Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

CMS Indefinitely Suspends Off-Cycle Medicare Revalidation Process for Nursing Homes

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Private equity and real estate investment trusts have had a profoundly negative impact on the quality of care provided by nursing homes. Studies and articles have documented the lower staffing levels and increased deficiencies that follow these private investments. In 2010, Congress included a provision in the Affordable Care Act requiring the Centers for Medicare & Medicaid Services (CMS) to issue rules to require nursing homes to disclose additional information about their owners. Final rules were published on November 17, 2023, 88 Fed. Reg. 80141. On October 11, 2024, CMS issued a revised Medicare enrollment application process for institutional providers, including a new attachment that required all skilled nursing facilities (SNFs) to complete an off-cycle revalidation process between October and December 2024. Implementation of off-cycle revalidation was delayed twice. Now, the Trump Administration has suspended implementation “indefinitely.” The indefinite suspension means that nursing homes can avoid immediate disclosure of critical ownership and control information. As Richard Mollot, Executive Director of the Long Term Care Community Coalition, said about the suspension, “These requirements are essential to understanding who truly owns, controls, and profits from nursing homes, particularly in an industry increasingly characterized by complex corporate structures and sophisticated private enterprise investment.”  

Concern about private equity’s ownership of nursing homes was raised on September 23, 2007, when The New York Times reported that private investment firms, including private equity firms that acquired nursing homes, “often reduced costs, increased profits and quickly resold facilities for significant gains,” resulting in dramatically deteriorating care for residents. Charles Duhigg, “At Many Homes, More Profit and Less Nursing,” The New York Times (Sep. 23, 2007). The Times compared investor-owned facilities to national averages:

Data includes homes purchased by Warburg Pincus, Formation Capital, and National Senior Care

The Times reported that facilities owned by investment companies were “41 percent more profitable than the average facility.” Facilities owned by private equity cut the number of registered nurses providing care to residents.

The lengthy front-page investigative article led to multiple Congressional hearings and ultimately, enactment of a provision in the Affordable Care Act (ACA), Public Law 111-148. Section 6101 of the Act (under Subtitle B, Nursing Home Transparency and Improvement, Part I, Improving Transparency of Information) is entitled “Required additional disclosure of ownership and additional disclosable parties information.” The ACA required the Secretary to promulgate final regulations in two years.

A proposed rule to implement §6101 was published on May 6, 2011, 76 Fed. Reg. 26364, but it was never published in final form.

The Biden Administration’s comprehensive initiative to improve nursing home quality, “Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes” (Fact Sheet, Feb. 28, 2022), included a commitment to “implement Affordable Care Act requirements regarding transparency in corporate ownership” of nursing facility, including the “collect[ion] and public reporting [of] more robust corporate ownership and operating data.”

On November 17, 2023, CMS published final rules to implement §6101 of the ACA. CMS, “Medicare and Medicaid Programs; Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities; Medicare Providers’ and Suppliers’ Disclosure of Private Equity Companies and Real Estate Investment Trusts,” 88 Fed. Reg. 80141.

CMS wrote in 2023, 88 Fed. Reg., 80144:

Reports have circulated that nursing facility quality has declined under private equity and similar owners. For example, in February 2021 the National Bureau of Economic Research (NBER) published an analysis titled ‘‘Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes.’’ The report stated: ‘‘Our estimates show that private equity (PE) ownership increases the short-term mortality of Medicare patients by 10%, implying 20,150 lives lost due to PE ownership over our twelve-year sample period. This is accompanied by declines in other measures of patient well-being, such as lower mobility, while taxpayer spending per patient episode increases by 11% [citing Atul Gupta, Sabrina T. Howell, Constantine Yannelis, and Abhinav Gupta, “Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes,” 2021, p. i.]. A November 2021 analysis published in the Journal of the American Medical Association contained similar findings concerning PEC-owned nursing facilities. Titled ‘‘Association of Private Equity Investment in US Nursing Homes with the Quality and Cost of Care for Long-Stay Residents,’’ the report stated that PECs seek annual returns of 20% or more; with this pressure to generate high short-term profits, private-equity-owned nursing homes might reduce staffing, services, supplies, or equipment, which could adversely affect quality of care [citing Robert Tyler Braun, Hye-Young Jung, Lawrence Casalino, et al., JAMA Health Forum, November 19, 2021]. The analysis concluded that: (1) private equity acquisition of nursing facilities was associated with higher costs and increases in emergency department visits and hospitalizations for ambulatory sensitive conditions; and (2) per the study’s findings, more stringent oversight and reporting on private equity ownership of nursing homes may be warranted. [citing Braun]. The previously mentioned concerns about nursing home ownership are not limited to PECs. Other types of private ownership, such as REITs, have generated similar concerns.

On October 11, 2024, CMS issued a revised Medicare enrollment application process for institutional providers, including a new attachment that required all skilled nursing facilities (SNFs) to complete an off-cycle revalidation process between October and December 2024.

On November 5, 2024, CMS extended the deadline to May 1, 2025 for all SNFs. CMS, Guidance for SNF Attachment on Form CMS-855A (Nov. 5, 2024). CMS reported the extension of the due date for SNFs’ revalidation in MLNConnects on November 14, 2024. CMS reiterated the May 1, 2025 deadline in MLNConnects on March 25, 2025. On July 17, 2025, CMS again delayed the requirement for off-cycle validation, this time, until January 1, 2026. The Trump Administration has now permanently suspended implementation of the off-cycle revalidation requirements.

For further information about nursing homes and private equity, see these CMA Alerts:

For additional information on corporatization of nursing home ownership, see these CMA Alerts:

January 8, 2026 – T. Edelman