Medicare Home Health Payment Integrity and Protection Act of 2026
- Sponsor
- Sen. Collins, Susan M. [R-ME]
- Committees
- Finance Committee (primary)
- Last action
- Aug 5, 2026
Bottom line
The bill seeks to bolster Medicare program integrity and combat fraud in home health services through stricter oversight, payment adjustments, and dedicated funding.
What it actually does
This bill aims to reduce fraud in Medicare's home health sector by enhancing enrollment screening for agencies deemed at 'extreme risk of fraud,' increasing survey frequency for certain agencies, and strengthening oversight of accreditation bodies. It also resets the standard prospective payment amount for home health services, suspends certain payment adjustments, and mandates the exclusion of 'suspect claims' from payment calculations and value-based programs. Furthermore, the bill appropriates significant funding for program integrity, enforcement, and state survey activities.
Proponents argue
Proponents argue that the bill is essential to protect the Medicare program from widespread fraud, waste, and abuse in the home health sector, which diverts critical resources and undermines the quality of care for beneficiaries. They contend that the enhanced screening, increased oversight, and payment adjustments will ensure that only legitimate providers participate in the program and that payments are based on accurate data, ultimately safeguarding taxpayer dollars and improving beneficiary trust.
Opponents contend
Opponents, or those with concerns, might argue that while fraud prevention is important, some provisions could create excessive administrative burdens for legitimate home health agencies, particularly new or smaller providers, potentially hindering access to necessary care. Concerns could also be raised about the subjectivity in defining 'extreme risk of fraud' or 'aberrant behavior,' which might unfairly penalize compliant agencies or lead to unintended consequences in service delivery.
The bill is relatively short and clearly structured, making it accessible for an informed reader to understand its core provisions within a reasonable timeframe.
Section 101, amending 42 U.S.C. 1395cc(j)(2)
Enhanced Enrollment Screening for Home Health Agencies at Extreme Risk of Fraud
This provision requires home health agencies (HHAs) identified as being at an 'extreme risk of fraud' to undergo additional screening measures. These measures include fingerprinting for the agency's administrator and requiring evidence of a comprehensive liability insurance policy. The Secretary of Health and Human Services will determine 'extreme risk' based on a significant increase in the number of HHAs in a specific state or county over the preceding year, along with other specified factors.
Supporters argue
Supporters argue that these enhanced screening measures are crucial for preventing fraudulent entities from enrolling in Medicare, thereby protecting program funds and ensuring that only legitimate and accountable providers deliver home health services. The focus on 'extreme risk' areas targets known vulnerabilities in the system.
Critics contend
Critics or concerned parties might contend that these additional requirements, particularly fingerprinting and liability insurance, could create undue barriers to entry for legitimate new home health agencies, especially those operating in areas identified as 'high-risk' due to rapid growth, potentially limiting access to care.
Tradeoffs
The provision balances the need for robust fraud prevention with concerns about increasing administrative hurdles for new and reactivating home health agencies, which could inadvertently impact market entry and service availability.
Section 102, amending 42 U.S.C. 1395bbb(c)(2)(B) and 42 U.S.C. 1395fff(b)(3)(B)(v)
Increased Survey Frequency and Payment Adjustment for Quality Data Non-Submission
This section mandates more frequent standard surveys for certain home health agencies. Specifically, newly enrolled, changed-ownership, or reactivated agencies will be surveyed annually for three years. Additionally, agencies that fail to submit quality data or display 'aberrant' beneficiary admission rates or other indicators of fraudulent behavior will be surveyed every 18 months. The bill also increases the payment reduction for agencies failing to submit quality data from 2% to 15% for 2029 and subsequent years, while establishing a 30-day grace period for agencies demonstrating a good faith effort to submit data.
Section 103, amending 42 U.S.C. 1395bb
Additional Survey and Training Requirements for Accreditation Organizations
This provision strengthens the requirements for national accreditation bodies that accredit home health agencies for Medicare participation. It mandates that their survey procedures must meet or exceed state agency standards and that their surveyors must complete relevant basic training courses offered by the Centers for Medicare & Medicaid Services (CMS). The Secretary is also required to establish a mechanism to periodically assess the performance of these accreditation bodies and impose remedies, including termination of approval, for deficiencies.
