If you rely on a visiting nurse or physical therapist, you may find that your “approved” number of visits is smaller this month than it was just a few weeks ago. For 2026, the Centers for Medicare & Medicaid Services (CMS) has implemented a significant recalculation of the home health payment system, which directly influences how agencies schedule your care. While the government officially announced an aggregate 1.3% reduction in payments, the internal shifts are much more dramatic. To stay profitable under these new rates, agencies are tightening their home health visit limits to avoid financial penalties, a move that is leaving many vulnerable seniors with fewer hours of professional support than they had in 2025.
The New “LUPA” Threshold Trap
The most technical, yet impactful, change for 2026 involves the Low-Utilization Payment Adjustment (LUPA) thresholds. Under the Patient-Driven Groupings Model (PDGM), every 30-day period of care is assigned a “visit threshold”—typically between two and six visits. If your agency provides even one visit fewer than the threshold, they aren’t paid the full 30-day rate; instead, they receive a much smaller “per-visit” payment. To avoid this “LUPA trap” in a year of recalculated case-mix weights, agencies are being extremely precise with their scheduling. This often means they will provide exactly the minimum number of visits to hit the threshold and then stop, effectively creating a “soft cap” on your care.
Functional Impairment Levels: The Scoring Shift
Another reason for the shifting home health visit limit is the update to how CMS scores your “functional impairment.” Every patient is ranked as Low, Medium, or High impairment based on their ability to perform activities like bathing, dressing, and walking. For 2026, CMS recalibrated these levels using 2024 claims data, which showed that patients were generally “improving” faster than expected. As a result, the “points” required to qualify for a “High” impairment rating have increased. If you were previously considered a high-needs patient, you might find yourself reclassified as “Medium” this year, which automatically lowers the amount of money—and thus the number of visits—your agency can afford to provide.
Recouping “Retrospective Overpayments”
The 2026 rules also include a 3.0% temporary adjustment aimed at recouping what CMS calls “retrospective overpayments” from the early years of the pandemic. Between 2020 and 2024, CMS determined that it paid roughly $4.76 billion more than it should have due to changes in how agencies billed for care. This “payback” period means that agencies are entering 2026 with tighter margins than ever before. To compensate for this 3% “clawback,” many providers are reducing the duration of each visit or lengthening the time between nursing check-ins, further tightening the home health visit limits for patients who require long-term stabilization.
The Expansion of “Face-to-Face” Practitioners
There is one bright spot for patients in the 2026 recalculation: more people can now sign off on your care. To improve access in a tightening market, CMS has broadened the language regarding who can perform the mandatory “face-to-face” encounter. In addition to your primary doctor, certain non-physician practitioners (like Nurse Practitioners and Physician Assistants) can now certify your need for home health, even if they aren’t the one “supervising” the plan. This change is intended to reduce the administrative delays that often lead to care gaps, though it doesn’t change the fact that the total number of visits allowed per month is under heavy pressure.
Protecting Your Right to Care
If you feel your home health visits are being cut too drastically, you have the right to a “Fast-Track Appeal.” When an agency tells you they are stopping your care, they must provide a “Notice of Medicare Non-Coverage” (NOMNC) at least two days before services end. This notice contains the phone number for your state’s Quality Improvement Organization (QIO). By calling this number immediately, you can trigger an independent medical review of your case. If the QIO determines you still have a “clinical need” for care, they can force the insurance company or agency to continue your visits, regardless of the new LUPA thresholds or payment recalculations.
The Era of “Precision” Home Health
The 2026 recalculation marks a transition from “needs-based” care to “data-driven” scheduling. As agencies navigate the 1.3% aggregate payment decrease and the 3% temporary adjustment, the days of open-ended nursing visits are likely over. Patients and their families must become active participants in the “scoring” process, ensuring that their OASIS assessments accurately reflect their daily struggles. By understanding the “LUPA” thresholds and the new functional scoring, you can better advocate for the visits you need to remain safe and independent in your home throughout the coming year.
Have you noticed a change in your home health schedule or been told you no longer qualify for “High” needs care? Leave a comment below and let us know how these 2026 recalculations are affecting your family’s daily routine.
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