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On Monday, I moderated a HHCN+ TALKS episode – our exclusive opportunity for HHCN+ members to hear from and engage directly with leading experts in real time. The topic was on the policy and regulatory landscape affecting the home-based care industry under the second Trump administration.
Needless to say, this was a timely discussion, given the way the week has unfolded. I write this as news is breaking that the House of Representatives has passed the massive tax-and-spending bill that includes major cuts to Medicaid that gravely concern providers. And the bill’s passage comes on the heels of other major developments this week. The TALKS discussion occurred just hours before CMS released its 2026 Medicare payment proposal for home health. During the TALKS discussion, Dr. Steven Landers, CEO of the National Alliance for Care at Home, said that the rule would provide some indication of the administration’s approach to the “behavioral adjustments” tied to the Patient Driven Groupings Model:
“Of course, we are any day now going to see a proposal for the Medicare home health payment system for 2026 and [we’re looking out for] will CMS moderate under the Trump administration this cycle of behavioral adjustments, which have been hanging over the home health system’s head, or will those adjustments be moved forward aggressively?”
After the proposed rule dropped, Landers would tell HHCN that it represents the largest cut ever floated. So much for moderation – at least so far. Landers noted that some of the work on this proposed rule was likely done by the previous administration, prior to Biden leaving office.
HHCN will continue its coverage of the proposed payment cut, which has included a recent story with insights from a slew of industry leaders, including Landers’ additional comments.
Despite the danger, industry stakeholders demonstrate cautious optimism. When I asked Landers and his co-panelists – Jeanette Weinz, Brand Leader of Executive Home Care and David Jackson, CEO of Choice Health at Home – to compare how they felt about the home-based care industry on Monday compared to how they felt in February, I got largely hopeful, though moderated, replies.
And this week also brought some policy news being hailed in the home care industry: The Department of Labor (DOL) move to reinstate the companionship exemption.
In this week’s exclusive members-only HHCN+ Update, I cover the most recent episode of HHCN+ TALKS, including possible repealing of the 80/20 rule, dealing with increased audits and surveys and future-proofing business strategies. I’ll offer analysis and key takeaways, including:
– Home health care implications of Trump administration’s pro-business and anti-fraud, waste and abuse approach
– The actions providers can take to set their businesses up for success and create change
Pro-business upside
For all the reimbursement and regulatory uncertainty, home-based care providers also stand to benefit from some Trump-spurred policies.
This week’s recommendation from the DOL to reinstate the companionship exemption for home care is one example. Bringing back the exemption, reverting to the situation that existed prior to 2013, would give agencies the ability to expand companionship services without incurring unsustainable overtime costs.
“Seniors want familiar, trusted caregivers, not a revolving door – when a care recipient opens their door to a caregiver, they open their life to them,” Bob Roth, managing partner at Cypress HomeCare Solutions, said in a LinkedIn post. “Yet agencies were forced to staff cases with multiple caregivers due to overtime burdens. This proposed rule marks a turning point. It’s not just a win for agencies; it’s a victory for older adults and their families who deserve continuity, stability, and safe, affordable care.”
Home care providers are anticipating wins on other policy priorities as well. I’ve previously reported that the Trump administration could re-reconsider the 80/20 rule that requires that 80% of Medicaid dollars be spent on worker compensation, with 20% going to providers for overhead and profit. But the TALKS conversation was the first time I’ve heard such confidence in the rule’s days being definitely numbered.
Landers said he could not pinpoint exactly when the rule would be repealed, but he expressed confidence that it would be some time during this administration.
The 80/20 rule is “not sustainable at all,” Weinz said. The rule did have contain some “good things,” Jackson said, but is a mixed bag, and good intentions ultimately did not equate to common sense.
“I think the whole access rule probably gets repealed,” Landers said. “There are things in there that I think our community would want to maintain, but ultimately, that 80/20 piece is just so damaging and unworkable that I think it’ll be good news when it gets put to bed.”
Repealing this rule would allow providers to make their own decisions with Medicaid dollars, and for an industry operating on razor-thin margins, that promises good news. But balancing the removal of the rule, in my eyes, must be accompanied by other changes that would allow home-based care benefits to provide desired benefits for their employees. If businesses were reimbursed sufficiently, they could provide insurance and other benefits for their workers, Landers said during TALKS.
