H.R. 10806

Medicare Home Health Payment Integrity and Protection Act of 2026

Sponsor: Claudia Tenney · 0 cosponsors

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I Home Health Program Integrity, Anti-Fraud, and Enrollment Reform

II Home Health Payment Reset and Data Integrity

Sec. 201. Calculation of home health prospective payment amount using reliable data

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:

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(v) Calculation of standard prospective payment amount for 2027 and subsequent years

(I) In general. Not later than 90 days after the date of enactment of this clause, the Secretary shall establish a revised standard prospective payment amount for calendar year 2027. In establishing such amount, the Secretary shall calculate the standard prospective payment amount beginning with the amount applicable for calendar year 2020, adjusted for each subsequent year under subparagraph (B).

(II) Data integrity and methodology. In carrying out subclause (I), the Secretary shall use a methodology and claims data that are appropriate to measure changes in provider behavior attributable to the implementation of the Patient Driven Groupings Model. Such methodology shall—

(aa) exclude claims data associated with fraudulent, wasteful, abusive, aberrant, or otherwise unreliable billing patterns, as determined by the Secretary;

(bb) account for the effects of the public health emergency declared under section 319 of the Public Health Service Act with respect to COVID–19 and other circumstances that materially affected home health utilization or spending but were not within the behavioral assumptions used to establish the Patient-Driven Groupings Model; and

(III) Subsequent years. For 2028 and each subsequent year, the standard prospective payment amount shall be the amount established under subclause (I) for the preceding year, updated under subparagraph (B).

III Reports, Rulemaking, Program Integrity Funding, and Implementation