrollment activity, none of which is fraudulent activity. Other proposals rely on standards that CMS does not define, raising questions and doubt among the provider community and ultimately threatening decreased investment in and access to care at home.
The consequences of these proposals in our industry are severe. A revocation or termination does not simply close a business. It ends the relationship that established agencies have built with their patients. For beneficiaries in a rural county served by a lone CHHA or hospice, there may be no alternative provider. An enforcement tool that does not distinguish between bad actors and legitimate providers operating in good faith ultimately reaches the very beneficiaries who depend on them. This is not in the best interest of the Medicare program.
HCANYS's Recommendations
HCANYS asks CMS to not finalize proposals of this scale without a proposal-specific assessment of the affected universe, estimated frequency of action, compliance and monitoring costs, implementation burden, and beneficiary access implications. CMS should also distinctly analyze the impact on rural and underserved communities, where one provider's removal or a multi-site organization's loss of enrollment can have significant consequences disproportionate to the alleged infraction. CMS should also solicit data on the number of existing shared location arrangements, the prevalence of shared vendors and management relationships, and the operational cost of identifying historic affiliations and newly reportable personnel.
Other Provider Enrollment Issues: Delays in processing provider enrollment applications and changes in information
HCANYS has heard from some of our CHHA members that the time frames for Medicare Administrative Contractors (MACs) to process enrollment applications, changes in ownership, and other updates to provider information have become increasingly lengthy. In some cases, MACs take many months to complete these transactions. Additionally, it is not unusual for MACs to request documentation that has already been submitted by the agency, creating unnecessary duplication and further delaying processing.
HCANYS Recommendations: CMS should:
Work with MACs to establish clear and reasonable processing timeframes for provider enrollment and change of ownership requests, with transparent tracking of progress.
Require MACs to implement systems that prevent duplicate document requests and ensure that information already submitted is appropriately retained and applied to the pending file. This would reduce the administrative burden on CHHAs, minimize operational disruption, and help ensure that beneficiaries have uninterrupted access to care.
Home Health Quality Reporting Program (HHQRP) Proposed Policy to Better Align this Program and the Home Health Value Based Purchasing (HHVBP) Model, including revisions to the Data Submission Timeframes
CMS proposes to change the OASIS assessment data submission and correction timeframe from 4.5 months to, essentially, 45 days beginning with the CY2027 data. The 45th day would be the 15th day of the second month after the end of each calendar quarter. In situations where the 15th day falls on a Friday, weekend, or Federal holiday, the date is delayed until 11:59 p.m. EST on the next business day.
This change would affect the CY 2029 annual payment update year. Part of the reason for this change is to reduce the lag time between the end of the data collection period and when measures are publicly reported. There is currently a 9-month lag, and this change could reduce it by 3 months. In last year's proposed rule, CMS included an RFI about a change of this kind and industry feedback was supportive of the change as most providers are currently submitting their OASIS records within the 45-day window. In fact, CMS found that nearly all OASIS assessments, 99.27%, are already submitted within 45 days.
HCANYS Comments
HCANYS supports CMS's proposal to change the OASIS assessment data submission and correction timeframe from 4.5 months to, essentially, 45 days beginning with the CY2027 data, which would affect the CY 2029 HHVBP payment update. We believe CMS's determination that 99.27% of OASIS assessments are already submitted with 45 days nationally and that New York agencies would be in that general range as well.
Conclusion
HCANYS thanks CMS for this opportunity to submit comments and respectfully request CMS's consideration of our concerns and recommendations. I would be pleased to answer any questions or assist CMS staff in any way going forward and can be contacted at pconole@hcanys.org or (518) 810-0661.
Sincerely,
Patrick Conole, MHA Vice President, Finance & Management Home Care Association of New York State, Inc.
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2311-0304
Essentia Health Raises Concerns Over Proposed Medicare Payment Cuts and Expanded Regulations Threatening Rural Home Health Access
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork
August 28, 2026
The Honorable Dr. Mehmet Oz
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1828-P
P.O. Box 8013
Baltimore, MD 21244-8013
Submitted electronically via regulations.gov
Re:
Calendar Year (CY) 2027 Home Health ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork August 28, 2026 The Honorable Dr. Mehmet Oz Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1828-P P.O. Box 8013 Baltimore, MD 21244-8013 Submitted electronically via regulations.gov Re: Calendar Year (CY) 2027 Home HealthProspective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the HH Value-Based Purchasing Expanded Model
Dear Administrator Oz:
On behalf of Essentia Health, we appreciate the opportunity to comment on the CY 2027 Home Health Prospective Payment System proposed rule. As outlined in our comments, we are concerned that the proposed policies to reduce Medicare payments for home health services pose a significant threat to the sustainability of the system and risk diminishing access to care-particularly in rural communities. Additionally, we have serious concerns regarding the expanded scope and definitions that are being proposed to Medicare provider eligibility.
Essentia Health is headquartered in Duluth, Minnesota, and combines the strengths and talents of 15,000 employees, including 2,200 physicians and advanced practitioners, who serve a largely rural region across Minnesota, Wisconsin, and North Dakota including 17 federally recognized Tribal Nations. Essentia Health is a mission-driven organization, being called to make a healthy difference in people's lives. Essentia lives out this mission with a patient-centered focus at 14 hospitals, 80 clinics, six long-term care facilities, two assisted and three independent living facilities, seven ambulance services, 29 retail pharmacies, and a rural health research institute.
Essentia Health delivers comprehensive home care services from seven communities located across Minnesota and eastern North Dakota. These services support patients recovering from procedures, injuries, or illnesses, along with managing chronic health conditions or disabilities. Our home health services reduce or eliminate the need for hospitalization, along with delaying or avoiding transitions to nursing homes or assisted living facilities. All Essentia Health locations offering home health care are fully certified by Medicare.
Payment Under the Home Health (HH) Prospective Payment System (PPS)
In the CY 2019 HH PPS final rule, home health payments changed from a 60-day episode to a 30-day period effective for those 30-day periods beginning on or after January 1, 2020. In this rule, CMS proposes to increase net Home Health (HH) payments by an estimated 2.4% or $420 million, after all policy changes, compared to estimated CY 2026 payments.
Budget Neutral Implementation of Patient Driven Groupings Model (PDGM)
The Bipartisan Budget Act required CMS to implement PDGM in a budget-neutral manner, measured through annual comparisons of assumed versus actual behavioral changes in aggregate expenditures. In the CY 2019 final rule, CMS finalized three behavioral assumptions: clinical group coding, comorbidity coding, and the low-utilization payment adjustment (LUPA) threshold. CMS was required to conduct these calculations from 2020 through 2026 and applied a series of permanent adjustments during that period.
For CY 2027, CMS determined that no additional permanent payment adjustment is necessary because recent utilization changes cannot be directly attributed to PDGM implementation. Essentia Health appreciates CMS's decision not to apply a permanent payment adjustment for CY 2027 and would encourage CMS to not implement further permanent payment reductions.
We urge CMS to use its "time and manner" discretionary authority under the Bipartisan Budget Act of 2018 to pause any additional budget-neutrality and behavioral adjustments until the flaws in prior implementation can be addressed.
Standardized Payment Amount and Temporary Adjustment to Base Payment Rate
Accounting for the market basket increase, behavioral adjustments, and budget neutrality factors, CMS proposes a standardized 30-day payment amount of $2,092.27. This is the standard amount that, in conjunction with case-mix weights and other factors, is used to determine claims payments. Providers who fail to submit quality data would receive a 2% reduction in this amount. CMS also proposes that if more recent data becomes available, the data may be used to determine the CY 2027 market-based percentage increase and productivity adjustment in the final rule.
We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork
CMS proposes to apply a -3.0% temporary adjustment to the base payment rate for CY 2027. Per CMS, this temporary adjustment is needed to recoup past overpayments; specifically, CMS states that this adjustment recoups $500 million of the $4.9 billion in overpayments it has estimated from the differences between the assumed and actual provider behavior under PDGM. Among these cuts, CMS proposes adjusting the fixed-dollar loss (FDL) amount for high-cost outliers, which it estimates will increase payments by an additional 0.3%, and proposes a reduction by a 1.0% productivity adjustment.
Essentia Health continues to have concerns regarding the 3.0% temporary reduction adjustment to the CY 2027 national, standardized 30-day base payment rate, along with a 1.0% productivity reduction adjustment. CMS' use of additional temporary adjustments in future years represents a pattern of downward adjustments that poses operational risks, especially for rural home health providers. Rural providers must travel greater distances to serve an increasingly older and medically complex population. As the workforce availability declines, staff members and clinicians are required to cover larger geographic territories which increases mileage, travel time, and recruitment costs. In fact, during the first seven months of 2026, four local home health care providers serving Minnesota and North Dakota either announced their closure or indicated plans to close citing regulatory burdens. Therefore, Essentia Health recommends CMS pause or scale back the 3.0% temporary reduction adjustment and remove the 1.0% productivity adjustment.
Home Health Case-Mix Weights Recalibration
CMS recalibrates home health case-mix weights each year using the most recent complete claims and patient assessment data. For the proposed CY 2027 weights, CMS used CY 2025 data, available as of March 15, 2026, for 30-day episodes under PDGM and found utilization remained similar to 2024 visit patterns. CMS also proposes updates to functional impairment levels, comorbidity subgroups, and LUPA thresholds, including a one-visit decrease in the LUPA threshold for 18 case-mix weights and a one-visit increase for two case-mix groups. Essentia Health recognizes CMS's annual recalibration process based on recent claims and assessment data.
Home Health Case-Mix Weights Recalibration references:
1. MK Manoylov, "Altru Health System to Close Home Health Service Line," Home Health Care News, August 11, 2026, https://homehealthcarenews.com/2026/08/altru-health-system-to-close-home-health-service-line/.
2. "RiverView Health Announces It Will Discontinue Home Care Services, Conduct Internal Restructuring, and Reduce Clinic Hours in RLF," KROX, January 21, 2026, https://kroxam.com/riverview-health-announces-it-will-discontinue-home-care-services-conduct-internal-restructuring-and-reduce-clinic-hours-in-rlf/.
3. Aspirus Health, "Important Change to Home Health Services at Aspirus St. Luke's," May 19, 2026, https://www.aspirus.org/press-room/important-change-to-home-health-services-at-aspiru-5113.
4. OAHS Marketing, "OAHS Announces Planned Transition of Home Health Services," Ortonville Area Health Services, July 28, 2026, https://oahs.us/oahs-announces-planned-transition-of-home-health-services/.
We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork
Essentia Health remains concerned that the proposed updates to functional impairment levels, comorbidity subgroups, and LUPA thresholds may not fully account for the resources needed to care for high-acuity patients. Standardized payments that do not adequately reflect clinical complexity could underfund care for patients requiring intensive, multidisciplinary support. We urge CMS to assess the long-term impact of these changes on access to care, particularly for vulnerable populations, and to provide data identifying outlier patients and the sources of additional costs.
Without appropriate payment adjustments, home health agencies may be forced to limit services, which could increase emergency department visits, hospitalizations, and overall costs.
Request for Information (RFI) - Construction of a Home Health Specific Wage Index
Currently, the inpatient prospective payment system (IPPS) hospital wage index is used when calculating the home health prospective payment system wage index. CMS is seeking comments on using alternative data sources to construct a home health specific wage index to use in future years.
Essentia Health urges CMS to carefully evaluate the implications of separating home health payments from the hospital wage index. Unlike hospitals, home health agencies vary in their mix of occupations and staffing ratios, including but not limited to, home health aides, nurses, physical and occupational therapists, and speech therapists. Consistent with the RFI in the proposed FY Hospice Wage Index and Payment Rate Update rule, Essentia Health encourages CMS to develop home health-specific wage index in a manner that reflects all relevant services and occupations and avoids unintended negative impacts on rural providers.
Home Health Quality Reporting Program
Since 1999, the Social Security Act has required Medicare-certified home health agencies to collect and submit patient assessment data through OASIS, and since 2007, to participate in the Quality Reporting Program (QRP). Agencies that do not meet these requirements receive a 2% reduction on their annual market basket update.
Home Health Quality Reporting Program Assessment Data Submission Deadline
Currently, HHAs have approximately 4.5 months after the reporting quarter to correct any errors of their assessment-based data to calculate the measures. During the time of data submission for a given quarterly reporting period and up until the quarterly submission deadline, HHAs may review and perform corrections to errors in the assessment data used to calculate the measures. CMS states it takes approximately nine months for data to be publicly available, and this does not meet the intent of CMS to relay timely data to consumers and families. CMS is proposing to reduce the data submission timeframe from 4.5 months to the 15th day of the second month after the end of the calendar quarter.
In the CY 2026 HH PPS Proposed Rule, CMS issued a request for information on reducing the assessment data submission timeframe from 4.5 months to 45 days. Essentia Health remains concerned that such a substantial reduction could create operational challenges for providers and increase the risk of payment penalties for reasons outside a provider's control. CMS subsequently finalized a similar policy in the FY 2027 Skilled Nursing Facilities (SNF) final rule, reducing the SNF QRP assessment data submission timeframe from 4.5 months to 45 days. Essentia Health urges CMS to establish a process allowing home health agencies to request and receive extensions when circumstances affect their ability to submit required assessment data within the shortened timeframe.
OASIS Annual Payment Update Reporting Timeframe
As finalized in the CY 2007 HH PPS rule, HHAs are required to collect 12 months of data, starting on July 1 of the corresponding year. CMS states that the current OASIS annual payment update (APU) reporting timeframe differs from other CMS payment updates, including the HHVBP Model and the HH PPS, both of which are based on a calendar year timeline. To improve alignment, CMS is proposing to revise the OASIS APU reporting timelines to reflect a January 1 through December 31 calendar year. Essentia Health supports CMS's proposal to move the OASIS APU reporting timeframe to a calendar year cycle.
Home Health CAHPS Annual Payment Update Reporting Timeframe
As finalized in the CY 2011 HH PPS rule, HHAs are required to collect four quarters of data, starting on April 1 of the corresponding year. CMS states that the current HHCAHPS APU reporting timeframe differs from other CMS payment policies. To improve alignment, CMS is proposing to revise HHCAHPS APU reporting timelines to reflect a January 1 through December 31 calendar year timeframe. Essentia Health supports CMS's proposal to move the HHCAHPS APU reporting timeframe to a calendar year cycle.
Request for Information - Advanced Care Planning
CMS seeks input on the importance, relevance, appropriateness, and applicability of a quality measure related to advanced care planning. Specifically, CMS is requesting feedback related to the relevant aspects of advanced care planning and measures in the HH setting.
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As Essentia Health has noted in prior proposed rules, advance care planning is an important part of supporting continuity of patient care. Giving patients the opportunity to document their care preferences and end-of-life plans helps providers and hospitals honor their wishes.
Measuring ACP conversations should be coupled with a payment code that is indicative of the time spent with patients and their families. Payment should be reflective of best practice care models where conversations are conducted with trained nurses in-person or via telehealth.
If CMS pursues an advance care planning measure for home health, the measure should initially be process-oriented, asking whether patients have an advance care plan on file and, if not, offering them the opportunity to create one. Any such measure should also be voluntary for HHAs to allow time for adoption into clinical care practices and operations.