While hope for sufficient reimbursement seems weak at the current moment, thanks to the Medicaid cuts in the budget bill and the recently proposed Medicare home health payment rule, I’m crossing my fingers that lawmakers will take action alongside repealing the 80/20 rule to improve providers’ standing while protecting their workers.
Surviving reimbursement, regulatory pressures
While some policies changes promise to ease challenges facing the at-home care sector, there is no escaping the financial crunch looming, should the 2026 CMS Medicare proposal be finalized while providers continue to struggle with Medicare Advantage rates, exacerbated by the potential trickledown effects of big Medicaid cuts.
Weinz and Jackson said preparing their businesses for the changes at hand is a top priority.
For Choice Health at Home, Jackson has taken up two main approaches to mitigate some of the pressures, with the first being diversification of services.
“At Choice, I’ve been very focused on building three distinct service lines, personal care, home health and hospice,” Jackson said. “Diversity is one way to hedge against regulatory stroke of the pen risk. You’ll see states, to Steve’s point, as they start to grapple with insufficient funds, they’ll move dollars around. And it can have unintended consequences that these congressmen and women that are dealing with this, they just can’t anticipate.”
In addition to diversifying its service lines, Choice is taking greater strides to incorporate artificial intelligence into every aspect of its back office.
“We found, very quietly in the home health care sector, we found that through improved authorization processing, even automating how we’re moving on authorizations … we’re trying to go at that in a way to enhance what we’re doing, so that anything that we can accomplish in negotiation with payers or at the federal level, as we think about Medicare reimbursement, is upside,” he said. “If you’re not doing that right now, our most precious resource is caregivers and clinicians, and there’s just simply not enough of them.”
Executive Home Care has narrowed in on strategic training, including sales training, that helps its franchises brand themselves and “work outside of the box,” with a primary goal being to maximize private-pay revenue.
“We really focus on the community, the relationships, the training, so that it can get them to have more of that private pay sector, and that is helping us to keep our margins,” Weinz said.
Caring for more private-pay clients may be the best for franchises that might be eager to accept MA.
“I see a lot of my franchises want to start with Medicare Advantage,” Weinz said. “Once they start that, they’re very excited about it, but it’s not sustainable. Because then they figure out what their margins are on that piece of it. So there’s definitely something that has to be done with Medicare Advantage, for their pricing, their reimbursement to go up on that, so we can afford these things.”
Another way for providers to take action relates to the Trump administration’s fixation on fraud, waste and abuse. This is an area that ultimately should benefit the sector, if bad actors are rooted out. Some sham companies or marginal operations do exist in the home-based care space, and should be targeted by CMS, Landers said. However, in the near-term, providers must make necessary investments in technology and operations to ensure compliance.
Regulators must not compromise the accessibility of good care because of administrative issues like a missed signature, Jackson and Landers said. To thrive under increased audits, providers should have “robust audit and loss prevention programs,” Jackson said.
“You need to be looking at programs that help you improve the compliance of a clean claim,” Jackson said. “I think you have to be perfect there.”
Providers that succeed here can set themselves apart from their peers, Landers said.
“That’s really important in this environment and going to be a differentiator for folks, is their compliance and internal controls,” Landers said. “This administration, as we look at it, they are very serious about advancing the cause of eliminating waste, fraud and abuse in health care … in their budget to to Congress. They have really shown how intensely they plan to prioritize fraud and abuse prevention.”
I expect providers to increasingly seek out software solutions that can help look over workers’ shoulders and ensure complete compliance – those that don’t take meaningful steps to set themselves apart this way will be susceptible to not only increased audit risk, but increased competition from their peers.
Lastly, and perhaps most importantly, providers can take action to bridge the communication gap between lawmakers and providers. Weinz, Landers and Jackson all championed the cost-saving nature of at-home care – while attesting that lawmakers seem to fail to connect that home-based care could be a tool to achieve goals of better outcomes and cost savings.
Providers must therefore use their voice, Landers said.
“It’s imperative that everybody includes, as part of their job description, speaking up, telling the story, engaging with their legislators, and with our associations, state and national, to make a difference,” Landers said. “I’m seeing grassroots participation and political action being stronger. It’s not strong enough, we’ve got to keep going, but there’s some momentum there, and we’ve got to keep investing.”
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