Medicare Advantage: A Powerful Tool for Aging in Place (Just in Time for Open Enrollment!)

As families plan for aging in place, maintaining independence at home rather than moving to a nursing home or assisted living facility is key. Medicare plays a pivotal role in either facilitating or frustrating aging in place plans. Original Medicare (Parts A and B) offers limited support for home-based care, but Medicare Advantage (MA) plans (Part C), offered by private insurers, significantly enhance options for home care, telehealth, and post-hospital recovery. These plans not only cover everything Original Medicare does but also provide supplemental benefits tailored to aging in place, often improving health outcomes and reducing costs. With Open Enrollment (October 15–December 7) approaching, understanding MA’s advantages is critical for  families committed to staying home.

Why Medicare Advantage for Aging in Place?

Aging in place involves services like home care (e.g., help with bathing, meal prep), short-term disability support (e.g., recovery from surgery), and long-term care (e.g., chronic condition management). Original Medicare covers short-term skilled home health care (nursing, therapy) if you’re homebound and a doctor certifies medical necessity, but it excludes ongoing custodial care, short-term disability income, and most non-skilled home care. Moreover, original Medicare incentivized institutional care by paying for institutional rehabilitation for a period of time following a three-day hospitalization. MA plans bridge these gaps with flexible, home-focused benefits, often reducing out-of-pocket costs and supporting independence.

Recent data underscores MA’s impact: studies show MA enrollees have lower hospital readmission rates compared to Original Medicare (even with shorter periods necessary for rehabilitation), thanks to enhanced care coordination and home-based services. For aging-in-place families, this translates to fewer disruptions and better recovery at home.

Key Medicare Advantage Benefits Over Original Medicare

Here’s how MA plans enhance aging-in-place elements, with specific advantages in telehealth, hospital-at-home programs, in-home physical/occupational therapy (PT/OT), and transitions from hospital to long-term care, plus other post-hospitalization perks:

●Home Care (e.g., aides, meal prep):

• Original Medicare Coverage (2025): Limited to skilled care (nursing, therapy) if homebound; no custodial care (e.g., bathing). 

• MA Advantages: MA plans can pay for help that isn’t strictly medical, unlike Original Medicare. This includes: aides (someone to assist with daily tasks like bathing or dressing), for about 20–40 hours per month (e.g., a few hours a week); meal delivery services that bring prepared meals to your home, helping if cooking is hard; and, home modifications like grab bars in the bathroom to make your home safer and easier to navigate.  These are typically limited to in-network providers (out of network may not be covered or might cost you) and prior authorization is often required. 

• Potential Cost Savings & Health Outcomes: Potentially saves $200–$500/month on meals or $4,000–$6,000/month on aides; reduces nursing home risk (average cost: $100,000+/year).

●Short-Term Disability (e.g., post-surgery): 

• Original Medicare Coverage (2025):  Up to 100 days skilled nursing/home health; 20% coinsurance after day 20 ($204/day in 2024) possibly covered by supplemental insurance.

• Medicare Advantage Advantages: Lower copays, durable equipment (walkers), temporary aides. Expenses typically counts toward out-of-pocket max ($3,000–$8,000/year).

• Potential Cost Savings & Health Outcomes: Caps costs vs. Original Medicare's unlimited coinsurance; 10–15% fewer ER visits due to better recovery support.

●Long-Term Care (e.g., chronic conditions): 

• Original Medicare Coverage (2025):  No custodial care; limited chronic management.

• MA Advantages:  Partial non-skilled care like bathing, dressing, or eating, which don’t require a nurse or doctor (unlike "skilled" care like wound treatment). Medicare Advantage (MA) plans may cover some of these non-skilled services for a limited number of hours (e.g., 20–40 hours per month) to help you stay at home. Original Medicare doesn’t cover this kind of help at all unless you’re homebound and need skilled care too.  Chronic Special Needs Plans (C-SNPs) are special types of MA plans designed for people with ongoing health conditions like diabetes, heart failure, or lung disease (COPD). These plans often include extra benefits like devices or services that check your health at home (e.g., blood sugar monitors or telehealth check-ins with a nurse). This helps you manage your condition without frequent hospital visits.  Pair with Medicaid/insurance for full coverage.

• Potential Cost Savings & Health Outcomes:  Offsets 10–20% costs ($100–$300/month); C-SNPs cut hospitalizations by 10–15%.

●Telehealth: 

• Original Medicare Coverage (2025):  Covers office visits, mental health via video/audio; home-based until Sept. 30, 2025, then rural-only for non-mental health. 20% coinsurance.
• MA Advantages:  With MA plans, you can use telehealth (like video or phone calls with doctors) from your home at any time, regardless of where you live (urban or rural); original Medicare, however, may limit home-based telehealth after September 30, 2025, to rural areas for most non-mental health services, requiring you to visit a clinic or hospital for telehealth in urban areas. MA plans often allow telehealth visits using just a phone call (no video needed), which is great if you don’t have a smartphone or reliable internet. Original Medicare covers audio-only for mental health and some services through September 2025, but MA plans may extend this option for more types of visits (like routine check-ups) even after that date. 

MA plans also cover a wider range of telehealth services than Original Medicare. Beyond standard doctor visits or mental health sessions, MA might include quick check-ins with nurses, medication reviews, or chronic condition management (e.g., diabetes monitoring). MA plans may cover telehealth for routine check-ins, follow-ups after hospitalization, chronic disease management (e.g., COPD or diabetes), and even physical/occupational therapy (PT/OT) guidance. Original Medicare sticks to a narrower list, like office visits and mental health. For example, an MA plan might let a nurse call to check your blood pressure readings, reducing the need for in-person visits.

