Preamble to LeadingAge’s 2025 Policy Platform: Our Priorities

As reflected in our 2025 Policy Platform, there are numerous policy issues across the aging services continuum. As we look ahead to 2025, the following goals stand out as LeadingAge’s priorities:

Affordable Housing

• Preserve and expand affordable housing for older adults.
• Increase the number of Service Coordinators in affordable housing for older adults.
• Expand the supply of affordable housing for the aging services workforce.
• Create Older Adult Special Purpose Vouchers to quickly prevent and end homelessness.

Aging Services Workforce

• Create clear and accessible pathways to citizenship as well as permanent and temporary residency status for the aging services workforce.
• Expand visa classifications and substantially raise visa caps for the workforce across all care settings.
• Offer substantial incentives and expand access to training and education programs and apprenticeships.
• Support programs and resources to increase the number of nurse faculty.

Nursing Homes

• Repeal the CMS nursing home staffing mandate.
• Oppose proposals to cut Medicaid funding and/or to reduce access to Medicaid.
• Implement the Risk Based Survey to modernize the survey and certification process.
• Advocate to remove the expansion of Civil Monetary Penalties.
• Revise Civil Monetary Penalties to enhance quality of care and strengthen consequences for poor performers.
• End the certified nurse aide training lock-out.

Medicare and Medicare Advantage

• Ensure beneficiary access to traditional Medicare A and B benefits.
• Preserve aging service providers’ financial viability.
• Identify ways to reduce administrative burden and sustain the Medicare Trust Fund.
• Preserve Medicare beneficiaries’ choice between traditional Medicare and Medicare Advantage.
• Advocate for enhanced data collection, transparency, and accountability.

Care in the Home and Community

• Oppose proposals to cut Medicaid funding and/or to reduce access to Medicaid.
• Promote the availability, accessibility, and sustainability of HCBS across all funding streams.
• Repeal the 80/20 component of the Medicaid Access Rule and advocate for smart enforcement of the HCBS settings rule.
• Support increased availability and accessibility of PACE services.
• Ensure home health payment sustainability in both FFS and Medicare Advantage.
• Advocate for a home health value based purchasing program that works for nonprofit home health agencies.
• Support appropriate palliative care reimbursement.

Hospice Services

• Secure hospice benefit reforms.
• Expand access to hospice respite and inpatient care.
• Improve the special focus program

Tax Policy

• Maintain current nonprofit tax status for LeadingAge members as 501(c)(3) exempt organizations.
• Oppose the elimination of the exemption for state and local bonds and the ending of tax preferences for other bonds.

LeadingAge Advocacy Goals

• Advance policy that promotes the availability of adult day services across funding streams, including Medicaid, Medicare, Older American Act programs, and Veterans Affairs (VA).
• Advocate with the Department of Veterans Affairs (VA) to:
  • Improve contract oversight of the Community Care network Third Party Administrators to increase accuracy of provider networks and access to adult day services.
  • Increase VA staff training and knowledge of adult day services and how to make referrals to providers.
  • Preserve policies that promote access to services for eligible veterans.
• Protect existing adult day providers from restrictive interpretation of the home and community-based settings final rule to ensure ongoing access to adult day services for participants in Medicaid programs.
• Ensure that LTSS models from the Center for Medicare and Medicaid Innovation are inclusive of all settings in the home and community (e.g., home health and personal care, adult day and other day-based services, PACE services) and provide the supports (e.g., transportation) needed to facilitate inclusion of these provider types and settings.
• Promote federal rulemaking that ensures access to and quality of home and community-based services (HCBS) for beneficiaries while minimizing provider burden.
• Educate policy makers on the value of adult day as a service that reduces family caregiver burden, depression, and isolation in an efficient and engaging service model.
• Reinforce federal rulemaking that supports access to and quality of home and community services for beneficiaries while minimizing provider burden, this includes maintenance of reduced burdens during application and redetermination that were included in the Medicaid Streamlining Eligibility and Enrollment final rule.

THE ISSUE

Home and community-based services (HCBS) providers remain at an inflection point, and adult day services providers are especially at risk. Over the last decade, significant improvement has been made in the availability of and public investment in these critical LTSS providers. As with most providers, however, the end of the public health emergency stalled additional federal investment. Further, enforcement of the home and community-based settings final rule (the HCBS rule) has threatened access for Medicaid participants. Structural changes to Medicaid financing would result in the scaling back of HCBS services including adult day.

Contracting and referrals with all payers remains challenging as knowledge of the services provided by adult day programs is not well understood by policy makers. Challenges accessing services through Medicaid and Veteran’s Affairs, along with sparse Medicare Advantage plan coverage of adult day (as a supplemental service), leaves many older adults in need of care they cannot access or afford.

Providers face mounting challenges as states transition to managed care threatening existing Medicaid provider agreements, putting access to Medicaid funded services at risk. Ensuring that HCBS is included in federal funding conversations and common-sense approaches to regulatory compliance are fundamental to making sure these services are available for older adults over the next decade and beyond.

ADVOCACY ACTION 2025

119^th Congress

• Protect Medicaid. We will educate and advocate for protection of the Medicaid financial system from cuts and policy changes that would threaten the viability of our members and the livelihood of those that they serve. We oppose financing reforms such as per capita caps, block grants, elimination or reduction of provider taxes, or changes to the federal share of Medicaid spending and oppose barriers to access such as work requirements.
• Medicaid rates. We support investments in the Medicaid program via increased Federal Medical Assistance Percentage (FMAP) for both HCBS and nursing homes. We will continue to work with state partners and members to ensure that state Medicaid rates paid to aging services providers are sufficient to cover the costs of care.
• Benefit categories. We ask Congress to revise Medicaid and put HCBS (including waiver, state plan services, and PACE) on equal footing with nursing homes, making HCBS a mandatory Medicaid benefit.
• Protecting access to Medicaid HCBS. We support key provisions that ensure access to HCBS, including the permanent enactment of federal spousal impoverishment protections for Medicaid HCBS, and the Money Follows the Person program. Additionally, we support initiatives that would allow states to innovate around the institutional level of care requirement for HCBS such as the pilot program proposed in H.R. 8307 from the 118^th session of Congress.
• Adult Day coverage under Medicare: We believe Congress should amend the Medicare program to make adult day services available to beneficiaries and offer technical assistance to interested adult day providers.
• Appropriations: We support increasing funding for key provisions that support HCBS, including Older Americans Act services and affordable housing which is fundamental to aging in place and receiving services in the community for individuals that rely on those properties.

Executive Branch

• Protect Medicaid financing. We oppose any Medicaid waiver or rulemaking that reduces or holds constant federal funding to the program, as these could ultimately jeopardize HCBS access and access for populations that support our providers and those they serve. To that end, CMS should not approve new and should rescind any existing waivers that allow per capita caps or block grant financing, work requirements, restructuring of the FMAP or other unnecessary coverage or enrollment barriers.
• MFAR. CMS should not propose rulemaking like the 2019 Medicaid Fiscal Accountability Regulation (MFAR) because of its significant implications for provider payment rates and state financing of Medicaid by disrupting current arrangements and restricting the future use of such arrangements.
• New models of payment and integrated services. We will continue to engage the Center for Medicare and Medicaid Innovation to shape care delivery and payment models that offer integrated service delivery and create opportunities within existing and new models for Medicaid focused providers especially HCBS providers.
• VA Coverage of Adult Day Services. We will closely monitor developments with the VA Community Care Network program and other VA initiatives that provide HCBS and advocate for our members and the veterans they support.
• Transportation and Medicaid. We support the maintenance of current rulemaking that subregulatory guidance issued in 2024 assigns non-emergency medical transportation (NEMT) as a mandatory Medicaid benefit.
• Supplemental Services under Medicare Advantage. We will encourage CMS to continue broadening adult day services available in Medicare Advantage and work with plans on implementation.
• HCBS Settings Rule. We will engage in ongoing advocacy with CMS on reasonable interpretation of compliance with the HBCS settings rule to ensure access to Medicaid funded HCBS.
• Mitigation of Enrollment Barriers for Medicaid. We will work to reinforce federal rulemaking that supports access to and quality of home and community services for beneficiaries while minimizing provider burden, this includes maintenance of reduced burdens during application and redetermination that were included in the Medicaid Streamlining Eligibility and Enrollment final rule.
• Eliminate 80/20 Wage Pass through in Final Medicaid Access Rule While Maintaining Components That Work. We continue to oppose untenable provisions of Medicaid Access Rule that require wage pass throughs and community-based provider cost reporting. Reinforce elements of the Access Rule that will promote access to Medicaid services such as state reporting requirements, mandatory adoption of standardized HCBS quality measures, and changes to critical incident reporting.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support the expansion and preservation of programs and services for older adults.
• Stay up to date with LeadingAge’s adult day work through our Adult Day, PACE, and HCBS page.
• Host Congress in Your Neighborhood to help your Members of Congress understand the great services you provide, how they affect your community by caring for older adults, providing jobs, or offering respite for family caregivers. Describe and demonstrate how policies impact providers, employees and residents. For example, structural changes to Medicaid will mean less federal funding is available, resulting in Medicaid rate reductions, increased out-of-pocket costs, or eligibility terminations for some staff.
• Get involved with LeadingAge member networks and our weekly Policy Pulse calls to stay up to date on policy proposals. Provide your feedback on how proposals would affect your community, staff, or participants. Email Georgia with questions, concerns, or to join the network.

LeadingAge Advocacy Goals

• Expand the supply of, and protect access to, affordable housing assistance for older adults.
• Preserve and modernize service-enriched affordable senior housing to support high-quality housing across both urban, rural, and suburban America.
• Improve resident outcomes by using affordable housing as a platform to connect residents to services and supports.

THE ISSUE

America needs more housing units that are affordable to older adults with low incomes and that have design features, including accessibility, and other supports needed for older adults to age in community. There is a severe shortage of affordable housing for older adults with low incomes. Older adult homelessness is the fastest-growing type of homelessness, and only one-in-three older adults eligible for federal rental assistance receives it. Waiting lists for housing assistance are often many years long and many are closed.

In its most recent Worst Case Housing Needs: 2023 Report to Congress, HUD told Congress that 2.35 million older adult renter households with very low incomes (incomes less than 50% of the area median income) spent more than half of their incomes on housing in 2021, an increase of 60% since 2011 and 130% since 1999. According to the report, in 2021, 52.3% of VLI older adult renter households had severe housing cost burdens (i.e., paid more than 50% of their incomes for housing) and an additional 23.9% VLI older adult renter households spent between 30 and 50% of their very low incomes on housing.

The aging services workforce also needs affordable homes in which to live. LeadingAge supports the preservation of existing affordable housing as well as expanded resources for additional affordable housing not only to meet the needs of older adults, but also to meet the needs of the aging services workforce.

LeadingAge believes in addressing the housing crisis by developing new affordable, service-enriched homes, preserving and upgrading existing affordable housing communities for long-term resilience, protecting and expanding access to rental assistance for older adults with low incomes, and streamlining and modernizing housing and services programs for older adults to age in community.

ADVOCACY ACTION 2025

119^th Session of Congress

Expand the supply of, and protect access to, affordable housing assistance for older adults.

• Improve and expand HUD’s flagship senior housing program, Section 202 Supportive Housing for the Elderly:
  • Provide $600 million for new capital advances and operating assistance, including service coordination, for approximately 2,000 new Section 202 homes nationwide, including in rural areas. At this funding level, Section 202 capital advances would be the primary funding source for development.
  • Streamline new Section 202 investment by allowing new capital advances to be paired with project-based Section 8 operating subsidy and ensure that Section 202 capital advances present a primary funding source for housing developments, reducing complex and costly financing deals.

• Expand targeted housing assistance for older adults with low incomes:
  • Provide $50 million for about 5,000 new Older Adult Special Purpose Vouchers, at least 50% of which could be project-based, for use in a variety of settings serving older adults, including communities financed by the Low Income Housing Tax Credit and assisted living communities.
• Revive proven housing assistance solutions to stem housing instability:
  • Authorize new Section 8 Project-Based Rental Assistance (PBRA) contracts to leverage the private housing market to provide high-quality, service-enriched housing options for older adults with low incomes.
• Expand and improve the Low Income Housing Tax Credit program, including by enacting the Affordable Housing Credit Improvement Act (ACHIA).
  • Increase state Housing Credit allocations by 50%.
  • Fix Right of First Refusal issues that continue to rob nonprofit housing providers of their housing credit-financed developments.
  • Lower the threshold of Private Activity Bond financing required to trigger the maximum amount of 4% Housing Credits from 50% to 25%.
  • Enable the Housing Credit to better serve households with extremely low incomes by providing a 50% basis boost for such housing.
  • Provide resources to bring service coordinators to Housing Credit communities.

Preserve and modernize service-enriched affordable housing communities:

• Preserve existing affordable housing and protect the housing stability of residents.
  • Fully fund existing Section 8 Project-Based Rental Assistance (PBRA) contracts and Project Rental Assistance Contract (PRAC) renewals, including funding that reflects annual increased costs for insurance, staffing, utilities, service coordination, and internet connectivity.
  • Expand ongoing budget adjustment options for Section 202/PRAC properties, including by implementing market-driven increases.
  • Ensure continued access to housing assistance without work requirements, time limits on assistance, or increased rents for residents.
• Streamline and invest in housing assistance programs that leverage both public assistance and the private market by ensuring Rental Assistance Demonstration (RAD) for PRAC success.
  • Improve the financial viability of preserved Section 202 PRACs by adjusting initial rent-setting and by allowing converted properties to access ongoing market-driven rent adjustments.
  • Provide $10 million for RAD for PRAC conversion subsidy to ensure the successful and long-term preservation of 202/PRAC homes, including adjusted Preservation Rent Increase eligibility thresholds that allow feasible access for properties in need.

• Support efforts to improve accessibility of the nation’s housing stock.
  • Support and expand aging-in-place modification programs, including HUD’s Older Adult Home Modification program and tax credits for older adults to update homes to be age-appropriate and climate resilient.
  • Expand resources to increase the accessibility of the nation’s housing stock.
  • Support legislation that requires universal design and visitability, including the Visitable Inclusive Tax Credits for Accessible Living (VITAL) Act.

• Prevent and end homelessness among older adults.
  • Fully fund HUD’s homeless assistance programs.
  • Improve partnerships between Continuums of Care, Older Americans Act programs, and Area Agencies on Aging.

Improve resident outcomes by using affordable housing as a platform to connect residents to services and supports:

• Invest in cost-effective interventions instead of premature moves to high-level care settings, like nursing homes, for older adults with services needs.
  • Provide $125 million for the renewal of existing service coordinator grants and improve leveraging of Service Coordinator reporting data.
  • Provide $100 million for 400 new, three-year service coordinator grants.
  • Provide a $31 million increase for new, budget-based service coordinators in Project-Based Section 8 properties, and streamline rent adjustment processes to add service coordination to property budgets.
  • Provide resources to equip affordable housing staff with Mental Health First Aid training to support resident mental and behavioral health.

• Address the digital divide for older adults in rural and high-needs areas.
  • Expand resources to install building-wide internet in federally-assisted communities.
  • Invest in whole-property Wi-Fi solutions to improve in-unit connectivity for older adults, including to address health at home.

• Enact the Expanding Service Coordinators Act to:
  • Authorize an additional $100 million a year for five years for 400 new grant-funded service coordinators in HUD-assisted multifamily housing.
  • Authorize $37 million for 150 three-year service coordinator grants via a new program administered by HHS’s Health Resources and Services Administration, including for properties financed by the Low Income Housing Tax Credit (LIHTC).
  • Make service coordinators eligible for federal student loan forgiveness.

Expand the supply of, and protect access to, affordable housing assistance for the aging services workforce.

• Preserve and expand the supply of affordable housing across HUD, USDA Rural Housing Service, and Low Income Housing Tax Credit programs not just for older adults but for the workforce that serves them.

Executive Branch

Expand and Preserve Affordable Senior Housing Options:

• Expand and modernize HUD’s flagship senior housing program, Section 202 Supportive Housing for the Elderly, including by issuing capital advances as primary financing and adjusting operating subsidy to the Section 8 platform.
• Preserve and improve the existing supply of affordable housing, including through improvements to the Rental Assistance Demonstration (RAD) to achieve improved initial rent-setting, better energy efficiency, and long-term financial viability.

