[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 5250 Introduced in Senate (IS)]
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119th CONGRESS
2d Session
S. 5250
To amend title XVIII of the Social Security Act to decrease fraud
related to home health agencies in Medicare, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
August 5, 2026
Ms. Collins introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to decrease fraud
related to home health agencies in Medicare, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Medicare Home
Health Payment Integrity and Protection Act of 2026''.
(b) Table of Contents.--
Sec. 1. Short title; Table of contents.
TITLE I--HOME HEALTH PROGRAM INTEGRITY, ANTI-FRAUD, AND ENROLLMENT
REFORM
Sec. 101. Enhanced enrollment screening for home health agencies.
Sec. 102. Additional oversight provisions for home health agencies.
Sec. 103. Additional survey and training requirements for accreditation
organizations.
TITLE II--HOME HEALTH PAYMENT RESET AND DATA INTEGRITY
Sec. 201. Reset of standard prospective payment amount.
Sec. 202. Suspension of permanent and temporary adjustments.
Sec. 203. Conforming protection for benchmarks and value-based
programs.
TITLE III--REPORTS, RULEMAKING, PROGRAM INTEGRITY FUNDING, AND
IMPLEMENTATION
Sec. 301. Report to Congress on home health payment data.
Sec. 302. Notice and comment rulemaking.
Sec. 303. Program integrity funding.
Sec. 304. Department of Justice and Office of Inspector General
enforcement funding.
Sec. 305. State survey agency funding.
Sec. 306. Rule of construction regarding existing fraud authorities.
TITLE I--HOME HEALTH PROGRAM INTEGRITY, ANTI-FRAUD, AND ENROLLMENT
REFORM
SEC. 101. ENHANCED ENROLLMENT SCREENING FOR HOME HEALTH AGENCIES.
Section 1866(j)(2) of the Social Security Act (42 U.S.C.
1395cc(j)(2)) is amended--
(1) in subparagraph (B)--
(A) in clause (i), by striking ``and'' at the end;
(B) in clause (ii)(V), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new clause:
``(iii) beginning 1 year after the date of
enactment of this clause, in the case of a home
health agency applying for enrollment under
this title that is at an extreme risk of fraud
(as determined under subparagraph (G)), shall,
in addition to any other screening required
under this subparagraph--
``(I) in the case where
fingerprinting is included in such
screening with respect to home health
agencies pursuant to clause (ii)(II),
require fingerprinting of the
administrator of such home health
agency; and
``(II) require obtaining evidence
that such home health agency has a
comprehensive liability insurance
policy, as determined by the
Secretary.''; and
(2) by adding at the end the following new subparagraph:
``(G) Home health agencies at extreme risk of
fraud.--
``(i) In general.--Beginning 1 year after
the date of enactment of this subparagraph, for
purposes of subparagraph (B)(iii), the
Secretary shall determine whether a home health
agency is at an extreme risk of fraud based
on--
``(I) the determination made under
clause (ii); and
``(II) such other factors as the
Secretary may specify.
``(ii) Determination of high-risk areas.--
For purposes of clause (i), the Secretary shall
determine whether a home health agency is
located in a State or county with respect to
which, during the most recent year for which
data is available, the total number of home
health agencies located in such State or county
significantly exceeded the total number of such
agencies located in such State or county during
the preceding year.''.
SEC. 102. ADDITIONAL OVERSIGHT PROVISIONS FOR HOME HEALTH AGENCIES.
(a) Increased Survey Frequency for Certain Home Health Agencies.--
Section 1891(c)(2)(B) of the Social Security Act (42 U.S.C.
1395bbb(c)(2)(B)) is amended--
(1) in clause (ii), by striking the period at the end and
inserting a semicolon;
(2) by redesignating clauses (i) and (ii) as subclauses (I)
and (II), respectively, and adjusting the margins accordingly;
(3) by striking ``subparagraph (A), a standard survey'' and
inserting the following: ``subparagraph (A)--''
``(i) a standard survey''; and
(4) by adding at the end the following new clauses:
``(ii) beginning 1 year after the date of
enactment of this clause, in the case where an
agency is newly enrolled under this title, has
undergone a change of ownership (as defined by
the Secretary), or has reactivated billing
privileges under this title in accordance with
section 424.540(b) of title 42, Code of Federal
Regulations (or a successor regulation), a
standard survey of such agency shall be
conducted not less frequently than once every
12 months during the 36-month period
immediately following such enrollment, change
of ownership, or reactivation of billing
privileges; and
``(iii) beginning 1 year after the date of
enactment of this clause, a standard survey of
an agency shall be conducted--
``(I) in the case where the agency
does not submit quality data to the
Secretary in accordance with subclauses
(II) and (IV) of section
1895(b)(3)(B)(v) for the most recent
year for which data is available (as
determined by the Secretary), not later
than 18 months after the date on which
the most recent such survey was
conducted with respect to such agency;
and
``(II) in the case where the agency
has a beneficiary admission rate that
is aberrant compared to peers (as
determined by the Secretary) or
otherwise displays characteristics or
engages in practices that may indicate
fraudulent or aberrant behavior (as
specified by the Secretary after
consultation with stakeholders, such as
beneficiary advocates and
representatives of the home health
industry, and the Inspector General of
the Department of Health and Human
Services, and updated as necessary
after additional consultation with such
stakeholders not less often than once
every 3 years), not later than 18
months after the date on which the most
recent such survey was conducted with
respect to such agency,
except that an agency shall not be subject to
more than 1 survey under this clause within any
18-month period.''.
