H.R. 10806 — Medicare Home Health Payment Integrity and Protection Act of 2026

This section requires home health agencies applying for Medicare enrollment that are at extreme risk of fraud to undergo fingerprinting of the agency administrator and to provide evidence of a comprehensive liability insurance policy, beginning one year after enactment. The Secretary must determine extreme risk based on whether the agency is located in a state or county where the number of home health agencies significantly exceeded the prior year’s total, plus any other factors the Secretary specifies.

This section increases required survey frequency for home health agencies newly enrolled in Medicare, undergoing a change of ownership, or reactivating billing privileges to at least once per month for the first 36 months after the triggering event, beginning one year after enactment. It also requires surveys no later than 18 months after the most recent survey for agencies that fail to submit required quality data or that display aberrant beneficiary admission rates or other suspicious practices, with a limit of one such survey per 18-month period. This section increases the annual payment reduction for home health agencies that do not submit quality data to 15 percentage points beginning in 2029 (from the prior rate) and authorizes the Secretary to grant up to 30 additional days for good-faith submissions in 2029 and later years.

This section requires national accreditation bodies to meet or exceed State and local agency survey standards under section 1864(a) agreements and mandates that surveyors complete relevant CMS basic training courses before serving on teams, effective 1 year after enactment. It also directs the Secretary to establish and implement a periodic performance assessment mechanism for accreditation bodies of home health agencies within 1 year after enactment, with remedies for deficiencies that may include corrective action plans, ongoing monitoring, or termination of approval.

This section revises the calculation of the standard prospective payment amount for Medicare home health services. It limits the existing methodology to calendar years 2020 through 2026 and requires the Secretary to establish a revised amount for 2027, using 2020 base data adjusted for subsequent years under a methodology that measures provider behavioral changes from the Patient-Driven Groupings Model, excludes fraudulent or unreliable claims, and accounts for COVID-19 public health emergency effects on utilization. For 2028 and later years, the amount updates from the prior year.

This section prohibits the Secretary from imposing permanent or temporary adjustments to Medicare home health prospective payment system rates for 2027 and subsequent years to offset differences between assumed and actual behavioral changes attributable to the Patient-Driven Groupings Model, as described in the November 9, 2019 final rule (84 Fed. Reg. 60478).

This section requires the Secretary to exclude or adjust for suspect claims when computing any quality, value-based, or benchmarked adjustments to payments for home health agencies under the prospective payment system for 2027 and each subsequent year. A suspect claim is defined as one containing unreliable data or data from a provider that may have engaged in fraud, waste, or abuse.

This section requires the Secretary of Health and Human Services to submit a report to Congress within 180 days of enactment that identifies the extent to which suspect claims and cost reports affected Medicare payments to home health agencies under section 1895 of the Social Security Act after 2020, analyzes the impact of excluding such claims from payment rate and case-mix calculations, and recommends permanent data-integrity safeguards.

This section provides $300 million to the Centers for Medicare & Medicaid Services for fiscal years 2027 through 2031 to implement the amendments made by sections 101, 102, and 103.

This section provides $150 million for fiscal years 2027 through 2031 to the Department of Justice and the Department of Health and Human Services Office of Inspector General for investigation of organized home health fraud schemes, forensic accounting, interstate fraud investigations, prosecution of Medicare fraud, and coordination with Federal law enforcement agencies.

This section provides $100 million to the Centers for Medicare and Medicaid Services for fiscal years 2027 through 2031 to support state survey agency activities relating to accelerated surveys, enrollment validation, unannounced site visits, and operational verification of home health agencies.

This section preserves the Secretary of Health and Human Services' authority to suspend payments to home health agencies under Medicare, revoke or impose moratoria on their enrollment, conduct site visits and audits, and exclude or deny payment for suspect claims.