Cultivate Connected, Service-Enriched Housing:

• Support service-enriched housing, including by improving HUD’s Service Coordinator grant administration, leveraging Service Coordinator reporting data, clarifying Service Coordination property eligibility, enhancing Supportive Services funding for Section 202/PRAC communities, elevating mental health training and resources for affordable housing staff, and clarifying Medicare Advantage supplemental benefits’ impact on rent determinations.
• Increase internet connectivity in affordable housing, including by adjusting HUD rules and by partnering with other federal agencies, like the Federal Communications Commission (FCC) and the National Telecommunications and Information Administration (NTIA). for infrastructure and internet service resources.

Support Mission-Driven Housing Operations:

• Streamline and modernize asset management practices, including through improved budget increase and contract renewal processes at HUD.
• Support clear and fair approaches to the Housing Opportunity Through Modernization Act (HOTMA) implementation, including retaining owner options to decline enforcement of new asset limits on in-place residents, and minimize negative impacts on residents and applicants of affordable housing communities.
• Address rising property insurance costs and limited coverage options for affordable senior housing providers.
• Enhance HUD oversight mechanisms, including by supporting feasibility of housing inspections and updated portfolio oversight.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support the expansion and preservation of affordable housing programs for older adults.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact affordable senior providers and residents.
• Stay up to date with LeadingAge’s affordable senior housing work through our Affordable Housing page.
• Engage with other affordable senior housing providers through the LeadingAge Housing Network (and its working groups), as well as other regular national, regional, and state meetings. Contact Linda or Juliana for more information.

ADDITIONAL RESOURCES

HUD’s Worst Case Housing Needs Report, 2023

Joint Center for Housing Studies at Harvard University’s Housing for an Aging Society Program

2024 GAO report, Homelessness: Actions to Help Better Address Older Adults’ Housing and Health Needs

LeadingAge Advocacy Goals

• Promote evidence-based policies for behavioral health services, including mental health and substance misuse prevention and treatment, for older adults and the aging services workforce.
• Promote new or expanded funding sources or allocations for behavioral or mental health services that specifically improve access, treatment or care for older adults and the aging services workforce.
• Raise legislators’ awareness of the increasing need for behavioral and mental health supports and services, as well as whole-person wellness, for older adults and the aging services workforce.
• Collaborate with stakeholder groups, including government agencies and advocacy associations, to promote, support, fund, advocate for, or provide education on the need for evidence-based behavioral health and substance use intervention programs for older adults and the aging services workforce.
• Advocate for robust community-based grief and bereavement supports. Advocate for the development of policies that support aging service providers, including hospice and palliative care providers, in their efforts to support their communities as they recover from trauma. Specifically, advocate for expanded funding for community grief and bereavement programs, development of standards to measure what constitutes a “good” bereavement program, and grief programming that supports older adults through losses of community, identity, and independence.

THE ISSUE

By 2030, 72.1 million people aged 65 or better will reside in America, and one in four of those people will live with either a mental health or substance misuse disorder. Of those, only 4 – 28% will have access to supportive services to address these disorders. Older people of color have even less access to reliable mental health resources. And, reportedly, illegal and recreational drug abuse, including opioid use, is increasing among older adults.

The World Health Organization, among many authorities on the subject of mental health, substance abuse and aging, offers a long list of risk factors that predispose an older adult to mental illness or substance misuse; equally lengthy are the known negative physiological impacts of such disorders on older adults. The cumulative effects of lifespan circumstances, stressors, losses, and post-retirement malaise certainly top the list, but also mentioned are several LeadingAge-championed causal factors such as ageism, social isolation and loneliness, elder abuse and traumatic experiences. Shortened life span, along with higher mortality from many common maladies (heart disease, hip fractures, diabetes and cancer, as examples,) are some of the poor health outcomes attributed with mental illness in older adults – and 2-3 times more Medicare/Medicaid dollars are spent on individuals than those without mental illnesses.

While there are known mental health and substance use interventions that work for older adults, many wide gaps in behavioral health and substance abuse services and supports exist across the continuum of care for this vulnerable population. A recent study published by the Gerontological Society of America outlined five policy issues specific to living with serious mental illness in U.S. Nursing homes that might provide a roadmap for addressing living with SMI for older adults living within the broad spectrum of seniors housing. LeadingAge seeks to narrow he behavioral / mental health supports and services gap for older adults by advocating for funding, services and programmatic supports that will expand access to the older adults most in need of proven, effective mental or substance abuse interventions. We include in that advocacy work the people who care for these vulnerable older people: both paid and family caregivers.

Advocacy Action 2025

119^th Congress

• Support Newly Enacted Workforce Training Programs. We support funding and full implementation of the HUD workforce training and education related to the identification of behavioral health, mental health and substance misuse challenges in older adults. This includes referral to appropriate intervention programs, and the creation of a wellness culture in the health care professions through the Dr. Lorena Breen Act.
• Promote Expanded Medicare Supports for Behavioral/ Mental Health and Substance Use Interventions. We will promote the extension of the Consolidated Appropriations Act of 2023 and the 2008 Mental Health Parity and Addictions Equity Act to increase the enrollment of mental health professionals in Medicare and expand mental health benefits in the Medicare Advantage programs.
• Geriatric Social Worker Education, Recruitment and Retention. We support the inclusion of expanded programs to recruit, educate, and retain geriatric social workers that encourage more social workers to join and specialize in the aging services field.
• Geriatric Psychiatrist Education, Recruitment and Retention. We support the inclusion in expanded programs for funding to recruit, educate and retain geriatric psychiatrists, with the goal of encouraging more geriatric psychiatrists to join the aging services field.

Executive Branch

• We will support efforts to expand funding to CDC’s Suicide Prevention Program.
• We will collaborate with HHS – SAMHSA to allocate grant funding from the Administration’s Unity Agenda platform towards behavioral health, mental health and substance misuse interventions that specifically support older adults and the aging services workforce.
• We will support CMS’s efforts to close long-standing gaps in Medicare substance use disorder coverage through the full implementation of the CY 24 changes to the Physician Fee Schedule, and to support access to other behavioral health services through implementation of actions described in the CY 25 Physician Fee Schedule, including promotion of safety planning interventions and interprofessional consultation.
• We will support HUD in launching and expanding training for affordable housing staff to recognize behavioral and mental health challenges and refer residents for care.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support behavioral health and substance misuse intervention programs for older adults and their caregivers.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact senior providers and residents.

ADDITIONAL RESOURCES

• LeadingAge: Behavioral Health and Dementia QuickPATH
• LeadingAge: Mood/ Behavior/ Medically Related Social Services QuickPATH
• SAMHSA: Resources Serving Older Adults

LeadingAge Advocacy Goals

• Promote increased access to elder justice programs.
• Advocate to include abuse identification, intervention and prevention training in educational requirements for all members of the aging services workforce.
• Collaborate with the Global Ageing Network to coordinate the response to elder abuse and neglect.
• Examine ways to incorporate abuse prevention training for home care, case managers, service coordinators, and residential counselors.

THE ISSUE

Elder abuse affects one in ten older adults, including our residents, clients, tenants, and those awaiting services from LeadingAge members. Increased incidents of isolation and loneliness have exacerbated conditions contributing to abuse, such as dependence on potentially abusive caregivers, loss of independence, fear, and diminished effectiveness of prevention programs. This abuse, including financial exploitation and physical or psychological harm, undermines the safety and dignity of all older adults.

LeadingAge remains at the forefront of combating elder abuse in our communities and care settings, driving prevention efforts and advocating for systemic change. Strengthening the fight against elder abuse is a core ethical obligation, reflecting our mission to be the trusted voice for aging, our vision of an America free from ageism, and our unwavering commitment to inspire, serve, and advocate.

ADVOCACY ACTION 2025

119th Congress

• Champion the passage of the Elder Justice Act reauthorization to strengthen protections, resources, and programs that prevent elder abuse, neglect, and exploitation, ensuring dignity and safety for all older adults. For example, in the last session of Congress, LeadingAge supported Elder Justice Reauthorization and Modernization Act of 2023 (H.R. 2718), and the provisions included in the Nursing Home Workforce Support and Expansion Act (H.R 7929).
• Advocate for the development and expansion of programs that mitigate loneliness in older adults, promoting social connection, mental health, and overall well-being. For example, in the last Congress, LeadingAge supported the Improving Measurements for Loneliness and Isolation Act of 2023 (H.R. 6284/S.3260) and the Addressing SILO Act of 2023 (H.R. 2692).

Executive Branch

• Promote best practices. We support advancing evidence-based programs and innovative funding models that incorporate restorative justice processes, fostering the repair of relationships and the strengthening of family connections whenever possible.
• Elder Justice Coordinating Council. We will continue to offer strategic guidance on aligning the efforts of LeadingAge providers with Council initiatives.
• Training. We will actively engage with the administration to advocate, develop and share effective abuse prevention and intervention strategies, prioritizing the safety, dignity, and well-being of vulnerable populations.

ADDITIONAL RESOURCES

• USC Center for Elder Justice
• Harry and Jeannette Weinberg Center for Elder Justice
• Frameworks Institute: Talking Elder Abuse A Framework’s Communications Toolkit
• National Center on Elder Abuse

LeadingAge Advocacy Goals

• Ensure that older adults are able to receive health care and long-term services and supports in their homes and communities if they prefer to do so.
• Protect Medicaid by educating and advocating for protection of the Medicaid financial system from cuts that would threaten the viability of our members and the livelihood of those that they serve. We oppose financing reforms and policy changes such as per capita caps, block grants, elimination or reduction of provider taxes, or changes to the federal share of Medicaid spending as well as opposing barriers to access such as work requirements.
• Protect providers from restrictive interpretation of the home and community-based (HCBS) settings final rule to ensure ongoing access for participants.
• Advance policy that promotes the availability of HCBS across funding streams, including Medicaid, Medicare, Older Americans Act, Veterans Affairs, and private pay.
• Secure funding for innovation in HCBS.
• Support increased availability of PACE services to older adults through regulatory and statutory flexibility, education, and investment at the federal and state levels.
• Ensure that long-term services and supports models from the Center for Medicare and Medicaid Innovation include HCBS.
• Promote federal rulemaking that ensures access and quality care for those receiving services in the home and community while minimizing provider burden.
• Preserve the ability and discretion of states to regulate assisted living.

THE ISSUE

Care in the home and community is broadly popular; a majority of older adults say they want to age in place. The ecosystem that would allow for this preference to be realized in a manner that is sustainable and affordable for beneficiaries, their families, and aging services providers does not exist. LeadingAge, as the only organization representing the continuum of aging services providers, supports policies across the continuum of care and housing to try to realize this vision. Robust support for affordable housing, reimagined home based care, and community based services are all critical components of age friendly communities that would truly allow for aging in place. We support policies that will enhance the financing available, the breadth and quality of providers, and the supportive services needed to effectively care for older adults in the home and community. These policies include enhanced access to and funding from Medicaid, expansion of Medicare to include long term services and supports, robust Medicare home health and hospice benefits, affordable housing, and access to services like food, transportation, and home modification that provide homes and communities to age in. We also need a robust, well trained and well compensated workforce to ensure that care in the home and community is feasible and safe.

Advocacy Action 2025

119^th Congress

• Medicaid rates. We support investments in the Medicaid program via increased FMAP for both HCBS and nursing homes. We will continue to work with state partners and members to ensure that state Medicaid rates paid to aging services providers are sufficient to cover the costs of care.
• Benefit categories. We ask Congress to revise Medicaid and put HCBS (including waiver, state plan services, and PACE) on equal footing with nursing homes, making HCBS a mandatory Medicaid benefit.
• Adding long-term care to Medicare. We support adding long-term care coverage to Medicare through offering services like non-skilled home care and adult day services in the Medicare program. Proposals like those offered by the Brookings Institute and the O’Neil Institute at Georgetown are starting places for these policy conversations which also must consider the role of a robust Medicare home health benefit.
• Non-Medicare LTC Financing Reform. We support equitable, flexible long-term care financing reform. It must include a strategy to cover the expenses that assures viability. This may include payroll deductions, similar to the Washington State Long-Term Care program. We support front end or catastrophic proposals and we support public private partnerships to cover the costs.
• Making aging in place accessible. We will advocate for housing with services, models like CAPABLE, care navigation services for older adults and family caregivers to better understand their housing and long term services and supports options, expanded transportation and respite, home modification programs, and other services that make it feasible to age in place.
• Preserve and Reform Medicare and Medicaid home health benefits. LeadingAge supports opportunities to preserve, reform, enhance, and expand home health benefits including opportunities to ensure payment adequacy, tie payment to serving rural and underserved communities to ensure robust access to care and ensuring adequate payment to allow the provision of aide and other supportive services within home health as appropriate. We also support amending definitions of homebound and skilled care to achieve a more flexible and accessible benefit structure.
• Hospice Benefit Reform. We will work on changes to the hospice benefit to promote access to care, reduce bad actors, promote sustainable reimbursement, and ensure the viability of high-quality providers into the future.
• Support appropriate palliative care reimbursement. We support efforts to assign appropriate payment under Medicare Part B for palliative care services as well as defining a standard set of services for part B.
• Establish a White House Office on Aging. Building on the work of the Interagency Coordinating Committee on Healthy Aging and Age-Friendly Communities (ICC), we will advocate that there needs to be a White House Office on Aging to promote interagency coordination to make care in the home and community as well as in residential settings affordable and accessible.
• Protecting access to Medicaid HCBS. We support key provisions that ensure access to HCBS, including the permanent enactment of federal spousal impoverishment protections for Medicaid HCBS, and the Money Follows the Person program. Additionally, we support initiatives that would allow states to innovate around the institutional level of care requirement for HCBS such as the pilot program proposed in H.R. 8307 in the 118^th Congress.
• Adult Day coverage under Medicare. We will advocate that Congress amend the Medicare program to make adult day services available to beneficiaries and offer technical assistance to interested adult day providers.
• Appropriations. We support increasing funding for key provisions that support care in the home and community, including Older Americans Act services, Elder Justice Act funding, and other programs that will allow aging in pace.

Executive Branch

• Protect Medicaid financing. We oppose any Medicaid waiver or rulemaking that reduces federal funding to the program, as these could ultimately jeopardize HCBS access. To that end, CMS should not approve and/or rescind waivers that allow per capita caps/block grant financing, work requirements and unnecessary coverage/enrollment barriers.
• New models of payment and integrated services. We will continue to engage the Center for Medicare and Medicaid Innovation to shape care delivery and payment models that offer integrated service delivery and create opportunities within existing and new models for care in the home and community. We will also advocate that existing models focused on care in the home and community like the Guiding an Improved Dementia Experience (GUIDE) continue and provide feedback to CMMI to make them successful.
• Medicaid Regulations. We support keeping components of new Medicaid regulations that ease access to services and eliminating those that increase burden on providers and those they serve such as the 80/20 provision of the access rule and strict enforcement of the HCBS settings rule.
• VA Coverage of HCBS. We will closely monitor developments with the VA Community Care Network program and other VA initiatives that provide HCBS and advocate for our members and the veterans they support.
• Transportation and Medicaid. We support the maintenance of current rulemaking that assigns non-emergency medical transportation (NEMT) as a mandatory Medicaid benefit.
• Supplemental Services under Medicare Advantage. We will encourage CMS to continue broadening home and community care availability in Medicare Advantage and work with plans on implementation.
• Rules, guidance, other federal policy documents. We will work with ACL, CMS, HRSA, HUD, and others on rules and guidance documents relevant to providers of care in the home and community.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support the expansion and preservation of HCBS programs and services for older adults.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact providers and beneficiaries.
• Engage with other providers through the LeadingAge home care network, home health network, adult day network, and our PACE network and other regular national, regional, and state meetings. Contact Katy or Georgia for more information.

ADDITIONAL RESOURCES

• Letter supporting a White House Office on Aging Policy

LeadingAge Advocacy Goals

• Promote a vision for the future of home health and home care services and their role in the continuum of post-acute, long-term, and end-of-life care, including creating designations for home health services serving populations with significant access issues such as rural older adults.
• Ensure appropriate reimbursement methodology and rates for home health services in fee-for-service and Medicare Advantage.
• Prevent the assessment of $4.45 billion in fee-for-services overpayments from decimating access to home health.
• Advocate for reasonable home health and home care regulations to allow quality, community-based care without unnecessary burdens.
• Work for meaningful inclusion of home care services in Medicare with efficient processes and fair payment.