Medicare Provider Enrollment
CMS proposes major changes to the Medicare provider enrollment regulations that it states are intended to strengthen and clarify the enrollment process for all Medicare providers and suppliers. It also states that the proposals reflect the agency's intent to enhance Medicare program integrity by expanding enforcement tools, clarifying requirements, and updating definitions to address emerging challenges in provider enrollment and oversight. The proposals cover a wide range of topics including revocations, denials, moratoria, reactivations, and definitions relevant to provider enrollment and program integrity.
Essentia Health appreciates CMS's continued efforts to strengthen program integrity and prevent fraud, waste, and abuse within the Medicare program. We support sensible program integrity policies to combat fraudulent activity and the agency's goals to identify and prosecute fraudulent activity. Simply put, bad actors negatively impact all health care providers. The tools the agency uses to identify and determine fraud should not shift costs and burdens to providers acting in good faith complying with Medicare regulations.
Regulations designed to prevent fraud, waste, and abuse should include clear policy parameters, objective standards, and appropriate agency discretion. Essentia Health is concerned that, as proposed, this package of provider enrollment policies would substantially expand CMS's discretionary authority without providing sufficient clarity to regulatees. Overly ambiguous standards create uncertainty for providers that are acting in good faith and making reasonable efforts to comply with Medicare enrollment requirements. This vagueness and lack of clear, measurable standards will increase health care costs, divert resources away from patient care, and create disproportionate compliance administrative burden for health systems. We believe it is imperative that HHS allow health care providers the opportunity to review and respond to inquiries and allow for corrective action, even those due to inadvertent errors.
CMS proposes to make all revocations retroactive to the date noncompliance began, and to shorten the post-revocation claims submission window from 60 days to 15. Under that proposed framework, for example, if a hospital or post-acute provider inadvertently failed to report a change in a nursing director, it would have its enrollment revoked retroactively to the date the reporting deadline passed, resulting in the recoupment of payments received, and a compressed window for submitting claims for care already delivered.
CMS also proposes to revoke a provider's other enrollments following denial of a single enrollment application. An adverse determination arising from an enrollment record omission at one location could risk enrollments at unrelated facilities, inappropriately interrupting access to care in communities that may have no alternative source of that service. We do not believe it is the intention of the agency to systematically revoke hospital and provider enrollments based on inadvertent errors or clerical omissions. However, the proposed rule appears to allow this to be deemed as violations of Medicare enrollment policies. It is imperative that fair review and appeal procedures are reiterated in the final rule to prevent unintended consequences.
New Revocation Authority - Abuse of Billing Privileges
CMS proposes adding new reasons for revocation of a provider's enrollment. A common violation on the grounds of Medicare revocation is abuse of billing policies. Currently, CMS must consider specific factors when deciding whether a provider has established a "pattern or practice" of submitting claims that do not meet Medicare requirements. These factors provide guardrails and help limit subjective decision-making, including:
a) The percentage of submitted claims that were denied during the period under consideration.
b) Whether the provider or supplier has any history of final adverse actions and the nature of any such actions.
c) The type of billing non-compliance and the specific facts surrounding said non-compliance (to the extent this can be determined).
d) Any other information regarding the provider or supplier's specific circumstances that CMS deems relevant to its determination.
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CMS proposes to remove the specific factors (A-D) that are currently rules to determine whether a provider or supplier has engaged in a pattern or practice of failing to submit claims that meet Medicare regulations. These factors function as criteria requiring CMS to consider the proportion of denied claims, the provider's history of final adverse actions, the nature and circumstances of the alleged billing noncompliance, and other relevant facts specific to the provider's situation. Eliminating these objective considerations would significantly broaden the agency's discretion and could allow revocation decisions to be based on far less defined assessment of billing activity it claims fail Medicare requirements.
For example, under the proposal, the agency notes that finding a "pattern or practice" of abuse could be established through a simple finding that several of the provider's claims fail to meet Medicare requirements. Such determination could be made without clearly identifying the threshold, context, materiality, or intent necessary to distinguish inadvertent billing errors from conduct that warrants enforcement intervention.
Essentia Health has numerous concerns on the expansive, subjective discretion that may inadvertently impact providers acting in good faith complying with Medicare billing and claims policies. While we support robust efforts to identify and revoke billing privileges due to fraud, simply removing all objective criteria could lead to determinations of billing abuse that are unwarranted. Providers acting in good faith that inadvertently have billing errors should have a fair means to address and correct errors without the agency simply "finding errors" and "revoking" Medicare enrollment.
To that end, we strongly urge CMS to retain clear procedural safeguards that balance program oversight with fairness for regulated health care providers. At a minimum, CMS should provide:
timely notice of alleged billing concerns
a meaningful opportunity to review and respond to those concerns
access to appropriate, appeal rights, and
a reasonable opportunity to correct inadvertent or remedial billing issues before revocation is considered.
Revocation of Medicare enrollment should only be reserved for circumstances in which there is clear evidence of intentional misconduct, repeated noncompliance, or failure to correct identified issues after other program enforcement tools have been attempted and proven insufficient. We request that CMS reiterate policies in the final rule that ensure consistency and fairness.
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Managing Employee Definition Expansion
The existing definition around health care providers and facilities pertains to any "general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, whether or not that person is a W-2 employee." We support the current definition and urge CMS to withdraw the proposed unnecessary expansion to the managing employee definition.
CMS proposes to change the definition of managing employee to specifically include nursing directors, departmental heads, alternate administrators, and all other clinical personnel that "exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier."
This proposed revision represents a substantial expansion of the managing employee definition. Finalizing the rule change would create significant operational and administrative burdens for Medicare-enrolled providers and suppliers. By extending the definition to include a broader and specified range of clinical and operational personnel, CMS would require providers to identify, report, and continuously update enrollment records for a much larger group of employees than is currently required.
For integrated health systems that provide acute and post-acute care services, this expanded updating and reporting obligation would be extremely complex. Staffing structures, departmental leadership, interim assignments, and clinical management responsibilities frequently change across hospitals, clinics, home health agencies, and other service lines. Requiring providers to update Medicare enrollment documentation with each addition, departure, reassignment, or change in responsibility for individuals who may fall within the expanded definition would impose substantial compliance costs without clear benefits to support program integrity goals of the HHS leadership.
Provider enrollment teams would be placed in an unnecessarily difficult position under the proposed expansion. Under a plain-language reading of the proposal, hospitals and other providers may be required to report dozens, if not hundreds, of employees and submit detailed personal information for each individual "managing employee." Finalizing this policy would make enrollment records significantly longer, less accurate, and less useful to CMS than the information currently reported. There needs to be a balance around administrative requirements and actions around identifying fraud.
Operational challenges
The operational, practical challenge of this proposal is amplified by:
normal workforce turnover
organizational restructuring
role changes, and
facility-level operational adjustments.
Compliance with these requirements would require ongoing monitoring and repeated enrollment updates, diverting resources from new provider enrollments to provide patient care and focused instead on unnecessary compliance functions. Maintaining such extensive reporting requirements would be operationally infeasible for health systems like Essentia Health. Greater resources and more personnel would be needed to simply update managing employee changes and provider enrollment forms. The example provided in the proposed rule preamble describing a "hospitals' chief of cardiology" is simply an impractical application of managing employee in a hospital setting. This level of responsibility is usually the hospital administration, chief executive officer, or other administrative designee.
Reporting and updating forms
Medicare requires reportable changes in managing employee status to be submitted within 30 or 90 days depending on the change type. Medicare enrollment applications require personally identifiable information. The proposed definition expansion would also require the collection and maintenance of sensitive personal information for a substantially broader set of employees. Information required on forms includes names, dates of birth, home addresses, and Social Security numbers. Collecting, maintaining, and continuously updating this information for a substantially larger group of individuals would create an extraordinary administrative burden. We are deeply concerned that a rule intended to identify fraudulent enrollments would instead impose significant administrative burden on the hospitals and post-acute care providers. This directly contrasts with the agency's own goals around reducing regulatory burden.
Instead, the definition of managing employees should remain as-is in the regulation and include those who have primary operational oversight of the hospital, clinic, home health agency, skilled nursing facility, etc. This would balance administrative burden while still supporting the goals of program integrity. We believe there are other ways to improve program oversight other than a significant expansion of "managing employee." Therefore, we urge CMS to retain the current definition.
Affiliations
CMS currently requires providers to report on affiliations (focused on ownership and management) for the previous five years. CMS proposes removing the five-year lookback and expanding the definition to encompass any point in the provider's enrollment, regardless of how long the affiliation occurred. CMS is also expanding the definition to include:
1) an interest in which individuals or entities-or any of their "owning or managing employees or organizations"-exercise control or conduct day-to-day operations of another organization; and
2) any marketing, business, fulfillment, financial, managerial, or beneficiary relationships.
The proposed definition is not merely a clarification, but a major expansion in regulatory scope with potentially significant implications. A plain language read of the proposal creates uncertainty around numerous relationships and partnerships. For example, the revised affiliate definition could be applied to community partnerships, marketing arrangements, contractual service providers, vendors, medical device companies, and other third parties. If so, providers may become exposed to enrollment consequences arising from activities over which they have little or no control.
Any business relationship
The proposed rule adds, "any business relationship" to the definition of affiliation that encompasses every contractual relationship and vendors a hospital and post-acute care provider has ever engaged. This could include, but is not limited to:
medical device and pharmaceutical suppliers;
group purchasing organizations;
vendors, including electronic health record and revenue cycle vendors;
reference laboratories;
telemedicine partners and platforms;
locum tenens and travel nursing agencies;
ambulance and patient transport providers;
food service and environmental services contractors;
construction companies;
community organizations; and
the collaborative arrangements with Tribal Nations and public health agencies.
The ambiguity surrounding affiliate relationships could discourage legitimate collaborations, community partnerships, and innovative business arrangements that help providers deliver care and serve patients. Essentia Health opposes the expanded definition of affiliations that is far beyond the scope of a business affiliation.
Across the nation, many nonprofit health care providers, home health agencies, and integrated health systems have participated in Medicare for decades. Like others, Essentia Health has experienced numerous organizational, operational, contractual, and leadership changes during that time. Requiring providers to identify and report affiliations without a defined lookback period would be administratively infeasible.
These policies would inadequately impose substantial retrospective due diligence obligations that would be extremely difficult to complete. Historical records may no longer be available, prior relationships may have been limited in scope or duration, and individuals with knowledge of past arrangements may no longer be with the organization.
As a result, an expanded, potentially unlimited affiliation disclosure requirement could place good-faith providers at risk of noncompliance based on incomplete or unavailable historical information, rather than current conduct or meaningful program integrity concerns.
Affiliation disclosure currently operates within defined parameters generally reflective of industry practice. Under Sec. 424.519, a provider must disclose affiliations upon CMS request; during enrollment or revocation, and only when CMS has reason to believe a provider or supplier may have a qualifying affiliation. The requirement is also limited to affiliation from the previous five years involving providers or suppliers with a disclosable event. Those limits are what make the disclosure requirement workable.
Disclosure Lookback Period
CMS is proposing to broaden the scope of affiliation disclosure. The proposal would eliminate the five-year lookback period and expand the overall affiliation definition. To determine where a disclosure is required, a hospital must first identify every relationship that falls within the affiliation definition. Then, it must determine whether each entity or individual is or was enrolled in Medicare, Medicaid, or CHIP, and whether they have experienced a qualifying adverse event.
As proposed, that review would extend across the entire history of the hospital's enrollment and to the owning and managing employees of affiliated entities. CMS's own enrollment regulations establish a seven-year documentation retention period. The agency should not require providers to report information from a period longer for which its regulations require records to be maintained. An obligation that depends on documentation the agency does not require providers to keep places unnecessarily in creases adds risk based on the unavailability of historical records rather than on anything about their current conduct.
Essentia Health urges CMS to retain a reasonable, time-limited lookback period and to narrowly tailor any expanded affiliation reporting requirements to relationships that are meaningful affiliations under current policy.
Conclusion
On behalf of Essentia Health, we appreciate the opportunity to provide feedback on the CY 2027 Home Health Prospective Payment System proposed rule. First, we appreciate that CMS is not proposing a permanent negative payment adjustment. Although a payment reduction jeopardizes access to home health care, we urge CMS to finalize a temporary reduction only and clearly state as policy that no permanent adjustments will be considered in future rulemaking. Second, we urge caution on developing a home health wage index to ensure there is adequate time to review input data for accurate application. Next, timelines for quality reporting data submissions should include reasonable requests and approval policies for extensions, especially in the first year of the new policy.
Finally, we have numerous concerns regarding the expansive policies around program integrity, specifically around various definitions that only lead to significant resource burden to maintain compliance. While we support combatting fraud and identifying and prosecuting bad actors, additional costs, resource burden, and time will be placed on providers.
Please feel free to contact me with any questions.
Sincerely,
Brian Vamstad, PhD
Director of Regulatory Affairs
Essentia Health
brian.vamstad@essentiahealth.org
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2311-0275
We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork
August 28, 2026
The Honorable Dr. Mehmet Oz
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1828-P
P.O. Box 8013
Baltimore, MD 21244-8013
Submitted electronically via regulations.gov
Re:
Calendar Year (CY) 2027 Home Health ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork August 28, 2026 The Honorable Dr. Mehmet Oz Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1828-P P.O. Box 8013 Baltimore, MD 21244-8013 Submitted electronically via regulations.gov Re: Calendar Year (CY) 2027 Home HealthProspective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the HH Value-Based Purchasing Expanded Model
Dear Administrator Oz:
On behalf of Essentia Health, we appreciate the opportunity to comment on the CY 2027 Home Health Prospective Payment System proposed rule. As outlined in our comments, we are concerned that the proposed policies to reduce Medicare payments for home health services pose a significant threat to the sustainability of the system and risk diminishing access to care-particularly in rural communities. Additionally, we have serious concerns regarding the expanded scope and definitions that are being proposed to Medicare provider eligibility.
Essentia Health is headquartered in Duluth, Minnesota, and combines the strengths and talents of 15,000 employees, including 2,200 physicians and advanced practitioners, who serve a largely rural region across Minnesota, Wisconsin, and North Dakota including 17 federally recognized Tribal Nations. Essentia Health is a mission-driven organization, being called to make a healthy difference in people's lives. Essentia lives out this mission with a patient-centered focus at 14 hospitals, 80 clinics, six long-term care facilities, two assisted and three independent living facilities, seven ambulance services, 29 retail pharmacies, and a rural health research institute.
Essentia Health delivers comprehensive home care services from seven communities located across Minnesota and eastern North Dakota. These services support patients recovering from procedures, injuries, or illnesses, along with managing chronic health conditions or disabilities. Our home health services reduce or eliminate the need for hospitalization, along with delaying or avoiding transitions to nursing homes or assisted living facilities. All Essentia Health locations offering home health care are fully certified by Medicare.
Payment Under the Home Health (HH) Prospective Payment System (PPS)
In the CY 2019 HH PPS final rule, home health payments changed from a 60-day episode to a 30-day period effective for those 30-day periods beginning on or after January 1, 2020. In this rule, CMS proposes to increase net Home Health (HH) payments by an estimated 2.4% or $420 million, after all policy changes, compared to estimated CY 2026 payments.
