Medicare Home Health Payment Integrity and Protection Act of 2026
- Sponsor
- Rep. Tenney, Claudia [R-NY-24]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Oct 13, 2026
Bottom line
The bill aims to combat Medicare home health fraud by tightening oversight, adjusting payment methodologies to exclude unreliable data, and increasing funding for enforcement and state surveys.
What it actually does
This bill amends Title XVIII of the Social Security Act to enhance fraud prevention and program integrity for Medicare home health agencies. It introduces stricter enrollment screening, increases survey frequency for certain agencies, mandates payment adjustments for non-submission of quality data, and revises payment calculations to exclude fraudulent data. Additionally, it provides significant funding for program integrity, enforcement, and state survey agencies to combat home health fraud.
Proponents argue
Supporters argue that this bill is crucial for protecting Medicare beneficiaries and taxpayers from widespread fraud and abuse in the home health sector. They contend it ensures that payments are based on legitimate data, improves the quality of home health services by holding agencies accountable, and strengthens the long-term solvency of the Medicare program.
Opponents contend
Critics might contend that the bill imposes undue administrative burdens and compliance costs on legitimate home health agencies, potentially leading to closures or reduced services, especially for smaller or rural providers. They may also argue that the proposed payment reset could negatively impact providers, limiting access to essential home health care for beneficiaries.
The bill is relatively short and its core provisions are clearly articulated, making it accessible for a reader to evaluate its contents within a reasonable timeframe.
Section 101
Enhanced Enrollment Screening for Home Health Agencies
This provision requires additional, more stringent screening for home health agencies applying for Medicare enrollment if they are determined to be at an "extreme risk of fraud." This enhanced screening includes mandatory fingerprinting of the agency's administrator and a requirement for the agency to hold a comprehensive liability insurance policy. An agency is deemed at extreme risk if it is located in a state or county where the number of home health agencies significantly increased in the most recent year.
Supporters argue
Supporters argue that these enhanced screening measures are essential to create a stronger barrier against fraudulent actors attempting to exploit the Medicare home health program, thereby protecting taxpayer dollars and ensuring that only legitimate providers serve beneficiaries.
Critics contend
Critics may contend that these additional requirements could create unnecessary administrative hurdles for new, legitimate home health agencies, especially those seeking to establish services in areas with growing demand, potentially limiting access to care for beneficiaries.
Tradeoffs
The provision balances the need for robust fraud prevention with concerns about potential barriers to entry for legitimate providers and the impact on access to care.
Section 102
Additional Oversight and Quality Data Requirements for Home Health Agencies
This section significantly increases oversight for home health agencies. It mandates monthly standard surveys for 36 months for newly enrolled agencies, those with a change of ownership, or those reactivating billing privileges. It also requires surveys every 18 months for agencies that fail to submit quality data or exhibit aberrant admission rates or other fraud indicators. Furthermore, the bill increases the payment reduction for agencies failing to submit quality data from 2% to 15% for 2029 and subsequent years, while introducing a 30-day grace period for agencies demonstrating a good faith effort to submit data.
Section 103
Additional Survey and Training Requirements for Accreditation Organizations
This provision mandates that national accreditation bodies seeking or maintaining approval from the Secretary for accrediting home health agencies must meet or exceed the survey standards applicable to state and local agencies. It also requires their surveyors to complete relevant basic training courses offered by the Centers for Medicare and Medicaid Services (CMS). The bill further establishes a mechanism for CMS to periodically assess the performance of these accreditation bodies and impose remedies, including corrective action plans or termination of approval, if deficiencies are found.
Section 201
Calculation of Home Health Prospective Payment Amount Using Reliable Data
This provision mandates the Secretary of Health and Human Services to establish a revised standard prospective payment amount for home health services for calendar year 2027 and subsequent years. The calculation must begin with the 2020 payment amount, adjusted annually, but critically, it must use a methodology that excludes claims data associated with fraudulent, wasteful, abusive, aberrant, or otherwise unreliable billing patterns. It also requires accounting for the effects of the COVID-19 public health emergency and other circumstances that materially affected home health utilization or spending but were not part of the Patient Driven Groupings Model (PDGM) behavioral assumptions.