THE ISSUE

Home health services are a vital component of the health care continuum, both as an important discharge destination for hospitals as well as providing care and therapies in the community that prevent hospitalizations. In 2023, 2.6 million Medicare beneficiaries received home health services in the U.S. However, three consecutive years of cuts in reimbursement as well as the staffing crisis have forced many agencies to decline new referrals knowing they do not have the capacity to adequately serve new patients. Compounding these issues is the growth of Medicare Advantage (MA) enrollment and the often-inadequate payment and burdensome authorization processes associated with MA, make supporting these beneficiaries nearly impossible.

Despite the continued public support for expanding care in the community, policymakers continued their drumbeat regarding overpayment to Medicare home health. Looming temporary retrospective payment adjustments remain a cloud over LeadingAge home health members and those they serve based on CMS’s interpretation of the Bipartisan Budget Act of 2018’s budget neutrality requirements. Though our advocacy since 2022 helped to forestall a significant portion of payment cuts, the future is still uncertain with regard to payment and as a result, access to care to the critically vulnerable populations our members serve every day. Home health members are experiencing workforce shortages, as are all LeadingAge provider members. Unlike retail or other business sectors, aging services providers cannot raise their prices. They are reliant on Medicare and Medicaid dollars to provide high-quality care. We will continue to advocate for policies that allow both the goal of expanded home and community-based care and appropriate reimbursement to co-exist.

Home health agencies must be recognized and reimbursed for their capabilities to coordinate and collaborate with other care providers, ensuring that the patient receives appropriate, high-quality care regardless of the setting or location in the evolving health care delivery system.

Advocacy Action 2025

119^th Congress

• Home health reimbursement. We support legislative efforts that seek to ensure transparent and evidence-based approaches to Medicare reimbursement in the Patient-Driven Groupings Model such as the “Preserving Access to Home Health Care Act” in the last Congress.
• Reform Medicare and Medicaid home health benefits. LeadingAge supports opportunities to reform, enhance, and expand home health benefits including opportunities to tie payment to serving rural and underserved communities to ensure robust access to care and ensuring adequate payment to allow the provision of aide and other supportive services within home health as appropriate. We also support amending definitions of homebound and skilled care to achieve a more flexible and accessible benefit structure.
• Reimbursement for telehealth visits. We support legislative efforts that allow virtual visits to be reimbursed by Medicare with appropriate guardrails and visit equivalency between in-person and virtual visits.
• Reinstate Medicare rural add-on payments. We support legislative efforts that would make permanent the add-on for services to rural patients.
• Allow occupational therapy to be a qualifying skilled service for home health. We support the Home Health Accessibility Act or similar legislation that would allow occupational therapy to be the qualifying skilled service to receive home health care.
• Support the home care workforce. We support legislative efforts to ensure that home care workers earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Medicare Advantage Reforms. We support efforts to revise Medicare Advantage law to reduce administrative burden on providers, provide tools to CMS to ensure provider rate adequacy, preserve beneficiary access to services and create some minimum expectations of plans as they contract with providers to ensure a more even playing field.  Specifically, we support the bipartisan, bicameral “Improving Seniors’ Timely Access to Care Act” introduced in the last Congress, which would modernize and bring more transparency to the prior authorization processes utilized by MA plans. We also seek greater transparency in the MA program. In addition, we support efforts, such as that proposed by the bipartisan “Encounter Data Enhancement Act” legislation proposed by the last Congress, which seek to collect more comprehensive encounter claims data from plans to evaluate the adequacy of provider payments and provide necessary oversight of MA plans related to quality and value delivered in comparison to the traditional Medicare program.
• Critical Access Designations. We support proposals to create federally recognized Critical Access Nursing Homes, Home Health Agencies, and Hospices, similar to the Critical Access Hospital program to prevent additional closures of these providers in rural areas (and potentially other areas with minimal access) and ensure that community residents have access to the care they need.
• Meaningful use. Aging services providers were not included in previous funding efforts that supported health care providers’ transition to electronic health records (EHR) systems that contain the medical and treatment histories of patients. We will continue to advocate for funding and payment incentives, including incentives tied to quality, to assist aging services providers in accessing EHR technology that is interoperable with that of their physician and hospital partners and peers and encourage the bi-directional exchange of information.
• Immigration reform. We promote and support legislative efforts that expand the international pipeline of aging services staff to enter and work in the U.S.

Executive Branch

• Patient-Driven Groupings Model (PDGM). We will provide feedback to CMS on members’ experience to accuracy and adequacy of PDGM.
• Home Health Fraud, Waste, and Abuse. We will continue to work with the administration to identify fraudulent providers of home health services that are contributing to CMS’ calculations of overpayments in the larger system while also working to reduce the burden of audits on reputable providers.
• Home Health Value Based Purchasing. We will monitor HHVBP and engage with CMS as needed to help our members with the requirements of this new payment system including advocating for risk adjustment that would allow the system to adequately address the impact of complex patients on our members’ performance on the program’s quality metrics.
• Home Health CY2026 rule. We will review and provide comments on the CY2026 Medicare home health proposed payment rule.
• IMPACT Act. Continue advocacy to slow the pace of the Medicare unified post-acute prospective payment system model development work of the Department of Health and Human Services and the Centers for Medicare and Medicaid Services to reflect relevant data collection not skewed by the experiences of the COVID-19 pandemic.
• Advocate for the use of data from new claims codes documenting home health virtual visits. Home health providers are allowed to use virtual visits as part of their documented plan of care. We will advocate for the analysis of the recently created G-Codes for these encounters for a variety of purposes including quality measurement.
• Medicare Advantage Reforms. Pursue regulatory reforms to the Medicare Advantage program to ensure provider payment adequacy and financial viability, beneficiary access to care and services, reduce the provider administrative burden of participating within an MA plan, and sustain the Medicare Trust Fund.
• New models of payment and integrated services. We will continue to engage the Center for Medicare and Medicaid Integration to shape care delivery and payment models that offer integrated service delivery and create opportunities within existing and new models for post-acute providers, such as exploring nested bundled payments within accountable care organizations.
• Quality measures. We will promote activities to establish quality measures that are evidence-based and accurately reflect quality care. We ensure home health agencies are not negatively impacted under the Home Health Value-Based Payment program or Home Health Quality Reporting Program payments.
• DEA Telehealth Flexibility. Continue to advocate for continuing COVID-era telehealth prescribing for controlled substances.
• Survey and certification. We call on CMS to improve consistency and accuracy in the survey and certification process including education and oversight of state surveyors and accrediting bodies. We will propose alternatives focused on a collaborative approach to quality improvement and utilization of enforcement remedies that reflect a just culture.
• Medicare Care Compare. We will provide feedback on the additions or changes to the Medicare Care Compare site to ensure important information is clearly displayed and consumers are not misled by icons and formatting that prioritize information that does not accurately capture home health quality information.
• Medicare Advantage supplemental services. We will encourage CMS to continue broadening the home-based care availability in Medicare Advantage and work with plans on implementation.
• Medicare Payment Advisory Commission. We will monitor and engage with MedPAC as needed regarding their home health recommendations including their Congressionally mandated review of the PDGM payment system, their definition of access to care, and the relationship between home health and Medicare Advantage.
• Medicaid and CHIP Payment Advisory Commission. We will monitor and engage with MACPAC as needed regarding their recommendations around Medicaid Home Health and ensuring continued access to these services in the Medicaid program.
• Family caregiving. LeadingAge recognizes the critical role family caregivers play in the care of older adults in the community. We will continue to monitor and engage on the U.S. Department of Health and Human Services, Administration of Community Living’s (ACL) National Strategy to Support Family Caregivers.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support home health care funding and access for older adults.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact home health providers and beneficiaries.
• Stay up to date with LeadingAge’s home health work through our Home Health page.
• Engage with other home health providers through the LeadingAge Home Health Network and other regular national, regional, and state meetings. Contact Katy for more information.

ADDITIONAL RESOURCES

• Home Health Topics
• LeadingAge Center for Managed Care Solutions and Innovation

LeadingAge Advocacy Goals

• Promote a vision for the future of hospice and palliative care services and their role in the continuum of post-acute, long-term, and end-of-life care including advocating for meaningful benefit reform to enable this vision.
• Ensure appropriate reimbursement to provide quality end-of-life care including expensive palliative care.
• Promote access to and use of appropriate palliative and end-of-life care in all health and long-term care settings.
• Work for reasonable hospice regulations and oversight to allow quality, home and community-based care without unnecessary burdens.
• Support policies that help hospice and palliative care providers expand access to their grief and bereavement programs.
• Work for meaningful coordination of hospice services for Medicare Advantage beneficiaries.

THE ISSUE

2024 culminated in the introduction of the Hospice Care Accountability, Reform and Enforcement (CARE) Act of 2024, which includes unprecedented proposals on program integrity efforts, benefit reforms, and payment changes. Our work on the Hospice CARE Act was and continues to be a unique chance to influence a precious benefit for the better and, by providing our nonprofit hospice providers’ point of view, continue their traditional role as standard bearers for quality care in the sector.

In addition, hospice and palliative care organizations are focused on opportunities that will facilitate the transition to value-based payment as well as continued regulatory pressures including how to promote quality care via a revised survey process and continued pressure from audits. We also continue work on advocacy around the newly created hospice Special Focus Program so that the program achieves its goals of improving hospice quality.

Community-based palliative care continues to find its footing given the realization by payers and patients alike that an extra layer of support at any point during a serious illness promotes quality and reduces unwanted utilization. LeadingAge members and state partners have been standard bearers for these benefits in the Medicaid program.

Hospice members are experiencing workforce shortages, like all LeadingAge provider members. Unlike retail or other business sectors, aging services providers cannot raise their prices. They are reliant on Medicare and Medicaid dollars to provide high-quality care. Palliative care professionals, especially in inpatient settings, were in high demand and this skillset needs to be ingrained into health care professionals’ training. Moving forward, the role of bereavement and grief supports services will be critical to communities as they recover from trauma. Hospice and community-based palliative care providers have a large role to play in supporting high quality care at home.

Advocacy Action 2025

119^th Congress

• Hospice Benefit Reform. We will work on changes to the hospice benefit to promote access to care, reduce bad actors, promote sustainable reimbursement, and ensure the viability of high-quality providers into the future.
• Expand access to hospice respite care. We support expanding access to hospice respite care through allowing respite to occur in the home.
• Expand hospice to include a “room and board” level of care. We support creating a hospice “room and board” level of care that allows for patients to die outside their homes without qualifying for GIP or inpatient respite care.
• Support appropriate palliative care reimbursement. We support efforts to assign appropriate payment under Medicare Part B for palliative care services as well as defining a standard set of services for Part B.
• Expanded use of nurse practitioners and physician assistants in hospice. We support a legislative fix that would allow nurse practitioners and physician assistants to certify the terminal prognosis as clinically appropriate. We also support seeking legislative fixes to the statute to clarify the role of physician assistants (PAs) in hospice and to allow PAs to provide face-to-face encounters.
• Supporting the hospice and palliative care workforce. We support legislative efforts to ensure that all aging services workers, including in hospice and palliative care earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Medicare Advantage Reforms. We support efforts to revise Medicare Advantage law to reduce administrative burden on providers, provide tools to CMS to ensure provider rate adequacy, preserve beneficiary access to services and create some minimum expectations of plans as they contract with providers to ensure a more even playing field.  Specifically, we support the bipartisan, bicameral “Improving Seniors’ Timely Access to Care Act” introduced in the last Congress, which would modernize and bring more transparency to the prior authorization processes utilized by MA plans. We also seek greater transparency in the MA program. In addition, we support efforts, such as that proposed by the bipartisan “Encounter Data Enhancement Act” legislation proposed by the last Congress, which seek to collect more comprehensive encounter claims data from plans to evaluate the adequacy of provider payments and provide necessary oversight of MA plans related to quality and value delivered in comparison to the traditional Medicare program. LeadingAge would advocate that any “carve-in” of hospice to Medicare Advantage would need safeguards to ensure the unique needs of the terminally ill are met, including access to care, meeting patient/family self-defined goals, maintaining quality standards, protecting providers from administrative burden, adequate payment, and network adequacy protections.
• Hospice Face-to-Face Recertification. We support allowing hospice face-to-face recertification to take place via telehealth on a permanent basis and that a claims code or modifier needs to be developed to monitor.
• Advocate for robust community-based grief and bereavement supports. We will advocate for the development of policies that support hospice and palliative care providers in their efforts to support their communities as they recover from trauma (e.g., expanded funding for community grief and bereavement programs, development of standards to measure what constitutes a “good” bereavement program).
• Advance care planning. We support expanding access to advance care planning in the Medicare program through elimination of statutory barriers and inclusion of more clinical professionals in payment.
• Critical Access Designations. We support proposals to create federally recognized Critical Access Nursing Homes, Home Health Agencies, and Hospices, similar to the Critical Access Hospital program to prevent additional closures of these providers in rural areas (and potentially other areas with minimal access) and ensure that community residents have access to the care they need.
• Meaningful use. Aging services providers were not included in previous funding efforts that supported health care providers’ transition to electronic health records (EHR) systems that contain the medical and treatment histories of patients. We will continue to advocate for funding and payment incentives, including incentives tied to quality, to assist aging services providers in accessing EHR technology that is interoperable with that of their physician and hospital partners and peers and encourage the bi-directional exchange of information.
• Immigration reform. We will promote and support legislative efforts that expand the international pipeline of aging services staff to enter and work in the U.S.

Executive Branch

• Oversight reforms. We will continue to engage with the CMS Center for Clinical Standards and Quality and the Center for Program integrity as well as the Office of Inspector General as they continue in their program integrity efforts on how to better target their efforts to ensure that fraud and abuse are targeted while alleviating burdensome audits on high quality providers.
• Medicare Advantage Reforms. Pursue regulatory reforms to the Medicare Advantage program to ensure provider payment adequacy and financial viability, beneficiary access to care and services, reduce the provider administrative burden of participating within an MA plan, and sustain the Medicare Trust Fund.
• New models of payment and integrated services. We will continue to engage the Center for Medicare and Medicaid Integration to shape care delivery and payment models that offer integrated service delivery and create opportunities within existing and new models for post-acute providers and hospice providers, such as exploring nested bundled payments within accountable care organizations.
• Hospice Outcomes and Patient Evaluation (HOPE). We will continue to work with CMS and their contractors on the implementation of the Hospice Outcomes and Patient Evaluation (HOPE) tool and corresponding quality measures. We will continue to engage in other quality improvement activities including improving the CAHPS survey and Star Rating.
• DEA Telehealth Flexibility. Continue to advocate for continuing COVID-era telehealth prescribing for controlled substances.
• Advocate for the creation of claims codes or modifiers to document hospice virtual visits. We will advocate that CMS create claims codes or modifiers both to track the utilization of the face-to-face encounter via telehealth and to track the utilization of virtual care in hospice akin the G-codes in home health
• Advocate for use of chaplain codes in documenting hospice visits. Three codes were recently authorized for use to Medicare claims to document chaplain visits. We will advocate for the documentation of these codes in claims for hospice services as well as advocating for the inclusion of chaplains as an eligible professional for purposes of the Hospice Visits in Last Days of Life (HVLDL) Measure.
• Advocate for change in definition of a hospice “day.” For both continuous home care and the visits in the last days of life measure, advocate for the addition of a modifier that allows hospices to indicate when the service has occurred over the course of two days.
• Advocate for more professionals to count in the hospice in the last days of life measure. We will advocate that visits by a wider range of members of the interdisciplinary team count in the hospice in the last days of life measure.
• Survey and Certification. We will actively advocate for changes to the Special Focus Program for hospices finalized in the CY2024 Home Health Final Rule. We call on CMS as part of this process to improve consistency and accuracy in the survey and certification process including education and oversight of state surveyors and accrediting bodies. We will propose alternatives focused on a collaborative approach to quality improvement and utilization of enforcement remedies that reflect a just culture.
• Medicare Care Compare. We will provide feedback on the additions or changes to the Medicare Care Compare site to ensure important information is clearly displayed and consumers are not misled by icons and formatting that prioritize information that does not accurately capture hospice quality information.
• Hospice wage rule. We will review and provide comments on the FY 2026 Medicare Hospice wage rule.
• Medicare Payment Advisory Commission. We will monitor and engage with MedPAC as needed regarding their hospice research agenda and current and future recommendations.
• Family caregiving. LeadingAge recognizes the critical role family caregivers play in the care of older adults in the community. We will continue to monitor and engage on the U.S. Department of Health and Human Services, Administration of Community Living’s (ACL) National Strategy to Support Family Caregivers.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support hospice funding and access for older adults.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact hospice providers and beneficiaries.
• Stay up to date with LeadingAge’s home health work through our Hospice page.
• Engage with other hospice providers through the LeadingAge Hospice Network and other regular national, regional, and state meetings. Contact Katy for more information.