Budget Neutral Implementation of Patient Driven Groupings Model (PDGM)
The Bipartisan Budget Act required CMS to implement PDGM in a budget-neutral manner, measured through annual comparisons of assumed versus actual behavioral changes in aggregate expenditures. In the CY 2019 final rule, CMS finalized three behavioral assumptions: clinical group coding, comorbidity coding, and the low-utilization payment adjustment (LUPA) threshold. CMS was required to conduct these calculations from 2020 through 2026 and applied a series of permanent adjustments during that period.
For CY 2027, CMS determined that no additional permanent payment adjustment is necessary because recent utilization changes cannot be directly attributed to PDGM implementation. Essentia Health appreciates CMS's decision not to apply a permanent payment adjustment for CY 2027 and would encourage CMS to not implement further permanent payment reductions.
We urge CMS to use its "time and manner" discretionary authority under the Bipartisan Budget Act of 2018 to pause any additional budget-neutrality and behavioral adjustments until the flaws in prior implementation can be addressed.
Standardized Payment Amount and Temporary Adjustment to Base Payment Rate
Accounting for the market basket increase, behavioral adjustments, and budget neutrality factors, CMS proposes a standardized 30-day payment amount of $2,092.27. This is the standard amount that, in conjunction with case-mix weights and other factors, is used to determine claims payments. Providers who fail to submit quality data would receive a 2% reduction in this amount. CMS also proposes that if more recent data becomes available, the data may be used to determine the CY 2027 market-based percentage increase and productivity adjustment in the final rule.
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CMS proposes to apply a -3.0% temporary adjustment to the base payment rate for CY 2027. Per CMS, this temporary adjustment is needed to recoup past overpayments; specifically, CMS states that this adjustment recoups $500 million of the $4.9 billion in overpayments it has estimated from the differences between the assumed and actual provider behavior under PDGM. Among these cuts, CMS proposes adjusting the fixed-dollar loss (FDL) amount for high-cost outliers, which it estimates will increase payments by an additional 0.3%, and proposes a reduction by a 1.0% productivity adjustment.
Essentia Health continues to have concerns regarding the 3.0% temporary reduction adjustment to the CY 2027 national, standardized 30-day base payment rate, along with a 1.0% productivity reduction adjustment. CMS' use of additional temporary adjustments in future years represents a pattern of downward adjustments that poses operational risks, especially for rural home health providers. Rural providers must travel greater distances to serve an increasingly older and medically complex population. As the workforce availability declines, staff members and clinicians are required to cover larger geographic territories which increases mileage, travel time, and recruitment costs. In fact, during the first seven months of 2026, four local home health care providers serving Minnesota and North Dakota either announced their closure or indicated plans to close citing regulatory burdens. Therefore, Essentia Health recommends CMS pause or scale back the 3.0% temporary reduction adjustment and remove the 1.0% productivity adjustment.
Home Health Case-Mix Weights Recalibration
CMS recalibrates home health case-mix weights each year using the most recent complete claims and patient assessment data. For the proposed CY 2027 weights, CMS used CY 2025 data, available as of March 15, 2026, for 30-day episodes under PDGM and found utilization remained similar to 2024 visit patterns. CMS also proposes updates to functional impairment levels, comorbidity subgroups, and LUPA thresholds, including a one-visit decrease in the LUPA threshold for 18 case-mix weights and a one-visit increase for two case-mix groups. Essentia Health recognizes CMS's annual recalibration process based on recent claims and assessment data.
Home Health Case-Mix Weights Recalibration references:
1. MK Manoylov, "Altru Health System to Close Home Health Service Line," Home Health Care News, August 11, 2026, https://homehealthcarenews.com/2026/08/altru-health-system-to-close-home-health-service-line/.
2. "RiverView Health Announces It Will Discontinue Home Care Services, Conduct Internal Restructuring, and Reduce Clinic Hours in RLF," KROX, January 21, 2026, https://kroxam.com/riverview-health-announces-it-will-discontinue-home-care-services-conduct-internal-restructuring-and-reduce-clinic-hours-in-rlf/.
3. Aspirus Health, "Important Change to Home Health Services at Aspirus St. Luke's," May 19, 2026, https://www.aspirus.org/press-room/important-change-to-home-health-services-at-aspiru-5113.
4. OAHS Marketing, "OAHS Announces Planned Transition of Home Health Services," Ortonville Area Health Services, July 28, 2026, https://oahs.us/oahs-announces-planned-transition-of-home-health-services/.
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Essentia Health remains concerned that the proposed updates to functional impairment levels, comorbidity subgroups, and LUPA thresholds may not fully account for the resources needed to care for high-acuity patients. Standardized payments that do not adequately reflect clinical complexity could underfund care for patients requiring intensive, multidisciplinary support. We urge CMS to assess the long-term impact of these changes on access to care, particularly for vulnerable populations, and to provide data identifying outlier patients and the sources of additional costs.
Without appropriate payment adjustments, home health agencies may be forced to limit services, which could increase emergency department visits, hospitalizations, and overall costs.
Request for Information (RFI) - Construction of a Home Health Specific Wage Index
Currently, the inpatient prospective payment system (IPPS) hospital wage index is used when calculating the home health prospective payment system wage index. CMS is seeking comments on using alternative data sources to construct a home health specific wage index to use in future years.
Essentia Health urges CMS to carefully evaluate the implications of separating home health payments from the hospital wage index. Unlike hospitals, home health agencies vary in their mix of occupations and staffing ratios, including but not limited to, home health aides, nurses, physical and occupational therapists, and speech therapists. Consistent with the RFI in the proposed FY Hospice Wage Index and Payment Rate Update rule, Essentia Health encourages CMS to develop home health-specific wage index in a manner that reflects all relevant services and occupations and avoids unintended negative impacts on rural providers.
Home Health Quality Reporting Program
Since 1999, the Social Security Act has required Medicare-certified home health agencies to collect and submit patient assessment data through OASIS, and since 2007, to participate in the Quality Reporting Program (QRP). Agencies that do not meet these requirements receive a 2% reduction on their annual market basket update.
Home Health Quality Reporting Program Assessment Data Submission Deadline
Currently, HHAs have approximately 4.5 months after the reporting quarter to correct any errors of their assessment-based data to calculate the measures. During the time of data submission for a given quarterly reporting period and up until the quarterly submission deadline, HHAs may review and perform corrections to errors in the assessment data used to calculate the measures. CMS states it takes approximately nine months for data to be publicly available, and this does not meet the intent of CMS to relay timely data to consumers and families. CMS is proposing to reduce the data submission timeframe from 4.5 months to the 15th day of the second month after the end of the calendar quarter.
In the CY 2026 HH PPS Proposed Rule, CMS issued a request for information on reducing the assessment data submission timeframe from 4.5 months to 45 days. Essentia Health remains concerned that such a substantial reduction could create operational challenges for providers and increase the risk of payment penalties for reasons outside a provider's control. CMS subsequently finalized a similar policy in the FY 2027 Skilled Nursing Facilities (SNF) final rule, reducing the SNF QRP assessment data submission timeframe from 4.5 months to 45 days. Essentia Health urges CMS to establish a process allowing home health agencies to request and receive extensions when circumstances affect their ability to submit required assessment data within the shortened timeframe.
OASIS Annual Payment Update Reporting Timeframe
As finalized in the CY 2007 HH PPS rule, HHAs are required to collect 12 months of data, starting on July 1 of the corresponding year. CMS states that the current OASIS annual payment update (APU) reporting timeframe differs from other CMS payment updates, including the HHVBP Model and the HH PPS, both of which are based on a calendar year timeline. To improve alignment, CMS is proposing to revise the OASIS APU reporting timelines to reflect a January 1 through December 31 calendar year. Essentia Health supports CMS's proposal to move the OASIS APU reporting timeframe to a calendar year cycle.
Home Health CAHPS Annual Payment Update Reporting Timeframe
As finalized in the CY 2011 HH PPS rule, HHAs are required to collect four quarters of data, starting on April 1 of the corresponding year. CMS states that the current HHCAHPS APU reporting timeframe differs from other CMS payment policies. To improve alignment, CMS is proposing to revise HHCAHPS APU reporting timelines to reflect a January 1 through December 31 calendar year timeframe. Essentia Health supports CMS's proposal to move the HHCAHPS APU reporting timeframe to a calendar year cycle.
Request for Information - Advanced Care Planning
CMS seeks input on the importance, relevance, appropriateness, and applicability of a quality measure related to advanced care planning. Specifically, CMS is requesting feedback related to the relevant aspects of advanced care planning and measures in the HH setting.
We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork
As Essentia Health has noted in prior proposed rules, advance care planning is an important part of supporting continuity of patient care. Giving patients the opportunity to document their care preferences and end-of-life plans helps providers and hospitals honor their wishes.
Measuring ACP conversations should be coupled with a payment code that is indicative of the time spent with patients and their families. Payment should be reflective of best practice care models where conversations are conducted with trained nurses in-person or via telehealth.
If CMS pursues an advance care planning measure for home health, the measure should initially be process-oriented, asking whether patients have an advance care plan on file and, if not, offering them the opportunity to create one. Any such measure should also be voluntary for HHAs to allow time for adoption into clinical care practices and operations.
Medicare Provider Enrollment
CMS proposes major changes to the Medicare provider enrollment regulations that it states are intended to strengthen and clarify the enrollment process for all Medicare providers and suppliers. It also states that the proposals reflect the agency's intent to enhance Medicare program integrity by expanding enforcement tools, clarifying requirements, and updating definitions to address emerging challenges in provider enrollment and oversight. The proposals cover a wide range of topics including revocations, denials, moratoria, reactivations, and definitions relevant to provider enrollment and program integrity.
Essentia Health appreciates CMS's continued efforts to strengthen program integrity and prevent fraud, waste, and abuse within the Medicare program. We support sensible program integrity policies to combat fraudulent activity and the agency's goals to identify and prosecute fraudulent activity. Simply put, bad actors negatively impact all health care providers. The tools the agency uses to identify and determine fraud should not shift costs and burdens to providers acting in good faith complying with Medicare regulations.
Regulations designed to prevent fraud, waste, and abuse should include clear policy parameters, objective standards, and appropriate agency discretion. Essentia Health is concerned that, as proposed, this package of provider enrollment policies would substantially expand CMS's discretionary authority without providing sufficient clarity to regulatees. Overly ambiguous standards create uncertainty for providers that are acting in good faith and making reasonable efforts to comply with Medicare enrollment requirements. This vagueness and lack of clear, measurable standards will increase health care costs, divert resources away from patient care, and create disproportionate compliance administrative burden for health systems. We believe it is imperative that HHS allow health care providers the opportunity to review and respond to inquiries and allow for corrective action, even those due to inadvertent errors.
CMS proposes to make all revocations retroactive to the date noncompliance began, and to shorten the post-revocation claims submission window from 60 days to 15. Under that proposed framework, for example, if a hospital or post-acute provider inadvertently failed to report a change in a nursing director, it would have its enrollment revoked retroactively to the date the reporting deadline passed, resulting in the recoupment of payments received, and a compressed window for submitting claims for care already delivered.
CMS also proposes to revoke a provider's other enrollments following denial of a single enrollment application. An adverse determination arising from an enrollment record omission at one location could risk enrollments at unrelated facilities, inappropriately interrupting access to care in communities that may have no alternative source of that service. We do not believe it is the intention of the agency to systematically revoke hospital and provider enrollments based on inadvertent errors or clerical omissions. However, the proposed rule appears to allow this to be deemed as violations of Medicare enrollment policies. It is imperative that fair review and appeal procedures are reiterated in the final rule to prevent unintended consequences.
New Revocation Authority - Abuse of Billing Privileges
CMS proposes adding new reasons for revocation of a provider's enrollment. A common violation on the grounds of Medicare revocation is abuse of billing policies. Currently, CMS must consider specific factors when deciding whether a provider has established a "pattern or practice" of submitting claims that do not meet Medicare requirements. These factors provide guardrails and help limit subjective decision-making, including:
a) The percentage of submitted claims that were denied during the period under consideration.
b) Whether the provider or supplier has any history of final adverse actions and the nature of any such actions.
c) The type of billing non-compliance and the specific facts surrounding said non-compliance (to the extent this can be determined).
d) Any other information regarding the provider or supplier's specific circumstances that CMS deems relevant to its determination.
We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork
CMS proposes to remove the specific factors (A-D) that are currently rules to determine whether a provider or supplier has engaged in a pattern or practice of failing to submit claims that meet Medicare regulations. These factors function as criteria requiring CMS to consider the proportion of denied claims, the provider's history of final adverse actions, the nature and circumstances of the alleged billing noncompliance, and other relevant facts specific to the provider's situation. Eliminating these objective considerations would significantly broaden the agency's discretion and could allow revocation decisions to be based on far less defined assessment of billing activity it claims fail Medicare requirements.
For example, under the proposal, the agency notes that finding a "pattern or practice" of abuse could be established through a simple finding that several of the provider's claims fail to meet Medicare requirements. Such determination could be made without clearly identifying the threshold, context, materiality, or intent necessary to distinguish inadvertent billing errors from conduct that warrants enforcement intervention.
Essentia Health has numerous concerns on the expansive, subjective discretion that may inadvertently impact providers acting in good faith complying with Medicare billing and claims policies. While we support robust efforts to identify and revoke billing privileges due to fraud, simply removing all objective criteria could lead to determinations of billing abuse that are unwarranted. Providers acting in good faith that inadvertently have billing errors should have a fair means to address and correct errors without the agency simply "finding errors" and "revoking" Medicare enrollment.
To that end, we strongly urge CMS to retain clear procedural safeguards that balance program oversight with fairness for regulated health care providers. At a minimum, CMS should provide:
timely notice of alleged billing concerns
a meaningful opportunity to review and respond to those concerns
access to appropriate, appeal rights, and
a reasonable opportunity to correct inadvertent or remedial billing issues before revocation is considered.
Revocation of Medicare enrollment should only be reserved for circumstances in which there is clear evidence of intentional misconduct, repeated noncompliance, or failure to correct identified issues after other program enforcement tools have been attempted and proven insufficient. We request that CMS reiterate policies in the final rule that ensure consistency and fairness.
We are called to make a healthy difference in people's lives. Quality | Hospitality | Respect | Joy | Justice | Stewardship | Teamwork
Managing Employee Definition Expansion
The existing definition around health care providers and facilities pertains to any "general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, whether or not that person is a W-2 employee." We support the current definition and urge CMS to withdraw the proposed unnecessary expansion to the managing employee definition.
CMS proposes to change the definition of managing employee to specifically include nursing directors, departmental heads, alternate administrators, and all other clinical personnel that "exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier."
This proposed revision represents a substantial expansion of the managing employee definition. Finalizing the rule change would create significant operational and administrative burdens for Medicare-enrolled providers and suppliers. By extending the definition to include a broader and specified range of clinical and operational personnel, CMS would require providers to identify, report, and continuously update enrollment records for a much larger group of employees than is currently required.
For integrated health systems that provide acute and post-acute care services, this expanded updating and reporting obligation would be extremely complex. Staffing structures, departmental leadership, interim assignments, and clinical management responsibilities frequently change across hospitals, clinics, home health agencies, and other service lines. Requiring providers to update Medicare enrollment documentation with each addition, departure, reassignment, or change in responsibility for individuals who may fall within the expanded definition would impose substantial compliance costs without clear benefits to support program integrity goals of the HHS leadership.