Section 202
Suspension of Permanent and Temporary Adjustments
This provision prohibits the Secretary of Health and Human Services, for 2027 and subsequent years, from imposing any permanent or temporary adjustments to home health prospective payment amounts. These adjustments were previously used to offset increases or decreases in estimated expenditures attributed to differences between assumed and actual behavioral changes following the implementation of the Patient-Driven Groupings Model (PDGM) in 2019.
Section 203
Conforming Protection for Benchmarks and Value-Based Programs
This provision requires the Secretary of Health and Human Services, for 2027 and subsequent years, to exclude or adjust for "suspect claims" when calculating benchmarks or applying any quality, value-based, or benchmarked adjustments to payments for home health agencies. A "suspect claim" is defined as any claim for home health services that the Secretary determines contains unreliable data or data from a provider that may have engaged in fraud, waste, or abuse.
This subclause defines how the Secretary shall determine whether a home health agency is located in a "high-risk area" for fraud. Specifically, it refers to a State or county where the total number of home health agencies significantly exceeded the total number of such agencies in that area during the preceding year.
Section 101(2)(G)(ii)
Why it matters:This is standard legislative practice for defining terms that are used elsewhere in the bill. While technically phrased, it provides a concrete, data-driven trigger for enhanced fraud screening.
Case for: Proponents argue that this provides a clear, objective, and data-driven metric for identifying geographic areas prone to rapid, potentially fraudulent, growth in home health agencies, allowing for targeted and efficient application of enhanced screening measures.
Case against: Critics might suggest that relying solely on this metric could inadvertently target areas experiencing legitimate, rapid growth in demand for home health services, potentially leading to unnecessary burdens on new, compliant agencies and limiting access to care in those areas.
Estimated impact: This provision directly influences where enhanced fraud screening efforts will be concentrated, potentially impacting the ease of entry for new home health agencies in specific geographic regions.
This subsection amends existing law to increase the payment reduction for home health agencies that fail to submit required quality data from 2% to 15% for 2029 and subsequent years. It also adds a new provision requiring the Secretary to establish a process for granting a 30-day extension to agencies that demonstrate a good faith effort to submit their data by the deadline.
Section 102(b)
Why it matters:This is standard legislative practice for amending existing sections of the Social Security Act. The structure is typical for updating specific parameters within an established program.
Case for: Proponents argue that a 15% payment reduction provides a much stronger incentive for agencies to comply with quality data submission requirements, which are crucial for program oversight, value-based care initiatives, and ensuring transparency. The added grace period offers a reasonable safeguard for agencies making good faith efforts.
Case against: Critics might argue that a 15% reduction is a substantial penalty that could severely impact the financial viability of legitimate agencies, especially smaller ones, even with a grace period. They may contend it could lead to financial distress or closures for those struggling with administrative compliance, potentially reducing access to care.
Estimated impact: This provision could lead to significant financial penalties for non-compliant home health agencies, while also likely increasing overall compliance with quality data submission requirements across the industry.
This section mandates that the Secretary of Health and Human Services must implement the amendments made by Titles I and II of this Act through notice and comment rulemaking under section 553 of title 5, United States Code.
Section 302
Why it matters:This is standard legislative practice for ensuring public input and transparency when significant regulatory changes are being implemented. It's a procedural safeguard rather than a hidden policy.
Case for: Proponents argue that requiring notice and comment rulemaking ensures transparency and allows all affected stakeholders—including home health agencies, beneficiaries, and accreditation bodies—to provide input on the specifics of implementation. This public engagement can lead to more effective, practical, and less burdensome regulations.
Case against: Critics might argue that requiring formal rulemaking can significantly slow down the implementation process, potentially delaying the intended benefits of fraud prevention and program integrity. They may prefer faster implementation, especially for urgent anti-fraud measures.
Estimated impact: This provision ensures that the implementation of the bill's major policy changes will be subject to public scrutiny and input, potentially influencing the final shape of regulations and their impact on the home health industry.