(b) Payment Adjustment if Quality Data Not Submitted.--Section
1895(b)(3)(B)(v) of the Social Security Act (42 U.S.C.
1395fff(b)(3)(B)(v)) is amended--
(1) in subclause (I), in the first sentence, by inserting
the following before the period: ``for years before 2029, and
by 15 percentage points for 2029 and subsequent years'';
(2) in subclause (II), by adding at the end the following
new sentence: ``For 2029 and each subsequent year, in
specifying a time for the submission of such data pursuant to
the previous sentence, the Secretary shall establish a process
under which any home health agency that has demonstrated a good
faith effort to submit such data by such time may be granted
additional time (not to exceed 30 days) to complete such
submission.''; and
(3) in subclause (IV)(cc), by adding at the end the
following new sentence: ``For 2029 and each subsequent year, in
specifying a time for the submission of such data pursuant to
the previous sentence, the Secretary shall establish a process
under which any home health agency that has demonstrated a good
faith effort to submit such data by such time may be granted
additional time (not to exceed 30 days) to complete such
submission.''.
SEC. 103. ADDITIONAL SURVEY AND TRAINING REQUIREMENTS FOR ACCREDITATION
ORGANIZATIONS.
Section 1865 of the Social Security Act (42 U.S.C. 1395bb) is
amended--
(1) in subsection (a)(2)--
(A) by striking ``In making'' and inserting the
following: ``(A) In making''; and
(B) by adding at the end the following new
subparagraph:
``(B)(i) Beginning 1 year after the date of enactment of
this subparagraph, the Secretary may not approve a request for
a finding under paragraph (1) with respect to a national
accreditation body unless the survey procedures of such
accreditation body--
``(I) met or exceeded the standards applicable to
the survey procedures that State and local agencies
that have entered into an agreement with the Secretary
under section 1864(a) are required to use; and
``(II) require surveyors to complete the relevant
basic surveyor training courses offered by the Centers
for Medicare & Medicaid Services before serving as a
member of a survey team.
``(ii) The Secretary may only continue to give effect to
any such finding made prior to the date that is 1 year after
the date of enactment of this subparagraph with respect to a
national accreditation body with respect to the accreditation
of home health agencies if the Secretary determines before such
date that the survey procedures of such accreditation body meet
the conditions described in clause (i).''; and
(2) by adding at the end the following new subsection:
``(f) Accreditation for Home Health Agencies.--
``(1) Not later than 1 year after the date of enactment of
this subsection, the Secretary shall establish and implement a
mechanism for periodically assessing the performance of an
accreditation body that has received approval from the
Secretary under subsection (a)(3)(A) for accreditation of home
health agencies.
``(2) In the case that the Secretary finds, pursuant to the
mechanism established under paragraph (1), that the performance
of such accreditation body is deficient, the Secretary shall
provide for an appropriate remedy, which may include the
imposition of a corrective action plan, ongoing monitoring of
the accreditation body, and the termination of such approval
with respect to the accreditation body for accreditation of
home health agencies.''.
TITLE II--HOME HEALTH PAYMENT RESET AND DATA INTEGRITY
SEC. 201. RESET OF STANDARD PROSPECTIVE PAYMENT AMOUNT.
Reset of Standard Prospective Payment Amount.--Section
1895(b)(3)(A) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(A))
is amended--
(1) in clause (i), in the matter preceding subclause (I),
by striking ``Under such system'' and inserting ``Subject to
clause (v), under such system'';
(2) in clause (iii)--
(A) in the heading, by striking ``and subsequent
years'' and inserting ``through 2026''; and
(B) in subclause (I), by striking ``and subsequent
years'' and inserting ``through 2026''; and
(3) by adding at the end the following new clause:
``(v) Basis for 2027 and subsequent
years.--With respect to payments for home
health units of service furnished during 2027
or a subsequent year, the standard prospective
payment amount shall be--
``(I) for 2027, $2382.87; and
``(II) for 2028 and each subsequent
year, the amount determined under this
clause for the preceding year, updated
under subparagraph (B).''.