Provider enrollment teams would be placed in an unnecessarily difficult position under the proposed expansion. Under a plain-language reading of the proposal, hospitals and other providers may be required to report dozens, if not hundreds, of employees and submit detailed personal information for each individual "managing employee." Finalizing this policy would make enrollment records significantly longer, less accurate, and less useful to CMS than the information currently reported. There needs to be a balance around administrative requirements and actions around identifying fraud.
Operational challenges
The operational, practical challenge of this proposal is amplified by:
normal workforce turnover
organizational restructuring
role changes, and
facility-level operational adjustments.
Compliance with these requirements would require ongoing monitoring and repeated enrollment updates, diverting resources from new provider enrollments to provide patient care and focused instead on unnecessary compliance functions. Maintaining such extensive reporting requirements would be operationally infeasible for health systems like Essentia Health. Greater resources and more personnel would be needed to simply update managing employee changes and provider enrollment forms. The example provided in the proposed rule preamble describing a "hospitals' chief of cardiology" is simply an impractical application of managing employee in a hospital setting. This level of responsibility is usually the hospital administration, chief executive officer, or other administrative designee.
Reporting and updating forms
Medicare requires reportable changes in managing employee status to be submitted within 30 or 90 days depending on the change type. Medicare enrollment applications require personally identifiable information. The proposed definition expansion would also require the collection and maintenance of sensitive personal information for a substantially broader set of employees. Information required on forms includes names, dates of birth, home addresses, and Social Security numbers. Collecting, maintaining, and continuously updating this information for a substantially larger group of individuals would create an extraordinary administrative burden. We are deeply concerned that a rule intended to identify fraudulent enrollments would instead impose significant administrative burden on the hospitals and post-acute care providers. This directly contrasts with the agency's own goals around reducing regulatory burden.
Instead, the definition of managing employees should remain as-is in the regulation and include those who have primary operational oversight of the hospital, clinic, home health agency, skilled nursing facility, etc. This would balance administrative burden while still supporting the goals of program integrity. We believe there are other ways to improve program oversight other than a significant expansion of "managing employee." Therefore, we urge CMS to retain the current definition.
Affiliations
CMS currently requires providers to report on affiliations (focused on ownership and management) for the previous five years. CMS proposes removing the five-year lookback and expanding the definition to encompass any point in the provider's enrollment, regardless of how long the affiliation occurred. CMS is also expanding the definition to include:
1) an interest in which individuals or entities-or any of their "owning or managing employees or organizations"-exercise control or conduct day-to-day operations of another organization; and
2) any marketing, business, fulfillment, financial, managerial, or beneficiary relationships.
The proposed definition is not merely a clarification, but a major expansion in regulatory scope with potentially significant implications. A plain language read of the proposal creates uncertainty around numerous relationships and partnerships. For example, the revised affiliate definition could be applied to community partnerships, marketing arrangements, contractual service providers, vendors, medical device companies, and other third parties. If so, providers may become exposed to enrollment consequences arising from activities over which they have little or no control.
Any business relationship
The proposed rule adds, "any business relationship" to the definition of affiliation that encompasses every contractual relationship and vendors a hospital and post-acute care provider has ever engaged. This could include, but is not limited to:
medical device and pharmaceutical suppliers;
group purchasing organizations;
vendors, including electronic health record and revenue cycle vendors;
reference laboratories;
telemedicine partners and platforms;
locum tenens and travel nursing agencies;
ambulance and patient transport providers;
food service and environmental services contractors;
construction companies;
community organizations; and
the collaborative arrangements with Tribal Nations and public health agencies.
The ambiguity surrounding affiliate relationships could discourage legitimate collaborations, community partnerships, and innovative business arrangements that help providers deliver care and serve patients. Essentia Health opposes the expanded definition of affiliations that is far beyond the scope of a business affiliation.
Across the nation, many nonprofit health care providers, home health agencies, and integrated health systems have participated in Medicare for decades. Like others, Essentia Health has experienced numerous organizational, operational, contractual, and leadership changes during that time. Requiring providers to identify and report affiliations without a defined lookback period would be administratively infeasible.
These policies would inadequately impose substantial retrospective due diligence obligations that would be extremely difficult to complete. Historical records may no longer be available, prior relationships may have been limited in scope or duration, and individuals with knowledge of past arrangements may no longer be with the organization.
As a result, an expanded, potentially unlimited affiliation disclosure requirement could place good-faith providers at risk of noncompliance based on incomplete or unavailable historical information, rather than current conduct or meaningful program integrity concerns.
Affiliation disclosure currently operates within defined parameters generally reflective of industry practice. Under Sec. 424.519, a provider must disclose affiliations upon CMS request; during enrollment or revocation, and only when CMS has reason to believe a provider or supplier may have a qualifying affiliation. The requirement is also limited to affiliation from the previous five years involving providers or suppliers with a disclosable event. Those limits are what make the disclosure requirement workable.
Disclosure Lookback Period
CMS is proposing to broaden the scope of affiliation disclosure. The proposal would eliminate the five-year lookback period and expand the overall affiliation definition. To determine where a disclosure is required, a hospital must first identify every relationship that falls within the affiliation definition. Then, it must determine whether each entity or individual is or was enrolled in Medicare, Medicaid, or CHIP, and whether they have experienced a qualifying adverse event.
As proposed, that review would extend across the entire history of the hospital's enrollment and to the owning and managing employees of affiliated entities. CMS's own enrollment regulations establish a seven-year documentation retention period. The agency should not require providers to report information from a period longer for which its regulations require records to be maintained. An obligation that depends on documentation the agency does not require providers to keep places unnecessarily in creases adds risk based on the unavailability of historical records rather than on anything about their current conduct.
Essentia Health urges CMS to retain a reasonable, time-limited lookback period and to narrowly tailor any expanded affiliation reporting requirements to relationships that are meaningful affiliations under current policy.
Conclusion
On behalf of Essentia Health, we appreciate the opportunity to provide feedback on the CY 2027 Home Health Prospective Payment System proposed rule. First, we appreciate that CMS is not proposing a permanent negative payment adjustment. Although a payment reduction jeopardizes access to home health care, we urge CMS to finalize a temporary reduction only and clearly state as policy that no permanent adjustments will be considered in future rulemaking. Second, we urge caution on developing a home health wage index to ensure there is adequate time to review input data for accurate application. Next, timelines for quality reporting data submissions should include reasonable requests and approval policies for extensions, especially in the first year of the new policy.
Finally, we have numerous concerns regarding the expansive policies around program integrity, specifically around various definitions that only lead to significant resource burden to maintain compliance. While we support combatting fraud and identifying and prosecuting bad actors, additional costs, resource burden, and time will be placed on providers.
Please feel free to contact me with any questions.
Sincerely,
Brian Vamstad, PhD
Director of Regulatory Affairs
Essentia Health
brian.vamstad@essentiahealth.org
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2311-0275
Dutch Medical Clinics Urges CMS To Finalize New Maternity Care Codes And Opposes Alternative G-Code Proposal
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
The Honorable Dr. Mehmet Oz
Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244
Re: CMS-2026-2377 - CY 2027 Medicare Physician Fee Schedule Proposed Rule;
Section II.D.3.b.(27) Maternity Care Services
Dear Administrator Oz,
On behalf of Dutch Medical Clinics, Inc., a multi-specialty medical group in Mississippi, we ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. The Honorable Dr. Mehmet Oz Administrator, Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 Re: CMS-2026-2377 - CY 2027 Medicare Physician Fee Schedule Proposed Rule; Section II.D.3.b.(27) Maternity Care Services Dear Administrator Oz, On behalf of Dutch Medical Clinics, Inc., a multi-specialty medical group in Mississippi, weappreciate the opportunity to comment on the CY 2027 Medicare Physician Fee Schedule proposed rule. We write specifically regarding the proposed adoption of the new CPT codes for maternity care services and the accompanying solicitation of comments on alternative HCPCS G-codes.
I. Dutch Medical Clinics, Inc. strongly supports finalizing the new maternity care CPT codes with the proposed wRVUs.
We urge CMS to finalize, without delay, the 12 new CPT codes for labor management, delivery, and associated procedures, together with the use of existing E/M codes for antepartum and postpartum services, as proposed in Tables A-D2.
The global obstetric bundle was created in the 1990s around an uncomplicated pregnancy model - 13 prenatal visits, delivery, and a single postpartum visit - that no longer reflects clinical reality or current standards of care. Today's obstetric population is older and more medically complex, with substantially higher rates of hypertensive disorders, diabetes, and other comorbidities than when the bundle was designed. Labor management is longer and more intensive, care is increasingly delivered by teams including hospitalists and laborists, and transfers of care - especially from rural facilities - are common. The bundle cannot accommodate any of this.
The new code set will allow accurate reporting of services as they are actually delivered, support timely reimbursement rather than delaying payment for nearly a year of care, enable appropriate billing when care is shared across providers and facilities, and generate the granular claims data policymakers need to design value-based payment models and address the nation's unacceptably high rates of maternal morbidity and mortality.
II. Dutch Medical Clinics, Inc. strongly urges CMS NOT to finalize the alternative HCPCS G-code proposal.
We oppose the creation of HCPCS G-codes that would maintain the global obstetric bundle as a concurrent billing pathway. Operating two competing code systems for the same services would create significant confusion for providers, payers, clearinghouses, and patients; complicate EHR and billing system configuration; fragment data; and undermine the very transition the new code set is designed to achieve. The AMA CPT Editorial Panel's multi-stakeholder workgroup process - which included physicians, nurses, family medicine practitioners, and payers - has already produced a feasible, well-vetted structure, and stakeholders across the industry are preparing for it. A clean commitment to the new code set is what providers and patients need.
III. Conclusion
We thank CMS for its leadership in modernizing maternity care payment and urge the agency to finalize the new maternity CPT codes with the proposed wRVUs and decline to adopt the concurrent G-code structure.
Please contact Mary Hutcherson, VP of Revenue at mkhutcherson@allegroclinics.com with any questions.
Sincerely,
Emily Wright
Revenue Cycle Management/Credentialing
Dutch Medical Clinics, Inc.
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2377-36265
The Honorable Dr. Mehmet Oz
Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244
Re: CMS-2026-2377 - CY 2027 Medicare Physician Fee Schedule Proposed Rule;
Section II.D.3.b.(27) Maternity Care Services
Dear Administrator Oz,
On behalf of Dutch Medical Clinics, Inc., a multi-specialty medical group in Mississippi, we ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. The Honorable Dr. Mehmet Oz Administrator, Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 Re: CMS-2026-2377 - CY 2027 Medicare Physician Fee Schedule Proposed Rule; Section II.D.3.b.(27) Maternity Care Services Dear Administrator Oz, On behalf of Dutch Medical Clinics, Inc., a multi-specialty medical group in Mississippi, weappreciate the opportunity to comment on the CY 2027 Medicare Physician Fee Schedule proposed rule. We write specifically regarding the proposed adoption of the new CPT codes for maternity care services and the accompanying solicitation of comments on alternative HCPCS G-codes.
I. Dutch Medical Clinics, Inc. strongly supports finalizing the new maternity care CPT codes with the proposed wRVUs.
We urge CMS to finalize, without delay, the 12 new CPT codes for labor management, delivery, and associated procedures, together with the use of existing E/M codes for antepartum and postpartum services, as proposed in Tables A-D2.
The global obstetric bundle was created in the 1990s around an uncomplicated pregnancy model - 13 prenatal visits, delivery, and a single postpartum visit - that no longer reflects clinical reality or current standards of care. Today's obstetric population is older and more medically complex, with substantially higher rates of hypertensive disorders, diabetes, and other comorbidities than when the bundle was designed. Labor management is longer and more intensive, care is increasingly delivered by teams including hospitalists and laborists, and transfers of care - especially from rural facilities - are common. The bundle cannot accommodate any of this.
The new code set will allow accurate reporting of services as they are actually delivered, support timely reimbursement rather than delaying payment for nearly a year of care, enable appropriate billing when care is shared across providers and facilities, and generate the granular claims data policymakers need to design value-based payment models and address the nation's unacceptably high rates of maternal morbidity and mortality.
II. Dutch Medical Clinics, Inc. strongly urges CMS NOT to finalize the alternative HCPCS G-code proposal.
We oppose the creation of HCPCS G-codes that would maintain the global obstetric bundle as a concurrent billing pathway. Operating two competing code systems for the same services would create significant confusion for providers, payers, clearinghouses, and patients; complicate EHR and billing system configuration; fragment data; and undermine the very transition the new code set is designed to achieve. The AMA CPT Editorial Panel's multi-stakeholder workgroup process - which included physicians, nurses, family medicine practitioners, and payers - has already produced a feasible, well-vetted structure, and stakeholders across the industry are preparing for it. A clean commitment to the new code set is what providers and patients need.
III. Conclusion
We thank CMS for its leadership in modernizing maternity care payment and urge the agency to finalize the new maternity CPT codes with the proposed wRVUs and decline to adopt the concurrent G-code structure.
Please contact Mary Hutcherson, VP of Revenue at mkhutcherson@allegroclinics.com with any questions.
Sincerely,
Emily Wright
Revenue Cycle Management/Credentialing
Dutch Medical Clinics, Inc.
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2377-36265
ANCSA Regional Association Calls for Extension and Tribal Consultation on SBA Size Standards Rule
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
11500 Skudu Way | Anchorage, AK 99515 | www.ancsaregional.com
September 15, 2026
Mr. Ryan Lambert Associate Administrator Office of Government Contracting and Business Development U.S. Small Business Administration 409 Third Street, SW Washington, DC 20002
Re: Request for Extension and Tribal Consultation - Small Business Size Standards: Revised Size Standards Methodology, Docket No. SBA-2026-0265 (comments currently due ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. 11500 Skudu Way | Anchorage, AK 99515 | www.ancsaregional.com September 15, 2026 Mr. Ryan Lambert Associate Administrator Office of Government Contracting and Business Development U.S. Small Business Administration 409 Third Street, SW Washington, DC 20002 Re: Request for Extension and Tribal Consultation - Small Business Size Standards: Revised Size Standards Methodology, Docket No. SBA-2026-0265 (comments currently dueSeptember 21, 2026); and Small Business Size Standards Proposed Rule, Docket No. SBA-2026-0199 (comments currently due September 21, 2026)
Dear Associate Administrator Lambert:
The ANCSA Regional Association (ARA), which represents the 12 Alaska Native regional corporations formed pursuant to the Alaska Native Claims Settlement Act of 1971 (ANCSA), writes to respectfully request that:
1. The U.S. Small Business Administration extend the comment periods for both the Revised Size Standards Methodology Notice and the related Small Business Size Standards Notice of Proposed Rulemaking (NPRM) by at least 90 days; and
2. Conduct meaningful, pre-decisional Tribal consultation with affected Tribal governments and Alaska Native Corporations (ANCs) regarding the proposed rule "Small Business Size Standards," published on August 20, 2026, at 91 Fed. Reg. 53,741.