These extra services help keep you healthy at home without frequent in-person visits.

• Potential Cost Savings & Health Outcomes:  Improves access (43% fewer missed follow-ups); vital for rural Ohioans post-Sept. 2025.  MA plans often have $0–$20 copays for telehealth, compared to Original Medicare’s 20% coinsurance (e.g., $50 for a $250 specialist visit). Some plans waive copays entirely for telehealth to encourage use. Telehealth counseling, often expanded in MA, improves post-hospital recovery by addressing depression, common in 20% of elderly post-discharge.

●Hospital at Home: 

• Original Medicare Coverage (2025):  No dedicated program; skilled home health only if homebound.

• MA Advantages: Covers acute care at home (IV meds, monitoring) as inpatient alternative. 

• Potential Cost Savings & Health Outcomes: Reduces readmissions by 20–30% in pilots; lowers infection risk vs. hospitals.

●In-Home Physical/Occupational Therapy (PT/OT): 

• Original Medicare Coverage (2025):  Covers if medically necessary (no cap, $2,410 threshold); 20% coinsurance.  Medicare will pay for in-home PT (to improve movement, strength, or balance) or OT (to help with daily tasks like dressing or cooking) only if a doctor says it’s needed for your health. For example, you might need PT after a hip replacement to regain mobility or OT after a stroke to relearn daily activities. For in-home coverage under Part A (home health benefit), you must be homebound (hard to leave home without help) and need skilled care (like therapy from a licensed professional). A doctor must certify this. If you’re not homebound, Part B may cover PT/OT as outpatient services, even at home, as long as it’s medically necessary.  

In 2025, Medicare starts paying closer attention once your PT or OT costs hit $2,410 per year (this applies to PT and speech therapy combined, or OT separately). After this threshold, providers must add a special code (KX modifier) to your claims to confirm the therapy is still needed. Medicare usually keeps paying if justified, but it’s a checkpoint to ensure necessity.

You pay 20% of the cost for each PT/OT session, and Medicare covers the other 80%. For example, if a session costs $100, you pay $20 out of pocket. This applies after you meet the Part B deductible ($257 in 2025). If you’re getting in-home care under Part A’s home health benefit (and you’re homebound), there’s no coinsurance for those services. 

• Medicare Advantage Advantages: Lower copays ($20–$50), extended sessions, non-homebound access. MA plans often reduce the 20% coinsurance to a fixed copay (e.g., $20–$50 per session) or waive it entirely, saving you money compared to Original Medicare’s uncapped 20%.  Some MA plans cover in-home PT/OT even if you’re not strictly homebound, making it easier to get therapy at home for aging in place. MA plans may also include virtual PT/OT (via telehealth) or home safety modifications (like ramps) to complement therapy, boosting recovery compared to Original Medicare.

• Potential Cost Savings & Health Outcomes: Unlike Original Medicare, MA plans have an annual out-of-pocket maximum ($3,000–$8,000 in 2025), so your PT/OT costs won’t spiral indefinitely. MA’s coordinated care (e.g., therapy paired with nurse check-ins) reduces hospital readmissions, as therapy continuity prevents setbacks like falls (5–8% of readmissions).

●Hospital-to-LTC Transition (MMI): 

• Original Medicare Coverage (2025): Medicare only pays for skilled care if it’s helping you get better or maintain your abilities. If your doctor decides you’ve reached a point where more care won’t improve your condition (called “maximum medical improvement”), Medicare stops covering it. For example, if you’re recovering from a stroke but can’t make more progress with therapy, Medicare will say the skilled care isn’t needed anymore, even if you still need help or assistance, even if needed on a daily basis throughout the day. Skilled care means specialized care from trained professionals, like nurses giving injections or physical therapists helping you regain strength after surgery. It’s different from everyday help (like bathing or cooking), which can be provided by non-professionals like family, and for which Medicare doesn’t cover.  

If you’re in a skilled nursing facility (like a rehab center after a hospital stay), Medicare Part A covers up to 100 days per “benefit period” (a specific time frame tied to your condition). But this coverage stops earlier if your condition isn’t improving. For the first 20 days, Medicare pays 100%; for days 21–100, you pay a daily copay (about $204 in 2024). If you hit 100 days or stop improving before that, Medicare stops paying, and you’d need to cover the full cost (often $300–$500/day) or find other help, like Medicaid.

• Medicare Advantage Advantages:  Flexible prior authorization, extended SNF days, care managers for transitions.  MA plans offer advantages over Original Medicare for managing care, particularly when moving from a hospital to a skilled nursing facility (SNF) or home. It’s about making transitions smoother and potentially extending coverage for certain services.

Prior authorization is when your MA plan needs to approve certain services (like therapy or nursing home stays) before they’re covered. Unlike Original Medicare, which has strict rules about when care is “medically necessary,” MA plans can be more flexible in approving these services. For example, they might okay extra therapy sessions or specialized care if it helps you stay out of the hospital, even if Original Medicare would deny it. Extra days can give you more time to recover without paying huge out-of-pocket costs (SNFs can cost $300–$500/day without coverage). This supports aging in place by helping you return home stronger.

MA plans often assign a care manager (like a nurse or social worker) to guide you through transitions in care, like when moving from a hospital to an SNF, home, or another care setting. They help coordinate things like therapy schedules, medication plans, or follow-up doctor visits. They also make sure everyone (doctors, therapists, family) is on the same page.  These managers reduce confusion and mistakes (like wrong medications), making your move from hospital to home smoother and safer. This can prevent you from going back to the hospital.