ADDITIONAL RESOURCES

• Hospice Topics
• LeadingAge Hospice Serial Post

LeadingAge Advocacy Goals

• NOTE: Life Plan Communities (LPCs), sometimes referred to in state statute as Continuing Care Retirement Communities (CCRCs), are multi-level provider systems where independent living, assisted living, memory care, and nursing home care often are offered on the same campus.  Many include home care, home health, hospice, and palliative care as well. It is critical to note that CCRCs are regulated in some states and are not federally regulated as a comprehensive entity; however, SNFs that are a part of LPCs are federally regulated by CMS, and ALs that exist within an LPC are state regulated. We work closely with LeadingAge state partners to support relevant state-specific advocacy for LPCs.

• Cultivate comparative research and resources on states’ statutory requirements of LPCs and offer analysis and insights that LeadingAge state partners and provider members can use in state-level advocacy efforts
• Support and promulgate state-level legislative activities that enable LPCs to grow, expand, diversify or improve communities and services for older adults, that mitigate or reduce the financial and reporting burdens for LPCs, or that offer realistic consumer protections that reward operational excellence in LPCs.
• Monitor state-level legislative activities that threaten the LPC model’s workforce, governance, financial solvency, or daily operations, or that undermine LPCs’ ability to provide quality services and mission fulfillment. Coordinate and support LeadingAge state partners’ work to advocate for and protect LPCs’ best interests when addressing these state-level legislative challenges.
• Identify and support federal funding or legislative activities that enable LPCs to expand into alternative services and supports, such as Continuing Care at Home, middle market projects, HCBS and satellite communities.
• Collaborate with federal government agencies such as, OSHA, DOL, NFTA and others to ensure that new guidance or programs that impact LPC operations are fair and feasible from an implementation perspective.
• Identify and advocate for federal financial protections that stabilize and strengthen the unique cost and revenue structures of the LPC model, such as insurance cost cap protections, cash flow protection loans, liability mitigation, and bankruptcy protections.
• Advocate for policies to ensure that payments/reimbursements for Medicare and Medicaid services, including those delivered through managed care, adequately cover the services provided.
• Oppose staffing standards for which there is no evidence, no workforce, and no funding.
• Support legislative efforts to ensure that the LPC workforce earns a living wage and have opportunities for professional development and support legislative efforts to increase the pool of qualified applicants both domestically and internationally.
• Engage in advocacy opportunities that address consumer protection advocacy efforts that impact LPCs.
• Raise legislators’ awareness of the increasing need for behavioral and mental health supports and services, as well as whole-person wellness, for older adults in congregate community settings.

• Pursue regulatory reforms to the Medicare Advantage program to ensure provider payment adequacy and financial viability, retain beneficiary access to care and services, reduce the provider administrative burden of participating within an MA plan, and sustain the Medicare Trust Fund.

THE ISSUE

The Life Plan Community (LPC), in many instances, is a representative cross-section of the aging services continuum of providers. Operating in an increasingly competitive and nuanced environment, LPC providers are adopting a two-pronged strategy of consolidation and diversification to survive and thrive. The LPC model requires of its leadership a proficiency and versatility in disparate and differently regulated aging services, including independent living, assisted living, nursing homes, and memory care. Some LPC providers have expanded their portfolios into home and community-based services, hospice, and palliative services, managed care programs, adult day programs, and affordable housing. Other LPC organizations are exploring alternative and niche markets to expand both their mission reach and margin cushion, including satellite campuses, university based LPCs, middle market projects, continuing care at home programs, and early acceptance programs.

While facing many of the issues that all aging services providers face—workforce shortages, behavioral and mental health program gaps, inadequate Medicare/ Medicaid reimbursement, and cost pressures due to inflation—Life Plan Communities further struggle with the financial sustainability of their operations because of their multi-faceted nature. Some LPCs have eliminated services, downsized or closed their nursing homes, consolidated with other providers, or pursued corporate restructuring in order to preserve their organizations and survive the myriad cost and market pressures that buffeted this provider group in 2024.  Financial metrics that evaluate the collective model’s solvency reflect divergent trends this fiscal year: internal operational competency paired with significant vulnerability to external fluctuations in the market. However, industry experts’ outlook for the LPC model brightened towards the end of 2024; occupancy trends, operating ratios, and cost pressures showed consisted improvement for both single- and multi-site operators.

Consumer advocacy activities, greater state-level attention to regulatory oversight, and legal and risk exposures have left LPCs strained in their capacity and ability to attend to what feels like, for many, challenges ‘on all fronts.’ Several states saw legislative challenges in 2024 that were successfully diffused, but similar challenges are anticipated in 2025. Lawmaker education, member mobilization in advocacy efforts, and consumer engagement promise to be important themes that will define the coming year.

Advocacy Action 2025

To review the full array of Congressional and Executive Branch advocacy actions that affect specific segments of Life Plan Communities, see individual service line policy priorities.

119^th Congress

• Strengthen the workforce. Support CNA training, geriatric grant programs, grants to recruit and retain direct care workers, and immigration reforms that will increase the supply of Life Plan Community workers.
• Professionalize the Workforce. We will work to promote policies that treat LTSS workers with respect and dignity. LTSS settings must feature greater standardization of competency-based training requirements and education needed to prepare the frontline workforce to deliver quality care.
• Support liability protection. We will continue to work with a coalition of national associations and state association partners to enact state civil liability protections for aging services providers relating to COVID-19 claims. Nearly half the states have enacted some sort of protections, and we are still advocating for protections on the federal level.
• Medicare Advantage Reforms. We support efforts to revise Medicare Advantage law to reduce administrative burden on providers and create minimum expectations of plans as they contract with providers to ensure a more even playing field. Specifically, we support the “Improving Seniors’ Timely Access to Care Act” that was passed as part of a larger bill, the Health Care Price Transparency Act (H.R. 4822), which would modernize and bring more transparency to the prior authorization processes utilized by MA plans.
• Telehealth. We support legislation to improve access to telehealth services in nursing homes.
• Geriatric social worker education, recruitment, and retention program. We support the inclusion of expanded programs to recruit, educate, and retain geriatric social workers to encourage more social workers to join and specialize in the aging services field.
• Adult day coverage under Medicare. We believe Congress should amend the Medicare program to make adult day services available to beneficiaries (e.g., FFS and managed care).
• Immigration reform. We promote and support legislative efforts that expand the international pipeline of aging services staff to enter and work in the U.S.

Executive Branch

• Internal Revenue Service (IRS). We support the ongoing claims-submission and -receipt process established by the Employee Retention Credit and will continue to work with IRS-issued guidance to enable eligible members to claim funds available to them through this program.
• Department of Labor (DOL). We advocate against the adjustment of overtime exemption thresholds or the setting of wage minimums that create an unrealistic and unsustainable cost burden for aging services providers unless accompanied by reimbursement increases.
• Office of State and Community Energy Programs (SCEP). We support the implementation of the Inflation Reduction Act’s energy efficiency goals for residential housing programs, and encourage the SCEP to work together with aging services providers to facilitate the adoption of energy-saving technologies and equipment.
• Alternative Payment Models. We engage in activities geared toward the development of alternative payment models, such as the Unified Post-Acute Care Prospective Payment System Technical Expert Panel.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support legislation that enables relevant components of Life Plan Communities to provide quality, consumer-responsive services.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact the residents and workforce of Life Plan Communities.

ADDITIONAL RESOURCES

• LeadingAge Serial Post: Financial Outlook
• LeadingAge Ziegler 200 2024 Edition
• CARF:  2024 Financial Trends and Ratios Report
• ASHA: State of Seniors Housing 2024
• National Investment Center: CCRC Research and Analytics

LeadingAge Advocacy Goals

• Propose and support LTSS reforms for older adults that include key provisions: older adults with low incomes must have housing and housing must include services as needed; new financing approaches must be considered, and communities must be prepared to include increasing numbers of older adults.
• Promote equitable LTSS financing reform to ensure that people at all economic levels (including “middle income” households) are able to access housing and services when they need them.
• Support the evolution of an aging-services continuum that builds on current successes and helps providers keep moving toward systems and services consumers want.
• Create policies that recognize that the consumer long-term care experience involves using many types of services; policies should enable consumers to transition to different types of services within the continuum.
• Support and complement the work of family caregivers.

THE ISSUE

In 2026, the oldest baby boomers will turn 80. The older population in 2030 is projected to be more than twice as large as 2000, growing from 35 million to 73 million and representing 21% of the U.S. population. (Older Americans 2020: Key Indicators of Well-Being (agingstats.gov) Complicating the increasing numbers of older people are economic declines in the over-65 group. Even with the relatively large 2023 cost of living increase in Social Security, many older adults face financial hardship.

The demographic trends are evolving in a changing environment that includes climate change, pandemics, changes in housing and transportation patterns, rapid technology advancements, evolving attitudes toward work, and growing inequity based on race, gender, age, income, and geography.

Most people in the United States do not save or plan for their own likely future need for LTSS, and the federal government has yet to offer a program.

Family caregivers provide much of that care, and LTSS insurance has shown limited success. Medicare does not cover ongoing LTSS needs. Medicaid finances some LTSS for people who have very limited incomes and assets, and for those whose health and LTSS expenditures drive them into poverty.

Individuals at the top of the income spectrum may be able to self-finance care. Those in the vast and increasing “middle market” have few options to meet their LTSS needs. We support proposals that will look at multiple financing mechanisms – both expanding Medicare to cover long term care services and providing options outside of the Medicare program. The option to include Medicare in the financing conversation was raised during the 2024 Presidential election and breathed new life into the LTSS financing reform conversation. There is bipartisan support to invest in options that support family caregivers. States are discussing LTSS financing proposals of their own.

While most people prefer to remain in place, at least until they need extensive supports, few reform proposals to date have taken into account that many people with low incomes have no real options to receive extensive services in any place other than a nursing home. LTSS financing reform proposals must consider the need for affordable housing for households of all incomes and age-ready communities. To receive home and community-based services, individuals must have a home. Any viable LTSS reform proposal must start with provisions to provide housing for people who qualify for affordable housing programs but do not receive it because affordable housing programs only meet about 30% of the need, and proposals must ensure that people that do have housing can receive services that help them remain in the community. Proposals must also address how people will access services, providing better support for navigating to the right care setting within a community and be able to transition smoothly between settings as their condition progresses.

Advocacy Action 2025

119^th Congress

• Adding Long-Term Care to Medicare. We support adding long term care coverage to Medicare through offering services like non-skilled home care and adult day services in the Medicare program. Proposals like those offered by the Brookings Institute and the O’Neil Institute at Georgetown are starting places for these policy conversations which also must consider the role of a robust Medicare home health benefit.
• Non-Medicare LTC Financing Reform. We support equitable, flexible long-term care financing reform. It must include a strategy to cover the expenses that assures viability. This may include payroll deductions, similar to the Washington State Long-Term Care program. We support front end or catastrophic proposals, and we support public private partnerships to cover the costs.
• Small steps. We will identify and support “small steps” toward long-term care financing reform, concurrent with working on comprehensive reform such as supporting initiatives like the Credit for Caring Act or similar proposals that allow the deductibility of long-term care expenses for family caregivers
• Expansions in existing programs. We support bills that would expand access to home and community-based or residential services, make more low-income senior housing available, and support the LTSS workforce.
• Educate policymakers. We will continue to build awareness of the need for LTSS after age 65 and promote proposals to address these needs, especially proposals that include a financing strategy, housing plus services, navigation and education support, and community infrastructure building. We will work with any Members of Congress interested in these ideas.

Executive Branch

• Encourage federal agencies (e.g., HHS, Treasury, OMB, White House) to continue developing and supporting LTSS financing reform proposals and conversations.
• Supplemental Benefits. We support efforts to encourage plans to include supplemental benefits that include some home and community-based services as well as targeted services and supports for those with chronic illness. We advocate for these benefits and their corresponding eligibility requirements to be clearly communicated to beneficiaries. We seek to ensure providers of all sizes have an opportunity to be part of these networks.
• New Models of Integrated Care. We will engage the Center for Medicare and Medicaid Innovation to further develop new demonstration projects or models that will allow post-acute providers and/or LTSS providers to be accountable and financially at-risk for the care of a population or an episode of care.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support legislation (comprehensive or partial) to offer programs that cover long-term services and supports for more individuals.
• Host Congress in Your Neighborhood to help your Members of Congress understand the importance of policies to create meaningful long-term care financing reform.
• Stay up to date with LeadingAge’s LTC financing reform work through our LTSS Financing page.

ADDITIONAL RESOURCES

• Special Issue of Generations, “The Financing of Long-Term Care: An American Conundrum,” April 2019.
• KFF/NYT Series, “Dying Broke.”

LeadingAge Advocacy Goals

• Educate and advocate for protection of the Medicaid financial system from cuts that would result from transitions to per-capita caps, block grants, reworking of FMAP calculations, or changes to the federal share of Medicaid spending.
• Oppose rulemaking or legislation that would put future limits on existing financial agreements between states and the federal government, similar to those previously proposed in the Medicaid Fiscal Accountability Rule (MFAR).
• Advocate for the availability of aging services across the continuum in Medicaid.
• Encourage the administration to maintain regulations governing the Medicare and Medicaid programs that promote high-quality care and are not burdensome to providers.
• Promote the importance of Medicaid rate adequacy for services to assure ongoing access to services and provider viability.
• Advance policy that promotes the availability of HCBS across funding streams, including in Medicaid, Medicaid managed care, Veterans Affairs, and Medicare.
• Advance managed care arrangements, reimbursement, and operational policies that enable aging services providers to meet their mission of serving older adults.
• Reinforce federal rulemaking that supports access to and quality of home and community services for beneficiaries while minimizing provider burden, this includes maintenance of reduced burdens during application and redetermination that were included in the Medicaid Streamlining Eligibility and Enrollment final rule.
• Oppose untenable provisions of Medicaid Access Rule that require wage pass throughs and community-based provider cost reporting.

THE ISSUE

Medicaid is a critical social safety net program covering long-term services and supports and health insurance for nearly 80 million Americans. The program will be scrutinized in 2025 and the potential for proposals to overhaul the financing and coverage requirements of the program will likely be debated. LeadingAge will defend the existing Medicaid program against proposals to change the financing in ways that would reduce access, provider payment, and coverage. While it is a key revenue source for many aging services providers, it is widely accepted and reported that Medicaid reimbursements for services are below costs to provide the service. Many organizations continue to participate in state Medicaid programs as a commitment to their missions of service.  We will oppose proposals that seek to weaken Medicaid. Preserving, strengthening, and improving Medicaid are vital to realizing an aging services system that meets the needs of every older adult. To achieve that, LeadingAge supports specific policy actions from both Congress and the executive branch as described below.

Advocacy Action 2025

119^th Congress

• Protect Medicaid. Educate and advocate for protection of the Medicaid financial system from cuts and policy changes that would threaten the viability of our members and the livelihood of those that they serve. We oppose financing reforms such as per capita caps, block grants, elimination or reduction of provider taxes, or changes to the federal share of Medicaid spending as well as opposing barriers to access such as work requirements.

• Staffing Standards. We oppose staffing standards for which there is no evidence, no workforce, and no funding. We advocate for policies that would assure minimum standards are based on clear, definitive evidence of the levels and types of staffing that impact quality. We work to advance initiatives that will reduce barriers to recruiting and retaining qualified, well-trained staff, including increased Medicaid reimbursement that will allow aging services providers to invest in staff wages, benefits, and supports.
• Medicaid rates. We support investments in the Medicaid program via increased FMAP for both HCBS and nursing homes. We will continue to work with state partners and members to ensure that state Medicaid rates paid to aging services providers are sufficient to cover the costs of care.
• Benefit categories. We ask Congress to revise Medicaid and put HCBS (including waiver, state plan services, and PACE) on equal footing with nursing homes, making HCBS a mandatory Medicaid benefit.
• Medicaid reimbursement enhancements beyond wage incentives. We continue to support legislative efforts that account for and incentivize additional funding to workers without increasing taxable income such as flexibilities in mileage and travel reimbursement.
• Protecting access to Medicaid HCBS. We support key provisions that ensure access to HCBS, including the permanent enactment of federal spousal impoverishment protections for Medicaid HCBS, and the Money Follows the Person program. Additionally, we support initiatives that would allow states to innovate around the institutional level of care requirement for HCBS such as the pilot program proposed in H.R. 8307 in the 118^th Congress.
• New models of payment and integrated services. We will continue to engage the Center for Medicare and Medicaid Innovation to shape care delivery and payment models that offer integrated service delivery and create opportunities within existing and new models for Medicaid focused providers especially HCBS providers.
• Support legislation to promote integrated services. We have a vision for integrated services for older adults and will support legislation designed to achieve this objective for dual eligibles such as the Delivering Unified Access to Lifesaving Services (DUALS) Act or other proposals that promote integration.
• MACPAC. We will monitor and engage with MACPAC as needed regarding their recommendations related to aging services providers, Medicaid, and Medicaid managed care financing reforms.
• We will monitor and engage with MedPAC as needed regarding their recommendations related to aging services and managed care or integrated models and financing.

