HHS Drops Appeal on Nursing Home Staffing Rule: A Setback for Care Quality and a Boost for Aging in Place Planning

In a quiet but seismic shift for long-term care, the U.S. Department of Health and Human Services (HHS) has dismissed its appeals in two key federal cases challenging the Biden-era nursing home staffing minimums rule. Filed in the Fifth and Eighth Circuit Courts of Appeals, these dismissals, announced in late September 2025, effectively concede the rule's fate, leaving the sector without enforceable national standards. For Ohio and Missouri families committed to aging in place, this development underscores the urgency of proactive planning: while nursing homes grapple with understaffing risks, aging-in-place strategies can help safeguard independence and assets from institutional pitfalls.

Recapping the Rule and Its Rocky RoadAs we discussed in our April 2025 blog post, "Federal Judge Blocks Biden-Era Nursing Home Staffing Rule: Implications for Care Quality and Families," the rule, finalized by CMS in April 2024, aimed to mandate 24/7 registered nurse (RN) coverage and at least 3.48 hours per resident day (HPRD) of total nurse staffing in Medicare/Medicaid-funded facilities. Rooted in the Federal Nursing Home Reform Act (FNHRA), it sought to combat chronic shortages exposed by COVID-19, where understaffed homes saw hospitalization rates spike 20–30% higher and physical and chemical restraint use climb due to overburdened aides.
The rule faced immediate backlash from trade groups like the American Health Care Association (AHCA) and states like Texas, which sued in May 2024, claiming HHS overstepped its authority under the Social Security Act. U.S. District Judge Matthew Kacsmaryk's April 7, 2025, ruling in Texas vacated core provisions, calling them a "one-size-fits-all" overreach that ignored the realities of rural areas and the variations in acuity of residents. Similar blocks followed in the Eighth Circuit. HHS appealed both, but with mounting opposition, including from 20 additional states and projected facility closures of 10–15% in underserved areas, the agency has now withdrawn, signaling a pragmatic pivot amid political and fiscal headwinds.The Bigger Picture: Understaffing's Toll on ResidentsWithout federal minimums, the U.S.'s 15,000+ nursing homes, serving 1.2 million residents, 60% Medicaid-funded, revert to patchwork state oversight. Studies we cited earlier, like the 2021 Health Affairs analysis, link adequate RN staffing (0.75 HPRD) to 15–20% fewer hospitalizations and infections. A 2022 CMS report tied understaffing to elevated COVID mortality, while a 2019 Gerontologist study showed it doubled chemical restraint use—violations of FNHRA rights affirmed in the Supreme Court's Talevski decision (2023).
For families, this means heightened risks of neglect, pressure ulcers, falls, and emotional distress, amplifying the emotional and financial strain of facility care. In Ohio, where Medicaid's $527 million nursing home shortfall (2024–2025) already strains resources, the absence of national standards could exacerbate closures in rural counties, displacing residents and pressuring families toward costlier private-pay options ($100,000+/year).Elder Law Ramifications: A Crack in ProtectionsThis retreat leaves elder law attorneys navigating regulatory quicksand. Without binding federal floors, litigation for substandard care relies more heavily on state surveys (e.g., Ohio's biennial inspections) and facility-specific plans, tools that often fall short due to underreporting (57% of falls go undocumented, according to AHRQ). Families may lean on ombudsman programs, but these are overwhelmed, handling just 20% of complaints effectively.
Critically, the ruling disrupts Medicaid planning, where irrevocable trusts shield assets during the five-year lookback period (42 U.S.C. § 1396p(c)), thereby preserving eligibility without a spend-down. Understaffing could trigger more penalties or denials, forcing asset liquidation and undoing trusts, echoing cases like Bartley Healthcare v. Ott (N.J. Super. App. Div. 2025), where facilities targeted family POA holders for "breaches" in Medicaid pursuit. In Ohio, filial responsibility (R.C. § 2919.21) remains criminal and narrow, but nursing homes may exploit contracts to claw back costs, threatening protected assets.A Silver Lining: Reinforcing Aging in Place StrategiesAs we noted in April, this saga highlights why aging in place, with structured home and community care, is a resilient alternative to institutional care in facilities. With nursing homes facing 15–20% staff turnover and quality dips, families can pivot to rigorous home-based healthcare and, when necessary, utilize Ohio's PASSPORT waiver (available to applicants with income under $2,901/month in 2025) for in-home aides, thereby avoiding FNHRA gaps altogether. Pair this with Medicare Advantage plans' supplemental benefits (e.g., $100–$300/month flex cards for home mods) to fund grab bars or telehealth, delaying institutional needs, and a family has a toolbag of options necessary to avoid institutional care.
Elder law tip: Review trusts now to include home care contingencies, and document POA limits to shield against facility pressures. The Talevski precedent still empowers suits for FNHRA violations, such as undue restraints; use it proactively.Looking Ahead: Advocacy in Uncertain TimesHHS's dismissal highlights the tension between care ideals and workforce realities, potentially stalling reforms until 2026 or beyond. Practitioners must monitor the Federal Register for state waivers or CMS updates, while counseling clients on their rights under the remaining federal baselines (e.g., 8-hour RN coverage).
For Ohioans and Missourians, this is a call to fortify plans. Subscribe to our blog for updates on staffing litigation or virtual workshops (e.g., our recorded "Aging in Place Essentials" at bit.ly/Aging-in-Place-Workshop). Contact OSHIIP (1-800-686-1578) for Medicare guidance, and consult an elder law attorney to align trusts with home-focused care. Aging in place isn't just viable—it's essential when facilities falter. Let's build resilience together.

