Literature Review

CMS budget proposal would shift nursing facility oversight Becker's Hospital Review; by Elizabeth Gregerson; 6/4/25 Key changes put forth in President Donald Trump’s proposed fiscal year 2026 budget may have downstream effects on the survey and certification of skilled nursing facilities. ... Here are three things to know about the proposed changes:

Experts warn of scams during Medicare Fraud Prevention Week Public News Service; by Suzanne Potter; 6/4/25 Medicare loses $60 billion to $80 billion a year to fraud and this year, for Medicare Fraud Prevention Week, your local Senior Medicare Patrol has good advice on how to spot a con. There are plenty of scams to be aware of. Karen Joy Fletcher, communications director with the nonprofit California Health Advocates, said beware if a caller asks to verify your Medicare number, claiming the program needs to send out a new type of card. ... ... Caregivers can be on the lookout for medical equipment arriving at the house even though the beneficiary never ordered it. Another red flag? A stranger may approach you in a parking lot asking you to sign up for new, free Medicare services like house cleaning or meals, which are then fraudulently billed to the government. ... Another scam involves tricking people into unknowingly signing up for hospice care. It is especially dangerous, because once a person is on hospice, Medicare will only approve palliative care and could mistakenly deny an essential surgery or medication.

Medicaid increase, program changes detailed in CMS Budget Proposal InsideHealthPolicy; by Dorothy Mills-Gregg; 5/30/25 Medicaid would see a nearly $57.5 billion increase under the Trump administration’s proposed 2026 budget, though federal Medicaid matching funds for state administrative expenses would be reduced by $1.2 billion compared to this year’s estimate, according to the CMS budget justification document for fiscal 2026 released Friday (May 30).

CMS’s Hospice Star Rating System limited by missing data Health Affairs; by Amanda C. Chen and David C. Grabowski; 6/3/25 Two-thirds of US hospices were not given a star rating when the Centers for Medicare and Medicaid Services (CMS) introduced its hospice star rating system in 2022. Since then, the share of hospices without a star rating has steadily increased, including through the most recent reporting period of 2024. This suggests that the CMS hospice star rating is having limited impact. We provide recommendations for CMS and other policy makers to improve the value for hospice patients of publicly reported star ratings.

Why CMS’ GUIDE Model could move home care from side act to main stage Home Health Care News; by Joyce Famakinwa; 5/29/25 The Guiding an Improved Dementia Experience (GUIDE) Model might be one of the biggest steps in the right direction for recent Medicare policy. The eight-year voluntary nationwide program was launched last year by the Centers for Medicare & Medicaid Services (CMS), with the goal of supporting individuals living with dementia, as well as their unpaid caregivers. The program’s focus is more important than ever, with an estimated 6.7 million people living with dementia. This amount is expected to skyrocket to 14 million cases by 2060, according to data made available by CMS.

CMS: Kidney Care Choices (KCC) Model CMS.gov - Centers for Medicare & Medicaid Services; 5/27/25 The Centers for Medicare & Medicaid Services (CMS) is announcing a coordinated set of changes to the Kidney Care Choices (KCC) Model starting in performance year 2026 that are expected to improve the model test by adjusting the financial methodology and participation options to improve model sustainability. In addition, the model is being extended by one year for continuation of quality care to beneficiaries through 2027. For more information, please visit KCC Model Performance Year 2026 Updates. 

Proposed California budget calls for prior authorization for hospice in Medicaid Hospice News; by Jim Parker; 5/22/25 The proposed California budget would require prior authorizations for hospice care within the state’s Medicaid program. Currently, Medicaid managed care plans who provide coverage through the state’s Medicaid system, Medi-Cal, may not perform prior authorizations for hospice. California’s Department of Health Care Services (DHCS) indicated in a 2025-2026 budget revision that this could save $25 million over the next two years and more than $50 million in the long term. If enacted, this would make California the first state in the nation to implement such a rule, according to the California Hospice & Palliative Care Association (CHAPCA). The association contends that the anticipated $25 million in cost savings is “speculative and fails to account for the downstream costs and systemic burdens this proposal would create,” according to a position paper shared with Hospice News. ... CHAPCA recommended to the state government three alternative approaches: ...