• Potential Cost Savings & Health Outcomes:  Flexible Prior Authorization  means you might get extra PT/OT at home to avoid a nursing home,  reducing reliance on institutional care.  MA care managers reduce hospital readmissions by significantly by ensuring proper medication and follow-up care (e.g., >15% fewer heart failure readmissions with MA coordination).  By way of illustration, a care manager might arrange telehealth check-ins or home PT to keep you stable after leaving an SNF, cutting risks like medication errors (reducing hospital readmissions).

●Utilization of Technology: Remote Patient Monitoring (RPM) and More: 

• RPM Defined: RPM uses devices like blood pressure cuffs, glucose monitors, or wearable heart rate trackers that send data to your doctor from home. MA plans, particularly Chronic Special Needs Plans (C-SNPs), often cover these for conditions like diabetes, heart failure, or COPD.

• Original Medicare Coverage (2025): Limited RPM coverage (only specific codes like 99453–99457 for chronic conditions).

• Medicare Advantage Advantages:   Unlike Original Medicare, which has limited RPM coverage, MA plans may include RPM as a supplemental benefit, covering device costs or monitoring services. For example, a 2025 Humana MA plan in Ohio offered free glucose monitors and monthly nurse check-ins for diabetic patients.

• Potential Cost Savings & Health Outcomes: RPM significantly reduces ER visits  by catching issues early (e.g., high blood sugar spikes). A 2024 study showed MA’s RPM programs improved blood pressure control in 60% of hypertensive patients within 6 months.  For example, If you have heart failure, an MA plan might provide a scale to monitor weight daily (fluid retention is a red flag). Data goes to your doctor, who can adjust meds via telehealth, preventing hospital trips.

• Other Technologies: 

• Smart Home Devices: Some MA plans cover or subsidize devices like motion-sensor lights or fall detection systems (e.g., integrated with Alexa or Apple Watch) as part of home safety benefits. These reduce fall risks, a leading cause of readmissions (5–8% of elderly cases).

• Health Apps and Portals: MA plans often provide apps for scheduling telehealth, tracking vitals, or accessing care coordinators. For instance, UnitedHealthcare’s 2025 MA plans include a portal for real-time medication reminders, boosting adherence significantly.

• Virtual PT/OT: Some MA plans offer virtual physical or occupational therapy sessions, guiding exercises via video to maintain mobility after in-person sessions end. This is rare in Original Medicare.

MA plans don’t cover all non-skilled care needs, especially if you need help 24/7. To fill this gap, you can combine MA with Medicaid (a state program for low-income people), private long-term care insurance, or spend-down of your personal assets and property. For example, Ohio’s PASSPORT program (through Medicaid) can cover more in-home aide hours if you qualify (income under $2,901/month in 2025). Private insurance can also help pay for ongoing care costs that MA doesn’t fully cover.

Moreover, some plans present challenges that only a Medicare Specialist would know.  It is imperative that, in addition to conducting your own investigation, you consult with a Specialist who can guide you based on "inside" information that might be unavailable to you, or at least hard to access and assess.

In short,  MA plans can give you some help with daily tasks and tools to monitor chronic illnesses at home, but they too are limited. To get full support for staying at home long-term, you’ll likely need to add Medicaid, private insurance, or asset spend-down to cover the rest.  If you select the latter, your assets will last longer, leaving a greater chance that assets will pass to heirs rather than being consumed by long=term care expenses. 

Additional MA Benefits for Post-Hospital Recovery

When Original Medicare’s benefits cease (e.g., after 100 skilled nursing days or when PT/OT no longer shows “progress”), MA plans offer unique supports to maintain health and prevent setbacks:

• Care Coordination: Dedicated managers ensure medication reconciliation and follow-ups, reducing readmissions by 8–20%. For example, a 2025 study by Providence VNA Home Health showed medication reconciliation cut 30-day hospitalizations from 12% to 9% for heart failure patients.

• Supplemental Benefits: Meal delivery, transportation, or flex cards ($50–$300/year for OTC items) support nutrition and mobility, reducing malnutrition-related readmissions.

• Behavioral Health: Expanded telehealth counseling addresses post-hospital depression, improving physical recovery by 10–15%.

• Out-of-Pocket Caps: MA caps annual costs ($3,000–$8,000), unlike Original Medicare’s unlimited costs, ensuring affordability for ongoing care.

Ohio Context: Why MA Matters Now

Recent Ohio developments, like the September 2, 2025, Ohio Supreme Court ruling previously discussed on this blog, (State ex rel. LeadingAge Ohio v. Ohio Dept. of Medicaid), highlight Medicaid funding shortfalls for nursing homes ($527 million in 2024-2025), threatening care quality for 66,000 residents. MA’s home-based benefits offer a buffer, reducing reliance on facilities and aligning with programs like Ohio’s PASSPORT waiver, which supports in-home aides for those with income under $2,901/month.

Steps to Leverage MA for Aging in Place

Assess Needs: Consult a doctor or geriatric care manager to outline required services (e.g., PT/OT, home mods).

Compare Plans: Use Medicare.gov’s Plan Finder to identify plans with telehealth, in-home care, or C-SNPs. Prioritize low out-of-pocket maximums and strong Ohio networks.

Speak with a Specialist: A Medicare specialist is a must, not only to access your needs and goals, but to advise regarding which plans are best, and which specific plan is best for you and your circumstances.  