As you know, Alaska Native corporations (ANCs) are fundamental to the economy and security of our nation, generating billions of dollars in economic activity and providing vital services in support of American defense. ARA advocates on behalf of its members, whose operations and subsidiaries include federal contractors, subcontractors, and small businesses. We also assist our members in navigating SBA regulations, size standards, socioeconomic programs, and federal procurement compliance requirements. We appreciate SBA's efforts to modernize its size standards framework and recognize the importance of the agency's ongoing five-year review.
SBA
2 Size Standards
(15SEP26)
The two proposals represent one of the most substantial restructurings of SBA's size standards framework in decades. As SBA has explained, the proposals would consolidate nearly 1,000 industry-specific size standards into approximately 338 broader classifications, shift numerous industries from receipts-based to employee-based standards, eliminate existing exceptions, and significantly expand the number of firms eligible for small-business status. SBA estimates that more than 110,000 additional firms could qualify as small businesses under the proposed framework.
We recognize that SBA's Tribal Consultation Policy generally calls for consultation on regulatory or policy changes that have a substantial direct effect on Tribal or ANC participation in SBA programs. Although the proposed rule applies broadly across the small business community, its scope and potential consequences for Tribal and Native entity-owned businesses are sufficiently significant to warrant formal Tribal consultation. SBA should therefore consult with Tribal governments and ANCs before finalizing these changes, even if the Agency does not view the proposal as directed specifically at Native entities.
Executive Order 13175, "Consultation and Coordination with Indian Tribal Governments," mandates regular and meaningful consultation with Tribal governments in the development of federal policies with Tribal implications, including regulations that have substantial direct effects on Tribes or the federal trust relationship. The Executive Order requires an accountable process that ensures meaningful and timely input from Tribes. Consultation must occur while policies are being developed, and while Tribal input can still affect the agency's decisions-not after positions have hardened or policy choices have effectively been finalized.
In other words:
1. Consultation must be a distinct, government-to-government process and cannot be replaced by the ordinary public notice-and-comment process; and
2. SBA must provide Tribes and ANCs a meaningful opportunity to influence the rule before options are foreclosed, and the Agency's position is fixed.
To address the need for federal consultation with Native Corporations, the Consolidated Appropriations Act of FY 2005 requires that "all Federal agencies" consult with Native Corporations pursuant to Executive Order 13175. Pub. L. No. 108-447, 118 Stat. 2809, 3267 (2005) ("Public Law 108-199 is amended in division H, section 161, by inserting 'and all Federal agencies' after 'Office of Management and Budget'.") (amending Pub. L. No. 108-199, 118 Stat. 3, 452 (2005) ("The Director of the Office of Management and Budget and all Federal agencies shall hereafter consult with Alaska Native corporations on the same basis as Indian tribes under Executive Order No. 13175.")). Therefore, federal agencies today are legally obligated to consult with Native Corporations pursuant to SBA
3 Size Standards
(15SEP26)
Executive Order 13175. As suggested above, this requirement does not diminish but strengthens the federal government's relationship with the Alaska Native community.
Given the scope and potential consequences of these changes, the current 30-day comment period does not provide sufficient time for our members and other stakeholders to conduct the analysis necessary to submit meaningful, data-driven comments. The proposals have potential implications for:
Existing small businesses competing for opportunities;
Mid-sized firms that may become newly eligible for small-business programs;
Large businesses with small-business subcontracting plans;
Federal prime contractors and subcontractors;
Workforce Development Program participants;
Joint ventures;
Small Business Loan Programs; and
Federal agencies that rely on SBA size determinations
Meaningful evaluation of the proposals will require affected businesses to model the consequences of moving from six-digit NAICS classifications to broader classifications; assess the impact of transitioning from receipts-based to employee-based size standards; evaluate changes to affiliation and employee-count calculations; and analyze how eliminating industry-specific exceptions could affect competitive opportunities and eligibility for federal programs. These efforts often require coordination among legal counsel, accountants, procurement professionals, industry associations, and business leadership teams.
The interrelationship between the two proposals further underscores the need for additional time. SBA has linked the methodology notice and the proposed size standards rule, and stakeholders cannot fully evaluate or comment on the proposed standards without first understanding the revised methodology used to develop them. Indeed, the methodology notice acknowledges that the revised methodology was applied concurrently in formulating the proposed size standards. Providing additional time would therefore allow stakeholders to evaluate both proposals as an integrated framework rather than attempting to assess the proposed standards without sufficient opportunity to understand the methodology underlying them.
ARA believes that robust public engagement is particularly important given the breadth of the proposed changes. Input from affected industries can help SBA identify practical consequences, incorporate meaningful industry data, and better understand how the proposed framework could affect competition, federal procurement, and small-business participation.
SBA
4 Size Standards
(15SEP26)
An additional 90 days would enhance, rather than impede, the rulemaking process. A longer comment period would allow businesses and other stakeholders to submit more comprehensive data, industry-specific analyses, and empirical evidence regarding competitive effects, market concentration, small-business participation, and the potential consequences for federal procurement and other SBA programs. Such information would assist SBA in developing a more complete and robust administrative record and would strengthen the agency's ability to assess the practical implications of the proposed changes before adopting final standards.
For these reasons, ARA respectfully requests a written response confirming that the SBA will:
1. Extend the comment periods for both Docket No. SBA-2026-0265 and Docket No. SBA-2026-0199 by at least 90 days;
2. Use the additional time to engage directly with affected stakeholders through public forums and other consultation opportunities;
3. Conduct nationwide Tribal consultation with Tribal governments and ANCs; and
4. Refrain from finalizing the proposed rule until the SBA has completed these engagements, considered the input received, and explained how that input informed the Agency's decision.
We sincerely appreciate SBA's consideration of this request and its commitment to ensuring that regulated businesses and other affected stakeholders have a meaningful opportunity to participate in this important rulemaking effort. ARA stands ready to assist SBA in engaging with the Alaska Native Corporation community and other stakeholders as the agency continues its review.
Respectfully Submitted, Nicole Borromeo President
Cc: U.S. Sen. Lisa Murkowski U.S. Sen. Dan Sullivan U.S. Congressmen Nick Begich
*
Original text of letter here: https://www.regulations.gov/comment/SBA-2026-0265-0262
11500 Skudu Way | Anchorage, AK 99515 | www.ancsaregional.com
September 15, 2026
Mr. Ryan Lambert Associate Administrator Office of Government Contracting and Business Development U.S. Small Business Administration 409 Third Street, SW Washington, DC 20002
Re: Request for Extension and Tribal Consultation - Small Business Size Standards: Revised Size Standards Methodology, Docket No. SBA-2026-0265 (comments currently due ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. 11500 Skudu Way | Anchorage, AK 99515 | www.ancsaregional.com September 15, 2026 Mr. Ryan Lambert Associate Administrator Office of Government Contracting and Business Development U.S. Small Business Administration 409 Third Street, SW Washington, DC 20002 Re: Request for Extension and Tribal Consultation - Small Business Size Standards: Revised Size Standards Methodology, Docket No. SBA-2026-0265 (comments currently dueSeptember 21, 2026); and Small Business Size Standards Proposed Rule, Docket No. SBA-2026-0199 (comments currently due September 21, 2026)
Dear Associate Administrator Lambert:
The ANCSA Regional Association (ARA), which represents the 12 Alaska Native regional corporations formed pursuant to the Alaska Native Claims Settlement Act of 1971 (ANCSA), writes to respectfully request that:
1. The U.S. Small Business Administration extend the comment periods for both the Revised Size Standards Methodology Notice and the related Small Business Size Standards Notice of Proposed Rulemaking (NPRM) by at least 90 days; and
2. Conduct meaningful, pre-decisional Tribal consultation with affected Tribal governments and Alaska Native Corporations (ANCs) regarding the proposed rule "Small Business Size Standards," published on August 20, 2026, at 91 Fed. Reg. 53,741.
As you know, Alaska Native corporations (ANCs) are fundamental to the economy and security of our nation, generating billions of dollars in economic activity and providing vital services in support of American defense. ARA advocates on behalf of its members, whose operations and subsidiaries include federal contractors, subcontractors, and small businesses. We also assist our members in navigating SBA regulations, size standards, socioeconomic programs, and federal procurement compliance requirements. We appreciate SBA's efforts to modernize its size standards framework and recognize the importance of the agency's ongoing five-year review.
SBA
2 Size Standards
(15SEP26)
The two proposals represent one of the most substantial restructurings of SBA's size standards framework in decades. As SBA has explained, the proposals would consolidate nearly 1,000 industry-specific size standards into approximately 338 broader classifications, shift numerous industries from receipts-based to employee-based standards, eliminate existing exceptions, and significantly expand the number of firms eligible for small-business status. SBA estimates that more than 110,000 additional firms could qualify as small businesses under the proposed framework.
We recognize that SBA's Tribal Consultation Policy generally calls for consultation on regulatory or policy changes that have a substantial direct effect on Tribal or ANC participation in SBA programs. Although the proposed rule applies broadly across the small business community, its scope and potential consequences for Tribal and Native entity-owned businesses are sufficiently significant to warrant formal Tribal consultation. SBA should therefore consult with Tribal governments and ANCs before finalizing these changes, even if the Agency does not view the proposal as directed specifically at Native entities.
Executive Order 13175, "Consultation and Coordination with Indian Tribal Governments," mandates regular and meaningful consultation with Tribal governments in the development of federal policies with Tribal implications, including regulations that have substantial direct effects on Tribes or the federal trust relationship. The Executive Order requires an accountable process that ensures meaningful and timely input from Tribes. Consultation must occur while policies are being developed, and while Tribal input can still affect the agency's decisions-not after positions have hardened or policy choices have effectively been finalized.
In other words:
1. Consultation must be a distinct, government-to-government process and cannot be replaced by the ordinary public notice-and-comment process; and
2. SBA must provide Tribes and ANCs a meaningful opportunity to influence the rule before options are foreclosed, and the Agency's position is fixed.
To address the need for federal consultation with Native Corporations, the Consolidated Appropriations Act of FY 2005 requires that "all Federal agencies" consult with Native Corporations pursuant to Executive Order 13175. Pub. L. No. 108-447, 118 Stat. 2809, 3267 (2005) ("Public Law 108-199 is amended in division H, section 161, by inserting 'and all Federal agencies' after 'Office of Management and Budget'.") (amending Pub. L. No. 108-199, 118 Stat. 3, 452 (2005) ("The Director of the Office of Management and Budget and all Federal agencies shall hereafter consult with Alaska Native corporations on the same basis as Indian tribes under Executive Order No. 13175.")). Therefore, federal agencies today are legally obligated to consult with Native Corporations pursuant to SBA
3 Size Standards
(15SEP26)
Executive Order 13175. As suggested above, this requirement does not diminish but strengthens the federal government's relationship with the Alaska Native community.
Given the scope and potential consequences of these changes, the current 30-day comment period does not provide sufficient time for our members and other stakeholders to conduct the analysis necessary to submit meaningful, data-driven comments. The proposals have potential implications for:
Existing small businesses competing for opportunities;
Mid-sized firms that may become newly eligible for small-business programs;
Large businesses with small-business subcontracting plans;
Federal prime contractors and subcontractors;
Workforce Development Program participants;
Joint ventures;
Small Business Loan Programs; and
Federal agencies that rely on SBA size determinations
Meaningful evaluation of the proposals will require affected businesses to model the consequences of moving from six-digit NAICS classifications to broader classifications; assess the impact of transitioning from receipts-based to employee-based size standards; evaluate changes to affiliation and employee-count calculations; and analyze how eliminating industry-specific exceptions could affect competitive opportunities and eligibility for federal programs. These efforts often require coordination among legal counsel, accountants, procurement professionals, industry associations, and business leadership teams.
The interrelationship between the two proposals further underscores the need for additional time. SBA has linked the methodology notice and the proposed size standards rule, and stakeholders cannot fully evaluate or comment on the proposed standards without first understanding the revised methodology used to develop them. Indeed, the methodology notice acknowledges that the revised methodology was applied concurrently in formulating the proposed size standards. Providing additional time would therefore allow stakeholders to evaluate both proposals as an integrated framework rather than attempting to assess the proposed standards without sufficient opportunity to understand the methodology underlying them.
ARA believes that robust public engagement is particularly important given the breadth of the proposed changes. Input from affected industries can help SBA identify practical consequences, incorporate meaningful industry data, and better understand how the proposed framework could affect competition, federal procurement, and small-business participation.
SBA
4 Size Standards
(15SEP26)
An additional 90 days would enhance, rather than impede, the rulemaking process. A longer comment period would allow businesses and other stakeholders to submit more comprehensive data, industry-specific analyses, and empirical evidence regarding competitive effects, market concentration, small-business participation, and the potential consequences for federal procurement and other SBA programs. Such information would assist SBA in developing a more complete and robust administrative record and would strengthen the agency's ability to assess the practical implications of the proposed changes before adopting final standards.
For these reasons, ARA respectfully requests a written response confirming that the SBA will:
1. Extend the comment periods for both Docket No. SBA-2026-0265 and Docket No. SBA-2026-0199 by at least 90 days;
2. Use the additional time to engage directly with affected stakeholders through public forums and other consultation opportunities;
3. Conduct nationwide Tribal consultation with Tribal governments and ANCs; and
4. Refrain from finalizing the proposed rule until the SBA has completed these engagements, considered the input received, and explained how that input informed the Agency's decision.
We sincerely appreciate SBA's consideration of this request and its commitment to ensuring that regulated businesses and other affected stakeholders have a meaningful opportunity to participate in this important rulemaking effort. ARA stands ready to assist SBA in engaging with the Alaska Native Corporation community and other stakeholders as the agency continues its review.
Respectfully Submitted, Nicole Borromeo President
Cc: U.S. Sen. Lisa Murkowski U.S. Sen. Dan Sullivan U.S. Congressmen Nick Begich
*
Original text of letter here: https://www.regulations.gov/comment/SBA-2026-0265-0262
Alabama Dermatology Society Urges CMS to Withdraw Proposed Payment Cuts Threatening Skin Cancer Detection and Access
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
Page 2 of 7
September 11, 2026
The Honorable Mehmet Oz, MD, MBA
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1848-P
P.O. Box 8016
Baltimore, MD 21244-8016
Submitted electronically via regulations.gov
RE: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. Page 2 of 7 September 11, 2026 The Honorable Mehmet Oz, MD, MBA Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1848-P P.O. Box 8016 Baltimore, MD 21244-8016 Submitted electronically via regulations.gov RE: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies;Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program
Dear Administrator Oz:
The Alabama Dermatology Society appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) in response to the calendar year (CY) 2027 Medicare Physician Fee Schedule (PFS) proposed rule.
We share the Administration's emphasis on prevention, early detection, and access to high-quality care. Consistent with the Administration's priority of promoting preventive care, we are concerned that policies included in the CY 2027 Medicare PFS proposed rule would have unintended consequences and decrease beneficiaries' access to timely skin cancer detection and treatment.
On behalf of our 200+ member dermatologists across Alabama, we write to urge CMS to withdraw proposals in the CY 2027 Medicare PFS proposed rule that severely reduce payment for dermatology care and jeopardize Medicare beneficiaries' access to timely skin cancer detection and treatment.
