The Centers for Medicare and Medicaid Services, part of the Department of Health and Human Services, issued an interim final rule on December 3, 2025, repealing minimum staffing standards for long-term care facilities participating in Medicare and Medicaid. Effective February 2, 2026, this rule responds to a legislative moratorium imposed by Public Law 119-21, signed into law on July 4, 2025, which prohibits enforcement of the standards until September 30, 2034. The repeal addresses concerns from facilities, especially in rural and tribal communities, about hiring challenges and risks of closure. It also considers recent court decisions vacating parts of the original rule and aims to align regulations with current policy views. This development marks a significant shift in federal oversight of nursing home staffing, potentially easing immediate burdens on providers while raising questions about resident care quality over the next decade.
Background on the 2024 Staffing Rule
In May 2024, CMS finalized a rule establishing minimum staffing standards for long-term care facilities, requiring a registered nurse onsite 24 hours a day, seven days a week, and specific hours per resident day: 0.55 for registered nurses, 2.45 for nurse aides, and 3.48 total for nurse staffing. These standards drew from data and literature available in 2022 and 2023, aiming to improve resident safety and care quality. The rule included phased implementation, with exemptions for certain facilities, and was intended to address longstanding concerns about understaffing in nursing homes.
However, Public Law 119-21 intervened, suspending these provisions. The law explicitly bars CMS from implementing, administering, or enforcing the standards until after September 30, 2034. This legislative action left the regulations unenforceable, prompting CMS to restore prior versions of the Code of Federal Regulations to avoid confusion and ensure compliance with statutory requirements under sections 1819 and 1919 of the Social Security Act, which mandate sufficient staffing without specifying quantitative levels.
Basis for the Repeal
CMS cited multiple factors for the repeal. The primary driver is the legislative moratorium, which renders sections of 42 CFR 483.5 and 483.35 unimplementable. Without repeal, the regulations would lack enforceable standards for nursing services, potentially leading to inconsistencies across states.
Policy considerations also played a key role. Facilities, particularly in rural and tribal areas, reported severe recruitment difficulties due to geographic isolation and workforce shortages. For instance, the National Indian Health Board warned that the standards could lead to closures, disrupting cultural bonds and elder care in tribal communities. Reports from the International Council of Nurses and the Health Resources and Services Administration highlight projected shortages, including 295,800 nurses nationwide by 2030, with greater deficits in nonmetropolitan areas.
Litigation further influenced the decision. Two federal district courts vacated core provisions: in American Health Care Association v. Kennedy (N.D. Tex. 2025), the court applied the major questions doctrine to find CMS exceeded its authority. In Kansas v. Kennedy (N.D. Iowa 2025), similar concerns were raised. Both cases are under appeal, but they underscore doubts about the standards' legal foundation.
CMS now views the one-size-fits-all approach as inappropriate, failing to account for local variations in labor supply, resident acuity, and resources. The agency emphasized commitments to resident health while acknowledging the need for flexibility, especially after further tribal consultations. The Tribal Technical Advisory Group supported the moratorium, noting its benefits for rural tribal facilities.
Key Provisions of the Interim Rule
The rule revises 42 CFR part 483 by removing the definition of 'hours per resident day' from section 483.5, as it relates solely to the repealed standards. In section 483.35, it eliminates the 24/7 registered nurse requirement and the specific hours per resident day mandates, reinstating the statutory minimum of eight consecutive hours of registered nurse services daily, seven days a week, with a full-time director of nursing, subject to waivers.
Technical corrections address citation errors from the 2024 rule, such as updating references to facility assessment requirements now at section 483.71. Existing requirements for sufficient staff, nurse aide proficiency, and daily posting of staffing data remain intact. CMS invites comments until February 2, 2026, particularly from tribes, to inform future rulemaking.
Implications and Perspectives
Short-term implications include relief for facilities facing compliance costs, estimated at over $5 billion annually in the 2024 rule's impact analysis. Rural and tribal providers may avoid closures, preserving access to care. However, advocates for residents argue this could compromise safety, as studies linked higher staffing to better outcomes. The repeal saves facilities approximately $55 billion over 10 years, per CMS estimates, but increases Medicare costs by $3.3 billion due to potential rises in hospitalizations from lower staffing.
Long-term effects depend on future actions. Without federal minimums, states may vary in standards, leading to uneven care quality. Perspectives differ: industry groups like the American Health Care Association welcome the change, citing impracticality, while labor unions and patient advocates, such as those referenced in the International Council of Nurses report, emphasize risks of burnout and shortages. CMS's invitation for tribal input signals potential tailored approaches ahead.
The repeal highlights tensions between regulatory uniformity and local realities, influenced by political forces including congressional intervention and judicial scrutiny. It avoids enforcement confusion during the moratorium but opens debates on balancing provider viability with resident protections.
In summary, this interim rule aligns regulations with current law and policy, providing clarity for long-term care facilities. Potential next steps include reviewing public comments, which could shape new proposals incorporating updated evidence on staffing needs. Ongoing challenges involve addressing workforce shortages through recruitment incentives or training programs, while debates persist on federal versus state roles in ensuring care standards. Future rulemaking may revisit quantitative standards post-2034, informed by evolving data and stakeholder input.
