The Moratorium's November Decision Point: What an Extension Would Mean for Sellers, Buyers, and Access

The November enrollment decision could change the timing and structure of home health or hospice transactions, but owners do not need to wait for certainty before preparing. This article explains how the freeze affects Medicare enrollment, CIMOs, buyer underwriting, valuation, payment risk, and patient access. It also provides a practical preparation plan for owners considering a sale or succession. Senate Healthcare is evaluating acquisitions with a focus on clean transferability, quality care, and sustainable operations.

9/8/20266 min read

CMS's nationwide enrollment moratorium on new home health and hospice providers reaches its first major decision point around November 13, 2026. This article explains what an extension, expiration, or modification could mean for agency owners, transaction structures, valuation, buyer underwriting, and patient access.

Quick Scan Summary

The six month moratorium does not shut down existing home health or hospice agencies. It restricts new Medicare enrollment, including certain changes in majority ownership that require an initial enrollment.

For owners considering a sale or succession, the key issue is not simply whether CMS lifts the freeze. The key issue is whether the agency can transfer cleanly under the proposed deal structure, with a clear ownership history, strong compliance file, stable financials, and manageable payment risk.

An extension could concentrate buyer demand around agencies that are already Medicare enrolled and operationally transferable. However, the payment overhang and stricter provider enrollment rules may limit how much buyers are willing to pay.

Who this is for

Home health or hospice owners with approximately $2 million to $10 million in annual revenue
Owners considering a sale, succession plan, or strategic partnership
Operators evaluating whether to sell before or after the November decision point
Owners concerned about the impact of the freeze on growth, staffing, patient access, or valuation

Key takeaways

CMS imposed a six month nationwide moratorium effective May 13, 2026.
The first decision point is around November 13, 2026.
CMS may allow the freeze to expire, extend it for another six months, or modify its scope.
Most ownership changes are not automatically blocked. The structure of the transaction determines the risk.
Cleanly transferable agencies may attract greater buyer attention while new entry remains restricted.
Payment uncertainty, including the proposed 3.0 percent temporary adjustment, will affect buyer underwriting and sale price.
Owners should prepare now instead of waiting for CMS to make the decision.

What is frozen, and until when?

CMS published the home health moratorium in the Federal Register on May 15, 2026, at 91 FR 27954. A companion hospice notice, document number 2026-09718, covers the nationwide hospice enrollment freeze. Both notices made the moratorium effective May 13, 2026.

The moratorium applies to initial Medicare enrollment applications for new home health or hospice providers. It also applies to certain changes in majority ownership, known as CIMOs, when the change requires the provider to enroll as a new entity.

Under 42 CFR 424.570(b), a temporary moratorium lasts six months and may be extended in additional six month increments. Any extension must be announced through a Federal Register notice.

CMS says the policy responds to longstanding fraud concerns. Its stated rationale includes more than 1,000 new home health agencies since 2019, a more than 40 percent increase in Los Angeles County home health agencies between 2019 and 2023, and clusters of five to 18 agencies operating from one Ohio address. CMS also says there are more than 11,500 home health agencies nationwide and no current evidence of a nationwide shortage.

The Washington Examiner has raised a different concern. Its September 7 op-ed warns that a nationwide freeze could create longer wait times, fewer choices, delayed hospital discharges, and reduced availability in rural and underserved communities.

Both issues matter to owners. Program integrity affects buyer risk. Patient access affects market need, referral relationships, workforce demand, and the long term strength of home based care.

What November could bring

The 2013 HHA moratorium shows why owners should not assume that expiration is automatic. That earlier moratorium began in Miami Dade County and Cook County, was extended repeatedly, and did not expire until January 30, 2019. In practical terms, a temporary restriction can become a multiyear operating reality.

Why the freeze may raise attention around transferable agencies

The freeze does not automatically increase every agency's value. It may, however, concentrate demand around existing Medicare enrolled agencies that can be transferred without triggering a new initial enrollment.

During the freeze, the buyer landscape includes existing operators expanding geographically, private equity platforms and portfolio companies, regional strategic buyers and health systems, and individual or physician buyers. These buyers may prefer an operating agency with an established provider number, referral base, workforce, compliance history, and census rather than waiting to build a new Medicare operation.

Consider a home health owner with $4.5 million in revenue and $540,000 of normalized EBITDA. At a 4.5 times EBITDA multiple, the illustrative enterprise value is $2.43 million. If stronger compliance documentation, reduced owner dependence, and reliable payer economics support a 5.25 times multiple, the value becomes $2.84 million. That is a difference of approximately $410,000.