Outpatient dermatology serves as a premier model of cost-effective, preventive care. Skin cancer is the most common cancer in the United States,, disproportionately impacting seniors aged 65 and older, who account for 71.4% of non-melanoma skin cancer and 60.3% of melanoma cases. When caught early in an outpatient setting, melanoma carries a 100% 5-year survival rate for localized disease in patients 65 years or older, with in-office treatment costing approximately $1,000., Conversely, if diagnosis is delayed and the disease metastasizes to distant sites, 5-year survival drops sharply to approximately 30.5% in this age group, and systemic treatment costs balloon to hundreds of thousands of dollars per patient annually. Proposed payment cuts threaten this highly effective model of early detection and preventive care, risking care delays that compromise patient outcomes and drive-up long-term Medicare expenditures.
According to the Centers for Disease Control and Prevention (CDC), approximately 71% of all melanoma deaths occur in adults aged 65 and older.6 Preserving access to immediate, same-day in-office evaluations is directly tied to saving senior lives in Alabama.
Specifically, two core proposals drive these severe payment reductions: a proposed 50% payment reduction on lower-cost services billed on the same day as an evaluation and management (E/M) visit (Modifier 25), and the proposed changes to the practice expense methodology, including the two-year phaseout of the Indirect Practice Cost Index (IPCI). It is estimated that the fully implemented combined annual impact by 2028 of the reduction in the Medicare conversion factor, the Modifier 25 cuts, and the practice expense changes, including phasing out the IPCI, would be a 16% payment cut (internally calculated awaiting third party verification).
Compounding Payment Reductions & Access Strain: These proposed Medicare cuts take effect within a payment system that has long failed to keep pace with operational inflation. Adjusted for practice expenses, Medicare physician payment declined 33% from 2001 to 2026.
Threat to Independent, Small-Business Medicine: Dermatology stands as a premier model of independent, small-business medicine. While much of healthcare has consolidated into large hospital systems, 68% of dermatologists continue to practice in private, non-hospital settings, including 54% in physician-owned practices and approximately 15% in private equity-backed firms. Federal data confirms this vulnerability: CMS's own Quality Payment Program data shows that over 50% of Merit-based Incentive Payment System (MIPS)-eligible dermatologists are officially designated as practicing in small practices. As independent small businesses, these practices bear full responsibility for operational overhead, making severe payment reductions far harder to absorb. Unlike hospital systems that offset physician losses through facility fees, small practice owners must absorb rising labor and supply costs directly. Deep cuts threaten the financial viability of these small businesses, accelerating forced consolidation into hospital outpatient departments where Medicare incurs significantly higher facility fees. In Alabama where each physician supports an average of 12 local jobs, these reductions threaten both healthcare employment and patient access.
Crossing the Medicaid Threshold: Kaiser Family Foundation (KFF) data indicates that proposed 2027 Medicare payment rates would reduce physician reimbursement below current Medicaid levels in multiple states. Because many state Medicaid fee schedules benchmark directly against Medicare, a collapse in Medicare rates will trigger cascading Medicaid cuts, further exacerbating access barriers for vulnerable populations.
Severe Access Bottlenecks for Seniors: Medicare beneficiaries reasonably expect their coverage to be accepted, and current data supports that expectation. In a national secret-shopper study of dermatology clinics, appointment success rates were 94% for Medicare compared to 17% for Medicaid. In a separate audit of visits for a changing pigmented lesion, only 11 to 13% of community dermatology practices accepted Medicaid, compared with more than 90% that accepted commercial coverage. These access barriers carry severe clinical consequences: peer-reviewed data demonstrates that Medicaid beneficiaries are more than twice as likely to present with advanced, thicker melanomas and face an 83% higher mortality risk compared to non-Medicaid patients, driven largely by specialist access bottlenecks and surgical delays. If Medicare payment falls to or below current Medicaid levels, the Alabama Dermatology Society is concerned that seniors will face these same severe access constraints and compromised health outcomes in Alabama.
Disproportionate Impact on Rural Communities: Decreased access to essential skin cancer and dermatologic services will fall hardest on rural seniors who already operate with severely limited care options. More than 60% of U.S. counties lack a practicing dermatologist,, leaving rural areas with a density of less than 0.1 dermatologists per 100,000 residents compared to over 4 per 100,000 in metropolitan counties. Because of these severe geographic barriers, rural seniors travel 40 or more miles one-way for care., Rural residents face a 54% higher rate of distant metastatic melanoma diagnoses and a 55% higher mortality risk compared to their urban counterparts. If local practices serving rural areas are forced to restrict their Medicare panel sizes or opt out of Medicare participation due to these proposed cuts, rural seniors, who have virtually no alternative local specialists, will face immediate care delays. In non-metropolitan areas where patients cannot simply drive to another local clinic, restricting Medicare access converts manageable, early-stage skin cancers into late-stage, high-cost medical crises.
Documented Clinical Risks of Care Delays: Real-world data underscores the dangerous link between delayed access and disease progression., Peer-reviewed research evaluating care delays during the COVID-19 pandemic demonstrated a statistically significant upstaging of cutaneous melanoma, with delayed presentations directly driving higher tumor thickness (Breslow depth) and advanced-stage diagnoses. Policies that restrict office-based practice capacity will reproduce these exact access bottlenecks, delaying early detection and leading to late-stage cancer diagnoses that harm patients and increase Medicare spending.
Commercial and Medicare Advantage Spillover: These proposed cuts will not be isolated to traditional Medicare, as commercial payers and Medicare Advantage plans in Alabama frequently tie their contracted fee schedules to the Medicare PFS and adopt CMS billing policies, including same-day service reductions for Modifier 25. If CMS finalizes a 50% same-day reduction, private payers and Medicare Advantage plans will quickly adopt the policy, compounding these losses across a practice's entire payer mix and threatening the financial survival of local independent clinics.
1. Proposed Modifier 25 (Same-Day Care Reductions): 50% payment reduction on lower-cost services furnished on the same day as an E/M visit.
Modifier 25 Usage Reflects Clinical Reality Medicine: Modifier 25 utilization in dermatology is a natural outcome of high-quality care, where direct examination routinely reveals both general medical evaluation needs and distinct procedural needs during a single visit. Addressing both evaluation and procedural care in the same encounter represents standard, comprehensive care, and flat utilization data over time confirms a stable, compliant baseline. Proposed payment reductions that fall below direct practice costs threaten overall practice sustainability, creating access barriers that risk delaying early detection and driving higher long-term costs for Medicare.
Appropriate & Stable Utilization: Modifier 25 utilization in dermatology has been stable and does not reflect an accelerating rate of billing. An independent analysis by the Academy using CMS Physician/Supplier Procedure Summary (PSPS) for CY2022 and CY2025, finds that dermatology's Modifier 25 utilization rate on office visits was 61.91% in CY2022 and 61.69% in CY2025.
While the total count of Modifier 25 visits in dermatology rose 5.7% during this period, the increase is accounted for by growth in dermatology's own office visit base, which rose 6.3%, and not by any change in how often dermatologists append the modifier. Independent work by the HHS Office of Inspector General (OIG) found a Modifier 25 rate of approximately 61.5% for dermatology in CY2019 and CY2020 and concluded that dermatologists generally met Medicare requirements, with 90 of 100 sampled services compliant. OIG measured claims and this analysis measures services, so the two are separate instruments rather than one continuous series. Read together, they indicate dermatology's Modifier 25 rate has sat at roughly the same level since 2019. Slight aggregate shifts in the Modifier 25 rate were largely driven by a change in coding mix rather than altered billing behavior.
Dermatologists' propensity to use Modifier 25 has not changed materially in any year observed since 2019. Beyond stable utilization, federal oversight confirms high billing integrity, confirming that dermatologists overwhelmingly met Medicare documentation requirements for same-day procedures.
Targeted Program Integrity Alternatives: If the Agency seeks to address potential coding compliance or over-utilization concerns, the appropriate remedy is targeted auditing, education, and data-driven oversight. Broad, across-the-board payment reductions penalize compliant practices that appropriately use Modifier 25 to deliver efficient care. CMS should utilize focused program integrity tools rather than implementing a blunt policy that harms compliant physicians and restricts patient access.
Existing RUC De-Duplication: The American Medical Association (AMA) Relative Value Scale Update Committee (RUC) valuation process already systematically strips out overlapping physician work and practice expenses for procedures frequently performed on the same day as an E/M visit. Imposing an additional 50% payment reduction arbitrarily discounts the exact same operational efficiency twice.
Overall Impact on Specialties (Modifier 25): Across all specialties, a third-party financial analysis commissioned by the American Academy of Dermatology Association (AADA) estimates that the proposed policy would reduce Medicare fee-for-service (FFS) allowed amounts for billing-group days (prior to any redistribution for purposes of Medicare PFS budget neutrality and excluding other policy proposals for CY 2027) by approximately $969 million in 2024 terms, or approximately 0.6% of total physician/supplier Part B allowed and 1.0% of total Medicare PFS allowed. A "billing-group day" is defined as a unique combination of beneficiary, date of service, and billing provider group that includes at least one eligible modifier 25 office/outpatient (O/O) E/M service and at least one eligible same-day 0-, 10-, or 90-day global procedure.
Disproportionate Specialty Impact (Modifier 25): Dermatology is the specialty with the largest estimated allowed reduction in absolute dollars, accounting for approximately $290 million of the estimated allowed reduction or approximately 30.0% of all specialty reductions, despite dermatology representing approximately 4.1% of total Medicare PFS allowed spending. The proposed policy would reduce total Medicare PFS allowed spending by approximately 7.0% across roughly 6.4 million billing-group days - among the highest modeled reduction allowed amounts of any specialty.
Concentration in Dermatology Services (Modifier 25): A small number of common services provided by dermatology practitioners drive a large share of the estimated dermatology impact. Billing-group days with five global procedure code combinations account for approximately 62% of the modeled dermatology reduction: 17000: Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of premalignant lesions (e.g., actinic keratoses); first lesion 11102: Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion 17110: Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 11102 + 17000: as defined above
17000 + 17110: as defined above
Table 1. Proposed Modifier 25 Policy for Top 5 Dermatologic Procedures: Medicare Payment vs. Direct Practice Costs by CPT Code Proposed Modifier 25 Policy for Top 5 Dermatologic Procedures Billed with Modifier 25: Medicare Payment vs. Direct Practice Costs by CPT Code
Volume Rank
CPT Code(s)
Estimated 2027 Payment:
Current Policy
Estimated 2027 Payment:
Proposed Policy
Direct Practice
Expense Cost
(Net Loss)
Used for Skin Cancer or Pre-Cancer
#1
Most Common
17000
$62.73
$31.36
$31.37 (-$0.01)
Yes
#2
11102
$89.98
$44.99
$56.82 (-$11.83)
Yes
#3
17110
$104.76
$52.38
$70.24 (-$17.86)
No
#4
11102 + 17000
$89.98 + $31.36
= $121.34
*MPPR applies in this scenario
$44.99 + $31.36
= $76.35
$56.82 + $31.37
= $88.19 (-$11.84)
Yes
#5
17000 + 17110
$31.36 + $104.76
= $136.12
*MPPR applies in this scenario
$31.36 + $52.38
= $83.74
$31.37 + $70.24
= $101.61 (-$17.87)
Yes
*Note: Values reflect non-facility, non-qualifying alternative payment model (APM) participant CY 2027 payment rates. A 50% payment reduction is applied to the lower-valued code, with the Multiple Procedure Payment Reduction (MPPR) applied where applicable.
The Alabama Dermatology Society is particularly concerned that the proposed reduction would, in many instances, result in Medicare payment that does not cover the direct practice expense required to furnish the service, much less the physician work involved or associated indirect costs. Payment at levels that fail to cover the resources required to furnish care is unsustainable for physician practices. As a result, this policy severely compromises practice viability, making it increasingly difficult for independent practices to remain open to Medicare beneficiaries.
2. Practice Expense Methodology & IPCI Elimination
Calculations Ignore Practice Overhead: CMS proposes to eliminate the Indirect Practice Cost Index (IPCI) over two years without empirical justification. Under current policy, IPCI scales practice expense relative value units (RVUs) to account for specialty-specific overhead. Non-facility dermatology practices carry high clinical staff-to-physician ratios, significant technical support needs, and facility-like infrastructure. Eliminating IPCI strips away accurate accounting for these costs. RAND analysis conducted for CMS demonstrated that indirect practice costs have low or negative correlations with direct inputs, confirming that increasing reliance on direct inputs distorts real-world care costs.
Practice Expense Cuts Impact Codes Used for Skin Cancer: The top 50 dermatology procedure codes represent almost all of the procedures dermatologists bill to Medicare (98% of all payments).27 Of these top 50 codes, 91% of the payments are used for the detection and treatment of skin cancer.
Specific Policy Asks
We urge CMS to protect Medicare beneficiary access by taking the following actions in the final rule: Modifier 25: Withdraw the proposed 50% payment reduction for same-day services appropriately reported with Modifier 25.
Practice Expense Methodology: Withdraw the proposal to eliminate the IPCI from the practice expense methodology.
Should CMS decline to accept the above recommendations, we request that CMS delay implementation of significant changes until the Agency provides greater transparency regarding its methodology and data, conducts a thorough specialty-level impact analysis, and establishes safeguards to prevent disproportionate payment reductions.
Thank you for considering the impact of these proposals on Alabama dermatologists and the seniors who depend on us for timely, life-saving skin cancer detection and care.
Sincerely,
Katie, Beckum, MD
President, Alabama Dermatology Society
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2377-34778
Page 2 of 7
September 11, 2026
The Honorable Mehmet Oz, MD, MBA
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1848-P
P.O. Box 8016
Baltimore, MD 21244-8016
Submitted electronically via regulations.gov
RE: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. Page 2 of 7 September 11, 2026 The Honorable Mehmet Oz, MD, MBA Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1848-P P.O. Box 8016 Baltimore, MD 21244-8016 Submitted electronically via regulations.gov RE: Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies;Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program
Dear Administrator Oz:
The Alabama Dermatology Society appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) in response to the calendar year (CY) 2027 Medicare Physician Fee Schedule (PFS) proposed rule.
We share the Administration's emphasis on prevention, early detection, and access to high-quality care. Consistent with the Administration's priority of promoting preventive care, we are concerned that policies included in the CY 2027 Medicare PFS proposed rule would have unintended consequences and decrease beneficiaries' access to timely skin cancer detection and treatment.
On behalf of our 200+ member dermatologists across Alabama, we write to urge CMS to withdraw proposals in the CY 2027 Medicare PFS proposed rule that severely reduce payment for dermatology care and jeopardize Medicare beneficiaries' access to timely skin cancer detection and treatment.
Outpatient dermatology serves as a premier model of cost-effective, preventive care. Skin cancer is the most common cancer in the United States,, disproportionately impacting seniors aged 65 and older, who account for 71.4% of non-melanoma skin cancer and 60.3% of melanoma cases. When caught early in an outpatient setting, melanoma carries a 100% 5-year survival rate for localized disease in patients 65 years or older, with in-office treatment costing approximately $1,000., Conversely, if diagnosis is delayed and the disease metastasizes to distant sites, 5-year survival drops sharply to approximately 30.5% in this age group, and systemic treatment costs balloon to hundreds of thousands of dollars per patient annually. Proposed payment cuts threaten this highly effective model of early detection and preventive care, risking care delays that compromise patient outcomes and drive-up long-term Medicare expenditures.
