Leverage Triage to Navigate CMS’s Proposed 6.4% Cut
On June 30, 2025, the Centers for Medicare & Medicaid Services (CMS) released the CY 2026 Home Health Proposed Rule, which includes an overall 6.4% cut to Medicare home health payments in 2026. This represents roughly $1.135 billion less in payments compared to 2025.
The cut is a combination of multiple payment adjustments, outlined in detail in CMS’s fact sheet, and is driven by data showing that the provider behavior under the Patient-Driven Groupings Model (PDGM) resulted in higher-than-expected payments.
Why the cut?
CMS is required by the Bipartisan Budget Act of 2018 to assess how provider behavior under PDGM has changed since its launch in 2020. Their data indicates that between 2020 and 2024, behavior under PDGM contributed to $5.3 billion in overpayments. This proposed rule is CMS’s effort to recalibrate.
Key changes in the CY 2026 proposed rule
- -4.059% permanent payment reduction. CMS continues adjusting for what it calls “behavioral assumptions” under PDGM.
- -5.0% temporary payment reduction. This one-year cut is designed to recover those prior overpayments.
- Updates to PDGM case-mix weights, face-to-face rules, and oversight polices.
- Changes to the Home Health Quality Reporting Program and the Home Health Value-Based Purchasing (HHVBP) model.
- Push for interoperability and digital quality measures. CMS is encouraging providers to move towards health IT standards like FHIR for automated data reporting and requesting feedback on this.
What this means for home health agencies
Agencies need to prepare for lower reimbursement, more scrutiny of coding and visit patterns, and new tech expectations. This proposed rule is not just about cost containment, though; it’s about proving value and care quality in new ways.
Triage is a more strategic asset now than ever
Your triage operations can help you respond proactively to these proposed changes:
- Strengthen triage documentation. CMS is watching for mismatches between the care delivered and the payment level. Ensure your triage encounters capture the full clinical context. Leveraging triage solutions that integrate with your EMR will help you ensure documentation accuracy.
- Minimize LUPA risk. You can use your triage data to support visit planning and escalation decisions. Proactive nurse follow-ups and automated engagement to proactively identify new or worsening symptoms can flag when a visit is necessary and help avoid low-utilization penalties.
- Equip triage nurses with tools to enhance efficiency. AI tools can help nurses make the right call quickly with real-time context, ensuring high acuity cases get timely care while reducing unnecessary visits.
- Track and close every triage loop. Document triage resolutions clearly and completely. This supports quality reporting and audit readiness, reduces care fragmentation, and improves patient outcomes.
- Prepare for digital quality reporting. Start assessing your systems for FHIR compatibility. CMS is suggesting a move toward automated quality data submission, and providers who are ready will have the advantage.
Make your voice heard
CMS is accepting public comments on this proposed rule through August 29, 2025. This is your chance to advocate for your agency and your patients.
Submit your comment here.