The freeze does not create that value by itself. It makes transferability and buyer confidence more important. An agency that cannot clearly demonstrate its ownership history, billing compliance, referral durability, and workforce stability may receive a discount even if demand is strong.

A hospice example is similar. A hospice with $3 million in revenue and $450,000 of normalized EBITDA might be valued at $1.8 million at 4.0 times EBITDA. If the agency has clean certification records, dependable medical leadership, low key person dependence, and a credible succession plan, a 4.75 times multiple would produce an illustrative value of $2.14 million.

These are examples, not market quotes or guarantees. The point is that buyer underwriting converts operational risk into a price adjustment.

The CY 2027 Home Health PPS proposed rule includes provider enrollment changes that owners should watch.

The proposal would clarify that the ownership change carve out applies to changes that do not require initial enrollment, while expressly addressing home health, hospice, and DMEPOS suppliers. It would also establish the effective date of a moratorium as the date the notice is filed for public inspection with the Office of the Federal Register, rather than the later publication date. That change is designed to prevent a rush of applications after a moratorium is announced.

The proposed rule also includes:

Broader retroactive revocation authority
New denial or revocation grounds involving certain misdemeanor convictions
High risk geographic areas with excessive provider concentration
Noncompliance with CIMO requirements
Hospice medical director and administrator requirements
A broader reapplication bar
Removal of the five year affiliation lookback
Additional marketing, business, financial, managerial, and beneficiary relationships in affiliation disclosures

The comment period closed August 31, 2026, with 657 comments received. These provisions are proposed, not final, but they reinforce the direction of buyer underwriting: provider enrollment, ownership history, documentation, and operational legitimacy will receive closer scrutiny.

The payment backdrop matters in negotiation

The proposed CY 2027 rule projects a 2.4 percent aggregate home health payment increase, or approximately $420 million. That figure includes a proposed 2.1 percent payment update and an estimated 0.3 percent increase from the updated fixed dollar loss ratio.

The positive headline has an important qualification. CMS proposes to continue a 3.0 percent temporary recoupment adjustment, collecting approximately $500 million in CY 2027. CMS also says the total temporary adjustment balance is approximately $4.9 billion and that a permanent adjustment of negative 5.043 percent would be needed to fully offset CY 2020 through 2025 under the illustrative calculation.

For sellers, this matters because buyers underwrite future cash flow, not just historical revenue. A buyer may normalize EBITDA for reimbursement pressure, payer mix, denials, authorization labor, and working capital needs. Owners should prepare monthly reporting on:

Net reimbursement per completed visit by payer
Authorized visits compared with clinically ordered visits
Denials and appeal overturn rates
Authorization labor hours per 100 Medicare Advantage episodes
Days in accounts receivable by payer
EBITDA margin by payer
Revenue concentration by individual Medicare Advantage plan
Referral volume by payer and referral source

So what should you do now?

Build three operating and valuation cases: expiration, extension, and modification.
Confirm your ownership history, CIMO exposure, provider enrollment records, and transfer path.
Clean the financials and separate owner specific expenses from sustainable operating costs.
Prepare a confidential buyer package that explains quality, compliance, patient access, workforce stability, and payment risk.

Plain Language Glossary

Moratorium: A temporary pause on accepting or processing certain new enrollment applications.

Initial enrollment: The process used when a provider first enrolls in Medicare or must enroll again as a new provider.

CIMO: Change in majority ownership. Some CIMOs are treated as initial enrollments under Medicare rules.

Seasoning: The length of time an agency has operated under its current enrollment and ownership structure.

Buyer underwriting: The buyer's process for testing revenue, expenses, compliance, transferability, and future cash flow before determining price and terms.

Normalized EBITDA: An adjusted measure of operating earnings that removes unusual, owner specific, or nonrecurring items.

Partner with Senate Healthcare

Senate Healthcare is the acquiring entity and strategic partner evaluating home health or hospice agency acquisitions. We work directly with owners who are considering a sale, succession plan, or structured partnership and help identify the risks that may affect transferability, valuation, and post closing operations.

If your agency is not perfectly positioned today, that does not mean the conversation must wait. A confidential discussion can help you understand how Senate Healthcare would evaluate your ownership history, compliance file, financial performance, patient census, workforce, and path to a successful transition.

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