Abstract
In its 2025 final payment rule for Medicare Home Health published November 7, 2024, the Centers for Medicare and Medicaid Services added 5 questions to the outcome and Assessment Information Set (OASIS) needing to be addressed: 4 new (i.e., 1 on living situation; 2 on food insecurity; 1 on utilities) and 1 that revised transportation. The rule states that the changes are responsive to issues in the social determinants of health category and take effect with the calendar year 2027 Home Health Quality Reporting Program. A literature review indicates no studies on the potential impact of these OASIS revisions on Medicare home health social work services, the service for social needs. This article summarizes an initial, exploratory study to address the literature gap, based on interviews of 31 Medicare home health social workers between January 6, 2025, and February 9, 2025, in the New York City metropolitan area. Three themes emerged, including: social workers believe the new requirements (1) are overdue, needed, and provide the potential to increase services to deal with many unmet social needs; (2) Medicare continues to neglect the expansion of social work coverage and payment to home health agencies for supplemental social needs necessary to make the new requirements effective for Medicare home health patients; and (3) Medicare still does not mandate that any Social Determinants of Health need detected through the new OASIS requirements must receive follow-up care with appropriate, covered interventions and the OASIS questions do not affect scoring for episode payment.
Keywords
Establishing Context
There has been significant attention recently on increasing the use of non-traditional skilled and non-skilled services to improve patient and system outcomes in Medicare and Medicaid by addressing social determinants of health (SDoH). Congress authorized Medicare Part C providers (Medicare Advantage) to deliver previously banned non-skilled services These services are referred to as non-medical supplemental benefits in Medicare Advantage and include homemaker, meal, housing, utilities, case management, home modifications, social support needs, complementary therapies, and transportation services, among others.1,2 In its most recent 2025 report on these benefits, ATI 1 found that the number of Medicare Advantage Plans offering the supplemental benefits in food, transportation, and housing had increased. Although there has been increased recognition and payment for these benefits under Medicare Advantage Plans, traditional Medicare providers are not permitted to provide such benefits and there has been no change in the Medicare or Medicaid home health benefit to allow delivery of such services.3,4 See Table 1 for a list of such services not covered for traditional Medicare beneficiaries.
Centers for Medicare and Medicaid Services (CMS) 2025 Final Medicare Home Heath Payment Rule
In its 2025 final payment rule for Medicare Home Health published November 7, 2024 the Centers for Medicare and Medicaid Services (CMS) 5 added 5 new questions to the Outcome and Assessment Information Set (OASIS) needing to be addressed: 4 new (i.e., 1 on living situation; 2 on food insecurity; and 1 on utilities) and 1 revised (i.e., transportation). The rule states that the changes are responsive to issues in the social determinants of health (SDoH) category and take effect with the calendar Year 2027 Home Health Quality Reporting Program (HH QRP). The specifics of the new OASIS questions as stated in the final rule are:
Living situation (housing instability, homelessness, poor quality housing)
• What is your housing situation today?
Food (Food security)
• Within the past 12 months, you worried that your food would run out before you got money to buy more.
• Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more.
Utilities
• In the past 12 months, has the electric, gas, oil, or water company threatened to shut off your services in your home?
Update to Transportation (A1250)
• In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, or from getting things needed for daily living? 5
Literature Review and Rationale
A literature review indicates no studies on Medicare home heath social workers’, or any other provider, perceptions of the potential impact of these OASIS revisions on traditional Medicare home health beneficiaries’ ability to receive either non-medical supplemental benefits or increased social work services, which are the service designated to address social needs. The literature review used CINAHL, PubMed, Medline, Cochrane Library, Campbell Collaboration, PsycINFO, Sociological Abstracts, and Social Science Abstracts databases with an initial search period of July 1, 2024 (the month when the CMS final rule was first proposed) through December 31, 2024, and updated through March 1, 2025, after the current study was concluded. Multiple keywords were used by applying Boolean search strategies: social determinants of health; home care social work; Medicare home health social work; CMS Medicare Home Health 2025 Final Payment Rule; psycho-social care and Medicare home health. The searches yielded 2 studies on home health social worker views on the exclusion of SDoH coverage in traditional Medicare and limited home health social work coverage, 6 and 1 study on OASIS-E revised requirements, 7 but no studies on the potential impact of the Medicare Home Health 2025 Final Payment Rule OASIS revisions on traditional Medicare home health beneficiaries’ ability to receive either non-medical supplemental benefits or increased social work services, the service designated to address social needs.
The current study was prompted by this gap in existing literature. The article presents the results of an exploratory research study of 31 Medicare home health social workers in the New York City metropolitan area between January 6, 2025 and February 9, 2025. The study used interviews to probe Medicare home health social worker perceptions of the CMS Medicare Home Health 2025 Final Payment Rule OASIS revisions.