AHA urges HHS to cut regulations that burden hospitals and staff OR Manager; by Matt Danford; 5/16/25 The American Hospital Association (AHA) has called on the Department of Health and Human Services (HHS) to eliminate or ease a variety of federal regulations, arguing that excessive administrative rules drive up costs, reduce patient access, and hinder innovation, Modern Healthcare reported May 13. According to the article, the AHA submitted more than 100 deregulatory suggestions to HHS, the Centers for Medicare and Medicaid Services (CMS), and the Office of Management and Budget. [Continue reading for descriptions specific to billing and payment, quality and safety regulations, and workforce-related recommendations.]

Medicaid hospice payments for room-and-board to resume in California Hospice News; by Jim Parker; 5/15/25 After years of nonpayment, the California Department of Health Care Services (DHCS) has instructed Medicaid managed care plans to pay hospices for nursing home room and board. The issue pertains to patients who are dually eligible for Medicare and Medicaid. When caring for patients in nursing homes, hospices typically pay for their room and board with the expectation that they will be reimbursed by Medicaid for those expenses. However, due to confusion among managed care plans that oversee Medicaid in most states, those hospices have not been receiving those payments.

Dementia patient discharged from hospice over Medicare requirement. Here’s why it happened WKMG-6, Deltona, FL; by Erika Briguglio and Louis Bolden; 5/14/25A Volusia County family is left scrambling after their loved one is abruptly dropped from hospice care. To qualify for hospice, patients must have a life expectancy of six months or less. However, for dementia patients, the prognosis can be unpredictable. Hospice care can be extended as long as the patient continues to meet Medicare requirements. Unfortunately, these requirements are why Amy Yates lost coverage for her 91-year-old grandmother. ... “I think it’s she hasn’t died fast enough, and it’s costing them money that they don’t want to spend,” Yates told News 6. ... What Yates’ family is dealing with is what Medicare calls live discharge, and they are not alone. The Hospice Foundation of America reports that 17% of people in 2022 who were admitted to hospice care were discharged; about 6% of the total caseload was discharged because they no longer met Medicare requirements for care under the hospice benefit.Editor's note: What are your hospice stats for live discharges? For Length of Stay (LOS)? This factor--with the face-to-face recertification requirement--is crucial. Unfortunately, many hospices misused President Jimmy Carter's extraordinarily long LOS with misleading information about hospice care. They watered down "end-of-life" care and never mentioned anything about a basic recertification process. Warm, user-friendly language can be used with integrity, authenticity, and patient/caregiver support.

Be ready for updated Special Focus Program, hospice experts sayMcKnight's Home Care; by Adam Healy; 5/9/25A revised hospice Special Focus Program is coming, and providers should make sure they have plans and procedures in place to be successful under this strict oversight program, Linda Woodle, director of accreditation at Community Health Accreditation Partner (CHAP), and Patricia D’Arena, vice president of clinical excellence at Enhabit Home Health and Hospice, said... When that program will be reinstated is anyone’s guess... The Centers for Medicare & Medicaid Services has indicated that assessments will place a high emphasis on four specific Conditions of Participation: patient’s rights; initial and comprehensive assessment of the patient; interdisciplinary group, care planning and coordination of care; and quality assessment and performance improvement. So providers should ensure they meet all of these conditions’ requirements.

States sue HHS over layoffs, restructuring: 5 updates Becker's Hospital Review; by Madeline Ashley and Mackenzie Bean; 5/5/25 Nineteen states and the District of Columbia filed a lawsuit against the federal government May 5 aiming to block the Trump administration’s large-scale restructuring of HHS. In the lawsuit, New York Attorney General Letitia James and 19 other AGs argue the restructuring is an “unconstitutional and illegal dismantling of the department.” They contend the government has violated hundreds of laws and bypassed congressional authority by enacting the plan, which has erased decades of public health progress and left HHS unable to execute many vital functions.

California man sentenced to 12 years’ imprisonment in connection with $17m Medicare fraud schemes U.S. Department of Justice - Office of Public Affairs; Press Release; 2/6/25 A California man was sentenced yesterday to 12 years in prison and three years of supervised release for his role in a years-long scheme to defraud Medicare of more than $17 million through sham hospice companies and his home health care company. According to court documents, Petros Fichidzhyan, 44, of Granada Hills, schemed with others to bill Medicare for hospice services that were not medically necessary and never provided. Fichidzhyan and his co-schemers controlled hospice entities and used foreign nationals’ personal identifying information (PII) to conceal the scheme, using the PII to, among other things, open bank accounts, submit information to Medicare, and sign property leases.