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

This bill would change Medicare rules for home health agencies with the stated goal of reducing fraud, improving data accuracy, and tightening oversight. It would also change how Medicare pays home health agencies starting in 2027.

Stricter enrollment checks for new or high-risk agencies

The bill would require extra screening for home health agencies that are considered at extreme risk of fraud. For those agencies, Medicare would have to:

• Fingerprint the agency administrator, if fingerprinting is already part of the screening process.
• Verify that the agency has a comprehensive liability insurance policy.

The Secretary of Health and Human Services would decide which agencies count as extreme risk, including agencies in states or counties where the number of home health agencies has risen sharply compared with the prior year.

More frequent surveys and oversight

The bill would require Medicare surveyors to inspect certain home health agencies more often. Newly enrolled agencies, agencies that change ownership, and agencies that restart billing would have to be surveyed at least once every 12 months during their first 3 years.

It would also require surveys within 18 months for agencies that:

• Do not submit required quality data, or
• Show unusually high admission rates or other patterns that may suggest fraud or unusual behavior.

No agency could be surveyed more than once in any 18-month period under this rule.

Changes to accreditation organizations

The bill would tighten standards for private accreditation bodies that certify home health agencies. To remain approved by Medicare, these organizations would need survey procedures that meet or exceed the standards used by state and local agencies, and their surveyors would have to complete CMS training before serving on survey teams.

CMS would also have to create a system to regularly evaluate these accreditation bodies. If one is found to be performing poorly, CMS could require a corrective action plan, monitor it more closely, or end its approval for home health accreditation.

New payment rules for home health

Starting in 2027, the bill would reset the standard Medicare payment amount for home health services to a fixed dollar amount of $2,382.87 for that year, and then update that amount each year after 2027.

It would also stop Medicare from making certain payment adjustments meant to offset assumed behavioral changes tied to the 2020 Patient-Driven Groupings Model. In other words, the bill would block those specific automatic payment offsets from being applied in 2027 and later.

Protection for payment benchmarks and value-based programs

The bill would direct Medicare to ignore or adjust for “suspect claims” when calculating payment benchmarks, quality measures, value-based adjustments, and similar calculations for home health agencies. A suspect claim would be one that contains unreliable data or comes from a provider that may have engaged in fraud, waste, or abuse.

This is meant to keep potentially bad data from affecting payment calculations for other agencies.

Reports and rulemaking

Within 180 days, HHS would have to report to Congress on how suspect claims and cost reports have affected home health payments since 2020, what would happen if those claims were excluded from payment calculations, and what permanent safeguards could be used to keep unreliable data out of Medicare formulas.

The bill would also require HHS to carry out the new rules through the normal notice-and-comment rulemaking process.

Funding for enforcement and oversight

The bill would provide new federal funding for implementation and enforcement, including:

• $300 million for CMS over fiscal years 2027 through 2031 to carry out the enrollment, survey, and accreditation changes.
• $150 million for the Department of Justice and HHS’s Office of Inspector General for fraud investigations and prosecutions.
• $100 million for state survey agencies to support accelerated surveys, enrollment checks, unannounced site visits, and operational verification.

Other provisions

The bill says it does not limit existing HHS authority to suspend payments, revoke enrollment, impose enrollment moratoriums, conduct site visits, audit agencies, or deny payment for suspect claims.

Relevant Companies

None found