联邦医保中心定版家庭健康最终规则：不合规机构资格可追溯撤销，预计每年省8200万美元
联邦医疗保险与医疗补助服务中心（CMS）11月4日宣布，2027年度家庭健康预付系统（Home Health PPS）最终规则已经定版，其中纳入一揽子医保诚信改革，预计每年为纳税人节省约8,200万美元。
新规强化了CMS追回付款的权限：对不合规的服务提供者与供应商，医保登记撤销可自其不合规开始之日生效，CMS可据此追回自该日起已支付的款项；高风险提供者进入或留在医保计划的通道也同步收紧。上述保护适用于各类医保提供者与供应商。
新规新增多项拒绝或撤销登记的理由，包括与性侵或金融不当行为有关的特定轻罪定罪，以及在有限地理区域内提供者过度集中、构成欺诈、浪费与滥用高风险的情形。CMS表示，这些新权限范围有针对性，将逐案考虑事实与情节，在处理不合规的同时保障受益人的就医可及性。临终关怀机构与家庭健康机构在所有权变更和管理员资质方面也面临更严格的要求。
在居家安宁疗护方面，最终规则说明了医保现有家庭健康福利如何覆盖专业安宁疗护，包括在家中的疼痛与症状管理。CMS指出，这旨在消除此前可能限制这类服务使用的提供者疑虑，并不创设新福利；资格取决于患者的护理需求及是否符合医保家庭健康标准，与具体诊断无关。安宁疗护与临终关怀是两回事，前者可在重病或进展性疾病期间为需要专业服务的患者提供支持。CMS计划在规则公布后另行发布指引，给出更多专业安宁疗护的示例。
家庭健康质量信息也将更快公开：结果与评估信息集（OASIS）数据提交期限由135天缩短至45天，公开报告滞后最多可缩短三个月。CMS称，约98%的家庭健康机构已经在45天内提交数据，新期限对多数机构而言只是与现行做法对齐。规则还汇总了将安宁计划（advance care planning）作为未来潜在质量指标的信息。
支付方面，CMS估算2027年度医保对家庭健康机构的付款将较2026年度增加约2.4%；规则另含3%的临时调整，延续上一年做法，以履行将家庭健康预付系统过渡至以患者为导向分组模式（PDGM）并保持预算中性的法定义务。规则还包含耐用医疗设备、假肢、矫形器与用品方面的更新。
CMS局长 Dr. Mehmet Oz 表示：「特朗普政府正采取行动，让不合规的提供者承担责任，确保医保与合法、合格的提供者合作。这些改变将有助于保护老年人、守护纳税人的钱，并保留受益人所需的护理可及性。」
（来源：联邦医疗保险与医疗补助服务中心）
CMS Finalizes Home Health Final Rule With Broad Medicare Integrity Changes, Expected to Save $82 Million a Year
The Centers for Medicare & Medicaid Services (CMS) announced on November 4 that it has finalized the Calendar Year (CY) 2027 Home Health Prospective Payment System final rule, including a package of Medicare integrity changes expected to save taxpayers approximately $82 million annually.
The rule strengthens CMS' ability to recover Medicare payments from noncompliant providers and suppliers. Medicare enrollment revocations can now be effective as of the date noncompliance began, allowing the agency to recover payments dating back to that point, and high-risk providers face tighter limits on entering or remaining in the program. The protections apply across Medicare provider and supplier types.
The rule adds new grounds for denying or revoking enrollment, including certain misdemeanor convictions related to sexual assault or financial misconduct, and circumstances in which an enrollment presents a high risk of fraud, waste, and abuse because of an excessive concentration of providers and suppliers within a limited geographic area. CMS said the new authorities are targeted in scope and that it will consider the facts and circumstances of each case while preserving beneficiaries' access to care. The rule also establishes stricter requirements for hospices and home health agencies related to ownership changes and administrator qualifications.
On palliative care, the final rule discusses how Medicare's existing home health benefit can cover skilled palliative care, including pain and symptom management at home. CMS said this addresses provider uncertainty that may have limited use of these services and does not create a new benefit; eligibility depends on a patient's care needs and whether the patient meets Medicare's home health criteria, rather than on a specific diagnosis. Palliative care under the home health benefit is distinct from hospice care. CMS said it plans to provide additional examples of skilled palliative care through guidance following publication of the rule.
Home health quality information will also become public sooner. The rule shortens the Outcome and Assessment Information Set (OASIS) data submission deadline from 135 days to 45 days, which is expected to reduce the public reporting lag by up to three months. About 98% of home health agencies already submit data within 45 days, CMS said. The agency also collected and summarized information on advance care planning as a potential future quality measure concept.
For CY 2027, CMS estimates that Medicare payments to home health agencies will increase by approximately 2.4% compared with CY 2026. The rule also includes a 3% temporary adjustment, consistent with the approach used in the prior year, as CMS continues its transition of the Home Health PPS to the Patient-Driven Groupings Model in a budget-neutral manner. The rule also includes updates related to durable medical equipment, prosthetics, orthotics, and supplies.
"The Trump Administration is taking action to hold noncompliant providers accountable and ensure Medicare works with legitimate, qualified providers," said CMS Administrator Dr. Mehmet Oz. "These changes will help protect seniors, safeguard taxpayer dollars, and preserve access to the care beneficiaries need."
(Source: Centers for Medicare & Medicaid Services)
来源：联邦医疗保险与医疗补助服务中心
发布：GSM·美国（发布链接）
图片来源：图：美国卫生与公众服务部总部大楼，联邦医疗保险与医疗补助服务中心（CMS）为其下属机构。GSM 固定图库（联邦核心包）。 / Photo: The U.S. Department of Health and Human Services headquarters; CMS is an HHS agency. GSM federal asset library.
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