HouseH.R. 10636119th Congress
Medicaid Fraud Prevention Act
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[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 10636 Introduced in House (IH)]
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119th CONGRESS
2d Session
H. R. 10636
To amend title XIX of the Social Security Act to require States to
conduct fraud risk assessments under the Medicaid program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 28, 2026
Mr. Rulli (for himself, Mr. Bentz, Mr. Carter of Georgia, Mrs.
Fischbach, Mr. Taylor, and Mr. Biggs of Arizona) introduced the
following bill; which was referred to the Committee on Energy and
Commerce
_______________________________________________________________________
A BILL
To amend title XIX of the Social Security Act to require States to
conduct fraud risk assessments under the Medicaid program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicaid Fraud Prevention Act''.
SEC. 2. REQUIRING MEDICAID FRAUD RISK ASSESSMENTS.
Section 1902 of the Social Security Act (42 U.S.C. 1396a) is
amended--
(1) in subsection (a)--
(A) in paragraph (89), by striking ``and'' at the
end;
(B) in paragraph (90), by striking the period at
the end and inserting ``; and''; and
(C) by inserting after paragraph (90) the following
new paragraph:
``(91) provide that the State shall comply with the fraud
risk assessment requirements under subsection (zz).''; and
(2) by adding at the end the following new subsection:
``(zz) Fraud Risk Assessment Requirements.--
``(1) In general.--For purposes of subsection (a)(91), the
fraud risk assessment requirements under this subsection are
that the State shall--
``(A) not later than 1 year after the date of the
enactment of this subsection and not less frequently
than annually thereafter, complete a fraud risk
assessment as described in paragraph (2);
``(B) not later than 90 days after completing such
an assessment, implement a corrective action plan to
address any vulnerabilities identified in such
assessment that includes measurable outcomes and
specific deadlines with respect to the completion of
corrective actions under such plan; and
``(C) not later than 1 year after the completion of
the first fraud risk assessment under this subsection,
and annually thereafter, submit to the Secretary a
report that includes the information specified in
paragraph (3) with respect to the preceding year.
``(2) Fraud risk assessment described.--
``(A) In general.--For purposes of paragraph (1), a
fraud risk assessment described in this paragraph is a
comprehensive assessment of fraud risks across all
components of the State plan (and any waiver of such
plan), including with respect to medical assistance
provided on a fee-for-service basis, medical assistance
provided through a managed care entity, and eligibility
determination and enrollment systems (including systems
operated by or on behalf of the State for the purposes
of eligibility verification and redetermination) under
such plan (or waiver), that--
``(i) to the extent practicable, uses data
from existing Federal and State program
integrity systems, including--
``(I) the Payment Error Rate
Measurement program (or any successor
program);
``(II) the Transformed Medicaid
Statistical Information System (or any
successor system);
``(III) managed care encounter
data;
``(IV) data from a State medicaid
fraud control unit (as defined in
section 1903(q)) or another program
integrity activity;
``(V) the Public Assistance
Reporting Information System (PARIS)
(or any successor system); and
``(VI) beginning October 1, 2029,
the system established by the Secretary
under subsection (uu);
``(ii) identifies and ranks the most
significant fraud, waste, and abuse
vulnerabilities of such plan (or waiver);
``(iii) estimates the amount that could
potentially be improperly expended under such
plan (or waiver) due to each such
vulnerability, including any improper payments
associated with each such vulnerability, with
respect to, at minimum, the 12-month period
beginning on the date on which such assessment
is completed;
``(iv) evaluates the effectiveness of
existing program integrity tools under such
plan (or waiver);
``(v) identifies gaps in data sharing,
oversight, and enforcement with respect to
fraud, waste, and abuse under such plan (or
waiver); and
``(vi) follows the guidelines established
by the Secretary under subparagraph (B).
``(B) Establishment of guidelines.--Not later than
January 1, 2027, the Secretary shall establish
guidelines that--
``(i) identify and define standardized
categories of fraud, waste, and abuse risk
across State plans (and waivers of such plans),
including with respect to eligibility
determinations, provider enrollments, claims
processing, and managed care;
``(ii) establish criteria for the
identification, scoring, and prioritization of
categories of risk identified under clause (i)
on the basis of the likelihood of such risks
and estimates of potential improper
expenditures (as described in subparagraph
(A)(iii)) due to such risks; and
``(iii) enable fraud risk assessments
completed under this subsection by different
States to be effectively compared.
``(3) Information specified.--For purposes of paragraph
(1), the information specified in this paragraph is--
``(A) the results of any fraud risk assessments
conducted under paragraph (1)(A);
``(B) the most significant fraud, waste, and abuse
vulnerabilities identified under such assessments;
``(C) the potential improper expenditures (as
described in paragraph (2)(A)(iii)) estimated under
such assessments;
``(D) corrective actions taken or planned to be
taken under paragraph (1)(B) with respect to such
vulnerabilities; and
``(E) an explanation of any progress made in
addressing such vulnerabilities.
``(4) Annual report to congress.--Not later than 1 year
after the date on which the first report under paragraph (1)(C)
is submitted to the Secretary, and annually thereafter, the
Secretary shall submit to Congress a report that, with respect
to the preceding year--
``(A) analyzes the findings from reports submitted
to the Secretary under such paragraph;
``(B) identifies national trends with respect to
Medicaid fraud risk;
``(C) evaluates State implementation of corrective
action plans implemented under paragraph (1)(B); and
``(D) includes recommendations for legislative or
administrative action to address fraud, waste, and
abuse vulnerabilities identified in such reports.''.
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