Enroll Strategically: Switch during Open Enrollment (October 15–December 7). Check for Special Needs Plans for chronic conditions.

Maximize Benefits: Request prior authorization early; combine with Veterans benefits, Area Agencies on Aging, or long-term care insurance. Track annual allowances.

Plan for Gaps: Budget for premiums ($0–$200/month) and copays; use trusts (e.g., $154,140 Community Spouse Resource Allowance in 2025) or Medicaid planning to cover full custodial care.

Monitor Health: Use MA’s telehealth and care coordination to prevent setbacks, leveraging data like 43% fewer missed follow-ups.

A Call to Action

Medicare Advantage plans empower Ohio families to age in place with dignity, offering cost savings, flexible care, and better health outcomes, like  fewer readmissions and !improved recovery. Amid uncertainties like Ohio’s Medicaid disputes, MA’s home-focused benefits are a lifeline. Don’t wait!  For tailored strategies, consult an elder law attorney or your State Health Insurance Assistance Program (SHIP). Secure your aging-in-place plan now to avoid facility costs and thrive at home.

Executive Order Expanding Apprenticeships Could Ease Staffing Shortages in Nursing Homes, Assisted Living Facilities

An executive order to consolidate federal workforce programs could address workforce shortages among senior living and other aging services providers by expanding apprenticeships, according to an article penned by Kimberly Bonvissuto, writing for McKnight's Senior Living. This comes at a critical time given that Biden era staffing mandates have been stuck down by a federal court.

Trump signed an executive order, “Preparing Americans for High-Paying, Skilled Trade Jobs of the Future,” on April 23 with the goal of expanding and improving job training for skilled trades. The order directs the Labor, Education and Commerce departments to streamline and consolidate federal workforce programs, with a focus on expanding registered apprenticeships to more than 1 million annually.

Although the initiative is most directly aimed at the  administration’s goal to revive US manufacturing, LeadingAge Director of Workforce Policy Amanda Mead said in a written announcement that it could help alleviate critical workforce shortages in the aging services sector: 

“While the president’s executive order is widely seen as part of the administration’s push to revitalize US manufacturing, the initiative to expand apprenticeships could also benefit direct care workers — such as nursing assistants and home health aides — by offering enhanced training and alternative educational pathways beyond traditional four-year degrees.” 

Argentum is a national trade association representing senior living communities across the United States. It advocates for policies that benefit the senior living industry and its residents, serving companies that own, operate, and support professionally managed senior living communities. Argentum’s mission includes promoting quality care, operational excellence, and workforce development within the sector.

Back in 2020, Argentum  touted the success of the Healthcare Apprenticeship Expansion Program, which served more than 7,600 incumbent workers through a $6 million Closing the Skills Gap grant from the Department of Labor. The association also petitioned the Centers for Medicare & Medicaid Services (CMS) to include assisted living in an incentive program geared toward attracting registered nurses to skilled nursing facilities.

Since the 2020 grant, staffing challenges in the senior living industry have persisted and intensified, particularly due to the COVID-19 pandemic. In response, several efforts emerged to bolster the workforce:

• Workforce Development Initiatives: Argentum has continued to prioritize workforce development, launching initiatives such as partnerships with educational institutions in 2022. These programs aim to create career pathways, offering training and opportunities for individuals entering the senior living field.

• Legislative Actions: At both state and federal levels, there have been efforts to address staffing shortages in healthcare, including senior living. These include funding for training programs, loan forgiveness for healthcare workers, and incentives for employers to hire and retain staff. For instance, discussions around immigration reform in 2023 have explored allowing more foreign workers to fill caregiving roles, while some states have introduced minimum staffing requirements for nursing homes, potentially influencing senior living practices.

• Improved Compensation and Benefits: To attract and retain staff, many senior living providers have increased wages and enhanced benefits, recognizing the competitive labor market and the need to make these roles more appealing.

• Technological Innovations: The industry has also turned to technology to supplement staffing needs. Solutions like telehealth services and remote monitoring have been adopted to enhance care delivery and reduce the workload on existing staff.

In late 2023, a survey I conducted for an article (I never published) suggested that  38 states and the District of Columbia had established their own minimum staffing standards for nursing homes, but that figure was gleaned from internet searches; I could find no readily available source cataloguing the states and their staffing regulations.  I was surprised that the information wasn't more readily available since federal staffing mandates were then a hot topic.  

An Argentum spokesman told McKnight’s Senior Living:

“There are far too few caregivers to meet the needs of our rapidly aging population, and it will take an across-the-board approach to recruit and retain more than 20 million workers who will be needed across long-term care by 2040.” Three million of that 20 million will be needed in senior living alone, according to Argentum."

The American Seniors Housing Association (ASHA) told McKnight’s Senior Living that  the aging population demands a steady pipeline of workers to serve older adults living in senior living communities and other long-term care settings. ASHA Vice President of Government Relations Jeanne McGlynn Delgado appears optimistic:  

“Identifying and implementing federal training programs that can attract and grow this workforce, whether it be in retooling existing grant programs or expanding apprenticeships specifically for senior living workers, shows much promise,” ASHA ."

The American Health Care Association/National Center for Assisted Living told McKnight’s Senior Living that it continues to support making apprenticeship programs more available and accessible, including supporting the recently introduced American Apprenticeship Act to provide tuition assistance to fund apprenticeship programs:

“We’ve seen the value they can bring through our own apprenticeship partnership with Equus Solutions, who has supported some of our long-term care providers with the process. Apprenticeships are one of the many solutions we need to help recruit and retain more long-term caregivers, and we appreciate this effort to help address the nation’s growing caregiver shortage.”