Executive Branch

• Mitigation of Enrollment Barriers for Medicaid.  We will reinforce federal rulemaking that supports access to and quality of home and community services for beneficiaries while minimizing provider burden, this includes maintenance of reduced burdens during application and redetermination that were included in the Medicaid Streamlining Eligibility and Enrollment final rule.
• Eliminate 80/20 Wage Pass through in Final Medicaid Access Rule While Maintaining Components That Work. We will oppose untenable provisions of Medicaid Access Rule that require wage pass throughs and community-based provider cost reporting. Reinforce elements of the Access Rule that will promote access to Medicaid services such as state reporting requirements, mandatory adoption of standardized HCBS quality measures, and changes to critical incident reporting.
• Protect Medicaid financing. We oppose any Medicaid waiver or rulemaking that reduces or holds constant federal funding to the program, as these could ultimately jeopardize HCBS access and access for populations that support our providers and those they serve. To that end, CMS should not approve new and should rescind any existing waivers that allow per capita caps or block grant financing, work requirements, restructuring of the FMAP. or other unnecessary coverage or enrollment barriers.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know that you support the preservation of Medicare and Medicaid.
• Host Congress in Your Neighborhood to help your Members of Congress understand the great services you provide, how they affect your community by caring for older adults, providing jobs, or offering respite for family caregivers. Describe and demonstrate how policies impact providers, employees and residents. For example, structural changes to Medicaid will mean less federal funding is available, resulting in Medicaid rate reductions, increased out-of-pocket costs, or eligibility terminations for some staff.
• Get involved with LeadingAge member networks and our weekly Policy Pulse calls to stay up to date on policy proposals. Provide your feedback on how proposals would affect your community, staff, or participants.

LeadingAge Advocacy Goals

• Seek confirmation from the federal government that it will not pursue civil or criminal actions against providers if they allow the use of medical cannabis pursuant to state laws and regulations.
• Support federal legislation or regulations to prohibit any federal agency interference with state medical cannabis laws.
• Work with state LeadingAge partners, as requested, to support legislation at the state level to enact medical cannabis statutes and regulations that will allow older adults to access it under appropriate circumstances to alleviate pain and other symptoms of disease.

THE ISSUE

Medical cannabis is legal in 39 states and the District of Columbia. Under federal law, however, marijuana is a Schedule I substance under the Controlled Substances Act (CSA) and is illegal.

There is on-going uncertainty concerning whether federal government agencies will pursue enforcement activities against those using medical cannabis pursuant to state laws allowing it.

In October 2022, President Biden directed the U.S. Department of Health and Human Services (HHS) and the Department of Justice to initiate a process to review how marijuana is scheduled under the federal Controlled Substances Act. Following a scientific and medical evaluation of factors set forth in the CSA, in August 2023 HHS recommended to the Drug Enforcement Administration (DEA) that marijuana be controlled in Schedule III. In May 2024, DEA issued a notice of proposed rulemaking, proposing to transfer marijuana to Schedule III, but the rulemaking process is not yet complete.

Advocacy Action 2025

Executive Branch

• Medical Cannabis Guidance. We will explore options for regulatory guidance or a memorandum from federal agencies discouraging any civil or criminal enforcement of medical cannabis usage in states where it is legal.
• Cannabidiol (CBD) Guidance. Now that CBD is legal after the passage of the 2018 Farm Bill, we will monitor the Food and Drug Administration’s (FDA) progress on issuing regulations/guidance on the use of CBD in Medicare- and Medicaid-financed settings.
• How Marijuana is Scheduled Under Federal Law. We will continue to monitor the progress of the DEA notice of proposed rulemaking to transfer marijuana from Schedule I to Schedule III. During the public comment period, we submitted a letter supporting the proposal. Researchers would face less strict regulatory controls in researching marijuana as a Schedule III substance than under Schedule I, which we believe will promote further beneficial research on medical uses of marijuana, as well as potential risks of misuse. Further, over time, rescheduling may begin to address some of the notable misalignment between federal and state laws governing marijuana. Under HUD guidance, for example, the use of medical marijuana is illegal under federal law even if it is permitted under state law, meaning that households with low incomes living in federally subsidized housing cannot access certain treatments that other, non-housing assisted older adults can legally access under state-established medical marijuana programs.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to identify opportunities to let your Representative and Senators know your views on the legal use of medical cannabis by older adults.
• Host Congress in Your Neighborhood in your community to help your Members of Congress understand how policies related to medical cannabis affect older adults.

ADDITIONAL RESOURCES

• CDC: State Medical Cannabis Laws (Current as of Feb. 2024; does not reflect medical cannabis measures approved in Nov. 2024 by Nebraska voters.)
• FDA Regulation of Cannabis and Cannabis-Derived Products, Including Cannabidiol (CBD)

LeadingAge Advocacy Goals

• Advocate for Medicare and Medicare Advantage (MA) policies and reforms that ensure beneficiary access to traditional Medicare A and B benefits, preserve aging service providers’ financial viability, identify ways to reduce administrative burden and sustain the Medicare Trust Fund.
• Preserve Medicare beneficiaries’ choice between traditional Medicare and Medicare Advantage, ensuring both provider-led and managed care models remain available options from which to choose.
• Advocate for enhanced data collection, transparency, and accountability within the Medicare Advantage (MA) program. This includes requiring MA plans to submit complete and accurate encounter data to CMS, ensuring robust oversight of plan practices (such as prior authorizations, denials, appeals, supplemental benefits and appropriate post-acute care coverage determinations), and improving consumer access to information for comparing care experiences across plans. Seek data to be reported by managed care plans at the plan level and by service type. Additionally, push for annual evaluations by MedPAC on payment adequacy and access to services, particularly in high MA-penetration markets, and for clear identification of plan ownership in the Medicare Plan Finder tool.
• Clarify federal policies on how supplemental benefits offered via flexible benefit cards should be treated when determining an individual’s eligibility for government assistance such as Medicaid, Supplemental Security Income and federal rental assistance.
• Protect current and advocate for policies that prohibit MA plans from using algorithms or artificial intelligence tools deny care.
• Advocate to establish a channel through which providers can report MA plans suspected of non-compliance with federal regulations to ensure plans are appropriately covering and paying for traditional Medicare A and B services for Medicare beneficiaries.
• Create value-based payment opportunities for aging service providers within risk-based models including MA and Accountable Care Organizations (ACOs).
• Seek opportunities for aging service providers and housers to be meaningful participants in Center for Medicare and Medicaid Innovation (CMMI) models.
• Oppose efforts that expand managed care organizations’ influence within the Medicare program.
• Pursue new payment model demonstration(s) or opportunities within existing CMMI models that give post-acute care and long-term service and support providers the opportunity to lead by accepting both the financial risk and rewards of such models.
• Support and advocate for policy initiatives and models that take a more holistic and integrated approach to addressing the needs of older adults and align incentives for all participating providers.
• Support initiatives to expedite beneficiary access to care by streamlining or eliminating onerous utilization management requirements.
• Support efforts to ensure supplemental benefit offerings and eligibility criteria are clearly communicated to beneficiaries and caregivers when evaluating their plan options and ensure once enrolled, beneficiaries know how to access these benefits.
• Pursue broad reimbursement policies that ensure adequate funding for aging services providers across payers and actuarial soundness. Advocate for policies to ensure that payments/reimbursements under Medicare and Medicaid managed care plans adequately cover the services provided and offer opportunities for providers to enter into contracts.
• Support policy changes that seek to deliver fully integrated services to dual eligibles through a variety of model options including those offered by PACE programs, through institutional special needs plans (ISNPs) and accountable care organizations; and preserve provider-led integration models.

THE ISSUE

The sustainability of Medicare and Medicare Advantage are intertwined. In addition, what happens in these programs has effects on the broader health care system. Therefore, inadequate payments to providers in Medicare can have dire consequences for health care access for the broader population. Aging services providers in many parts of the country have reached a tipping point where managed care—Medicare Advantage (MA), Medicaid managed care, and CMMI payment reform initiatives—is the dominant payer. Medicare Advantage enrollment reached 54% nationally in 2024 according to KFF, with penetration rates as high as 80% in some areas of the country. This exponential growth has exposed glaring areas for improvement as outlined by a series of reports (Office of Inspector General -April 2022, 2024 U.S. Senate Permanent Subcommittee on Investigations report, OIG report – October 2024, MedPAC – March 2024 ). The trail of MA plan misdeeds range from inappropriately refusing MA enrollees access to basic Medicare services, refusing to pay for services rendered to MA enrollees, and overpayments to MA plans by 22%. Under these programs, providers often face inadequate payments on top of increased expectations and administrative burden (often presented as take it or leave it), all of which is threatening the viability of aging services providers and beneficiary access to needed care.

On a parallel track, the Center for Medicare and Medicaid Innovation (CMMI) over the past few years has focused on evolving its core models, such as accountable care organizations, and also sought to test alternative payment models for new populations such as the Guiding an Improved Dementia Experience (GUIDE) model and the mandatory episode-based bundled payment model called TEAM (Transforming Episode Accountability Model) that will expand into new geographies in January 2026. All of these models are designed to help CMS and CMMI meet its goal to have all Medicare beneficiaries and most Medicaid recipients in an accountable care relationship by 2030 and is about halfway to achieving that goal. However, we remain concerned that post-acute care and long-term services and supports (PAC-LTSS) providers have largely been excluded from leading and taking on financial risk under these models though the ACO REACH program and GUIDE model provided some limited opportunities for PAC-LTSS providers to meaningfully participate. Most PAC-LTSS providers have seen little to no financial benefit by participating in existing models as partners. With no ability to lead a CMMI model, interested providers, who can accept financial risk, are increasingly pursuing the development of their own provider-led Special Needs Plans. LeadingAge has actively engaged CMMI around developing opportunities for PAC-LTSS and contributed to a white paper with the National Association of Accountable Care Organizations (NAACOs) and other stakeholders to further opportunities for nursing homes and other providers to benefit from value-based payment arrangements nested within the ACO and similar accountable relationships.

In 2017, LeadingAge painted a picture describing the fundamental elements of what an integrated services could and should look like for older adults. We continue to push for this vision in our Congressional and CMMI conversations. In 2024, a bipartisan group of members of the Senate Finance Committee introduced the Delivering Unified Access to Lifesaving Services (DUALS) Act to achieve their own vision for how to ensure dual eligibles receive fully-integrated care and services both clinically and administratively. LeadingAge supports the vision and framework the legislation outlines but also continues to collaborate with its sponsors to further refine the proposal to ensure it offers the necessary protections for beneficiaries and participating providers.

Advocacy Action 2025

119^th Congress

LeadingAge will pursue legislation to preserve access to care for beneficiaries, ensure financial viability of providers, reduce their administrative burden when contracting with plans, establish some minimum expectations of plans related to their interactions with providers, and ensure compliance and enforcement of MA requirements to ensure a more even playing field for providers.

• Repeal MA non-interference clause or other legal barriers, which prevent CMS from establishing rate floors and/or goals for value-based payment adoption by MA/SNP plans for post-acute care providers.
• Require plans to accurately and completely report a revised and more robust set of encounter claims data by provider type and require MedPAC to annually evaluate the adequacy of those rates to ensure Medicare beneficiary access to various Medicare services in both traditional Medicare and MA and provider’s financial viability.
• Oppose legislation to make MA the exclusive option for receiving Medicare A and B benefits and monitor initiatives to make MA the default enrollment option for Medicare beneficiaries.
• Improve Accuracy and Completeness of MA Claims Data and Use to Assess Provider Payment Adequacy and for Enforcement. Advocate for CMS to collect more complete and accurate encounter claims data from MA plans, with incentives for proper submissions, and require the Medicare Payment Advisory Commission (MedPAC) to analyze the submitted data and report to Congress and CMS on the adequacy of MA plan payments to providers and beneficiaries’ access to core Medicare services. LeadingAge supports efforts, such as that proposed by the bipartisan “Encounter Data Enhancement Act” legislation proposed by the last Congress, which seek to collect more comprehensive encounter claims data from plans to evaluate the adequacy of provider payments and provide necessary oversight of MA plans related to quality and value delivered in comparison to the traditional Medicare program.
• Treatment of Flex Benefit Cards Related to Other Government Assistance. Seek federal policy clarifying how MA supplemental benefits offered via flexible benefit cards should be treated when determining an individual’s eligibility for government assistance.
• Establish MA whistleblower/compliance line for providers to report violations. Expand current or create new MA complaint and compliance line or submission process allowing providers to report issues with plans that are tracked as part of the Complaint Tracking Module. This offers another layer of protection for beneficiaries and offers a more complete picture of issues incurred.
• Reduce the administrative burden on providers participating in MA. We support the “Improving Seniors’ Timely Access to Care Act” introduced by the last Congress that would modernize and bring more transparency to the prior authorization processes utilized by MA plans.
• Monitor artificial intelligence legislation. As Congress pursues legislation to establish parameters for the use of artificial intelligence in health care, we will seek to ensure policies prohibit AI from overriding health care professional decisions and assessments of beneficiaries’ care and service needs.
• Support legislation to ensure integrated services. LeadingAge has a vision for integrated services for older adults and as such, we support legislation, such as the bipartisan Delivering Unified Access to Lifesaving Services (DUALS) Act, designed to achieve this vision for dual eligibles and other older adults. To this end, we provided input into the DUALS legislation and will work to further refine this legislation to ensure provides necessary provider and beneficiary protections.
• Ensure beneficiaries’ ability to return to Medigap with guaranteed issue. Allow Medicare beneficiaries who enroll in MA plans to return to FFS and a Medigap plan with guaranteed issue as long as they have continuous coverage so beneficiaries don’t lose this option once enrolled in MA.
• Protect CMMI program and funding. We seek to preserve the ability of the Center for Medicare and Medicaid Innovation to test new care delivery and payment models where aging services providers can play a meaningful role.
• Support efforts to expand Medicare benefits. There have been efforts to expand the standard Medicare benefit to include services such as vision, hearing and dental, which would provide more parity with services offered through MA plans. LeadingAge also supports efforts to include other services such as adult day services that have a direct impact on health care outcomes for Medicare beneficiaries through a more holistic approach to addressing needs and are proven to reduce other care costs.

Executive Branch

• Broad MA Reform. Seek regulatory reforms of the MA program to ensure necessary protections now that MA is the predominant model for receiving Medicare benefits. Identify and pursue new language to be included in the Medicare and Medicaid managed care regulations, including the Medicare Managed Care Manual, that clarifies certain provider rights and plan obligations in their interactions with providers, assures beneficiary access to medically necessary services, and seeks to streamline and/or standardize required elements of participation in these programs to reduce administrative burden. Pursue regulatory reforms to the Medicare Advantage program to preserve aging service providers’ financial viability, beneficiary access to care and services, reduce the provider administrative burden of participating within an MA plan, and sustain the Medicare Trust Fund.

• MA as the default enrollment option. Monitor proposals that would make MA the sole delivery method or default enrollment option for Medicare beneficiaries. Oppose any efforts to make MA the exclusive option for receiving Medicare A and B benefits.

• Transparency. Support CMS data collection and analysis efforts to compare MA and Medicare on a variety of topics, including: MA plan prior authorization statistics, supplemental benefit utilization by MA enrollees and whether it demonstrates value based upon the rebate dollars that fund the benefits, effects of the dominance of a few plans in a market on access and provider viability, etc. Support efforts to ensure consumers have more robust data about their care experience if they enroll in an MA plan (e.g., length of stay in hospital and SNF, prior authorizations needed and frequency of denials, etc.)
• Ensure provider payment adequacy. Pursue legislative language to remove barriers that currently prevent CMS from establishing a provider rate floor that plans must pay, establish goals or incentives for plans to negotiate pay-for-performance or other value-based arrangement with the providers and/or require plans to pass along a certain percentage of any rate increase received as part of CMS-established rate adjustments for the plans.
• Ensure access to quality providers within MA plans. Pursue regulatory changes adding provider quality as a factor in determining a plan’s network adequacy to preserve a beneficiary’s ability to select high quality providers for their care.