Section 201, amending 42 U.S.C. 1395fff(b)(3)(A)
Reset of Standard Prospective Payment Amount for Home Health Services
This provision resets the standard prospective payment amount for home health units of service. For 2027, the amount will be set at $2382.87. For 2028 and subsequent years, this amount will be updated annually according to existing statutory update mechanisms. This reset aims to establish a new baseline for payments.
Section 202, amending 42 U.S.C. 1395fff(b)(3)(D)
Suspension of Behavioral Adjustment Offsets
This provision suspends the Secretary's authority to impose permanent or temporary adjustments to offset increases or decreases in estimated expenditures attributable to the difference in assumed versus actual behavioral changes due to the implementation of the Patient-Driven Groupings Model (PDGM) for 2027 and subsequent years. This means that past adjustments related to PDGM behavioral changes will not be applied in future years.
Section 203, adding new subsection (f) to 42 U.S.C. 1395fff
Exclusion of Suspect Claims from Benchmarks and Value-Based Programs
This provision requires the Secretary, starting in 2027, to exclude or adjust for 'suspect claims' when computing benchmarks or applying 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.
Defines 'extreme risk of fraud' for home health agencies as being located in a State or county where the total number of home health agencies significantly exceeded the number in the preceding year.
Section 101(2)(G)(ii)
Why it matters:This is standard legislative practice for defining terms within a specific context, though the precise threshold for 'significantly exceeded' is left to the Secretary, which could be a point of future policy debate.
Case for: Supporters argue this provides a clear, data-driven trigger for enhanced scrutiny in areas experiencing rapid, potentially suspicious growth in home health agencies, allowing for targeted fraud prevention.
Case against: Critics might contend that a rapid increase in agencies could also reflect legitimate market growth or increased demand, and that this definition might unfairly target areas with genuine expansion, leading to over-regulation or reduced access.
Estimated impact: This definition will directly determine which new or reactivating home health agencies are subjected to the enhanced screening requirements (fingerprinting, liability insurance).
Specifies additional conditions for mandatory standard surveys of home health agencies every 18 months: (I) failure to submit quality data for the most recent year, or (II) having an aberrant beneficiary admission rate or other characteristics indicating fraudulent or aberrant behavior (as determined by the Secretary after stakeholder consultation).
Section 102(a)(4)(iii)
Why it matters:This is a technical specification of operational triggers for regulatory action, common in amendments to administrative statutes.
Case for: Proponents assert these specific triggers allow for targeted and proactive oversight of agencies exhibiting red flags for potential fraud or quality issues, ensuring timely intervention.
Case against: Concerns could be raised about the subjectivity of 'aberrant beneficiary admission rate' or 'characteristics indicating fraudulent or aberrant behavior,' potentially leading to arbitrary enforcement or requiring significant clarity through rulemaking.
Estimated impact: These conditions will significantly increase the number of mandatory surveys for specific categories of home health agencies, leading to greater scrutiny and compliance costs for those affected.
Establishes a process for home health agencies to be granted an additional 30 days to submit quality data if they demonstrate a good faith effort, applicable for 2029 and subsequent years.
Section 102(b)(2) and (3)
Why it matters:This is a technical detail providing administrative flexibility, often placed within the larger policy change it modifies.
Case for: Supporters argue this grace period is a reasonable safeguard, acknowledging that legitimate agencies may encounter unforeseen technical difficulties, and ensures that the increased penalty for non-submission is applied fairly.
Case against: No specific opposition is typically raised against such administrative flexibilities, as they are generally seen as pragmatic.
Estimated impact: This provision will provide a crucial safety net for home health agencies facing technical or administrative challenges in meeting quality data submission deadlines, potentially preventing a 15% payment reduction for good faith efforts.
Defines 'suspect claim' 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.
Section 203(2)
Why it matters:This is standard legislative practice for defining terms within the section where they are primarily used.
Case for: Proponents argue that a clear definition of 'suspect claim' is essential for the effective implementation of the provision to exclude fraudulent data, ensuring that legitimate providers are not unfairly impacted by the actions of bad actors.
Case against: Concerns could arise regarding the subjectivity of 'unreliable data' or 'may have engaged in fraud, waste, or abuse,' which could lead to disputes or require robust due process for providers whose claims are deemed 'suspect.'
Estimated impact: This definition is foundational to the policy of excluding fraudulent data from payment calculations and value-based programs, directly impacting the financial outcomes for providers and the integrity of Medicare's data.