Proposed Rules Regarding AI, Prior Authorization Guardrails for MA Plans May Remain in Limbo, Providers Say

McKnight’s Home Care / By Adam Healy
 
The Centers for Medicare & Medicaid has proposed new rules governing the use of artificial intelligence and prior authorization in Medicare Advantage. However, it is unclear whether the incoming Trump administration will finalize these regulations, according to LeadingAge.
“The Biden administration takes steps to further address concerns LeadingAge has raised related to MA prior authorizations, flexible supplemental benefit card benefits, marketing and communication concerns, and an array of other issues in its CY26 MA Rule,” Nicole Fallon, vice president of integrated services and managed care at LeadingAge, said Friday in a statement. “What isn’t known is how much of the proposed rule will be finalized by the incoming Trump administration.”

The proposed 2026 MA rule was published in December and seeks to “hold MA plans more accountable for delivering high-quality coverage,” according to CMS. Its provisions, if finalized, would remove barriers to care stemming from insurers’ inappropriate use of prior authorization and impose new rules surrounding plans’ use of AI for coverage decisions. Many in Congress have been pushing for moreoversight of MA plans’ use of AI. 

CMS’ 2026 proposed MA rule would mandate that MA plans abide by preset criteria when making coverage decisions, improving data collection efforts and establishing new guardrails surrounding artificial intelligence.

These issues have garnered attention from stakeholders including home care providers. In June, Sens. Elizabeth Warren (D-MA), Mike Braun (R-IN) and Bernie Sanders (D-VT), and Reps. Pramila Jayapal (D-WA) and Alexandria Ocasio-Cortez (D-NY) urged CMS to better protect beneficiaries from AI-informed coverage determinations and wrongful denials.
Providers expect the new administration to do away with certain regulations impacting home care providers, such as the 80/20 spending provision of the Medicaid Access Rule, which was finalized last year. Last month, home care legal experts said that deregulation may be a cornerstone of the Trump administration. 

Comments on the 2026 MA Rule are due Jan. 27.

How the DOGE Agenda Could Impact Medicaid, Veterans' Healthcare

Fierce Healthcare / By Noah Tong 

Axes and chainsaws, not butter knives and chisels.

That’s how Department of Government Efficiency (DOGE) commission co-chair Vivek Ramaswamy describes the approach he and world’s richest man Elon Musk will take to reducing the size of the federal government.

Musk has said he wants $2 trillion slashed from the budget, a figure that borders on ambition and an impossibility depending on who you ask. Benefits to Medicaid could be on the chopping block.

The duo outlined their goals in a Wall Street Journal op-ed. DOGE will work with the Office of Management and Budget (OMB) to rescind regulations and cut costs, they say, on the belief that recent court cases give them authority to reverse prior executive overreach under other administrations.

They also want to reduce the head count of federal employees at agencies by skirting civil service protection norms, mandate in-person work (with support from some senators and despite union pushback) and move agencies out of Washington, D.C.

Lastly, Musk and Ramaswamy intends to “take aim” at unauthorized spending from Congress to eliminate funds to Planned Parenthood. If possible, Trump and co. are looking to sidestep the 1974 Impoundment Control Act, which ensures a president cannot refuse to release congressionally appropriated funds to programs. The strategy to fight impoundment law in the court system is endorsed by former House Speaker Newt Gingrich.

Lawmakers fluctuate on how they hope to accomplish the DOGE’s plans. Some say entitlement programs like Medicare and Medicaid won’t be touched, while others make no such promises. Outgoing Rep. Michael Burgess, R-Texas, suggested the DOGE eliminate redundant departments (PDF) within the the Centers for Medicare & Medicaid Services.

Fierce Healthcare took a closer look at the healthcare implications of the DOGE and recent comments made by Ramaswamy and other Republicans on Medicaid and veterans’ care.

Healthcare for veterans 

On Nov. 13, just over one week after the presidential election, Ramaswamy denounced expired government programs that account for $516 billion each year.

“There are 1,200+ programs that are no longer authorized but still receive appropriations,” he said on X. “This is totally nuts. We can & should save hundreds of billions each year by defunding government programs that Congress no longer authorizes. We’ll challenge any politician who disagrees to defend the other side.”

Top of the list of these programs is the Veterans’ Health Care Eligibility Reform Act of 1996, costing the government $119 billion a year. This law continues to self-authorize and receive discretionary funding each year through spending bills. The law expired in 1998 but continues to provide medical benefits to veterans today.

Does Ramaswamy actually want to de-fund this program, which has the potential to be politically devastating to his party?...

Medicaid 

If the DOGE and the Trump administration are looking for cuts wherever they can find them in the $6.75 trillion federal budget, and all of discretionary funding accounts for $1.7 trillion, they will have to look toward Social Security, Medicare or Medicaid for further action.

Ramaswamy is leaving the door open to reform Medicare and Medicaid by eliminating waste and fraud through program integrity measures, reported multiple news publications. He has also called on reducing duplicative payments for individuals enrolled in Medicare Advantage and veterans’ healthcare.

Republicans could be shy to cut benefits to Medicare and Medicaid, but lawmakers seem to be keeping an open mind. Rep. Ralph Norman, R-South Carolina, said “nothing is sacrosanct” following a closed doors DOGE meeting with Musk and Ramaswamy in early December. Other lawmakers—like Reps. Brett Guthrie of Kentucky and Mark Alford of Missouri, as well as Sens. Rand Paul of Kentucky, John Cornyn of Texas and Chuck Grassley of Iowa—say various options of federal program reforms are possible.