Despite these efforts, staffing remains a critical and ongoing challenge in senior living. The effectiveness of these measures is under evaluation as needs increase, and the industry and governments continue to seek innovative and sustainable solutions to ensure high-quality care for residents. 

You can help.  Develop a plan to age in place.  To the extent possible, relegate institutional choices to "when and if it is absolutely necessary, and there is no available alternative."  You and your loved ones will likely experience better outcomes, and you will relieve an already burdened system.  

Federal Judge Blocks Biden-Era Nursing Home Staffing Rule – Implications for Care Quality and Families

On April 8, 2025, a federal judge in Texas struck down a Biden administration rule aimed at establishing minimum staffing requirements for nursing homes that receive Medicare and Medicaid funding. This ruling, issued by U.S. District Judge Matthew Kacsmaryk, has significant implications for the quality of care in nursing homes, the families who depend on these facilities, and the broader debate over healthcare regulations in the U.S. I'll explores the details of the rule, the lawsuit challenging it, the court’s rationale for blocking it, and the potential effects on nursing home residents and their families.

The Blocked Rule: Minimum Staffing Standards for Nursing Homes

The rule, announced by the U.S. Department of Health and Human Services (HHS) in April 2024, sought to address chronic staffing shortages in nursing homes by imposing the first-ever federal minimum staffing standards for long-term care facilities. Issued by the Centers for Medicare & Medicaid Services (CMS), the regulation required nursing homes to:

• Employ a registered professional nurse (RN) 24 hours per day, seven days a week, a significant increase from the existing federal requirement of eight hours per day.

• Maintain total nurse staffing, including nurse aides, at a minimum of 3.5 hours per resident per day (HPRD), ensuring a baseline level of care for residents.

The Biden administration framed the rule as a critical step to improve care quality for the 1.2 million residents in Medicare- and Medicaid-certified facilities, citing systemic issues exposed during the COVID-19 pandemic, such as understaffing leading to neglect and poor health outcomes. CMS argued that higher staffing levels would enhance resident safety, reduce infections, and improve overall care, aligning with the Federal Nursing Home Reform Act’s (FNHRA) goal of protecting residents’ “health, safety, and dignity”.

The Lawsuit: Basis for Challenging the Rule

The lawsuit by the American Health Care Association (AHCA), a major nursing home industry group, and Texas Attorney General Ken Paxton, among others, in May 2024 argued that the rule was unlawful on several grounds:

Exceeding Statutory Authority: The plaintiffs contended that HHS and CMS lacked the authority to impose such stringent staffing mandates. Federal law, specifically the Social Security Act, explicitly requires nursing homes to have an RN on-site for eight consecutive hours per day and to provide “sufficient” staff to meet residents’ nursing needs. The plaintiffs argued that the new rule’s 24/7 RN requirement and 3.5 HPRD standard went beyond what Congress had authorized, effectively rewriting the law.

Financial and Operational Burdens: The nursing home industry highlighted the practical challenges of compliance, citing workforce shortages and financial strain. The AHCA claimed that the mandate would force many facilities to close, displacing vulnerable seniors, as the industry already struggles to hire and retain staff amid a national shortage of healthcare workers. At least one operator, LaVie Care Centers, blamed the staffing rule for its bankruptcy filing.

Arbitrary and Capricious Rulemaking: The plaintiffs argued that CMS failed to adequately justify the rule’s immediate implementation and did not tailor the staffing requirements to the diverse needs of nursing home populations, as required by federal law. They claimed the 3.5 HPRD formula was a “one-size-fits-all” approach that ignored facility-specific factors.

The Court’s Ruling: Legal Basis for Blocking the Rule

Judge Matthew Kacsmaryk, granted summary judgment to the plaintiffs on April 7, 2025, vacating key provisions of the CMS rule. His decision rested on the following legal bases:

Lack of Congressional Authority: Kacsmaryk ruled that HHS and CMS exceeded their statutory authority under the Social Security Act. He noted that Congress had explicitly set the RN staffing requirement at eight hours per day, and the 24/7 RN mandate went beyond this limit. Similarly, the 3.5 HPRD standard was deemed inconsistent with the law’s requirement for “sufficient” staffing tailored to residents’ needs, as it imposed a rigid national formula.

Failure to Tailor Requirements: The court found that CMS did not meet statutory requirements to customize staffing levels based on the specific needs of each facility’s resident population. Kacsmaryk criticized the 3.5 HPRD formula as an unlawful “one-size-fits-all” approach, arguing that it did not account for variations in resident acuity or facility resources.

Procedural Deficiencies: The judge held that CMS failed to adequately explain the need for immediate implementation of the rule, a requirement under the Administrative Procedure Act. This procedural lapse further supported the decision to block the mandate.

The ruling was celebrated by the AHCA and industry groups as a victory for nursing homes, with AHCA President Clif Porter stating that the “unrealistic staffing mandate threatened to close nursing homes and displace vulnerable seniors.” Critics, including elder abuse attorney Ed Dudensing, argued that the decision “undermines the very safeguards designed to protect our elders’ dignity and well-being.”

Impact on Quality of Care: RN Staffing and Health Outcomes

Vacating the staffing rule raises significant concerns about the quality of care in nursing homes, particularly given the establishment view of well-documented correlation between RN staffing levels and resident health outcomes.  In a later article I will address critically recent challenges to this establishment view.  Regardless,  studies have consistently shown that higher RN and LPN staffing is associated with generally better physical and psychological outcomes for residents, while understaffing contributes to neglect, infections, and increased mortality.