Study Method
The current study used a grounded theory approach. 9 Grounded theory is the research methodology of choice because it was developed for interpreting qualitative data in the absence of pre-existing theory.
The data was collected through interviews of 31 Medicare home health social workers, selected from the New York City metropolitan area from January 6, 2025, to February 9, 2025. Home health social workers were used as subjects because they are the primary professionals responsible for assessing and treating social and psychosocial needs of Medicare home health beneficiaries. 8 Subjects were selected using a snowball convenience sampling technique, whereby home care industry professionals known to the author identified potential interviewees. In-person interviews were conducted by the author at locations at locations convenient for participants and off-site from where they worked. The author stopped doing interviews at 31 participants because he believed he had reached saturation on the topic. Interviews averaged 45 minutes and were guided by an interview guide which was used to help standardize the data collection. Each interviewee was given a copy of the 5 OASIS changes in the final 2025 rule at the outset of their interview. The study was not subject to an Institutional Review Board (IRB) approval since the author is self-employed and the study is financed privately. Nevertheless, all participants were assured of voluntary participation, anonymity, and confidentiality through an informed consent they signed, following federal requirements. Qualitative analysis began shortly after the initial data were collected and resulted in additional questions and probes that were applied to subsequent interviews, in an ongoing iterative process. Analysis followed the grounded theory 3-stage coding of interview data: open, axial, and selective coding.
Open coding was used to fracture the data to “identify some categories, their properties, and dimensional locations” 9 (p. 27). The coding and classification generated a list of 323 codes. Code and category labels were created, systematically sorted, compared, and contrasted until they were complete, with no new codes or categories produced and all data accounted for. Through axial coding, multiple phenomena were identified from the connected categories and subcategories. These phenomena included Medicare home health social workers’ perceptions of how the new OASIS requirements impact their ability to assess and provide Medicare-covered care of non-medical supplement (or social) needs for Medicare beneficiaries.
Finally, using selective coding, a “story line” was identified and a “story” written that integrated the axial coding phenomena. 9
In keeping with the grounded theory approach, the data analysis and interpretation were facilitated by analytical and self-reflective memo writing, which helped move empirical data to a conceptual level; expanded and refined the data and codes; developed core categories and interrelationships; and integrated the experiences, interactions, and processes embodied in the data. 9 All initial abstraction, analysis, and interpretation were done by the author. After the initial process, all abstraction, analysis, and interpretations were reviewed by 2 additional experienced qualitative researchers. Any differences were discussed by the 2 external reviewers and the author to reach final decisions used for the study results. All analysis was done using ATLAS.ti software.
Study Participants
Limited demographic data were collected from study participants using a short survey. The results appear in Table 2. Overall, the Medicare home health social workers were 36 to 55 years old (82%); female (90%); Caucasian, non-Hispanic (87%); had 6 to 10 years of home care experience (51%); and had an average caseload of 5 to 10 patients (81%). Statistical analysis of the demographic variables’ impact on study outcomes was not done due to the qualitative nature of the study.
Home Care Social Worker Participant Demographic Characteristics.
Study Results
The selective coding used in the study identified a story line: Medicare home health care social workers’ perceptions of the impact of the CMS Medicare Home Health 2025 Final Payment Rule OASIS revisions on Medicare home health beneficiaries’ ability to be assessed for and receive non-medical supplemental benefits and Medicare home health social work services, the service designated to address social needs
Three themes emerged from interviews, which are detailed below with supporting quotes.
Theme 1: Social workers believe the new requirements are overdue, needed, and provide the potential to increase services to address many unmet social needs.
The first theme was supported by all social workers interviewed (31 of 31; 100%). This is a positive move. It’s way overdue. I do not know what took them so long to do this or why they are waiting until 2027 to make it effective, but, anyway, I guess it is a positive step. Social Worker 1 These needs so obviously affect patient care that, sure, just asking questions on the OASIS is needed. It is ridiculous they [CMS] took so long to do this. It is obvious to anyone working in home health. Social Worker 2 There is no doubt these OASIS questions are overdue and needed. I just wish they [CMS] had done it sooner. This seems like a good start in [CMS] finally recognizing things like housing, food, and transportation affect patient health. Social Worker 3
Theme 2: Social workers believe the new OASIS requirements do not mandate that any social determinants of health need detected through the new OASIS requirements must be addressed with appropriate, covered interventions and do not affect OASIS scoring for episode payment.
The second theme was supported by virtually all home care social workers interviewed (30 of 31; 97%).