Cuts to Medicaid could be pushed in one or two big reconciliation packages where only a simple majority is needed, said Kristin Wikelius, chief program officer at United States of Care, a think tank advancing expanded health access. Medicaid policies will likely mirror Trump’s first term. 

There is likely to be return to work requirements for state Medicaid programs, said Eric Levine, associate principal at Avalere. Those requirements normally look different on a state-by-state basis

“You can see redder states implementing them as a way to reduce enrollment for a populations who would be deemed able to work and to not divert resources from the traditional Medicaid population,” he explained…

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National Alliance for Care at Home Statement on the Death of Jimmy Carter, 39th President of the United States 

National Alliance for Care at Home / Press Release

(Alexandria, VA and Washington, DC) – The National Alliance for Care at Home (the Alliance) extends its deepest sympathies to the Carter family and the American people for the loss of Jimmy Carter, the 39^th President of the United States and the Founder of the Carter Center. We mourn this profound loss. 

President Jimmy Carter devoted his life to service above self. As a young man, he had a distinguished career as a Naval officer before serving as Governor of Georgia and later, as President of the United States. After his time in office, through the Carter Center, President Carter and Former First Lady Rosalynn Carter led incredible efforts to increase peace and improve health around the world.  

Consistent with his life of service and leadership, President Carter made the courageous decision in February 2023 to publicly share his choice for hospice care. Since then, he received hospice services from the comfort of his home surrounded by loved ones. By making his choice public, President Carter once again led by example, showing Americans how to embrace a stage of life that many don’t want to think or talk about. He showed the nation how hospice helps patients live full lives at the end of life.  

In 1979, Carter was President, and the budding hospice movement was growing. There was no Medicare Hospice Benefit, so hospices ran on volunteer work and donations, meaning access was quite limited. The Carter Administration ran demonstration programs at 26 hospices to test how hospice might work as part of Medicare. Those demonstration projects helped prove the model and led to Congress passing the law under the next administration that created the Medicare Hospice Benefit we know today. Carter’s leadership as President helped create today’s hospice care, and even through his death, he continued to light the hospice path for all of us.  

“On behalf of every member of the Alliance, thank you to the late President Jimmy Carter and the entire Carter family for bringing hospice care into the national conversation and helping everyday Americans become better equipped to think and talk about their end-of-life journeys and wishes,” said Alliance CEO Dr. Steve Landers.  

Join us in recognizing and thanking President Carter for his impact on social media by using the #CandlesforCarter hashtag.  

2024 Post Election Analysis: Impact on Business, Healthcare and Care Delivery in the Home

 Axxess / By Janice Mitchell, Communications Specialist

President-elect Donald Trump’s election has the potential to bring significant changes to the government’s healthcare policy over the next four years. The care at home industry could be impacted by the policies of a second Trump administration.

Deborah Hoyt, Senior Vice President of Public Policy at Axxess, led a post-election webinar with Dr. Steve Landers, President and CEO of the National Alliance for Care at Home; Andrew Woods, Chairman of Liberty Partners Group; Ander Crenshaw, Senior Advisor at King & Spalding; and E.J. Dionne, Senior Fellow at the Brookings Institution.

The panel discussed the implications of the election results on home-based care and its role in shaping future healthcare debates.

Affordable and Quality Healthcare

It is important to provide affordable and quality healthcare services. The panelists emphasized the potential of home-based care to create value, save money for the healthcare industry and maintain patients’ dignity and independence.

“Every American deserves good, quality healthcare in the place they prefer most, which is their own homes,” said Hoyt.

Crenshaw emphasized that home care can solve the healthcare crisis. “This is one of the ways that both solves the crisis in terms of access and a way to lower the cost,” said Crenshaw. “This is an area where you can still deliver quality healthcare and make it less expensive.”

Address Regulatory and Legislative Issues

The panelists discussed the regulatory and legislative issues that need to be addressed in the care at home industry. It is important to have a supportive and accommodating government that can help the sector grow without imposing unnecessary regulatory constraints.

Woods pointed out the impact of certain regulatory measures on the sector. “Here’s a way we can nearly solve two problems for the price of one, that is the access problem as well as the cost problem,” said Woods.

He explained that regulatory relief is needed in the current Congress to ensure that the care at home industry can thrive and meet the need for accessible care options.

Landers stressed the need for the government to support the industry. “Our members [providers] need to be supported. They’re a national treasure. Our sector is a national treasure. It’s a strategic asset especially for an aging nation,” said Landers.

Future of Home Care in the Healthcare Debate

Debates about healthcare will have a significant impact on the future of the care at home industry.

“The combination of long-term care and home care is definitely on the table for our future,” explained Dionne.

With healthcare reform likely on the agenda in the next Congress, the care at home industry could be positioned at the center of debates about Medicare, long-term care and reimbursement structures.

Panelists agreed that home care is a bipartisan issue with strong support across the political spectrum, making it a potential area of collaboration between parties.

Crenshaw mentioned that the new government might bring in individuals who understand market-driven economies and could see home healthcare as a solution to the healthcare crisis.

“I think he [President-elect Trump] will bring in some really good people and I think in that sense, we’ll be able to see some of the savings that we’re talking about and the increase in quality that we’re talking about,” explained Crenshaw.

With both political parties recognizing the value of care in the home, the opportunity for reforms that streamline reimbursement processes and expand access to services is within reach.

By focusing on cost-effective solutions and maintaining the dignity of patients, home-based care could play a transformative role in reshaping healthcare delivery for the future.

Axxess’ cloud-based software solutions provide healthcare organizations with a comprehensive technological infrastructure, empowering them to deliver exceptional patient care and achieve sustainable success.