• Accurately Target Fraud. Advocate that program integrity resources are targeted at true fraud and abuse and not at high quality providers. We will also advocate for new ways to deal with technical denials – such as for missing paperwork – so that these oversight actions are less administratively burdensome and costly to our members.

• Seek further clarifications on CY2024 regulatory changes related to prior authorizations related to how the requirement for a prior authorization to cover a “course of treatment” is applied to skilled nursing and home health services.
• Prohibit MA plans from excluding providers due to size. Pursue an any willing provider clause that would allow all providers to participate in plan networks if they are willing to accept contract terms and wish to be in network. This would prevent plans from excluding small providers due to size.
• Administrative simplification. Pursue changes in MA policies to streamline routine processes such as credentialing, prior authorizations, and other health information exchange to reduce administrative burden on providers and plans. Such policies may include establishing a single electronic clearinghouse/portal for submitting credentialing (e.g., national provider directory), standardizing prior authorization requests across plans, and similar measures.
• Ensure provider payments adjust for cost of living, inflationary increases and/or new regulatory requirements. Require plans to have a clause in their contracts that requires them to adjust payment rates to reflect external pressures, such as updating rates in accordance with inflation and other factors similar to the Medicare FFS payment rule process.
• Limit egregious audit reviews by plans. Establish parameters for the number and type of claims that can be audited and limit the timeframe in which a plan can retroactively seek repayment so that these decisions are made quickly and provider administrative burden is reduced.
• Establish timely prior authorization (PA) timelines for plans or require plans to staff their PA process 24/7/365 with qualified personnel. Establish and enforce penalties for plans who do not meet the required timeframes resulting in care delays.
• Duals Integration. Support and pursue policies that both clinically and financially integrate care and services for dual eligibles to better address their needs.
• Supplemental benefits. We support efforts to encourage plans to include supplemental benefits that include home and community-based services as well as targeted services and supports for those with chronic illness. We support efforts to ensure beneficiaries’ awareness of and access to these benefits. We seek to ensure providers of all sizes have an opportunity to be part of these plan networks to deliver these services.
• MA Regulatory Updates. Monitor and comment on Medicare Advantage annual proposed rules governing MA policies and payments.
• Medicaid Managed Care and LTSS. Monitor Medicaid managed care regulations relating to LTSS.

• New models of payment and integrated services. LeadingAge will continue to engage CMMI to shape care delivery and payment models that offer integrated service delivery and create opportunities within existing and new models for post-acute providers, housers and/or LTSS providers to play a meaningful role that ensures a share of the financial gains achieved, including exploring nested bundled payments for nursing homes within accountable care organizations.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your representative and senators hear your voice on Medicare and Medicare Advantage issues.
• Host Congress in Your Neighborhood to have your members of Congress visit your organization.
• Stay up to date with LeadingAge’s Medicare Advantage work on serial post.
• Engage with other providers through the LeadingAge Managed Care Network. Contact Nicole for more information.

LeadingAge Advocacy Goals

• Promote a positive vision of the future of nursing homes as an integral part of the continuum of care where both residents and staff are supported to reach their fullest potential.
• Promote initiatives to examine and address the workforce crisis and repeal the federal minimum staffing standards. We will not support staffing standards without adequate reimbursement and assurance of policy changes that will ensure an adequate supply of workers.
• Advocate for reimbursement rates that are sufficient to cover the full range of costs to provide quality care and services including supply needs, training, and fair wages for staff.
• Implement the Risk Based Survey to modernize the survey and certification process.
• Advocate to remove the expansion of Civil Monetary Penalties.
• Revise Civil Monetary Penalties to enhance quality of care and strengthen consequences for poor performers.
• Promote modernization of the survey process to include approaches that focus on resident outcomes, foster surveyor accountability, and support quality improvement.
• Ensure regulations promote person-centered quality and support positive clinical outcomes and evidence-based best practices without adding unnecessary burden. We support a quality measurement system underlying the regulatory process that truly reflects quality care and quality of life for residents. Support the Moving Forward Nursing Home Quality Coalition by collaborating on quality improvement initiatives, facilitating discussions with Coalition members and policymakers to identify consensus-driven solutions, and developing the infrastructure, resources, and community needed for future progress.

THE ISSUE

Nursing homes are an essential element of the long-term services and support system, serving individuals with serious functional impairments who are unable to live independently in the community. Although fewer than 4% of those over 65 will ever live in a nursing home, these settings provide treatment and care in a safe, home-like environment that supports a quality of life when aging in the community is no longer an option.

Medicaid is the primary payer for nursing home care, covering six out of 10 stays. But Medicaid rates do not cover the cost of care. The pandemic further exacerbated the impact of reimbursement shortfalls stemming from inadequate Medicaid rates and a lack of comprehensive investment in long-term services and supports and nursing homes have not recovered. These issues, combined with impending staffing standards, will have a lasting impact on the healthcare system as the gap between the cost of quality care and reimbursement for that care widens. Rising costs related to workforce challenges and aging buildings and outdated physical plant designs all demand attention.

Advocacy Action 2025

119^th Congress

• Repeal Federal Minimum Staffing Standards. We support legislation that would stop implementation of CMS’s final minimum staffing rule for nursing homes. During the last Congress, LeadingAge actively supported the introduction and advancement of the Protecting Rural Seniors’ Access to Care Act (H.R. 5796 / S. 3410) and the Protecting American Seniors’ Access to Care Act (H.R. 7513), both of which would have prevented implementation of the proposed minimum staffing rule. We also advocated for the introduction of resolutions in the House and Senate (H.J.Res. 139 / S.J.Res. 91) that would have overturned the final minimum staffing rule using the Congressional Review Act, which gives Congress the authority to overturn regulations issued by federal agencies. We will also continue pursuing other legislative avenues to address this issue, such as appropriations language preventing CMS from utilizing funds to implement the rule.
• Medicaid rates. We support investments in the Medicaid program via increased FMAP for both nursing homes and HCBS. We will continue to work with state partners and members to ensure that state Medicaid rates paid to aging services providers are sufficient to cover the costs of care.
• CNA Training Lock-Out. We will work with House and Senate leaders on the reintroduction of legislation to address the two-year certified nursing assistant (CNA) training lockout that is contributing to nursing home staffing shortages. Last Congress, we actively supported and advanced the Ensuring Seniors’ Access to Quality Care Act (H.R. 3227 / S. 1749) to fix outdated provisions in law that prohibit a nursing home from running nurse aide trainings and competency evaluations when the nursing home has been subject to a certain level of fines, as long as the facility has addressed deficiencies associated with the penalties and has not been found to have deficiencies related to patient harm or quality of care.. The ability of nursing homes to provide in-house training is especially critical given persistent workforce shortages across the long-term care continuum.
• TNA Flexibilities. We support the reintroduction of legislation to enable temporary nurse aides (TNAs) to continue working in their roles for longer than the current 120 day timeframe while putting their on-the-job experience and training toward the 75-hour federal CNA training requirement. Last Congress, we supported the Building America’s Health Care Workforce Act (H.R. 468) that would have created a waiver process to address this issue. Testing and certification delays on top of ongoing staffing challenges continue to pose problems for long-term care providers and must be addressed by Congress.
• Observation Stays.We support the reintroduction of legislation to address hospital observation stays that prevent Medicare beneficiaries from receiving follow-up care in a nursing home. In previous Congresses, we have advocated for passage of the Improving Access to Medicare Coverage Act (H.R. 5138 / S. 4137) to mandate that all time spent in a hospital, regardless of admission status, would count toward the 3-day qualifying stay required for SNF services under the Medicare benefit. The waiver of the 3-day hospital stay requirement during the pandemic reinforces the lack of rationale for this restriction on Part A eligibility.
• Medicare Advantage Reforms. We support efforts to revise Medicare Advantage law to reduce administrative burden on providers, provide tools to CMS to ensure provider rate adequacy, preserve beneficiary access to services and create some minimum expectations of plans as they contract with providers to ensure a more even playing field.  Specifically, we support the bipartisan, bicameral “Improving Seniors’ Timely Access to Care Act” introduced in the last Congress, which would modernize and bring more transparency to the prior authorization processes utilized by MA plans. We also seek greater transparency in the MA program. In addition, we support efforts, such as that proposed by the bipartisan “Encounter Data Enhancement Act” legislation proposed by the last Congress, which seek to collect more comprehensive encounter claims data from plans to evaluate the adequacy of provider payments and provide necessary oversight of MA plans related to quality and value delivered in comparison to the traditional Medicare program.
• We advocate taking bold action to sustain, strengthen, and grow the nursing home workforce. We will work with Congress to enhance the pipeline of healthcare professionals in aging services through expanded training opportunities, increased immigration pathways, and reimbursement mechanisms that support fair compensation for all nursing home staff. We also support policies that expand the availability of nurse faculty through competitive compensation, loan forgiveness, and advanced education incentives to address workforce shortages and open pathways for direct care professionals and nursing students to access classroom and hands on training opportunities.

• Survey and Certification Funding. We support increasing funding for survey and certification activities to reduce surveyor backlogs and improve consistency in surveyor training. Last Congress, we supported the introduction of the SAFER Nursing Homes Act (H.R. 9529) to increase CMS’s survey and certification funding for nursing homes to $492 million in Fiscal Year 2025 (or 21% over current funding levels) and then shift funding for nursing home surveys from discretionary to mandatory funding beginning in Fiscal Year 2026.
• Telehealth Extension and Expansion. We support keeping certain pandemic flexibilities in place permanently and advocate for expansion of telehealth flexibilities for the future of aging services. Last Congress, we supported the Telehealth Modernization Improvement Act (H.R. 7623 / S. 3967) and the Preserving Telehealth, Hospital, and Ambulance Access Act (H.R. 8261), both of which would have extended telehealth flexibilities relevant to aging services, including permanently removing geographic requirements for telehealth services, allowing the home to serve as an originating site, expanding the list of practitioners who can bill for telehealth services, continuing to allow audio-only technology, and continuing to allow hospice face-to-face recertification to be done via telehealth.   We also supported the CONNECT for Health Act (H.R.4189 / S. 2016), having joined multiple stakeholders to provide input on this legislation prior to its introduction, including the need for federal financial support to ensure nationwide interoperability of Health Information Technology – specifically in the long-term and post-acute care sector.
• Critical Access Designations. We support proposals to create federally recognized Critical Access Nursing Homes, Home Health Agencies, and Hospices, similar to the Critical Access Hospital program to prevent additional closures of these providers in rural areas (and potentially other areas with minimal access) and ensure that community residents have access to the care they need.

Executive Branch

• Repeal Federal Minimum Staffing Standards. We oppose staffing standards for which there is no workforce and inadequate funding. We advocate for policies that would ensure implemented minimum standards are based on clear, definitive evidence of the levels and types of staffing that impact quality. We work to advance initiatives that will reduce barriers to recruiting and retaining qualified, well-trained staff, including increased reimbursement that will allow nursing homes to invest in staff wages, benefits, and supports.
• Workforce Support. We call on the Administration to provide resources to support nursing homes in developing a robust, well-trained workforce. We will work with policymakers to increase the pipeline of available healthcare professionals working in long-term care through expanded training programs and increased immigration opportunities; reduce barriers for direct care professionals to complete training and certification testing; increase opportunities for aging services providers to support direct care professionals through career pathways.
• Medicare Advantage Reforms. We will pursue regulatory reforms to the Medicare Advantage program to ensure provider payment adequacy and financial viability, beneficiary access to care and services, reduce the provider administrative burden of participating within an MA plan, and sustain the Medicare Trust Fund.
• New models of payment and integrated services.We will continue to engage the Center for Medicare and Medicaid Integration to shape care delivery and payment models that offer integrated service delivery and create opportunities within existing and new models for post-acute providers, such as exploring nested bundled payments within accountable care organizations.
• Survey and Certification.We call on CMS to improve consistency and accuracy in the survey and enforcement process. We urge CMS to improve surveyor-provider relations and support enhanced data monitoring to focus surveyor resources where they are needed most, to implement the Risk Based Survey to further modernize the survey and certification process, and for the removal of the expansion of Civil Monetary Penalties.
• Requirements of Participation (RoPs). We urge CMS to ensure that regulations and interpretive guidance are clear and evidence-based. We advocate for regulatory and sub-regulatory changes that allow members to focus staff resources on the activity of providing quality care as opposed to draining staff resources through paper compliance and mounting reporting requirements.
• Emergency Preparedness. We provide feedback to CMS on barriers to emergency planning and needed resources and advocate for increased collaboration with federal, tribal, state, and local entities to ensure nursing homes are included in disaster planning, response, and recovery activities. We will work with emergency partners to analyze and respond to new regulations and provide resources and training to support members in compliance.
• Quality Measures. We promote activities to establish quality measures that are evidence-based and accurately reflect quality care. We provide feedback to CMS on proposed measures and advocate for public reporting of measures and changes to measures that are misleading or give an incomplete picture of nursing home care such as staff turnover measures and the long-stay antipsychotic measure.
• Health Equity. We work with CMS, nursing home members, and other stakeholders to integrate practices that will help identify, evaluate, address, and remediate health disparities in the populations we serve. We support efforts that utilize accessible and understandable data that can be easily operationalized by nursing homes in their internal quality improvement work.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your representative and senators hear your voice on the issues facing nursing homes.
• Host Congress in Your Neighborhood to help your members of Congress understand how policies impact nursing homes and the people who live and work in them.
• Stay up to date with LeadingAge’s nursing home work, including survey and certification reform activities, through our Nursing Home page.
• Engage with other providers through the LeadingAge Nursing Home Network and other regular national, regional, and state meetings. Contact Janine, Jodi or Todd for more information.

LeadingAge Advocacy Goals

• Oppose structural Medicaid funding reforms that could be detrimental to participants’ access to services and providers such as block grant or per capita cap policies.
• Promote the ability of older adults to receive health care and long-term services and supports in their homes and communities if they prefer to do so.
• Support increased availability of PACE program services to older adults through regulatory and statutory flexibility and investment at the federal and state levels.
• Expand PACE across the country via new and additional service areas and increased enrollment.
• Advance policies that promote availability of PACE across funding streams such as inclusion as an option for Veterans through the VA.
• Advocate that any LTSS models from the Center for Medicare and Medicaid Innovation include all settings in the home and community (e.g., home health and personal care, adult day other day-based services, PACE services) and provide the supports (e.g., transportation) needed to facilitate these.
• Reinforce federal rulemaking that supports access to and quality of home and community services for beneficiaries while minimizing provider burden, this includes maintenance of reduced burdens during application and redetermination that were included in the Medicaid Streamlining Eligibility and Enrollment final rule.

THE ISSUE

The combination of nimble and personal service delivery, stable reimbursement, and the ability of PACE to keep older adults in their homes and communities make the model attractive to participants, payer (e.g., Medicare and Medicaid), and PACE organizations thought it isn’t broadly available to participants in all areas of the country.

Federal barriers exist that limit the growth and availability of PACE, including the optional status of all home and community-based services (waiver, state plan, PACE) as Medicaid benefit categories, first-of-the-month enrollments, onerous requirements that hinder PACE expansion or new sites, federal and state requirements that are not aligned, limitations on populations that can access the program, and competition with other managed care products hinder PACE from being available to a broader swath of eligible older adults.

Workforce is a key priority for our members, yet workers providing PACE participants with home health, personal care, and other services in recipient homes face unique and unexpected challenges that often include hoarding, difficult family dynamics, under resourced communities, and increasing incidents of threats to personal safety. Staff willingly take on these challenges as part of providing individual care in the field without the immediate support of coworkers and supervisors.

