Can the Medicare Home Health Benefit be a Tool to Accelerate Palliative Care?

On July 1, 2026, CMS posted the CY 2027 Home Health PPS proposed rule, with comments due August 31, 2026. While most will focus on the payment increase of 2.4% (notably, almost identical to what we’ve seen in prior PPS rules this year and the Medicare Advantage Final Notice), CMS did even include in the Fact Sheet and Press Release, not just buried in the text of the proposed rule text, that palliative care can be provided within the existing home health benefit to patients with serious illness and that they want to see more community-based palliative care.

They emphasized that palliative care is separate from hospice and may support patients earlier in the course of serious illness. CMS notes they plan to add examples of qualifying skilled care in home health through sub-regulatory guidance after the final rule is published, which is in November. It appears these examples will be added to Chapter 7 of the Medicare Benefit Policy Manual (BPM), which is for home health. They do offer a few examples in the Home Health proposed rule itself, starting on Federal Register page 41275. You can access the proposed rule and download the pdf version here.

They also posted a Request for Information (RFI) in the 2027 Hospice proposed rule, which they directly reference in the HH proposed rule, where they ask how to best promote access to community-based palliative care.

I went back and reviewed that proposed rule. Here’s some of what was in that RFI, including the questions asked. Unfortunately, that RFI comment period is closed. The approach to take here is to answer these RFI questions in your comment letter to the 2027 HH proposed rule as it relates to home health.

From the RFI in the 2027 Hospice proposed rule:

A note about RFIs: CMS will often post them when they are looking for feedback and ideas prior to doing rulemaking on something that’s a goal, but that they weren’t ready to act on yet.

Medicare policy runs on two layers.

The bottom layer is statute, the Social Security Act, the part that actually says what Medicare is and who it covers. Only Congress can change it, and Congress makes permanent changes in Medicare statute VERY infrequently.

The top layer is where CMS lives: the regulations and guidance that spell out how the statute works in practice. You'll hear people say regulators can't make new policy. That's not quite right. They can, but only inside the room Congress already built for them.

So when CMS wants more palliative care in the community, it has a choice. It can go wait for Congress’ stars to align to create a brand new benefit, which might never happen. Or it can look at the benefits that already exist and clarify that palliative care fits inside one of them. CMS took the second path.

In the companion hospice rule earlier this year, the agency wrote that it wanted to expand palliative care "without requiring legislative reform or the creation of an entirely new benefit." Two rules in a row now, hospice in April and home health in July, working the same angle. That's intentional. I wouldn’t be surprised to see something in the 2027 Physical Fee Schedule proposed rule, which could be out as early as this week (this is the week of 7.5.26).

There's also a legal reason the “clarify-what-exists” approach is likely a smart one right now.

After the Supreme Court ended Chevron deference in 2024, agencies get a lot less benefit of the doubt when they stretch a statute to do something new. Pointing out what a benefit already covers stands on much firmer ground than inventing something the text never mentioned. So "no new benefit" is CMS picking the version most likely to survive.

A clarification like this changes what patients actually get, not just what's printed in a manual. Because when rules are murky, providers default to self-protection over clinical innovation. Let’s look at how we decide what to offer in the first place

When we agree to bill a third party payer, including Medicare, we agree to something specific. We'll submit claims for covered services, and if a service isn't covered, we understand the patient may end up on the hook for it. No provider wants to be the one having that second conversation.

We might also risk being accused of providing care that wasn’t medically necessary and attempting to submit claims for that outside of what’s considered “covered.” Because is Medicare fee-for-service for home health, for example, there’s no “prior authorization.” This would mean an audit could be what surfaces a potential issue.

So we do the rational thing and hold back on anything we're not confident will be paid and what we aren’t confident would be considered “following Medicare’s guidelines.” (I’ve seen Medicare’s definitions be interpreted almost by habit in different sites of care, not by what I read in the Medicare Benefit Policy Manual. But I digress…) Spread that across an entire industry in something like the care of patients with serious illness, and it’s a massive missed opportunity with major downstream impacts.

Also, plenty of us honestly don't know the guidance well enough to be sure. Coverage rules are dense and scattered across manuals nobody reads for fun (except maybe the odd duck like me 😀 ). CMS seems to understand that decoding the dense policy is a problem, too. The questions it asked in the hospice rule were all about exactly this: claims denials, uncertainty about compliance, services people deliver but can't figure out how to bill. If they can take away that uncertainty, they may be offering access to care that was sitting there available the whole time.