According to the Centers for Disease Control and Prevention (CDC), approximately 71% of all melanoma deaths occur in adults aged 65 and older.6 Preserving access to immediate, same-day in-office evaluations is directly tied to saving senior lives in Alabama.
Specifically, two core proposals drive these severe payment reductions: a proposed 50% payment reduction on lower-cost services billed on the same day as an evaluation and management (E/M) visit (Modifier 25), and the proposed changes to the practice expense methodology, including the two-year phaseout of the Indirect Practice Cost Index (IPCI). It is estimated that the fully implemented combined annual impact by 2028 of the reduction in the Medicare conversion factor, the Modifier 25 cuts, and the practice expense changes, including phasing out the IPCI, would be a 16% payment cut (internally calculated awaiting third party verification).
Compounding Payment Reductions & Access Strain: These proposed Medicare cuts take effect within a payment system that has long failed to keep pace with operational inflation. Adjusted for practice expenses, Medicare physician payment declined 33% from 2001 to 2026.
Threat to Independent, Small-Business Medicine: Dermatology stands as a premier model of independent, small-business medicine. While much of healthcare has consolidated into large hospital systems, 68% of dermatologists continue to practice in private, non-hospital settings, including 54% in physician-owned practices and approximately 15% in private equity-backed firms. Federal data confirms this vulnerability: CMS's own Quality Payment Program data shows that over 50% of Merit-based Incentive Payment System (MIPS)-eligible dermatologists are officially designated as practicing in small practices. As independent small businesses, these practices bear full responsibility for operational overhead, making severe payment reductions far harder to absorb. Unlike hospital systems that offset physician losses through facility fees, small practice owners must absorb rising labor and supply costs directly. Deep cuts threaten the financial viability of these small businesses, accelerating forced consolidation into hospital outpatient departments where Medicare incurs significantly higher facility fees. In Alabama where each physician supports an average of 12 local jobs, these reductions threaten both healthcare employment and patient access.
Crossing the Medicaid Threshold: Kaiser Family Foundation (KFF) data indicates that proposed 2027 Medicare payment rates would reduce physician reimbursement below current Medicaid levels in multiple states. Because many state Medicaid fee schedules benchmark directly against Medicare, a collapse in Medicare rates will trigger cascading Medicaid cuts, further exacerbating access barriers for vulnerable populations.
Severe Access Bottlenecks for Seniors: Medicare beneficiaries reasonably expect their coverage to be accepted, and current data supports that expectation. In a national secret-shopper study of dermatology clinics, appointment success rates were 94% for Medicare compared to 17% for Medicaid. In a separate audit of visits for a changing pigmented lesion, only 11 to 13% of community dermatology practices accepted Medicaid, compared with more than 90% that accepted commercial coverage. These access barriers carry severe clinical consequences: peer-reviewed data demonstrates that Medicaid beneficiaries are more than twice as likely to present with advanced, thicker melanomas and face an 83% higher mortality risk compared to non-Medicaid patients, driven largely by specialist access bottlenecks and surgical delays. If Medicare payment falls to or below current Medicaid levels, the Alabama Dermatology Society is concerned that seniors will face these same severe access constraints and compromised health outcomes in Alabama.
Disproportionate Impact on Rural Communities: Decreased access to essential skin cancer and dermatologic services will fall hardest on rural seniors who already operate with severely limited care options. More than 60% of U.S. counties lack a practicing dermatologist,, leaving rural areas with a density of less than 0.1 dermatologists per 100,000 residents compared to over 4 per 100,000 in metropolitan counties. Because of these severe geographic barriers, rural seniors travel 40 or more miles one-way for care., Rural residents face a 54% higher rate of distant metastatic melanoma diagnoses and a 55% higher mortality risk compared to their urban counterparts. If local practices serving rural areas are forced to restrict their Medicare panel sizes or opt out of Medicare participation due to these proposed cuts, rural seniors, who have virtually no alternative local specialists, will face immediate care delays. In non-metropolitan areas where patients cannot simply drive to another local clinic, restricting Medicare access converts manageable, early-stage skin cancers into late-stage, high-cost medical crises.
Documented Clinical Risks of Care Delays: Real-world data underscores the dangerous link between delayed access and disease progression., Peer-reviewed research evaluating care delays during the COVID-19 pandemic demonstrated a statistically significant upstaging of cutaneous melanoma, with delayed presentations directly driving higher tumor thickness (Breslow depth) and advanced-stage diagnoses. Policies that restrict office-based practice capacity will reproduce these exact access bottlenecks, delaying early detection and leading to late-stage cancer diagnoses that harm patients and increase Medicare spending.
Commercial and Medicare Advantage Spillover: These proposed cuts will not be isolated to traditional Medicare, as commercial payers and Medicare Advantage plans in Alabama frequently tie their contracted fee schedules to the Medicare PFS and adopt CMS billing policies, including same-day service reductions for Modifier 25. If CMS finalizes a 50% same-day reduction, private payers and Medicare Advantage plans will quickly adopt the policy, compounding these losses across a practice's entire payer mix and threatening the financial survival of local independent clinics.
1. Proposed Modifier 25 (Same-Day Care Reductions): 50% payment reduction on lower-cost services furnished on the same day as an E/M visit.
Modifier 25 Usage Reflects Clinical Reality Medicine: Modifier 25 utilization in dermatology is a natural outcome of high-quality care, where direct examination routinely reveals both general medical evaluation needs and distinct procedural needs during a single visit. Addressing both evaluation and procedural care in the same encounter represents standard, comprehensive care, and flat utilization data over time confirms a stable, compliant baseline. Proposed payment reductions that fall below direct practice costs threaten overall practice sustainability, creating access barriers that risk delaying early detection and driving higher long-term costs for Medicare.
Appropriate & Stable Utilization: Modifier 25 utilization in dermatology has been stable and does not reflect an accelerating rate of billing. An independent analysis by the Academy using CMS Physician/Supplier Procedure Summary (PSPS) for CY2022 and CY2025, finds that dermatology's Modifier 25 utilization rate on office visits was 61.91% in CY2022 and 61.69% in CY2025.
While the total count of Modifier 25 visits in dermatology rose 5.7% during this period, the increase is accounted for by growth in dermatology's own office visit base, which rose 6.3%, and not by any change in how often dermatologists append the modifier. Independent work by the HHS Office of Inspector General (OIG) found a Modifier 25 rate of approximately 61.5% for dermatology in CY2019 and CY2020 and concluded that dermatologists generally met Medicare requirements, with 90 of 100 sampled services compliant. OIG measured claims and this analysis measures services, so the two are separate instruments rather than one continuous series. Read together, they indicate dermatology's Modifier 25 rate has sat at roughly the same level since 2019. Slight aggregate shifts in the Modifier 25 rate were largely driven by a change in coding mix rather than altered billing behavior.
Dermatologists' propensity to use Modifier 25 has not changed materially in any year observed since 2019. Beyond stable utilization, federal oversight confirms high billing integrity, confirming that dermatologists overwhelmingly met Medicare documentation requirements for same-day procedures.
Targeted Program Integrity Alternatives: If the Agency seeks to address potential coding compliance or over-utilization concerns, the appropriate remedy is targeted auditing, education, and data-driven oversight. Broad, across-the-board payment reductions penalize compliant practices that appropriately use Modifier 25 to deliver efficient care. CMS should utilize focused program integrity tools rather than implementing a blunt policy that harms compliant physicians and restricts patient access.
Existing RUC De-Duplication: The American Medical Association (AMA) Relative Value Scale Update Committee (RUC) valuation process already systematically strips out overlapping physician work and practice expenses for procedures frequently performed on the same day as an E/M visit. Imposing an additional 50% payment reduction arbitrarily discounts the exact same operational efficiency twice.
Overall Impact on Specialties (Modifier 25): Across all specialties, a third-party financial analysis commissioned by the American Academy of Dermatology Association (AADA) estimates that the proposed policy would reduce Medicare fee-for-service (FFS) allowed amounts for billing-group days (prior to any redistribution for purposes of Medicare PFS budget neutrality and excluding other policy proposals for CY 2027) by approximately $969 million in 2024 terms, or approximately 0.6% of total physician/supplier Part B allowed and 1.0% of total Medicare PFS allowed. A "billing-group day" is defined as a unique combination of beneficiary, date of service, and billing provider group that includes at least one eligible modifier 25 office/outpatient (O/O) E/M service and at least one eligible same-day 0-, 10-, or 90-day global procedure.
Disproportionate Specialty Impact (Modifier 25): Dermatology is the specialty with the largest estimated allowed reduction in absolute dollars, accounting for approximately $290 million of the estimated allowed reduction or approximately 30.0% of all specialty reductions, despite dermatology representing approximately 4.1% of total Medicare PFS allowed spending. The proposed policy would reduce total Medicare PFS allowed spending by approximately 7.0% across roughly 6.4 million billing-group days - among the highest modeled reduction allowed amounts of any specialty.
Concentration in Dermatology Services (Modifier 25): A small number of common services provided by dermatology practitioners drive a large share of the estimated dermatology impact. Billing-group days with five global procedure code combinations account for approximately 62% of the modeled dermatology reduction: 17000: Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of premalignant lesions (e.g., actinic keratoses); first lesion 11102: Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion 17110: Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 11102 + 17000: as defined above
17000 + 17110: as defined above
Table 1. Proposed Modifier 25 Policy for Top 5 Dermatologic Procedures: Medicare Payment vs. Direct Practice Costs by CPT Code Proposed Modifier 25 Policy for Top 5 Dermatologic Procedures Billed with Modifier 25: Medicare Payment vs. Direct Practice Costs by CPT Code
Volume Rank
CPT Code(s)
Estimated 2027 Payment:
Current Policy
Estimated 2027 Payment:
Proposed Policy
Direct Practice
Expense Cost
(Net Loss)
Used for Skin Cancer or Pre-Cancer
#1
Most Common
17000
$62.73
$31.36
$31.37 (-$0.01)
Yes
#2
11102
$89.98
$44.99
$56.82 (-$11.83)
Yes
#3
17110
$104.76
$52.38
$70.24 (-$17.86)
No
#4
11102 + 17000
$89.98 + $31.36
= $121.34
*MPPR applies in this scenario
$44.99 + $31.36
= $76.35
$56.82 + $31.37
= $88.19 (-$11.84)
Yes
#5
17000 + 17110
$31.36 + $104.76
= $136.12
*MPPR applies in this scenario
$31.36 + $52.38
= $83.74
$31.37 + $70.24
= $101.61 (-$17.87)
Yes
*Note: Values reflect non-facility, non-qualifying alternative payment model (APM) participant CY 2027 payment rates. A 50% payment reduction is applied to the lower-valued code, with the Multiple Procedure Payment Reduction (MPPR) applied where applicable.
The Alabama Dermatology Society is particularly concerned that the proposed reduction would, in many instances, result in Medicare payment that does not cover the direct practice expense required to furnish the service, much less the physician work involved or associated indirect costs. Payment at levels that fail to cover the resources required to furnish care is unsustainable for physician practices. As a result, this policy severely compromises practice viability, making it increasingly difficult for independent practices to remain open to Medicare beneficiaries.
2. Practice Expense Methodology & IPCI Elimination
Calculations Ignore Practice Overhead: CMS proposes to eliminate the Indirect Practice Cost Index (IPCI) over two years without empirical justification. Under current policy, IPCI scales practice expense relative value units (RVUs) to account for specialty-specific overhead. Non-facility dermatology practices carry high clinical staff-to-physician ratios, significant technical support needs, and facility-like infrastructure. Eliminating IPCI strips away accurate accounting for these costs. RAND analysis conducted for CMS demonstrated that indirect practice costs have low or negative correlations with direct inputs, confirming that increasing reliance on direct inputs distorts real-world care costs.
Practice Expense Cuts Impact Codes Used for Skin Cancer: The top 50 dermatology procedure codes represent almost all of the procedures dermatologists bill to Medicare (98% of all payments).27 Of these top 50 codes, 91% of the payments are used for the detection and treatment of skin cancer.
Specific Policy Asks
We urge CMS to protect Medicare beneficiary access by taking the following actions in the final rule: Modifier 25: Withdraw the proposed 50% payment reduction for same-day services appropriately reported with Modifier 25.
Practice Expense Methodology: Withdraw the proposal to eliminate the IPCI from the practice expense methodology.
Should CMS decline to accept the above recommendations, we request that CMS delay implementation of significant changes until the Agency provides greater transparency regarding its methodology and data, conducts a thorough specialty-level impact analysis, and establishes safeguards to prevent disproportionate payment reductions.
Thank you for considering the impact of these proposals on Alabama dermatologists and the seniors who depend on us for timely, life-saving skin cancer detection and care.
Sincerely,
Katie, Beckum, MD
President, Alabama Dermatology Society
*
Original text of letter here: https://www.regulations.gov/comment/CMS-2026-2377-34778
AASA Warns of Negative Impact of Proposed EDGAR Revisions on School Funding and Administrative Capacity
Carter Struck
WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site.
September 17, 2026
The Honorable Linda McMahon
Secretary of Education
U.S. Department of Education
400 Maryland Ave SW
Washington, DC 20202
RE: 2026-17239 EDGAR NPRM
Dear Secretary McMahon:
On behalf of AASA, The School Superintendents Association and the Association of School Business Oficials International (ASBO), representing thousands of school district leaders across the United States, and AESA, the Association ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. September 17, 2026 The Honorable Linda McMahon Secretary of Education U.S. Department of Education 400 Maryland Ave SW Washington, DC 20202 RE: 2026-17239 EDGAR NPRM Dear Secretary McMahon: On behalf of AASA, The School Superintendents Association and the Association of School Business Oficials International (ASBO), representing thousands of school district leaders across the United States, and AESA, the Associationof Education Service agencies, representing 470 regional education service organizations that work with those public schools, we submit these comments in response to the U.S. Department of Education's (ED's) proposed revisions to the Education Department General Administrative Regulations (EDGAR), published on August 24, 2026.
We are deeply concerned by some of ED's proposed changes to EDGAR due to the negative impact they will have on local educational agencies, including school districts and educational service agencies. The proposed changes of greatest concern to our members are outlined below.
34 CFR 75.100 - Eliminating the requirement to publish application notices in the Federal Register
We oppose the proposed amendment to eliminate the requirement for the Secretary to publish application notices and the content of the notices in the Federal Register from Section 75.100. While we understand that this information will continue to be published on Grants.gov, publication in the Federal Register provides an additional, longstanding source for prospective applicants to identify funding opportunities and understand the requirements and priorities associated with grant competitions. Federal grant opportunities should be as transparent and accessible as possible to encourage broad participation from eligible applicants. Sharing grant information through multiple established channels makes it easier for school districts and other prospective applicants to learn about and apply for available funding. We strongly encourage ED to retain the existing Federal Register publication requirement while continuing to use Grants.gov to broadly disseminate information about grant opportunities.
34 CFR 75.228 - What procedures does the Secretary use if the Secretary decides to give special consideration to applicants voluntarily electing to be more cost effective, including use of a lower indirect cost rate?
