Nursing Home Staffing Mandate Delayed

​When the Centers for Medicare & Medicaid Services (CMS) finalized the standards in 2024, those minimums were deemed by the agency as “essential” to providing residents with “safe, high-quality care while being treated with dignity.” AARP championed the standards, noting that more staff was linked to higher quality of care in nursing homes. ​

The staffing rule was slated to go in full effect for almost all nursing home facilities by May 2029 through a staggered implementation plan. But the new law postpones implementation until October 2034. ​

This means most nursing home residents are unlikely to receive adequate care before then. Less than 1 in 5 facilities met all three of the direct nursing care staffing standards in the final months of 2023, according to KFF. And not much progress has been made since then, says KFF’s Chidambaram. ​

Some other parts of CMS’s original staffing rule have not been delayed by the new law. For example, states will still have to meet new transparency requirements, including reporting the percentage of Medicaid payments spent on pay to direct care workers and support staff in nursing homes and publicly disclosing facilities’ staffing levels. Also, nursing homes will still be required to perform more robust facility assessments that better focus on residents’ needs and to create staffing plans that meet those needs. ​

That’s little consolation, though, says National Consumer Voice’s Brooks. “The real meat of the rule isn’t there now,” he says, “and the legacy of that is literally going to be tens of thousands of deaths and more suffering for hundreds and thousands of older Americans who continue to reside in nursing homes that don’t have adequate staffing.”

Reduced retroactive Medicaid coverage

Before the new law passed, people could get coverage for nursing home care and other medical expenses incurred three months before they applied for Medicaid. Under the new law, this timing would narrow to one month prior to application for Medicaid expansion enrollees and two months prior for traditional enrollees. Most nursing home residents are traditional enrollees. ​

Retroactive Medicaid coverage is crucial to preventing low-income Americans from accumulating huge medical bills for services received before they apply for Medicaid. The change could lead to financial hardship for nursing home residents and their families, warns AARP’s Rhonda Richards, a government affairs director focused on long-term care. ​

“One month’s worth of nursing home care can be very expensive,” Richards says — roughly $8,700 a month, based on KFF’s estimated costs for a semiprivate room in 2023.

New home equity limit for Medicaid eligibility

Medicaid has specific financial rules for people who want to qualify for long-term care coverage, including nursing home care. ​

To be eligible for Medicaid-covered nursing home care, your home equity — how much your home is worth, minus any loans or mortgages — can’t exceed the federal limit of $500,000 (which, adjusted to inflation, is $730,000 in 2025) or an upper limit of $750,000 (which, adjusted to inflation, is $1,097,000 in 2025) if a state has chosen to set that higher limit. ​

Under the new law, however, that limit will be capped at $1 million in home equity for most properties, starting in 2028, with no adjustments for inflation.

​While most states don’t currently have home equity limits over $1 million, the provision is likely to reduce the number of people who qualify for Medicaid-covered nursing home care over time. As home values rise, many states have increased home equity limits, says KFF’s Chidambaram. With the new federal cap, this will no longer be an option.

Delays to Medicaid enrollment improvements

​The majority of the country’s 1.2 million nursing home residents have both Medicaid, which pays for their long-term care, and Medicare, which pays for other medical care, like hospital stays and doctor visits. ​

Enrolling in and maintaining this “dual-eligible” health care coverage has often been administratively challenging for nursing home residents and states. After the COVID-19 pandemic, many people enrolled in both programs lost Medicaid coverage for procedural reasons and not because they were ineligible. ​

To curb this problem, CMS issued two separate rules, under the Biden administration, intended to make it easier for people to enroll in and renew Medicaid coverage. Collectively, they are referred to as the eligibility and enrollment final rule. AARP advocated for both. ​

The new law recently signed by Trump, however, prohibits the implementation of both rules until October 2034. The delay is likely to perpetuate the existing administrative challenges for nursing home residents as they try to access and maintain Medicaid coverage, Chidambaram says. The CBO estimates that the delay will reduce the number of dual-eligible beneficiaries by 1.3 million through 2034.