Advocacy Action 2025

119^th Congress

• Protect Medicaid. Educate and advocate for protection of the Medicaid financial system from cuts that would threaten the viability of our members and the livelihood of those that they serve. We oppose financing reforms or policy changes such as per capita caps, block grants, elimination or reduction of provider taxes, or changes to the federal share of Medicaid spending as well as opposing barriers to access such as work requirements.
• Medicaid rates. We support investments in the Medicaid program via increased FMAP for both HCBS and nursing homes. We will continue to work with state partners and members to ensure that state Medicaid rates paid to aging services providers are sufficient to cover the costs of care.
• Benefit categories. We ask Congress to revise Medicaid and put HCBS (including waiver, state plan services, and PACE) on equal footing with nursing homes, making HCBS a mandatory Medicaid benefit.
• Support legislation to promote integrated services. We have a vision for integrated services for older adults and will support legislation designed to achieve this objective for dual eligibles such as the Delivering Unified Access to Lifesaving Services (DUALS) Act or other proposals that promote integration as long as they keep PACE on equal footing to other integrated care options.
• Support legislation that expands PACE. We support legislation that would allow PACE organizations to serve new populations, reduces administrative burdens related to opening new or additional PACE sites, and other efforts to streamline and align state and federal requirements to make PACE more widely available.
• Flex Cards. Clarify federal policies on how supplemental benefits offered via flexible benefit cards should be treated when determining an individual’s eligibility for government assistance such as Medicaid, Supplemental Security Income and federal rental assistance.

• Appropriations. We support increasing funding for key provisions that support HCBS, including Older Americans Act services and affordable housing to sustain affordable housing allowing people to age in place.
• Leveling Enrollment Options. The requirement that PACE Organizations may only enroll new participants on the first of the month limits access for individuals that need services more rapidly such as proposed in the PACE Expanded Act.
• PACE Part D Choice. We support allowing Medicare only beneficiaries to buy Part D prescription drug plans not operated by the PACE program which are often more affordable to them and make PACE an accessible option such as proposed in the PACE Part D Choice Act.

Executive Branch

• Enrollment and Expansion Support. Onerous regulations limit PACE enrollment to the first of the month and prohibit providers from having multiple expansion proposals open simultaneously and unnecessarily stifle PACE growth. We will look for flexibility and advocate with the administration to mitigate harms from these limitations.
• Protect Medicaid financing. We oppose any Medicaid waivers or rulemaking that reduces federal funding to the program, as these could ultimately jeopardize PACE access. To that end, CMS should not approve new and should rescind any existing waivers that allow per capita caps/block grant financing, work requirements, or other unnecessary coverage/enrollment barriers. CMS should not propose rulemaking similar to the 2019 Medicaid Fiscal Accountability Regulation (MFAR) which jeopardizes billions in federal Medicaid share for select states.
• Flex Cards. We will promote policies that reduce inappropriate disenrollments from PACE organizations to access flexible spending cards.
• Implement recommendations to expand PACE in rural areas. The National Advisory Committee on Rural Health and Human Services examined barriers to PACE in rural areas made a number of recommendations—we concur with them and advocate to implement them.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support the expansion and preservation of PACE programs for older adults.
• Review LeadingAge’s current PACE work through our Adult Day, PACE, and HCBS page.
• Host Congress in Your Neighborhood to help your Members of Congress understand the great services you provide, how they affect your community by caring for older adults, providing jobs, or offering respite for family caregivers. Describe and demonstrate how policies impact providers, employees and residents. For example, structural changes to Medicaid will mean less federal funding is available, resulting in Medicaid rate reductions, increased out-of-pocket costs, or eligibility terminations for some staff.
• Get involved with LeadingAge member networks and our weekly Policy Pulse calls to stay up to date on policy proposals. Provide your feedback on how proposals would affect your community, staff, or participants. Email Georgia with questions, concerns, or to join the network.

LeadingAge Advocacy Goals

• Federal and state regulatory and payment policies must recognize and accommodate challenges facing rural providers, including the special challenges rural providers face that have been exacerbated by the pandemic.
• We work to advance initiatives that will reduce barriers to recruiting and retaining qualified, well-trained staff, including increased Medicaid and Medicare reimbursement that will allow providers across the continuum to invest in staff wages, benefits, and supports.
• We oppose staffing standards for which there is no evidence, no workforce, and no funding.
• Promote policies that address the lack of affordable housing and transportation for staff in rural areas and that support older persons’ mobility and independence.
• Support improving access to affordable broadband in rural and frontier communities so that aging services providers can better reach the people they serve and provide additional services to older adults.
• Support increased Medicaid funding and Medicare rural add-ons for aging services.
• Replicate programs and models that hold promise such as the Rural Aging Action Network.

THE ISSUE

Rural aging services providers face the same financing and policy challenges that all other providers face, but these challenges are magnified by distance and loss of working age population. Transportation, housing, workforce shortages, care coordination, telehealth, technology, and internet challenges, along with inadequate public financing, raise significant public policy challenges. As populations shift to urban areas, these problems are exacerbated. And yet our aging services members form the backbone of many rural areas, providing care, services, and employment. We have members across the continuum (nursing homes, home health agencies, and others) that have closed and others in the verge of closure. If and when closures occur, communities and the older adults remaining in them face losing the only provider within driving distance in many cases—whether that is a nursing home or housing community where friend and family can easily visit or a provider that will actually come out to the home in these communities.

Policymakers must support further investments in creating critical access designations for aging services providers to incentivize continued services to the 1 in 4 American seniors living in a rural area. Regulatory burdens must be reduced for these providers to continue to sustain their services and incentives for workers to move to rural areas must be developed.

Advocacy Action 2025

119^th Congress

• Rural Internet Access. We support legislation to help improve high-speed internet access in rural areas. Extend the subsidized broadband connectivity rates available for certain health care providers in rural areas under the FCC’s Rural Health Care Program to additional aging services providers by amending the Social Security Act (as was done in the 2015 Rural Connectivity Act, which added nursing homes to the definition of healthcare providers).
• Workforce. We support legislative efforts to ensure that aging services workers earn at least a living wage and have opportunities for professional development. We support efforts to increase the pool of qualified applicants domestically and internationally.
• Medicaid reimbursement.  We support permanently increasing the Federal Medical Assistance Percentage (FMAP) for all aging services/long-term care providers. We would like to see these increases, at least in part, reimburse aging services providers at a level that allows them to pay workers a living wage.
• Critical Access Designations. We support proposals to create federally recognized Critical Access Nursing Homes, Home Health Agencies, and Hospices, similar to the Critical Access Hospital (CAH) program to prevent additional closures of these providers in rural areas (and potentially other areas with minimal access) and ensure that community residents have access to the care they need.
• Telehealth. We support legislation to improve access to telehealth services across the continuum of aging services and allow pandemic era flexibilities to be implemented permanently.
• DEA Telehealth Flexibility. Continue to advocate for continuing COVID-era telehealth prescribing for controlled substances.
• Reinstate CNA training programs within SNFs. We support repealing the CNA training “lock-out” and reinstating training programs when SNFs are in compliance.
• Expanded use of nurse practitioners and physician assistants in hospice. We support a legislative fix that would allow nurse practitioners and physician assistants to certify the terminal prognosis as clinically appropriate. We also support seeking legislative fixes to the statute to clarify the role of physician assistants (PAs) in hospice and to allow PAs to provide face-to-face encounters.
• Reinstate Medicare home health rural add-on payments. We support legislative efforts that would make permanent the add-on for services to rural patients.
• Ensure critical access hospital payment policy does not interfere with post-acute care access. We will advocate that Congress examine the incentives between Critical Access Hospitals and post-acute care to ensure payment incentives are aligned so post-acute care can survive independent of the CAH and to eliminate existing barriers to collaboration between CAHs and nursing homes, hospice, and PACE.

Executive Branch

• Staffing Standards. We oppose staffing standards for which there is no evidence, no workforce, and no funding.
• Workforce. We work to advance initiatives that will reduce barriers to recruiting and retaining qualified, well-trained staff, including increased Medicaid and Medicare reimbursement that will allow providers to invest in staff wages, benefits, and supports.
• Oversight. We call on CMS to improve consistency and accuracy in the survey and certification process as well as ensure appropriate and targeted oversight via the audit process.
• Rural Service Coordination. We support the U. S. Department of Agriculture (USDA) to launch Service Coordination in Rural Development-subsidized rental housing, including by establishing internal processes for program funding approval and external strategies for communication and marketing with housing stakeholders.
• Implement recommendations to expand PACE in rural areas. The National Advisory Committee on Rural Health and Human Services examined barriers to PACE in rural areas made a number of recommendations—we concur with them and advocate to implement them.
• Transportation and Medicaid. We support the maintenance of current rulemaking that assigns non-emergency medical transportation (NEMT) as a mandatory Medicaid benefit; we also support additional action to ensure greater access to transportation in rural areas.
• CMMI and Rural Models of Care. We will encourage CMMI to look at funding models that replicate successful rural centric coordinated care models.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your representative and senators hear your voice on policy related to aging services in rural areas.
• Host a Congress in Your Neighborhood (leadingage.org)  in your community to help your Members of Congress understand the challenges and opportunities in providing aging services in rural areas and policy changes they can make to address them.

ADDITIONAL RESOURCES

• Rural Members Network

LeadingAge Advocacy Goals

• Maintain current nonprofit tax status for LeadingAge members as 501(c)(3) exempt organizations.
• Oppose elimination of the tax exemption for state and local bonds and the ending of tax preferences for other bonds.
• Enhance Low Income Housing Tax Credit program to broaden its availability for use in developing affordable housing for seniors.
• Support charitable deductions through tax deductions.
• Support the deductibility of medical expenses at 7.5% of adjusted gross income.
• Support tax credit incentives that help aging services providers continue to recover from COVID-era expenses and that promote the utilization of innovative technologies to improve the well-being of older adults and the communities in which they live.

THE ISSUE

A wide variety of temporary Internal Revenue Code changes enacted as part of the Tax Cuts and Jobs Act (TCJA), enacted in 2017, are scheduled to expire. Many of these provisions affect individuals and families and are scheduled to expire at the end of 2025. Others affecting businesses are scheduled to expire between 2025 and 2028.  This means that the structuring of tax policies – relating to whether expiring provisions should sunset, be renewed or modified, to what other tax reforms should be enacted, and to whether legislation creating tax relief will be paid for through offsetting additional revenues or spending cuts – will be a top priority of the White House and of Congressional lawmakers in both parties.

In addition to organizational-level tax exemption, which is essential to maintain, federal tax laws have various incentives to support charitable institutions, such as allowing individuals to deduct charitable contributions and a certain amount of medical expenses from their tax returns, encouraging investment in housing through tax credits, and incentivizing other activities such as installation of energy efficient systems. Tax-exempt organizations rely on these mechanisms to support their philanthropic missions and outreach and their ability to address low-income housing needs.

Nonprofits also often rely on tax-exempt bond financing to refinance existing debt and for capital projects. Therefore, we oppose elimination of the tax exemption for state and local bonds and the ending of tax preferences for other bonds.

Advocacy Action 2025

119^th Congress

As Congress and the President evaluate these issues we will support and advocate for tax policies that positively impact members.

These efforts will include vigilance and dedicated advocacy efforts to ensure that tax policies are not enacted that would threaten the ability of LeadingAge members to fulfill their missions to those they serve directly and to their broader communities, such as proposals to restrict or eliminate tax exempt status for currently eligible nonprofits.

Our efforts will also include the introduction and support of bills on the following topics:

• Low Income Housing Tax Credits. We will support efforts that would increase state LIHTC allocations by 50%, provide a 50% basis boost for LIHTC communities that serve households with extremely low incomes in at least 20% of their apartments, and lower the bond financing threshold from 50% to 25% to make more efficient use of existing Private Activity Bond resources. Each of these provisions were included in the Affordable Housing Credit Improvement Act (H.R. 3238 and S. 1557) during the 118^th Congress, which LeadingAge supported. We will also support the expansion of Housing Credit units, such as those accessible through the Visitable Inclusive Tax Credits for Accessible Living (VITAL) Act (H.R. 3963 and S. 1377 in the 118^th Congress), and the replacement of the current right of first refusal with a purchase option to facilitate the ability of nonprofits to maintain ownership/control of housing credit properties beyond Year 15.
• Charitable Contributions. In order to encourage charitable giving, which may be affected by the size of the standard deduction for individual taxpayers or other policy concerning individual deductions, we support efforts, such as the bi-partisan Charitable Act introduced in the 118^th Congress (S.556 / H.R. 3435), that allow a universal charitable donation deduction, meaning that it would be available to individual taxpayers who do not otherwise itemize their tax deductions.
• Medical Expense Tax Deduction. We support maintenance of the current standard that allows deduction of unreimbursed medical expenses that exceed 7.5% of adjusted gross income, versus a higher threshold that would negatively impact seniors.
• Workforce Supportive Tax Policies. We will advocate for tax policies that support our members’ ability to hire, retain, and support their workforce, such as incentives or opportunities for healthcare and aging services providers, including affordable housing providers, to support the costs of employee travel (whether mileage incurred in personal vehicles, or the costs of transit) to the workplace or to the homes of those whom they serve in the community. Such an incentive could be structured as a tax credit that can be applied against payroll tax liability, not just the federal income tax.
• Support for Family Caregivers. We support policies that will help family caregivers to offset the cost of long-term care and caregiving through tax incentives. This includes support for bills like the Credit for Caring Act (S. 3702/H.R. 7165 in the 118^th Congress) that would provide a tax credit for a percentage of qualified expenses incurred by a caregiver.

Executive Branch

• Employee Retention Credit. We support and will continue to monitor the full implementation of the Employee Retention Credit (ERC), which was designed to offset the unprecedented rise in the workforce costs, both during and after the COVID-19 pandemic, for aging services providers. We urge the Internal Revenue Service to continue efforts to shorten the processing time for existing ERC claims and will continue to work within IRS-issued guidance to enable eligible members to receive the benefit available to them through this program.  We also advocate that the redemption of the ERC not be a part of cost-reporting for the calculation of Medicare or Medicaid reimbursement.
• Inflation Reduction Act. We support implementation of Inflation Reduction Act (IRA) policies to include the not-for-profit aging services sector across the entire continuum of providers, and especially for those providers that serve older adults in rural, disadvantaged and economically suppressed regions, such as HHS’s Catalytic Program, that offers guidance to the health sector and nonprofits concerning green energy or resilience programs and available opportunities, including clean energy tax incentives and direct payment program options that are accessible for not-for-profit providers and government entities.

ACTIONS YOU CAN TAKE NOW

• Continue social accountability efforts to document how your organization gives back to the broader community and fulfills its responsibilities as a tax-exempt entity.
• Visit the Advocacy Action Center to identify opportunities to let your Representative and Senators know your position on tax legislation.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact affordable senior providers and residents.

ADDITIONAL RESOURCES

• Low Income Housing Tax Credit Basics
• Scan of State Housing Credit Allocation Plans
• Charitable Giving – Independent Sector

LeadingAge Advocacy Goals

• Advocate for permanent changes to Medicare, Medicaid, and commercial payer telehealth policy based on lessons learned during and after the COVID-19 public health emergency (PHE).
• Ensure all aging services providers are included in future permanent telehealth expansions.
• Permanently remove Medicare’s restrictions of patients’ homes as an originating site for audio-only, synchronous audio-only, and asynchronous biometric remote patient monitoring (RPM) and for individuals with chronic conditions living independently, and for individuals with chronic conditions living independently but helped by home health clinicians. Also, promote policies supporting the use of synchronous audio-video telehealth in skilled nursing homes and assisted living communities.
• Create an equitable payment policy for the post-pandemic era that balances providers’ costs with patient protections.
• Promote funding and technical support for the adoption of interoperable electronic health records and enhancement of cybersecurity systems.
• Promote the use of standards-based health information exchange between aging services providers and their partners including primary and acute care providers and payers.
• Ensure equitable internet connectivity for all aging services providers and older adults, including in affordable senior housing, where whole property internet access is critical for the wellbeing of older adults and for modernized property operations.
• Promote policies that support the use of technology to reduce social isolation among older adults.
• Modernize IT infrastructure at the Department of Housing and Urban Development to improve affordable senior housing and service coordinator program administration.

Health IT Incentives:

Secure government funding for the Office of National Coordinator at the U.S. Department of Health and Human Services (HHS) to:

• Establish an electronic health record (EHR) Interoperability Certification Criteria/Program relevant to long-term, post-acute care (LTPAC) providers, but aligned, where possible, with the acute care certification program.
• Establish health IT education and training for staff in LTPAC providers, like the Regional Extension Centers (RECs) that supported small physician practices.
• Fund technical assistance resource centers to provide technical assistance for LTPAC providers, like the RECs that supported small physician practices.
• Direct financial incentives for LTPAC Providers (SNFs/NFs, home health, hospice, long-term acute care hospitals (LTACHs), in-patient rehabilitation facilities (IRFs) to:
  • Upgrade to interoperable EHR technology;
  • Upgrade their infrastructure and broadband connectivity;
  • Subscribe and connect to health information exchange entities or networks, and add technically competent staff to support use;
  • Conditional Sustainable Use financial incentives/payment modifiers that, tied to quality measures, would be impacted by effective exchange of health information with partners for the next five years.