As much as I believe this is positive, I do not see how they [the new OASIS questions] will be effective if there is no mandate that we [social workers] must act on the answers to these questions. I see no guidance, no protocol, no criteria on if or when we, as social workers, must provide assessment or care based on the initial or ongoing answers to these questions. Why bother adding the questions if they are not linked to assessment and treatment? Social Worker 4 What’s the point of these requirements if they do not affect payment? Everything in home health nowadays is about money. I hear it all the time. So what if these questions must be answered if the answers do not affect the episode payment. And they don’t even say these questions should be posed and followed up by a social worker! I don’t get it. Social Worker 5 No mandate for further assessment or care! That seems to make these questions useless. What is the point? Social Worker 6
Similar issues were raised by social workers in a study related to new OASIS-E requirements effective in 2023 to address mental health issues. 10 Multiple studies have associated unmet social determinants of health needs with increased occurrence of mental health and physical health conditions, particularly falls and depression.2,6,11
Theme 3: Social workers believe Medicare Home Health continues to neglect the expansion of social work coverage and payment to home health agencies for supplemental social needs (currently only allowed under Medicare Advantage plans) necessary to make the new requirements effective Medicare home health patients.
The third theme was supported by virtually all home care social workers interviewed (29 of 31; 93%).
Well, these new questions are helpful, but if a need is detected, we [home health social workers] can’t address it under the current [Medicare home health social work] coverage policies. We cannot help patients apply for SNAP, or housing assistance, or senior centers, or even Medicaid. It is social work case management 101, an essential part of what social workers do, and we can’t do it because of these limitations. Creating these [new OASIS] questions does not address that issue. That is sad. Social Worker 7 Most of my caseload needs help with food, housing, transportation insecurity. That has always been the case. Until Medicare lets us [social workers] assess these needs and provide services with pay to meet these needs, they can include all the new questions they want in OASIS but it will not help patients. Social Worker 8 I think it is a cruel joke. They [CMS] now create questions in OASIS that are new, but that should have been asked forever, since OASIS was created. Then they do not link the results of answering the questions to our [Medicare home health social workers] ability to deliver covered assessments and treatments. Yes, it s a cruel joke; just adds more paperwork and frustration to our job. Social Worker 9
The social workers’ perceptions are correct. As noted earlier, social workers have a limited ability to assess, provide, and receive payment for care for social and psychosocial needs Medicare home health only covers psychosocial care by social workers, which is limited to individual therapy; no group therapy; limited case management services including limitations on assisting with application for or acquisition of government or private-sourced benefits and transportation, housing, food, and utility services; and limitations on assistance with acquiring other public or privately-funded limited support services.6,8,11,12 One reflection of such limitations is the historic status of Medicare home health social work being the least utilized Medicare home health service, including the most recent 2021 MedPac data reporting social work as the lowest average visits per stay at 0.1 visits per stay. 4
Limitations
The study was a qualitative, exploratory study. As such it does not address causality and has several limitations including: lack of random sampling for sample selection; use of a sample of home care social workers only from home health agencies in the New York City metropolitan area; and lack of a randomized controlled trial experimental design to test specific interventions against a control group. Additionally, each social worker interviewed was asked to respond based on their overall experience as a home care social worker, not only based on their current experience.
Discussion of Policy Options
Despite its limitations, the study does begin to address a gap in the literature and policy by reporting Medicare home health social workers’ perceptions of how the new OASIS requirements impact their ability to assess and provide Medicare-covered care of non-medical supplement (or social) needs for Medicare beneficiaries.
The social workers’ perceptions revealed through the interviews are supported by significant professional literature on the topic, as noted above. There are several possible policy routes to achieve such policy reform.
One policy action would be for the Center for Medicare and Medicaid Services (CMS) to create a protocol, based on professional criteria, mandating when a social worker should do a further assessment and necessary treatment based on answers to the new 2025 final rule OASIS requirements, and any OASIS questions related to social or psychosocial needs.
A second policy action would be for CMS to review and propose modification of the current prospective payment episode payment system to include scoring of the new 2025 final rule OASIS requirements, and any OASIS requirements related to social and psychosocial needs, in the episode payment calculations.
A third policy option would be for CMS to expand coverage and payment for Medicare home health social work services required to assess and treat any conditions addressed in any OASIS questions related to social or psychosocial needs, including the new 2025 final rule social needs questions in OASIS.
Conclusion
Given the existing studies and the social worker input from this study, it seems policymakers should consider improving patient care, which could more effectively address SDoH issues, such as housing, food insecurity, utilities, and transportation, among others, which affect the health of Medicare home health beneficiaries. Although it is possible that improved patient care might require higher costs, an alternative outcome might be the reduction of Medicare costs based on evidence of such impacts from increased coverage of SDoH. 2 This potential for improving beneficiary health and cost reduction might be enhanced by CMS mandating when a social worker should do a further assessment and necessary treatment based on answers to the new 2025 final rule OASIS requirements, and any OASIS questions related to social or psychosocial needs; adding responses to the new OASIS social needs and other OASIS social and psychosocial needs questions into a revised Medicare home health episode-based payment system; and by expanding Medicare social work services coverage so that assessments and treatments related to SDoH questions in the OASIS can actually be covered and paid.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.