Physical Health Outcomes: 

• A 2021 study published in Health Affairs found that nursing homes with higher RN staffing levels (at least 0.75 hours per resident per day) had significantly lower rates of hospitalizations, pressure ulcers, and infections compared to facilities with lower RN staffing. The study estimated that increasing RN staffing to this level could prevent 136,000 hospitalizations annually.

• During the COVID-19 pandemic, a 2022 CMS report highlighted that nursing homes with RN staffing below 0.4 HPRD had a 30% higher mortality rate from the virus, as understaffed facilities struggled with infection control and timely care. See, CMS, “Nursing Home Staffing and COVID-19 Outcomes” (2022).

• The blocked rule’s requirement of 3.5 HPRD, including RN presence 24/7, aimed to address these issues by ensuring consistent oversight and care. Without this mandate, facilities may continue to operate with insufficient RN staffing, potentially leading to increased physical health risks for residents, such as falls, medication errors, and untreated infections.

Psychological Health Outcomes:

• A 2019 study in The Gerontologist found that higher RN staffing was associated with lower rates of depression and anxiety among nursing home residents. RNs, with their advanced training, are better equipped to recognize and address psychological distress, provide emotional support, and coordinate mental health interventions.

• Understaffed facilities often rely on chemical restraints (e.g., psychotropic medications) to manage resident behavior, a practice that led to litigation in the Talevski case, where the Supreme Court affirmed residents’ rights under the FNHRA to be free from unnecessary restraints. The blocked staffing rule could have reduced such practices by ensuring RNs were available to implement non-pharmacological interventions, improving residents’ psychological well-being.

Impact on Families of Nursing Home Residents

Families who depend on nursing homes to keep their loved ones safe and well face significant challenges as a result of this ruling. To family members, the decision removes a federal safeguard that could have ensured consistent care, leaving families with heightened uncertainty and potential risks:

Increased Risk of Neglect and Abuse: 

• Understaffing is a leading cause of neglect and abuse in nursing homes, as overworked staff may lack the time to provide adequate care. The NHRA requires personalized care plans and regular reviews, but without sufficient RNs, these plans may not be implemented effectively. Families may worry about their loved ones experiencing preventable issues like pressure ulcers, dehydration, or untreated infections due to inadequate staffing.

• For example, in the Talevski case, a family discovered that their father was chemically restrained with psychotropic medications due to understaffing at a county-owned facility, leading to his deterioration. Families will likely worry that such incidents may become more common without mandated staffing improvements.

Emotional and Financial Strain:

• Families often choose nursing homes expecting professional care that they cannot provide themselves, particularly for loved ones with complex needs like dementia. The ruling may force families to spend more time monitoring their loved ones’ care or hiring private caregivers to fill gaps, increasing emotional and financial burdens.

• If facilities close due to financial pressures, as the AHCA warned, families may face the trauma of relocating their loved ones, potentially to facilities farther away or with even lower staffing levels.

Aging in Place Planning

One positive effect of the court's decision, and the controversy surrounding it, is that more potential residents and families of potential residents will take seriously the need to age in place, and implement comprehensive aging in place planning. If you would like to know more, subscribe to this blog.  You will be receive periodic notifications of online aging in place planning workshops. If you can't or don't want to wait, there is a recorded, somewhat dated, workshop available here: https://bit.ly/Aging-in-Place-Workshop.  You can watch this presentation in the comfort of your home, and share it with your successor trustees and health care agents. 

Aging in Place Planning is a comprehensive estate, financial, and health care plan orienting your decision-making and resources to make aging in place more attainable, likely, and enforceable by your trusted advisors and fiduciaries, all to the goal of avoiding non-hospital institutional care entirely.  It incorporates reducing the risks of guardianship, and protecting assets from a court-appointed guardian.  

Aging in Place Planning can be incorporated into any existing estate plan.  It can be can be used in conjunction with irrevocable trust planning to shield assets from nursing home spend down, or as an alternative to such planning if it is deemed unnecessary or unacceptable.  

Advocacy Challenges

The NHRA provides for ombudsmen to investigate and address nursing home issues, but without federal staffing mandates, families may need to rely more heavily on these advocates to ensure care quality. Ombudsmen, too, are often overstretched, and their ability to enforce improvements may be compromised by increased demand resulting from the consequences of inadequate staffing.  Of course, like any funded resource, the ombudsmen program is limited without robust federal backing.

Broader Implications and Critical Analysis

The ruling reflects a broader tension between regulatory oversight and industry autonomy in healthcare. While the AHCA and nursing homes argue that the mandate was unworkable amid workforce shortages, critics assert that it was a necessary step to protect vulnerable residents. The decision also highlights the political divide on healthcare policy: Congressional Republicans and the Trump administration, including CMS Administrator Mehmet Oz, have signaled opposition to the rule, while Democrats sought to preserve it.

The establishment narrative—both from CMS and the industry—has obvious gaps. CMS’s rule, while well-intentioned, did not adequately address the root causes of staffing shortages, such as low wages, poor working conditions, vaccine mandates, and a lack of training programs, which continue to drive nurses away from the industry. Mandatory staffing may, actually miss the point entirely, since it is the nature of the resident population that dictates needs; some populations require less from an RN, and more from either LPNs or aids. Finally, staffing is not likely a panacea for the inherent risks of institutional care, many of which lead to rehospitalizations, the real target of federal effort. 

On the other hand, the AHCA’s claim that the mandate would lead to widespread closures may be overstated, as some facilities might have adapted by leveraging technologies like telehealth, and future demand may slow as a result of greater reliance on hospital-at-home, the former as specifically suggested by Oz.

Regardless, from a resident and family perspective, the ruling is a setback. The public will likely perceive that without federal enforcement, care quality may remain inconsistent, particularly in underfunded facilities, leaving families to bear the burden of advocacy and oversight.

A focus on either providing more alternatives to institutional care or encouraging and financing aging in place where possible might provide greater and more satisfying solutions. Reconsideration and reorientation of long-term care in the U.S. is long overdue.

Conclusion

The federal judge’s decision to block the Biden-era nursing home staffing rule on April 7, 2025, removes a critical safeguard intended to improve care quality for nursing home residents. The rule aimed to address systemic understaffing by mandating 24/7 RN coverage and a minimum of 3.5 HPRD, but the court ruled that CMS exceeded its authority, citing inconsistencies with congressional legislation and procedural deficiencies. The ruling is likely to perpetuate understaffing, increasing risks of neglect, infections, and psychological distress for residents, as evidenced by studies showing the benefits of higher RN staffing.

For families, the decision heightens concerns about safety and well-being, potentially requiring greater involvement and resources to ensure adequate care. While the nursing home industry celebrates the ruling, the long-term impact on vulnerable residents underscores the need for alternative solutions, such as state-level mandates or incentives to address workforce shortages, to uphold the FNHRA’s promise of dignity and care for nursing home residents.

More is not Always Better - CMS Adds Staffing Information to Care Compare

The Centers for Medicare and Medicaid Services (CMS) recently announced that it will add data on staff turnover rates and weekend staffing levels to its Care Compare website, giving consumers another tool when choosing a nursing home.  The official Medicare website, previously called Nursing Home Compare,  offers up to five-star ratings of nursing homes based on health inspections, staffing, and quality measures. Users can search for nursing homes by location and directly compare one institution to another.  

CMS will post the following additional information for each nursing home on its website:

• Weekend Staffing: The level of total nurse and registered nurse staffing on weekends provided by each nursing home over a quarter. 
• Staff Turnover: The percent of nursing staff and number of administrators that stopped working at the nursing home over a 12-month period. 

CMS will begin adding the information to the Care Compare website in January, but the information will not be incorporated into the rating system until July 2022. 

The staffing information could not come at a more meaningful time.  Nursing homes are plagued by chronic understaffing and high turnover rates.  The problem has existed for years, but is exacerbated by the COVID-19 pandemic. A study reported in Health Affairs found that the turnover among nursing staff was 94 percent in 2017 and 2018 and mean turnover rates were as high as 140.7 percent among registered nurses, 129.1percent among certified nursing aides and 114.1 percent among licensed practical nurses. 

CMS previously noted a relationship between turnover and ratings. CMS noted in a memo that:

"facilities with lower nurse turnover may have more staff that are familiar with each resident’s condition and may therefore be more able to identify a resident’s change in condition sooner. In doing so, the facility may be able to implement an intervention to avoid an adverse event, such as a fall, acute infection, or hospitalization, which are indicators of quality. Similarly, facilities with lower nurse turnover may be more familiar with the facility’s policies and procedures and can potentially operate more efficiently and swiftly to deliver a higher quality of care to residents. Lastly, facilities with lower administrator turnover may have greater leadership stability, direction, and operations, which may help staff provide care more consistently or effectively to residents."

Regardless of the reasons for the association between turnover and quality, CMS acknowledging the relationship is encouraging.  

CMS has also acknowledged that  the additional information is important and is thus valuable to consumers.  For example, regarding weekend staffing, CMS acknowledged that consumers may not realize that nursing home staffing levels can vary on weekends. CMS hopes to encourage facilities to hire more weekend staff by adding weekend staff numbers to the nursing home rating system.

The fundamental underlying question, though, is whether adding additional information will help transform a questionable and unreliable system into a more meaningful system for consumers.  There is good reason to remain skeptical; there are numerous reports and examples suggesting that the federal ratings are inaccurate or misleading.  Consider the following:   

• NYT: "Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public;
• Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death;
• Nursing Home Compare Does Not Accurately Reflect Patient Safety In Nursing Homes;
• Half of Most Dangerous Nursing Homes Remain Treacherous for Residents After Homes Are Cleared By Regulators.

Worse, even if information regarding nursing homes is more accurate, it does little to help the most vulnerable seniors, those being transferred from acute care in a hospital to a nursing home for rehabilitation; patients are simply given little guidance or information to help them direct accurately their own care decisions: 

• Patients Are Not Given Quality-Of Care Information When Discharged From Hospitals to Nursing Homes.

Providing additional information through Care Compare will only be comforting for consumers and planners when the reporting deficits underlying the system are fixed, and seniors are provided quality of care information prior to transfer. 

Industry reaction to the change has been "mixed," according to Amy Novtney, writing for Mcknight's Longterm Care News.  David Grabowski, professor of healthcare policy at Harvard Medical School, told  industry stakeholders during a LeadingAge conference call, that the timing of the change “feels like a gut punch to nursing homes who are really struggling right now.”

Grabowski called on providers, however, to view the move as a positive development for the industry in the long run. Grabowski said the data could provide benefits such as shedding light on the fact that there aren’t staff available to work on the weekends, that turnover is high and that there’s a high use of contract nurses. That, in turn, could lead to policy changes.