Which brings me to the confusion that costs patients the most

A lot of people, including plenty of clinicians, hear "palliative care" and picture hospice, or some lighter version of it. It isn't that. Hospice is for the (approximate) final six months of life when curative treatment is no longer the chosen path and/or a viable option, and the patient is willing to stop the curative route.

Palliative care runs right alongside curative treatment, and it can start years before anyone is talking about hospice. It's for serious illness, a much bigger cohort. It’s also the cohort who commonly has unmanaged symptoms and conditions that land them in the emergency room.

Part of why the confusion holds is that, surprise surprise, the value of palliative care isn't obvious to everyone. Our fee-for-service, transactional system trains our brains to look only for line-item line billing codes, not the underlying clinical gaps. Palliative care often looks like a conversation, a medication list that finally gets untangled, and symptoms that finally get controlled. For someone living with one or more serious illnesses, that can be worth more than almost anything else we do for them.

If you want to see palliative care hiding in plain sight, borrow a trick from Toyota. On the factory floor, when something breaks, you ask "why" five times to get past the symptom and down to the real cause.

That invisibility is a money problem and a clinical one.

So much of what palliative care does well is work the payment system has no clean slot for. CMS admits it. The agency wrote that "because Medicare does not recognize palliative care as a distinct billable service, providers must rely on a variety of codes and benefit categories." There's a code for a palliative care encounter, Z51.5, but as CMS points out, it doesn't say what services it's supposed to cover. The social worker, the chaplain, the nurse spending an hour on symptoms and fears, these are often the heart of the visit and the hardest parts to put on a claim.

Work that doesn't get paid doesn't get done at scale. so it doesn’t help an organization keep its doors open. Not to mention, this isn’t a skill every physician has or they don’t feel comfortable doing it. It may not be something they have done regularly or saw the value in, or saw it as their job. These are real issues to be tackled when we want palliative care to be carried out by medical providers.

Tucking palliative care into an existing, billable benefit matters more than it sounds. Home health is a place where this work can finally get delivered and paid for under rules that are already on the books.

Take action and provide your comments by the deadline

Comments on the home health proposed rule are due August 31, 2026. CMS said that it wants comments "on any concerns or suggestions regarding reaching this goal."

Don't send a comment that just says you're in favor. Say what you actually see. Name the skilled services you provide to seriously ill patients. Describe a real patient who would have qualified and what stood in the way. Point out where the coverage still feels murky enough that your team hesitates to bill. CMS already published the questions it cares about in the hospice rule, which services get billed under that Z code, where claims get denied, which team members you can't bill for at all. Answer those, with specifics. Specifics are what turn into guidance.

And don’t be afraid to call out what doesn’t make sense. Here’s what I want to explore: palliative care is ideally provided in care teams. However, the physician, NP, or PA is required to discuss medical orders and patient wishes, and is required to make sure patients understand their options.

If someone is making decisions about Medical/Physician Orders for Life-Sustaining Treatment (MOLST/POLST), that requires their involvement and signature. If a patient’s medication is causing unmanageable symptoms, it will be the physician/APP who partners with the patient to potentially make changes.

Home health providers may be concerned that they will need strong partnerships with the referring physicians so the care teams in the home can collaborate with them and the patient on medical treatment changes. Physicians and APPs providing the palliative medical care often don’t have the incentives in fee-for-service to make home visits because of windshield time and the impact home visits have on their daily “RVU productivity.”

I want to call this palliative care's time to shine—and it very well might be. But it also opens up a massive can of worms: what is the actual dividing line between medical palliative care and team-based care? And is the fee-for-service system even capable of yielding what CMS expects through mere sub-regulatory guidance?

Home-based primary care programs serving the seriously ill population, like the ACO REACH High Needs ACO Model, provide a monthly payment to cover the costs of the full team to provide home-based, team-based care. 

Here’s my take:

CMS has seen the benefit of programs like the ACO High Needs ACO and similar programs in Medicare Advantage, which provide home-based, team-based, advanced primary care, and they want to see those concepts scale to fee-for-service. I see alignment here with CMS creating and expanding the advanced primary care management (APCM) codes, where . These are steps to make the fee-for-service system more value-oriented, and to provide another starting glide path towards managing patients with the long view in mind.

Palliative care is an obvious success lever in value-based care. Helping patients with serious illness better manage their chronic conditions and symptoms is often a multi-year exercise and should be inherent to how this large population is treated across the board. I’ve seen first hand the push-back.

Maybe this nudge will at least help build momentum.

Additional reading from pages 41275,6 of the Federal Register on the 2027 Home Health proposed rule: