August 27, 2025
VIA ELECTRONIC SUBMISSION
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244-8013
Re: Home Health CY2026 Proposed Rule
Dear Administrator Oz:
The Center for Medicare Advocacy appreciates this opportunity to comment on 90 FR 29108, Calendar Year 2026 Home Health Prospective Payment System (HH PPS) Rate Update Physician Fee Schedule Proposed Rule (7/2/2025). Founded in 1986, the Center for Medicare Advocacy (the Center/CMA), is a non-profit, non-partisan law organization that works to advance access to comprehensive Medicare, quality health care, and health equity. The organization represents Medicare beneficiaries, their families, and caregivers nationally and responds to over 7,000 inquires for assistance each year. We focus on the needs of people with longer-term and chronic conditions who rely on Medicare to obtain necessary health care in the most appropriate, least restrictive environment. Assisting patients to obtain Medicare-covered home health care as authorized by law is a priority of the Center.
In the proposed rule, the Secretary clarifies that the current Medicare home health payment model, the Patient-Grouping Payment Model (PDGM) did not change Medicare coverage standards:
The PDGM did not change eligibility criteria or coverage criteria for Medicare home health services, and as long as the individual meets the criteria for home health services, as described at 42 CFR 409.42… the individual can receive Medicare home health services, including therapy.” 90 FR 29118 [Emphasis added.]
The Secretary further notes that the PDGM case mix methodology was intended,
“To better align payment with patient care needs and to better ensure that clinically complex and ill beneficiaries have adequate access to home health care… (83 FR 56406)”
Unfortunately, PDGM has not met these goals. Access to home health care, particularly for “clinically complex and ill beneficiaries” has diminished dramatically. For example, under the law, Medicare authorizes up to 28 to 35 hours a week of home health aide (personal hands-on care) and nursing services combined.[1] Currently, however, this level of coverage and care is almost non-existent. For example, a beneficiary with quadriplegia, who established he met Medicare coverage criteria for years, wrote the Center for Medicare Advocacy in August 2025. He sought help because he now cannot find any Medicare-certified home health agencies to provide his care. He wrote:
“I am a 64-year-old C4-C5 quadriplegic for 35 years. I would say for the first 25 years while I was receiving Medicare home health services, I was receiving home health aide visits once a day-five days a week without any issues. I would also receive daily visits Monday through Friday for a nurse to straight catheterize me. My wife would take care of my catheterization needs in the evenings and on the weekends. Over the years I was with several home health care agencies and the number of visits for home health aides to address my ADLs diminished to one day a week in 2017. In 2023, I was informed by my home health care agency I could no longer be receiving home health aide services due to lack of personnel. Since then my wife is been solely responsible for assisting me with my shower. Having psoriatic arthritis, she has medical concerns over own. Psoriatic arthritis is a progressive disease that attacks the joints and muscles. There is no cure. Time is quickly approaching when she will no longer be able to attend to my shower. None of the Medicare approved home health care agencies in my area provide home health aide services.” [Emphasis added.]
This is not an unusual cry for help. The Center for Medicare Advocacy is regularly contacted by similar patients and their families who cannot find the care they need from Medicare-certified agencies. This is true, even when, like the gentleman quoted above, they meet legal qualifying criteria: They have an authorized plan of care, meet the law’s homebound and skilled care requirements – and often seek the bare minimum services covered under the law.
The current payment model simply does not “align payment with patient care needs … to better ensure that clinically complex and ill beneficiaries have adequate access to home health care.”
In fact, since PDGM’s inception in 2020, the length of Medicare-covered home health care has dropped significantly as has any access to home health aides. Home health aide utilization has declined steadily over the past two decades by almost 94% – from a 30-day average of 6.7 visits in 1998[2] to less than half a visit a month in 2022.[3] As a percent of total visits from 1997 to 2021, home health aides declined from 48% of total services to 5%.[4]
As the proposed rule itself notes, there is clearly a decrease in the availability of home health aides. Each year since the PDGM was implemented, there has been a decrease in the percentage of 30-day episodes of care in which beneficiaries received any home health aides and/or social worker visits. There has also been a decrease in the availability of skilled nursing services. Further, there is a decline in services for people with high functional impairment levels who need more assistance. (See, Proposed Rule, Tables 9, 11, and 12.)
Access to the full array of Medicare-covered home health services is lacking for beneficiaries in traditional Medicare. It’s even worse for those enrolled in private Medicare Advantage plans. In 2021 the Center surveyed 200 home health agencies across 17 states about access to Medicare-covered care. When asked if there were differences in services they could provide in traditional Medicare vs. Medicare Advantage, agencies commented that, in their experience, Medicare Advantage plans provide less to patients and require more of agencies. Common themes included, MA plans deny and limit services through prior authorizations and during the course of care, allow fewer visits, and require more changes to care plans.
Medicare home health access problems were recently reported in a study published in the Journal of the American Medical Association. The study reported a drop in Medicare home health for people with dementia/high need populations. This was attributed, in part, to PDGM – and an even higher drop in care was noted for people in Medicare Advantage vs. traditional Medicare.
“Decreasing rates of home health care use since 2020 in this high-need population point to a need for ongoing monitoring of service use and outcomes for people with dementia.”[5]
See, Trends in Home Health Care for Beneficiaries With or Without Dementia, JAMA Network Open, Vol. 8 No. 5, May16, 2025; https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2834204
The Secretary states that the 2026 payment rate was based on past claim experience and home health utilization. This “continue[s] the practice of using the most recent complete home health claims data at the time of rule-making, which is CY 2024 data.” 90 CFR p. 29163
“To determine the CY 2026 national, standardized 30-day period payment rate, we would continue our practice of using the most recent, complete utilization data at the time of rulemaking; that is, we are using CY 2024 claims data for CY 2026 payment rate updates. We apply a permanent adjustment factor, a case-mix weights recalibration budget neutrality factor, a wage index budget neutrality factor, the home health payment update percentage, and a temporary adjustment factor to update the CY 2026 payment rate. As discussed in section II.C.1. of this proposed rule, we are proposing the implementation of a permanent adjustment of −4.059 percent …” https://www.federalregister.gov/d/2025-12347/p-299
“This analysis incorporates the latest estimates of growth in service use and payments under the Medicare home health benefit, based primarily on Medicare claims data for periods that ended on or before December 31, 2024.” 90 FR 29297; https://www.federalregister.gov/d/2025-12347/p-1731
This is not an appropriate means of developing a payment model. In fact, it creates a vicious cycle in which fewer services are provided, and fewer services are anticipated in the future. This, in turn, creates a self-fulfilling prophecy in which fewer and fewer services are provided because fewer and fewer services are anticipated and assumed in the payment model. Thus, the payment rate rubber-stamps and encourages the continued shrinking of the Medicare home health benefit.
Ironically, this continual decrease in access to Medicare-covered home health care costs the Medicare program more than if patients received the care they need and that’s authorized under the law. A recent actuarial report supports this:
Increasing dosage of home health aide utilization appears to contribute to lower overall expenditures compared to lower home health aide utilization as patients seem to rely on these services more than expensive inpatient and skilled nursing facilities. More readily employing the use of Home Health Aides may help redirect care from institutional settings to the home, contributing to lower overall expenditures. …
The majority of the expense differential between cohorts is attributed to lower inpatient expenses for HH utilizers. We note that this may in part be due to the definition of non-utilizers which relies on having multiple inpatient stays. Although that definition is imperfect, it is a characteristic that is consistent with the majority of HH utilizers and thus an important criterion for appropriately identifying the non-HH utilizing population who would be eligible for HH services.
In summary, these cohort-level comparisons suggest that Home Health utilizers tend to have lower expenditures than non-utilizers indicating that ensuring access to Home Health services may contribute to material savings in the Medicare program by reducing inpatient visits and/or lengths of stay. Ruby Well Home Health Report, Executive Summary, Wakely Consulting Group, LLC (Wakely), 8/19/2025
Conclusion
The Center for Medicare Advocacy urges CMS to readjust the current home health payment model to ensure that patients can obtain reasonable and necessary home health care as envisioned by Congress and authorized by law. As currently implemented, the PDGM model does not meet this need. In fact, it continues to diminish the care that is available at home, bases future payments on the limited care that is provided, and leaves patients without the care they need. An honest methodology should be developed that includes adequate payment for all the services covered by law, including home health aides.
Respectfully submitted,
Judith Stein
Attorney, Founder & Senior Advisor
Center for Medicare Advocacy
[1] 42 U.S.C. 1395x(m)(7)(B)
[2] Medicare Payment Advisory Commission (MedPAC), “Report to Congress: Medicare Payment Policy” (March 2021), Ch. 8, page 236: https://www.medpac.gov/wp-content/uploads/2021/10/mar21_medpac_report_ch8_sec.pdf.
[3] Centers for Medicare & Medicaid Services (CMS), Proposed Home Health Rule (CMS-1780-P), 88 Fed Reg 43654 (July 10, 2023), at pp. 43663, 43671.
[4] Medicare Payment Advisory Commission (MedPAC), “Report to Congress: Medicare Payment Policy” (March 2023), Ch. 8, p. 250, available at: https://www.medpac.gov/wp-content/uploads/2023/03/Ch8_Mar23_MedPAC_Report_To_Congress_SEC.pdf; Medicare Payment Advisory Commission (MedPAC), “Report to Congress: Medicare Payment Policy” (March 2019), Ch. 9, pp. 234-235, available at: http://www.medpac.gov/docs/default-source/reports/mar19_medpac_ch9_sec_rev.pdf?sfvrsn=0.
[5] See, Trends in Home Health Care for Beneficiaries With or Without Dementia, JAMA Network Open, Vol. 8 No.5, May16, 2025; https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2834204