While the 2026 Calendar Year Medicare Home Health Final Payment Rule is most discussed for its methodology and total 1.3% reduction, other aspects of the final rule will require home health providers to carefully strategize for next year.
In the final rule, the Centers for Medicare and Medicaid Services (CMS) recalibrated all 432 PDGM case-mix weights and associated low-utilization payment adjustment (LUPA) thresholds using calendar year 2024 utilization data. According to a webinar hosted by WellSky, this realignment will shift payments from certain PDGM groups to others, ultimately improving coding accuracy for more severely ill patients.
WellSky, based in Overland Park, Kansas, is a healthcare technology company serving more than 20,000 customer locations, including hospital systems, home health, hospice operations, and other acute care providers.
According to Cindy Campbell, senior director of advisory services at WellSky, in 2026, determining casemix weighting and how to work with different PDGM groups will be key for providers.
The mixed weight of some cases increased and some decreased. High-severity 30-day periods classified as early, regional, high-functioning, and cross-comorbidity may result in increased payments due to increased case-mix weight.
On the other hand, a 30-day period of low severity classified as late, institutionalized, low-functioning, and without comorbidities may result in lower case-mix weights and lower payments.
Some of the rule changes include changes to LUPA thresholds. Although the changes are relatively small and involve only one visit, Campbell said they warrant the attention of health care providers. This change means providers need to be especially careful to perform comprehensive assessments every 60 days.
“If you have a specific patient group, for example a cardiopulmonary or orthopedic group, the LUPA threshold in 25 years might have been four visits,” Campbell said. “Those groups may have grown up to five people. Other groups… may have been reduced to one person per visit.”
For other patients, such as monthly long-term Foley catheter patients, providers may think they can skip the 60-day evaluation because nothing needs to change. However, reevaluating and repeating the care plan ensures that staff are aware of changes in the patient's body that occur over time, which may influence the need for further intervention.
In the future, as new technologies become available, tools such as generative AI and ambient listening will ensure a comprehensive assessment rather than a patient's medical history to guide future low-utilization payment adjustments, Campbell said.
The final rule also finalized changes that would allow for in-person care, allowing physicians other than board-certified physicians or physicians other than physicians to care for patients at the location where the patient was directly admitted to home health care. The goal of the changes is to ensure that physicians or licensed physicians providing in-person care have the most first-hand information about a patient's current clinical condition, the webinar said.
The rule also revised the Consumer Assessment of Health Care Providers and Systems Home Health Survey (HHCAHPS) to begin with sample collection in April 2026.
CMS added three new questions, including whether the care provided helped the patient manage his or her health, whether the patient's family and friends were given adequate information and instructions, and whether the patient felt the staff cared about him or her “as a human being.”
The number of medication questions was reduced to two, and questions that were not used in the synthesis of public reports were removed. Two composite scales remained but were modified, and three new independent scales replaced the Special Care composite scale.
Additionally, CMS removed the COVID-19 Vaccination Assessment, which required providers to complete the OASIS item by April 1, and also removed the four social determinants of health assessment items.
Still, some of these changes to HHCAHPS will not be permanent.
“CMS is working on coordinating and staffing the various data elements, and we know that they are critical to the relative performance and spending of programs. But we also know that we are collecting too much right now and need to reconcile that,” Campbell said. “I wouldn’t be surprised if they integrated and came back in the future.”