Access to Broadband:

• Extend the subsidized broadband connectivity rates available for certain health care providers in rural areas under the Federal Communications Commission’s (FCC) Rural Health Care Program to additional aging services providers.
• Create funding opportunities for congregate affordable low-income housing providers to collectively apply for and receive broadband internet connectivity to the building and to their residents’ units, to ensure equitable access to services.

THE ISSUE

The ability to use telehealth during the COVID-19 emergency was vitally important, protecting the health of staff and patients and expanding the reach of overextended health care personnel. During the PHE, both Congress and CMS acted to establish a number of significant telehealth flexibilities, on a temporary basis, that became an essential lifeline for our health care system and drove an increase in the use of technology to deliver appropriate and timely care to keep people safe, healthy, and well-connected. These included waivers in Medicare rules that allowed the home to be an originating site of care, expanded the types of technology that can be used for telehealth visits and expanded the types of providers that can bill for telehealth services, all of which have proven to be valuable in many ways.

Following the end of the PHE, and in recognition of the progress made and lessons learned during the pandemic, Congress and CMS have extended these flexibilities but, in many cases, on a time limited basis only. Looking forward, our goal is to make sure that telehealth is incorporated into practice in an equitable, cost-effective (for both the government and providers), and accessible way.

In addition to making many of the pandemic flexibilities permanent, aging services providers need payment policies that support their ability to recruit and retain staff who can either deliver interventions, including therapy under a physician-approved care plan, or can assist a remote physician during an asynchronous telemedicine visit. Moreover, providers need support to maintain and upgrade technology. In short, they need adequate reimbursement from all payer sources to sustain and maintain the investments they have already made in delivering care via telehealth.

Broadband investment, especially in rural and underserved areas, is critical to making sure telehealth is an accessible service nationwide, including in affordable senior housing communities, many of which lack connectivity and where federal investment in wireless internet capability is imperative. Continued investments in broader health information technology to support information management and the secure exchange of health information are also critically important and need to be inclusive of aging services providers.

Finally, those providers who treat patients in their own home—like home health, hospice, and PACE—who have not been able to take full advantage of the affordable internet connectivity like healthcare peers in rural areas, or telehealth in the past, or even the expanded telehealth flexibilities, need to be included.

Advocacy Action 2025

119^th Congress

• LeadingAge supports legislation to advance our technology and telehealth policy priorities, including the use of telehealth models to improve care across the continuum of aging services. As we have done in prior Congresses, LeadingAge will advocate for and work to shape legislation, such as the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act (H.R.4189/S. 2016), the Telehealth Modernization Improvement Act (H.R. 7623 / S. 3967); and the Preserving Telehealth, Hospital, and Ambulance Access Act (H.R. 8261) that were introduced in the last Congress.
• Keeping key pandemic-era flexibilities. We support keeping the following pandemic-era flexibilities in place permanently: (i) Permanently removing the geographic restrictions on telehealth; (ii) allowing the home to be an originating site of care; and (iii) expansion of the providers who can furnish telehealth services relating to both physical and mental health, including audiologists, physical therapists, speech language pathologists, and facilities that provide these services.
• Hospice face-to-face recertification. We support allowing the hospice face-to-face recertification to take place via telehealth on a permanent basis.
• Reimbursement for home health telehealth visits. We support legislative efforts that allow virtual home health visits to be reimbursed under Medicare with appropriate guardrails.
• PACE and telehealth. We support legislation that would allow audio-only diagnoses that are made via telehealth to be used for purposes of determining risk adjustment to payments for PACE and Medicare Advantage programs.
• Housing and technology. We support federal funding for the installation and service fees for whole property wireless broadband internet in all HUD-assisted senior housing communities.
• Meaningful use. Aging services providers were not included in previous funding efforts that supported health care providers’ transition to EHR systems. We will continue to advocate for funding and payment incentives, including incentives tied to quality, to assist aging services providers in accessing EHR technology that is interoperable with that of their physician and hospital partners and peers and encourage the bi-directional exchange of information.
• Affordable rural internet connectivity for aging services providers. We support legislative action aimed at expanding the scope of the 2015 Rural Healthcare Connectivity Act, which added nursing homes to the definition of healthcare providers that may access subsidized broadband connectivity, to include home health, hospice, and other aging services providers in the home and community. Such action would allow all aging services providers to benefit from lower internet connectivity costs offered to acute care and nursing homes.
• Affordable Connectivity Program. Ensuring that all federally-assisted senior housing residents have access to quality, affordable internet is an on-going policy priority. One important program that served this goal was the FCC’s Affordable Connectivity Program (ACP). The ACP ended on June 1, 2024, due to a lack of additional funding by Congress. LeadingAge supports efforts in Congress to restore funding to the program and make reforms for streamlined program access by affordable senior housing communities.
• Cybersecurity. We will seek support for aging services providers in implementing cybersecurity technologies and best practices, such as through technical support, financial incentives, workforce development initiatives, and work to ensure that proposed requirements are appropriate and reflective of aging services operations.

Executive Branch

• Health Equity in Telehealth Services.  LeadingAge encourages CMS to continue to focus on improving health equity in telehealth services and to expand access among underserved populations, including addressing disparities such as those identified in this HHS analysis of Medicare Beneficiaries’ Use of Telehealth in 2020.
• CMS Extension of Telehealth Flexibilities. LeadingAge will continue to advocate for CMS to increase telehealth and technology flexibilities where it can do so without Congressional action, including utilization of telehealth for hospice routine home care visits and flexibility in licensure requirements in the Medicare and Medicaid program.
  LeadingAge supported CMS’s inclusion in the Calendar Year 2025 Physician Fee Schedule Final Rule of telehealth policy changes, including: (i) adding certain caregiver training services to the Medicare Telehealth Services list on a provisional basis; (ii) continuing the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations for CY 2025; and (iii) beginning January 1, 2025, and on a permanent basis, an interactive telecommunications system may include two-way, real-time, audio-only communication technology for any Medicare telehealth service furnished to a beneficiary in their home, if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology.
• Remote patient monitoring. LeadingAge will work to ensure that all appropriate aging services providers can utilize and bill for asynchronous remote patient monitoring, which is a critical and effective tool to support the health of individuals with chronic conditions.
• Advocate for the creation of claims codes or modifiers to document hospice virtual visits.  We will advocate that CMS create claims codes or modifiers both to track the utilization of the face-to-face encounter via telehealth and to track the utilization of virtual care in hospice akin the G-codes in home health.
• Advocate for the use of data from new claims codes documenting home health virtual visits. Home health providers are allowed to use virtual visits as part of their documented plan of care. We will advocate for the analysis of the recently created G-Codes for these encounters for a variety of purposes including quality measurement.
• Clarify and improve HUD Guidance on Funding Internet Infrastructure and Services in Affordable Housing. We support clarifications and improvements to current HUD guidance related to the use of property budgets and reserve for replacement accounts to pay for internet access. This includes both the initial internet infrastructure costs and the ongoing internet services costs.
• Tele-Prescribing of Controlled Medications. In response to COVID, the Drug Enforcement Administration (DEA) granted temporary exceptions under the Ryan Haight Online Pharmacy Consumer Protection Act that allowed healthcare providers to prescribe certain controlled substances via telemedicine without the need for a prior in-person examination, for the duration of the COVID-19 PHE. The DEA has issued a third temporary extension of these flexibilities, through December 31, 2025.  LeadingAge supports making these flexibilities permanent.  and calls for DEA to allow patients enrolled in hospice and palliative care, as well as nursing home residents, to be included in the exemptions as authorized under the Ryan Haight Act.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to identify opportunities to let your Representative and Senators know your views on eliminating barriers to the utilization and expansion of telehealth services in the Medicare program and other technology policy issues.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies related to technology and telehealth models in Medicare affect older adults.

ADDITIONAL RESOURCES

• LeadingAge Center for Aging Services Technologies

LeadingAge Advocacy Goals

• Advocate for policy solutions that establish responsive and integrated funding models that support competitive wages commensurate with the professionalism, expertise, and skill of the aging services workforce
• Support the development, expansion and financial support of apprenticeship programs tailored to the aging services workforce.
• Advance policies that promote the development and implementation of crosswalk and career lattice programs that acknowledge education, work and life experience enabling workers to seamlessly transition between roles and advance their careers within the aging services sector.
• Support policies that expand the availability of nurse faculty through competitive compensation, loan forgiveness, and advanced education incentives to address workforce shortages and ensure the training of a skilled nursing workforce for aging and healthcare services.
• Support policies that expand immigration pathways and create specialized visa categories for foreign-born workers in aging services and healthcare to address workforce shortages and ensure high-quality care for older adults and vulnerable populations.
• Advocate to raise and modernize employment visa caps to ensure a steady supply of skilled professionals into aging services and healthcare.
• Advocate for policies that remove accompanying family members from employment visa caps, enabling the recruitment of more skilled workers into the aging services and healthcare sectors while supporting family reunification and stability.
• Champion policies that remove barriers to training and certification for direct care professionals, enhancing access to affordable, high-quality culturally competent education and streamlined testing processes to build a well-equipped, proficient workforce that meets the growing demands of aging and healthcare services.
• Advocate for expanding the role of allied health professionals, like Certifies Nurse Aide, in training the direct care workforce to enhance workforce capacity and improve the quality of care for older adults and other vulnerable populations.
• Support the establishment of a center of excellence charges with supporting high road employers to employ and retain foreign-born workers.
• Champion the expansion and support of international training and testing centers to support foreign born nurses and direct care professionals.
• Advance policies and programs that protect and empower foreign-born workers by ensuring fair wages, prevent and combating exploitation, promote inclusivity, and create pathways for integration and success in the U.S. workforce.
• Advocate to preserve and expand housing affordable to the aging services workforce.

THE ISSUE

The U.S. population of adults over 65 is surging and will grow by nearly 50% from 58 million in 2022 to 83 million by 2050. This dramatic and unprecedented demographic shift is compounded by a shrinking working-age population, creating a critical workforce shortage that demands immediate action. By 2030, the U.S. will require an additional 3.5 million workers in aging services and supports including nearly two million registered nurses. The aging services sector is grappling with an increasingly challenging landscape, driven by soaring service demands, fierce competition for talent, and an immigration system that restricts the flow of skilled workers. Providers face relentless pressure to recruit and retain the workforce necessary to deliver high-quality care and maintain access to vital services for older adults, making workforce expansion and support a critical national priority.

LeadingAge is dedicated to driving transformative change through bold, innovative, and forward-thinking policies that expand, empower and strengthen the aging services workforce at every level, and every job ensuring a resilient and sustainable care system for generations to come.

Advocacy Action 2025

119^th Congress

• Advocate for and champion bold policies that create clear and accessible pathways to citizenship as well as permanent and temporary residency status for the aging services workforce. For example, in the last session of Congress, LeadingAge supported The Healthcare Workforce Resilience Act (S. 3211 / H.R. 6205) and The Asylum Seeker Work Authorization Act of 2023 (S.255 / H.R.1325)
• Advance comprehensive policy proposals that expand visa classifications, to include foreign born workers without bachelor’s degrees, and substantially raise caps for the workforce across all care settings. For example, in the last session of Congress, LeadingAge supported The Equal Access to Green Cards for Legal Employment (EAGLE) Act of 2023 (S.3291) and its companion, the Immigration Visa Efficiency and Security Act of 2023 (H.R.6542)
• Advocate for the removal of immediate family members from employment visa caps to ensure a more efficient immigration system that supports workforce needs while keeping families united.
• Champion bold legislation that offers substantial incentives and dramatically expands access to training and education programs, creating a pipeline of highly skilled professionals capable of meeting the urgent and growing demands of healthcare and aging services. For example, in the last session of Congress, LeadingAge supported the Immigrants in Nursing and Allied Health Act of 2023 (H.R. 3731), the National Nursing Workforce Center Act of 2023(H.R. 2411), National Nursing Shortage Task Force Act of 2023 (H.R. 4328) and the Nursing Home Workforce Support and Expansion Act (H.R. 7929).
• Strongly support and advocate for legislation that significantly expands the use of apprenticeship programs creating structured pathways, providing robust, hands-on training opportunities that develop a skilled workforce, bridge talent gaps, and ensure long-term sustainability in aging services and healthcare. For example, in the last session of Congress, LeadingAge supported the National Apprenticeship Act of 2023(H.R. 2851 / S. 2122)
• Push for increasing the number of nurse faculty advocating competitive salaries, loan forgiveness programs, and professional development opportunities. For example, in the last session of Congress, LeadingAge supported the Support Faculty and Expand Access to Nursing School Act of 2023(H.R. 3263) and the Nurse Faculty Shortage Reduction Act of 2024 (H.R. 7002)
• Advocate for robust incentives and reimbursement programs to support aging service providers offering clinical placements and training opportunities, ensuring a well-prepared workforce to meet the needs of older adults.
• Push for analysis and reporting from Health Resources and Services Administration (HRSA) outlining tools and strategies for Home and Community Based Service (HCBS) providers to recruit and retain the foreign-born workforce. In particular, the report should focus on programs supported by Medicaid operating in areas with labor shortages.
• Advocate to preserve Deferred Action for Childhood Arrivals (DACA) and Temporary Protected Status (TPS), as these programs play a crucial role in supporting vulnerable individuals, maintaining family unity, and contributing to the nation’s economic and social well-being.
• Support substantive increases in asylum seekers granted refugee status and reduce the waiting period to obtain work authorization documents, ensuring asylum seekers can contribute to their communities and achieve stability while awaiting full adjudication of their asylum applications. For example, in the last session of Congress, LeadingAge supported the Asylum Seeker Work Authorization Act of 2023 (H.R. 1325) and the ASPIRE Act (H.R. 4309 / S.2175).
• Promote expanding work opportunities for international students enabling them to gain valuable experience and contribute to their communities and the economy.
• Advance and support policies that create pathways for foreign-born caregivers working in the “Gray Market” care economy to achieve legal status and join the regulated care economy. That pathway must include training, oversight, protections, competitive compensation, and career advancement opportunities.
• Push policies and guidance that encourage the proliferation of training and testing for direct care professionals in their native language.

Executive Branch

• Partner with the Department of Education to create and authorize a Career Technical Education (CTE) program for high school and middle school students to earn valuable hands-on experience, academic credit and compensation for working in aging services.
• Collaborate with the Department of Education and key stakeholder groups to forge stronger, strategic connections between nurse training programs and aging service providers, ensuring that aging services are highlighted as a vital career pathway.
• Work with the Administration through the Departments of State and Homeland Security (including U.S. Citizenship Immigration Services) to streamline immigration processes ensuring efficiency, fairness, and timely access to legal pathways that support economic growth and workforce needs. This should include a comprehensive review of countries that require foreign born nurses to complete English language proficiency testing as established by the Commission on Graduates of Foreign Nursing Schools.
• Work with the Administration to streamline education and work requirements for the nurse faculty ensuring a robust cadre of skilled instructors able to educate and inspire the next generation of caregivers and nurses.
• Work with the Administration through the Department of Labor to ensure that aging services are represented in the National Apprenticeship Program (NAP), including designated funding categories for programs that provide training and support to foreign-born workers creating career pathways and pipelines that recognize the experience and skill of existing workforce and ladders to clinical and non-clinical positions.
• Advocate for the establishment of excellence to help employers support foreign-born workers. This center should advance innovative, evidence-based resources and tools employers can use to hire and integrate foreign born workers into their new work settings and communities.
• Request and advocate for the Office of Refugee Resettlement and the Health Resources and Services Administration issue a report outlining culturally concordant best practices for organizations employing recently immigrated foreign-born workers in the aging services sector.

ACTIONS YOU CAN TAKE NOW

• Visit the Advocacy Action Center to let your Representative and Senators know you support our assisted living and memory support initiatives.
• Host Congress in Your Neighborhood to help your Members of Congress understand how policies impact the residents and workforce of assisted living or memory support communities, as well as their families.
• Engage with other affordable senior housing providers through the Workforce Network and other regular national and state meetings. Contact Nicole or more information.

ADDITIONAL RESOURCES

• The Immigration Imperative
• LeadingAge Center for Workforce Solutions for older adult services
• LeadingAge LTSS Center @UMass Boston
• Hiring Refugees in Aging Services