We are concerned that the proposed language offering a competitive preference to entities that elect to use a lower indirect cost rate could disadvantage LEAs and nonproit organizations. LEAs generally have lower negotiated indirect cost rates (including unrestricted indirect rates at or below the de minimis rate of 15% modiied total direct costs) and thus would not be able to meet the tiered reductions outlined in Sec. 75.228(b)(1) or demonstrate a higher-than-de minimis negotiated indirect cost rate under Sec. 75.228(b)(2) in order to receive the competitive preference. Similarly, many nonproit organizations already operate with relatively low negotiated indirect cost rates or rely on the de minimis rate and therefore may have little or no ability to further reduce their rates to obtain a competitive advantage. As a result, the proposal could unintentionally favor applicants with higher negotiated indirect cost rates while disadvantaging entities that are already operating in a cost-effective manner.
34 CFR 75.252 - Clarifying the process for frontloading grant funds of a multi-year project
We request additional clariication regarding ED's proposed new authority under 34 CFR 75.252 to partially or fully frontload funds for multi-year projects. The proposal states that "A grantee may only draw down funds in accordance with its approved budget for that budget year and may not draw down funds in excess of that amount without prior approval." However, the proposal does not clearly explain the legal and accounting status of funds that have been frontloaded and obligated for a multi-year project but that the grantee has not yet been authorized to draw down. We request clariication regarding the circumstances under which frontloaded but undrawn funds may be withheld, restricted, or de-obligated; what notice a grantee would receive before such actions are taken; what opportunity there is to respond to or appeal those actions; and how ED expects grantees to account for inancial commitments made in reasonable reliance on frontloaded funds.
We are also concerned about the administrative implications of frontloaded grants for grantees with limited capacity, including small and rural districts, which often have limited staff and bandwidth for federal grants administration. Receiving multiple years of funding at once could create additional responsibilities related to budgeting, accounting, grant reporting and accountability, internal controls, cash management, and tracking funds across multiple budget periods. ED should ensure that frontloading does not inadvertently increase administrative burdens or disadvantage districts with limited capacity. We request additional clariication regarding the criteria ED will use to determine which grants or grantees receive partial or full frontloaded funding; whether ED will consider a grantee's administrative capacity and preference when making that determination; whether grantees will have an opportunity to decline frontloading or request an alternative funding structure if frontloading would impose additional administrative challenges; and what technical assistance ED will provide to help grantees manage frontloaded grants.
34 CFR 75.253 - Continuation of a multiyear project after the irst budget period
We oppose the proposed removal of "regarding grantee performance" from the existing 34 CFR 75.253(b). ED proposes to allow the Secretary to consider "any relevant information" in making continuation awards, as opposed to the existing authority of "any relevant information regarding grantee performance" (emphasis added). We are concerned that this proposed change will be used to permit decisions to be based on factors outside of grant performance or program requirements. Under the proposed language, ED could discontinue grants to entities simply because they have policies the administration does not agree with. This creates an ambiguous standard, and it would be dificult for grantees to determine how to meet requirements for continuation. Further, if an administration were to issue new grant priorities or policies mid-grant cycle, we are concerned that grantees may be held to policies that they were not aware of when initially accepting a federal award. This will lead to uncertainty among grantees as to what requirements, priorities, or policies they need to comply with in order to receive continuation awards.
In addition, the new proposed language in 34 CFR 75.253(e)(5) would allow the Secretary, when making a continuation award, to "issue a partial award, providing funding in installments, or delay the release of funds." The proposed language does not outline under what circumstances the Secretary may take these actions, such as delaying the release of funds. This proposal will make it dificult for grantees to discern what actions they need to take or requirements they must follow to receive their full continuation award in a timely manner. Unexpected delays in funding result in signiicant challenges for grantees in making budgeting decisions.
34 CFR 75.901 - Suspension and termination
We are also concerned by the proposal to add new language under 34 CFR 75.901 to permit the Secretary of Education and pass-through entity to terminate discretionary grants "for convenience." This change would seemingly give the Secretary of Education broad authority to terminate a grant mid-cycle, without reasonable cause like noncompliance or failure to meet program goals. This change would introduce signiicant uncertainty into the discretionary grants process, as the proposed rule does not clearly outline under what types of circumstances the Secretary may use this new termination authority. This lack of clarity means that grantees may unfairly lose federal funding based on factors that are not made clear to them. Further, ED states that this change is similar to existing authority under 2 CFR 200.340(a)(4), but that authority is limited to when the award "no longer effectuates the program goals and agency priorities," which is not the same. Therefore, we request that ED remove this proposed authority.
34 CFR 76.700 - Compliance with the U.S. Constitution, statutes, regulations, stated institutional policies, and applications
We oppose the proposed addition of "Executive Orders" to the list of requirements that grantees under State-administered programs must comply with in exchange for receiving federal funds. We are concerned that this change will provide ED with greater enforcement authority over State-4 administered grants regarding policies that may be outlined in Executive Orders but not incorporated into law or regulations. Executive Orders are policy directives from the White House that do not have the force and effect of law. Federal agencies must take separate action, such as issuing or amending regulations, for Executive Order policies to be legally binding. Under this proposed change, Executive Orders would seemingly become legally binding to grantees immediately after issuance. This further raises concerns about policies changing in the middle of a grant cycle, when grantees had not agreed to such policies when funds were initially awarded. This proposed change would bring instability into the grants process over time as future administrations withdraw or issue new Executive Orders that may be contrary to existing policy, and it will make it dificult for grantees to be certain of the policies that they are legally required to comply with in exchange for receiving federal funds.
34 CFR 75.500 and 76.500 - Constitutional rights, freedom of inquiry, and federal statutes and regulations on nondiscrimination
We oppose the proposed addition of paragraph (f) to both 34 CFR 75.500 and 76.500, which would require grantees to ensure compliance with broad and unclear standards. The proposed changes restate existing obligations under federal civil rights laws and other legal requirements and are, therefore, unnecessary. If ED believes a grantee is violating those laws, it has existing enforcement mechanisms available to use. In addition, the proposed changes would impose vague requirements that may extend beyond federal civil rights requirements. The proposed changes use terms such as "political views" and "proxies," but they provide no standards for determining when, for example, a facially neutral action becomes a proxy. Lack of adequately deined terms creates uncertainty for grantees. Grantees should be able to determine what standards govern their awards, what speciic actions they must take to remain eligible for those awards, and what conduct ED believes will violate these rules.
Thank you for reviewing our feedback on the proposed rule. We are happy to explain any of these issues in more detail.
Sincerely,
Sasha Pudelski
Director of Advocacy
AASA
Elleka Yost
Director of Advocacy & Research
ASBO International
*
Original text of letter here: https://www.regulations.gov/comment/ED-2026-OPEPD-2542-0080
September 17, 2026
The Honorable Linda McMahon
Secretary of Education
U.S. Department of Education
400 Maryland Ave SW
Washington, DC 20202
RE: 2026-17239 EDGAR NPRM
Dear Secretary McMahon:
On behalf of AASA, The School Superintendents Association and the Association of School Business Oficials International (ASBO), representing thousands of school district leaders across the United States, and AESA, the Association ... Show Full Article WASHINGTON, Sept. 17 -- In response to a federal agency request for information, the following public comment letter was submitted electronically to the regulations.gov site. September 17, 2026 The Honorable Linda McMahon Secretary of Education U.S. Department of Education 400 Maryland Ave SW Washington, DC 20202 RE: 2026-17239 EDGAR NPRM Dear Secretary McMahon: On behalf of AASA, The School Superintendents Association and the Association of School Business Oficials International (ASBO), representing thousands of school district leaders across the United States, and AESA, the Associationof Education Service agencies, representing 470 regional education service organizations that work with those public schools, we submit these comments in response to the U.S. Department of Education's (ED's) proposed revisions to the Education Department General Administrative Regulations (EDGAR), published on August 24, 2026.
We are deeply concerned by some of ED's proposed changes to EDGAR due to the negative impact they will have on local educational agencies, including school districts and educational service agencies. The proposed changes of greatest concern to our members are outlined below.
34 CFR 75.100 - Eliminating the requirement to publish application notices in the Federal Register
We oppose the proposed amendment to eliminate the requirement for the Secretary to publish application notices and the content of the notices in the Federal Register from Section 75.100. While we understand that this information will continue to be published on Grants.gov, publication in the Federal Register provides an additional, longstanding source for prospective applicants to identify funding opportunities and understand the requirements and priorities associated with grant competitions. Federal grant opportunities should be as transparent and accessible as possible to encourage broad participation from eligible applicants. Sharing grant information through multiple established channels makes it easier for school districts and other prospective applicants to learn about and apply for available funding. We strongly encourage ED to retain the existing Federal Register publication requirement while continuing to use Grants.gov to broadly disseminate information about grant opportunities.
34 CFR 75.228 - What procedures does the Secretary use if the Secretary decides to give special consideration to applicants voluntarily electing to be more cost effective, including use of a lower indirect cost rate?
We are concerned that the proposed language offering a competitive preference to entities that elect to use a lower indirect cost rate could disadvantage LEAs and nonproit organizations. LEAs generally have lower negotiated indirect cost rates (including unrestricted indirect rates at or below the de minimis rate of 15% modiied total direct costs) and thus would not be able to meet the tiered reductions outlined in Sec. 75.228(b)(1) or demonstrate a higher-than-de minimis negotiated indirect cost rate under Sec. 75.228(b)(2) in order to receive the competitive preference. Similarly, many nonproit organizations already operate with relatively low negotiated indirect cost rates or rely on the de minimis rate and therefore may have little or no ability to further reduce their rates to obtain a competitive advantage. As a result, the proposal could unintentionally favor applicants with higher negotiated indirect cost rates while disadvantaging entities that are already operating in a cost-effective manner.
34 CFR 75.252 - Clarifying the process for frontloading grant funds of a multi-year project
We request additional clariication regarding ED's proposed new authority under 34 CFR 75.252 to partially or fully frontload funds for multi-year projects. The proposal states that "A grantee may only draw down funds in accordance with its approved budget for that budget year and may not draw down funds in excess of that amount without prior approval." However, the proposal does not clearly explain the legal and accounting status of funds that have been frontloaded and obligated for a multi-year project but that the grantee has not yet been authorized to draw down. We request clariication regarding the circumstances under which frontloaded but undrawn funds may be withheld, restricted, or de-obligated; what notice a grantee would receive before such actions are taken; what opportunity there is to respond to or appeal those actions; and how ED expects grantees to account for inancial commitments made in reasonable reliance on frontloaded funds.
We are also concerned about the administrative implications of frontloaded grants for grantees with limited capacity, including small and rural districts, which often have limited staff and bandwidth for federal grants administration. Receiving multiple years of funding at once could create additional responsibilities related to budgeting, accounting, grant reporting and accountability, internal controls, cash management, and tracking funds across multiple budget periods. ED should ensure that frontloading does not inadvertently increase administrative burdens or disadvantage districts with limited capacity. We request additional clariication regarding the criteria ED will use to determine which grants or grantees receive partial or full frontloaded funding; whether ED will consider a grantee's administrative capacity and preference when making that determination; whether grantees will have an opportunity to decline frontloading or request an alternative funding structure if frontloading would impose additional administrative challenges; and what technical assistance ED will provide to help grantees manage frontloaded grants.
34 CFR 75.253 - Continuation of a multiyear project after the irst budget period
We oppose the proposed removal of "regarding grantee performance" from the existing 34 CFR 75.253(b). ED proposes to allow the Secretary to consider "any relevant information" in making continuation awards, as opposed to the existing authority of "any relevant information regarding grantee performance" (emphasis added). We are concerned that this proposed change will be used to permit decisions to be based on factors outside of grant performance or program requirements. Under the proposed language, ED could discontinue grants to entities simply because they have policies the administration does not agree with. This creates an ambiguous standard, and it would be dificult for grantees to determine how to meet requirements for continuation. Further, if an administration were to issue new grant priorities or policies mid-grant cycle, we are concerned that grantees may be held to policies that they were not aware of when initially accepting a federal award. This will lead to uncertainty among grantees as to what requirements, priorities, or policies they need to comply with in order to receive continuation awards.
In addition, the new proposed language in 34 CFR 75.253(e)(5) would allow the Secretary, when making a continuation award, to "issue a partial award, providing funding in installments, or delay the release of funds." The proposed language does not outline under what circumstances the Secretary may take these actions, such as delaying the release of funds. This proposal will make it dificult for grantees to discern what actions they need to take or requirements they must follow to receive their full continuation award in a timely manner. Unexpected delays in funding result in signiicant challenges for grantees in making budgeting decisions.
34 CFR 75.901 - Suspension and termination
We are also concerned by the proposal to add new language under 34 CFR 75.901 to permit the Secretary of Education and pass-through entity to terminate discretionary grants "for convenience." This change would seemingly give the Secretary of Education broad authority to terminate a grant mid-cycle, without reasonable cause like noncompliance or failure to meet program goals. This change would introduce signiicant uncertainty into the discretionary grants process, as the proposed rule does not clearly outline under what types of circumstances the Secretary may use this new termination authority. This lack of clarity means that grantees may unfairly lose federal funding based on factors that are not made clear to them. Further, ED states that this change is similar to existing authority under 2 CFR 200.340(a)(4), but that authority is limited to when the award "no longer effectuates the program goals and agency priorities," which is not the same. Therefore, we request that ED remove this proposed authority.
34 CFR 76.700 - Compliance with the U.S. Constitution, statutes, regulations, stated institutional policies, and applications
We oppose the proposed addition of "Executive Orders" to the list of requirements that grantees under State-administered programs must comply with in exchange for receiving federal funds. We are concerned that this change will provide ED with greater enforcement authority over State-4 administered grants regarding policies that may be outlined in Executive Orders but not incorporated into law or regulations. Executive Orders are policy directives from the White House that do not have the force and effect of law. Federal agencies must take separate action, such as issuing or amending regulations, for Executive Order policies to be legally binding. Under this proposed change, Executive Orders would seemingly become legally binding to grantees immediately after issuance. This further raises concerns about policies changing in the middle of a grant cycle, when grantees had not agreed to such policies when funds were initially awarded. This proposed change would bring instability into the grants process over time as future administrations withdraw or issue new Executive Orders that may be contrary to existing policy, and it will make it dificult for grantees to be certain of the policies that they are legally required to comply with in exchange for receiving federal funds.
34 CFR 75.500 and 76.500 - Constitutional rights, freedom of inquiry, and federal statutes and regulations on nondiscrimination
We oppose the proposed addition of paragraph (f) to both 34 CFR 75.500 and 76.500, which would require grantees to ensure compliance with broad and unclear standards. The proposed changes restate existing obligations under federal civil rights laws and other legal requirements and are, therefore, unnecessary. If ED believes a grantee is violating those laws, it has existing enforcement mechanisms available to use. In addition, the proposed changes would impose vague requirements that may extend beyond federal civil rights requirements. The proposed changes use terms such as "political views" and "proxies," but they provide no standards for determining when, for example, a facially neutral action becomes a proxy. Lack of adequately deined terms creates uncertainty for grantees. Grantees should be able to determine what standards govern their awards, what speciic actions they must take to remain eligible for those awards, and what conduct ED believes will violate these rules.
Thank you for reviewing our feedback on the proposed rule. We are happy to explain any of these issues in more detail.
Sincerely,
Sasha Pudelski
Director of Advocacy
AASA
Elleka Yost
Director of Advocacy & Research
ASBO International
*
Original text of letter here: https://www.regulations.gov/comment/ED-2026-OPEPD-2542-0080