S. 5250 — Medicare Home Health Payment Integrity and Protection Act of 2026

This section requires home health agencies applying for Medicare enrollment that the Secretary determines are at extreme risk of fraud to undergo additional screening beginning one year after enactment. It mandates fingerprinting of the agency administrator (when fingerprinting is already required) and submission of evidence of a comprehensive liability insurance policy, and directs the Secretary to identify extreme-risk agencies based on significant year-over-year growth in the number of home health agencies in a state or county plus any other factors the Secretary specifies.

This section increases the frequency of standard surveys of home health agencies, requiring them at least once every 12 months during the first 36 months after new enrollment, ownership change, or billing reactivation, and not later than 18 months after the prior survey for agencies that fail to submit required quality data or display aberrant admission rates or practices, beginning one year after enactment. It also increases the annual payment reduction for agencies that do not submit quality data to 15 percentage points for 2029 and subsequent years and allows up to 30 additional days for good-faith data submissions.

This section requires national accreditation bodies to meet or exceed State and local survey standards under section 1864(a) and to require surveyors to complete CMS basic training courses before the Secretary may approve their requests, beginning one year after enactment. It also directs the Secretary to establish a performance assessment mechanism for accreditation bodies of home health agencies within one year after enactment, with remedies for deficiencies that may include corrective action plans, ongoing monitoring, or termination of approval.

This section resets the standard prospective payment amount under the Medicare home health prospective payment system. For 2027 the amount is set at $2,382.87; for 2028 and each subsequent year the amount is the prior year’s amount updated under the existing update rules. The prior rules for computing the amount apply only through 2026.

This section suspends permanent and temporary adjustments to Medicare home health prospective payment rates for 2027 and subsequent years. It prohibits the Secretary from applying adjustments under clauses (ii) or (iii) to offset differences between assumed and actual behavioral changes resulting from implementation of the Patient-Driven Groupings Model.

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

This section directs the Secretary of Health and Human Services to submit a report to Congress within 180 days of enactment identifying the influence of suspect claims and cost reports on home health agency payments under section 1895 of the Social Security Act after 2020, analyzing the effects of excluding such claims from payment rate, case-mix, and behavioral calculations, and recommending 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 & Medicaid Services for fiscal years 2027 through 2031 to support state survey agency activities, including accelerated surveys, enrollment validation, unannounced site visits, and operational verification of home health agencies.

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