SEC. 202. SUSPENSION OF PERMANENT AND TEMPORARY ADJUSTMENTS.
Section 1895(b)(3)(D) of the Social Security Act (42 U.S.C.
1395fff(b)(3)(D)) is amended--
(1) in clause (i), by striking ``The Secretary'' and
inserting ``Subject to clause (iv), the Secretary''; and
(2) by adding at the end the following new clause:
``(iv) Suspension of permanent and
temporary adjustments for 2020 and subsequent
years.--Notwithstanding any other provision of
law, for 2027 and subsequent years, for
purposes of making any adjustment under this
subparagraph, the Secretary shall not impose
any adjustment under clause (ii) or (iii) 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 as described in the final rule
entitled `Medicare and Medicaid Programs; CY
2020 Home Health Prospective Payment System
Rate Update; Home Health Value-Based Purchasing
Model; Home Health Quality Reporting
Requirements; and Home Infusion Therapy
Requirements' published in the Federal Register
on November 9, 2019 (84 Fed. Reg. 60478).''.
SEC. 203. CONFORMING PROTECTION FOR BENCHMARKS AND VALUE-BASED
PROGRAMS.
Section 1895 of the Social Security Act (42 U.S.C. 1395fff), is
amended by adding at the end the following new subsection:
``(f) Conforming Protection for Benchmarks and Value-Based
Programs.--
``(1) In general.--For 2027 and each subsequent year, in
order to ensure that fraudulent and suspected fraudulent
entities do not impact benchmarks or the application of any
quality, value-based, or benchmarked adjustments for legitimate
providers of home health services, the Secretary shall exclude
or adjust for suspect claims when computing any such
adjustments to payments to home health agencies under this
section.
``(2) Suspect claim defined.--In this subsection, the term
`suspect claim' means any claim for home health services
submitted under this title that the Secretary determines
contains unreliable data or data from a provider that may have
engaged in fraud, waste, or abuse.''.
TITLE III--REPORTS, RULEMAKING, PROGRAM INTEGRITY FUNDING, AND
IMPLEMENTATION
SEC. 301. REPORT TO CONGRESS ON HOME HEALTH PAYMENT DATA.
Not later than 180 days after the date of enactment of this Act,
the Secretary of Health and Human Services shall submit to Congress a
report--
(1) identifying the degree to which suspect claims and cost
reports influenced payments made to home health agencies under
section 1895 of the Social Security Act (42 U.S.C. 1395fff)
after 2020;
(2) analyzing the effect of excluding suspect claims (as
defined in subsection (f) of such section 1895) from the
calculation of payment rates, case-mix weights, behavioral
assumptions, and adjustments under such section 1895; and
(3) including recommendations for permanent data-integrity
safeguards for home health agencies to prevent the inclusion
and application of utilization, cost, and payment data from
home health agencies that the Secretary determines are at risk
of providing unreliable and inaccurate data.
SEC. 302. NOTICE AND COMMENT RULEMAKING.
The Secretary of Health and Human Services shall 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.
SEC. 303. PROGRAM INTEGRITY FUNDING.
In addition to any other funds otherwise available, there are
appropriated to the Centers for Medicare & Medicaid Services, out of
any amounts in the Treasury not otherwise appropriated, $300,000,000
for fiscal years 2027 through 2031 for the implementation of the
amendments made by sections 101, 102, and 103.
SEC. 304. DEPARTMENT OF JUSTICE AND OFFICE OF INSPECTOR GENERAL
ENFORCEMENT FUNDING.
In addition to any other funds otherwise available, there are
appropriated to the Department of Justice and the Office of Inspector
General of the Department of Health and Human Services, out of any
amounts in the Treasury not otherwise appropriated, $150,000,000 for
fiscal years 2027 through 2031 for investigation of organized home
health fraud schemes, forensic accounting, interstate fraud
investigations, prosecution of Medicare fraud, and coordination with
Federal law enforcement agencies.
SEC. 305. STATE SURVEY AGENCY FUNDING.
In addition to any other funds otherwise available, there are
appropriated to the Centers for Medicare & Medicaid Services, out of
any amounts in the Treasury not otherwise appropriated, $100,000,000
for fiscal years 2027 through 2031 to support State survey agency
activities relating to conducting accelerated surveys, enrollment
validation, unannounced site visits, and operational verification of
home health agencies.
SEC. 306. RULE OF CONSTRUCTION REGARDING EXISTING FRAUD AUTHORITIES.
Nothing in the provisions of, or amendments made by, this Act shall
be construed to limit the authority of the Secretary of Health and
Human Services to suspend payments to home health agencies under title
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), revoke
enrollment or impose a moratorium on the enrollment of such agencies
under such title, conduct site visits of such agencies, audit such
agencies, or exclude or deny payment for suspect claims for home health
services under such title.
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