According to Novtney, Grabowski continued: 

“I do think longer term this data will add value and can serve as a signal to all of us that we need to invest more in direct care staff. We get the turnover we pay for and since we aren’t paying enough, we’re seeing high turnover. That’s not something nursing homes can fix on their own. I really believe we need more reimbursement from Medicaid and Medicare to make that happen.”

Other industry associations agree that the decision’s timing is unfortunate given the ongoing challenges related to the pandemic. 

Others criticized the addition information as impotent to improves staffing issues. “While we support transparency and agree that staffing hours and turnover metrics are important, more reporting will not solve this issue,” the American Health Care Association/National Center for Assisted Living said in a statement to McKnight’s this week. “The addition of this reporting requirement when we are in the middle of the worst labor shortage the nursing home sector has ever faced is tone deaf. We need public health officials to do more than acknowledge these challenges, but stand up to address them. By offering funding and policy solutions that will help us attract and retain the caregivers we so desperately need, policymakers can ensure nursing home residents are well supported.”

To read CMS’s announcement about this new policy, click here.

Three Assisted Living Workers Charged in Death of Resident

Three assisted living facility workers are being prosecuted in the death of 86-year-old, Hazel Place, a resident who suffered from Alzheimer’s disease.  Authorities alleged the three left Ms. Place outside in sweltering weather for six hours.

Jamie Johnston, 30, Jenny Logan, 50, and Letticia Martinez, 27, employees of  Cappella Assisted Living and Memory in Grand Junction, Colorado, were charged with negligent death of an at risk person and criminally negligent homicide, both felonies.  

Johnston and Martinez were also charged with a misdemeanor for allegedly forging patient records, according to court documents describing the charges.

National Weather Service data shows that the high temperature in Grand Junction that day was 102 degrees Fahrenheit (38.9 Celsius).

The court documents detailing the evidence gathered against the workers have been sealed.

Place could walk and did so frequently in a routine that was familiar to caregivers, but was supposed to be checked on every hour because she was at risk of falling, her daughter, Donna Golden, told The Daily Sentinel in Grand Junction.

“What it boils down to, as the caregivers that day and probably on other days, none of them were doing their job. Not a one of them checked her,” she said.

Cappella Assisted Living and Memory said in a statement that it reported the circumstances surrounding Place’s death to regulators and conducted an internal investigation which led to the dismissal of two of the workers. The third worker was placed on “investigatory leave,” the statement said.

“We are very saddened by the passing of this beloved resident, and we continue to send our sincerest sympathy to this resident’s family and friends,” the statement said.

Outbreak of Untreatable, Drug-Resistant Super-Fungus Unnerves Experts in Two Major US Cities

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As the delta variant of Covid-19 races through populations and consumes government and media resources, the Centers for Disease Control and Prevention (CDC) announced discovery of multiple instances of Candida Auris that appear to be resistant to all medicines in two health institutions in Texas and a long-term care facility in Washington, D.C.  According to researchers, the deadly, difficult-to-treat fungal infection spreading through nursing homes and hospitals across the United States is becoming even more dangerous. For the first time, the fungus, Candida Auris, has proven to be "utterly impervious" to all existing medication in several cases.

C. Auris, is a hardy yeast infection first found in Japan in 2009, and it is spreading rapidly throughout the globe.  During the coronavirus pandemic, federal health officials believe the disease spread more quickly and even farther, with overburdened hospitals and nursing homes unable to keep up with the surveillance and control procedures needed to manage local outbreaks.

According to the CDC's recent study, at least five out of over 120 cases of C. Auris were resistant to therapy.  The CDC did not name the facilities where the novel infections occurred. Still, health officials said there was no apparent link between the outbreaks in Texas at a hospital and a long-term care facility that shared patients and in Washington, D.C. at a single long-term care center. Between January and April, epidemics occurred.

According to the C.D.C., about a third of infected patients died within 30 days, although officials said it was unclear if their deaths were caused by the fungus because they were already "critically ill."

The CDC has discovered more than 2,000 Americans colonized with C. Auris - meaning the fungus was found on their skin - during the last eight years, with most cases centered in New York, New Jersey, Illinois, and California. Approximately 5% to 10% of individuals infected with the virus develop more severe bloodstream infections.

The fungus is difficult to eradicate from healthcare institutions once it has established itself, sticking to cleaning carts, IV poles, and other medical equipment. While the yeast infection is usually innocuous to individuals in good health, it can be fatal to critically ill hospital patients, long-term care facility residents, and others with weaker immune systems.

Dr. Cornelius J. Clancy, an infectious diseases specialist at the V.A. Pittsburgh Health Care System, told NatureWorldNews, "If you wanted to conjure up a nightmare scenario for a drug-resistant virus, this would be it." "Immunocompromised patients, transplant recipients, and critically sick patients in the I.C.U. would all be at risk from an untreatable fungal infection."

While C. Auris has a reputation for being difficult to treat, researchers discovered five individuals in Texas and Washington, D.C., who had infections that did not respond to any of the three primary antifungal classes. In addition, Panresistance had previously been reported in three C. Auris patients in New York.

Still, health officials said the newly registered panresistant infections occurred in patients who had never received antifungal drugs,  Dr. Meghan Lyman, a medical officer at the CDC specializing in fungal diseases, told the New York Times.

"What's alarming is that the individuals at risk aren't just a tiny group of folks who have infections and are already taking these medications," she added.

The discovery of a panresistant C. Auris is a sobering reminder of the risks presented by antimicrobial resistance, from superbugs like MRSA to antibiotic-resistant salmonella. According to the CDC, such diseases sicken 2.8 million Americans each year and kill 35,000.