Literature Review

CMS, hospice groups mull Wage Index reform Hospice News; by Jim Parker; 1/13/26 Some stakeholders in the hospice space are seeking reforms to the hospice wage index. ... CMS has given indications that it would mull changes to the hospice wage index. In 2025, the agency convened a technical expert panel to consider the issue. One point of discussion is the application of new data sources, including potential changes to hospice cost reports. ... One proposal discussed within the panel would be to revise the hospice cost report to collect accurate information about costs related to full-time employees, ... To implement a new wage index methodology, CMS would also have to go through a proposed rulemaking process, including public notice and a comment period. With any wage index changes, some hospices would “win” and others would “lose.” Some providers may see higher payments as a result, whereas others may see their rates go down. ...

CMS releases RFI to overhaul Medicare claims system Inside Health Policy; by Jalen Brown; 1/9/26 CMS unveiled a request for information (RFI) Thursday (Jan. 8) aimed at replacing Medicare’s decades-old claims processing system with a modern, cloud-based platform that would be capable of adjudicating millions of claims per day in real time, which would fundamentally re-architect how Medicare pays providers. In Thursday’s RFI, dubbed “ClaimsCore,” CMS is asking large-scale technology vendors to demonstrate whether they can operate a full Medicare claims adjudication system inside a CMS-owned Amazon Web Services cloud environment.

In or out: The hospice, Medicare Advantage conundrum Hospice News; by Jim Parker; 1/2/26 Opposition to a Medicare Advantage hospice “carve-in” remains strong in the field, though some say the lack of one creates a serious gap in the MA program. Medicare Advantage enrollment continues to grow. As of 2025, 54% of Medicare beneficiaries were enrolled in Medicare Advantage, about 31.4 million people, according to the Kaiser Family Foundation. However, MA health plans, by design, do not cover hospice care. When an MA beneficiary elects hospice, they transition to the traditional Medicare benefit, though they may keep their Medicare Advantage coverage for care or services deemed unrelated to their terminal condition.

Hospice care for medicaid cancer patients in Puerto Rico: implications on healthcare costs and utilization JNCI Cancer Spectrum; by Karen J Ortiz-Ortiz, Marjorie Vázquez-Roldán, Axel Gierbolini-Bermúdez, María Ramos-Fernández, Carlos R Torres-Cintrón, Yisel Pagán-Santana, Tonatiuh Suárez-Ramos, Kalyani Sonawane; 12/27/25 Online ahead of print Background: ... In Puerto Rico, Medicaid had no provisions for hospice care until July 2024, representing a significant public health challenge. This study examined the association between hospice coverage policy and EoL outcomes among patients with cancer enrolled in Medicaid.Conclusion: Hospice enrollment among Medicaid enrollees was associated with lower health expenditure, lower healthcare resource utilization, and a lower likelihood of mortality in an acute setting. The recent policy change to include hospice services coverage in Puerto Rico Medicaid is a positive step that must be sustained beyond 2027.

Medicaid agencies made millions in unallowable capitation payments to managed care organizations on behalf of deceased enrolleesOIG press release; 12/23/25A new OIG audit found that from July 2021 to June 2022, state Medicaid programs made an estimated $207.5 million in capitation payments to managed care organizations for enrollees who were already deceased. This estimate is based on the results of our review of 100 statistically sampled capitation payments. We determined that Medicaid agencies made unallowable capitation payments after enrollees’ deaths for 99 of the 100 sample capitation payments.

Long-term hospice stay: New edit to prevent overpayment CMS - MLN Matters - Medicare Learning Network; by the U.S. Department of Health & Human Services; 12/5/25Related CR Release Date: December 5, 2025Effective Date: April 1, 2026Implementation Date: April 6, 2026Action Needed: Make sure your billing staff knows about a new edit that will help identify and prevent overpayments of long-term hospice care for claims submitted with matching “admission” and “from” dates.Key Updates: This new edit in the CWF will close the gap in the system that allows claims to pay at a higher rate when the “admission” and “from” dates match. MACs will reject hospice claims when the “admission” date doesn’t match the election period start date on the corresponding election period. ...

The Medicare Advantage question hospitals want answered Becker's Hospital Review; by Alan Condon; 12/4/25 With Medicare Advantage enrollment approaching 55% of eligible beneficiaries, health systems across the country are grappling with a question that’s gone largely unaddressed in policy circles: What happens if the healthcare providers best equipped to care for seniors can no longer afford to participate?

MedPAC to recommend 7% cut to 2027 home health payment rate Home Health Care News; by Morgan Gonzales; 12/8/25 Just over a week after home health providers were hit with the announcement that their 2026 Medicare payment rates would be reduced by a 1.3% aggregate cut, the Medicare Payment Advisory Commission (MedPAC) agreed to recommend a significantly more drastic cut for the following year. On Friday, MedPAC released a draft report recommending that Congress reduce the Medicare base payment rate for home health care services for calendar year 2027 by 7%. 

Maryland acts after Spotlight ‘trafficking’ probe: Seniors removed, criminal referral filedBaltimore Sun; by Gary Collins; 12/3/25...Maryland officials were taking action following a Spotlight on Maryland investigation found more than 115 suspected unlicensed assisted living facilities were operating across Baltimore, some with little oversight, few inspections and no trained medical staff to attend the seniors housed there.

BULLETIN: HHS repeals nursing home staffing rule provisions McKNights Long-Term Care News; by Kimberly Marselas; 12/2/25 The Department of Health and Human Services today repealed key provisions of the minimum staffing standards for long-term care facilities finalized in 2024. The move follows months of legal and legislative challenges, which had already rendered hourly staffing and registered nurse requirements moot. HHS said it was repealing provisions in alignment with the One Big Beautiful Bill Act, which imposed a nine-year moratorium on the rule’s staffing measures. ... Notice of the appeal was posted in the Federal Register Tuesday morning. Editor's Note: Click here for the official publication of this repeal, scheduled to be published on 12/3/25.

New from MedPAC: 2025 Payment Basics series MedPAC - Medicare Payment Advisory Commission; 11/24/25 MedPAC announces the release of the updated 2025 Medicare Payment Basics series. MedPAC's mission is to advise the Congress on Medicare issues, and part of that mission is providing clear and accessible information about how Medicare works. Payment Basics is a series of explainers on how Medicare's payment systems function. These "basics" are typically no more than 5 pages long and feature handy diagrams that visually depict how the payment systems calculate providers' payments. MedPAC produces "basics" for the major payment systems (20 in all), and updates the series once a year in the fall. The updated versions are now available here.

Calendar Year (CY) 2026 End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule CMS Newsroom - Fact Sheets; by CMS; 11/20/25 Key points:

AGG Files Amicus Brief on Behalf of the National Alliance for Care at Home and AAHPM JD Supra; by Jason Bring, Bill Dombi, and T. Chase Ogletree; 11/20/25 AGG Healthcare attorneys Bill Dombi and Jason Bring and Litigation & Dispute Resolution attorney TC Ogletree filed an amicus (or “friend of the court”) brief on behalf of the National Alliance for Care at Home (the “Alliance”) and the American Academy of Hospice and Palliative Medicine (the “AAHPM”) with the United States Court of Appeals for the Sixth Circuit. The case involves a hospice audit that proceeded through the administrative appeals process to an administrative law judge (“ALJ”) hearing, in which the ALJ denied the hospice’s Medicare reimbursement claims.