Consumer Alert from ODI: What Insurance Agents Can and Can’t Do During Medicare Open Enrollment

 

Agents are prohibited from making uninvited visits to homes and senior 

Medicare’s open enrollment period runs from Oct. 15 through Dec. 7, giving Ohioans on Medicare a valuable opportunity to review and compare their current coverage and explore Medicare plans for 2026.

During this time, insurance agents can be a helpful resource in understanding coverage options and navigating plan changes. Most agents follow the rules and act in their clients’ best interests. However, agents, consumers, and OSHIIP volunteers need to understand what agents can and cannot do during this period and to remain vigilant for those who may not be following the guidelines.

Agents should never visit individual residences or enter senior living communities without being specifically invited and having the invitation confirmed in advance. While agents play an important role in helping individuals make informed Medicare choices, unsolicited visits to homes or facilities are not permitted. In addition, it is illegal for anyone to pose as a representative of OSHIIP or Medicare. OSHIIP and Medicare do not send representatives to residences or facilities without a formal invitation.

Pro Seniors, Ohio’s Senior Medicare Patrol, created this flyer to help recognize, avoid, and report Medicare impersonators.

OSHIIP and Aging in Place Planning

The Ohio Senior Health Insurance Information Program is a free, state-sponsored service provided by the Ohio Department of Insurance, designed to help Medicare beneficiaries navigate complex health insurance options. As Ohio's official State Health Insurance Assistance Program (SHIP), a network funded by the Centers for Medicare & Medicaid Services (CMS), OSHIIP offers unbiased, one-on-one counseling to seniors, their families, and caregivers, ensuring informed decisions about coverage without sales pressure.

Key Services Provided by OSHIIPOSHIIP focuses on empowering older adults (65+ or those eligible for Medicare due to disability) to maximize their benefits while minimizing costs. Core offerings include:

• Personalized Counseling: Free phone, email, or in-person sessions to explain Medicare Parts A/B/D, Medicare Advantage (Part C), Medicare Supplement (Medigap) plans, and long-term care insurance. Counselors review eligibility, compare plans during Open Enrollment (October 15–December 7), and help appeal denials.
• Education and Resources: Workshops, speaker bureaus, and trained volunteers cover topics like prescription drug coverage, fraud prevention, and coordinating benefits with employer plans. They also assist with applications for low-income programs like Extra Help or Medicare Savings Programs.
• Hotline Support: Call 1-800-686-1578 (Monday–Friday, 9 AM–4:30 PM ET) for immediate guidance—no appointment needed. Email: OSHIIPmail@insurance.ohio.gov. Website: insurance.ohio.gov (search "OSHIIP").

In 2024, OSHIIP assisted over 100,000 Ohioans, saving an estimated $50 million in premiums through better plan choices. It's especially valuable during Medicare's Annual Enrollment, when switching plans can reduce out-of-pocket costs by 20–30% for many.Why OSHIIP Matters for Aging in Place and Elder Law PlanningFor Ohio families committed to aging in place, staying home with support like in-home aides or modifications rather than nursing facilities, OSHIIP is an informational lifeline. It helps consumers bridge gaps in Medicare coverage, which doesn't pay for most custodial long-term care (e.g., daily activities like bathing). Key ties to planning include:

• Medicaid Coordination: OSHIIP counselors can explain how Medicare pairs with Ohio's Medicaid (e.g., PASSPORT waiver for home care, income under $2,901/month in 2025), and asset protection strategies like irrevocable trusts to navigate the five-year lookback.
• Avoiding Pitfalls: OSHIIP provided guidance on spotting scams (e.g., fake Medicare cards) and reviewing contracts prevents costly errors, like signing unintended guarantees in facility admissions (as seen in recent cases like Bartley Healthcare v. Ott).
• Estate Planning Synergy: Use OSHIIP to align insurance with trusts or powers of attorney, ensuring assets fund home-based care without estate recovery claims.

Avoiding pitfalls is essential to aging-in-place planning.  First, assets lost to scams and mismanagement threaten independence and autonomy by removing financial capability.  Second, being subjected to scams can raise questions regarding capacity and capability; a senior who has been taken advantage of is more likely to be deemed incapacitated and in need of guardianship services, legally removing that senior's decision-making authority.  Third, agents appointed or nominated by powers of attorney, or trustees of a trust, can be removed for being unable to protect assets from scammers, separating the senior from his or her most trusted advisors.  

How to Get Started

• Contact OSHIIP: 1-800-686-1578 or visit insurance.ohio.gov/oshii p.
• Local Access: Find counselors via your Area Agency on Aging (e.g., Central Ohio: 614-645-7250) or SHIP locator at shiphelp.org.
• Pro Tip: Schedule a session early in Open Enrollment to lock in 2026 coverage—pair it with an elder law attorney for holistic planning.

OSHIIP isn't insurance itself but a trusted navigator, helping Ohio seniors avoid overpaying and underinsuring. For personalized advice, reach out today; independence starts with informed choices.