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Congressional Research Service
Version 00 · Introduced in House · Mar 17, 2016
Medicaid Program Integrity Enhancement Act of 2016
This bill amends title XIX (Medicaid) of the Social Security Act to require a state Medicaid agency to establish a process by which a provider may appeal a decision by the agency to suspend payment to the provider on the basis of credible fraud allegations.
The Centers for Medicare & Medicaid Services (CMS) must revise specified regulations related to such suspensions in order to comply with due process requirements established by the bill.
Showing the opening paragraphs of the official summary.
Specifically, a state Medicaid agency may not suspend payment until the agency: (1) consults with the state's Medicaid fraud control unit or, if the state has no such unit, with the state's attorney general; (2) certifies that it has considered whether the suspension will jeopardize beneficiary access and whether there is good cause not to suspend payment; and (3) furnishes the provider with the agency's reasons for finding no such good cause.
Furthermore, the agency must periodically evaluate whether there is good cause to discontinue a suspension for which an investigation is pending. With specified exceptions, such good cause shall be deemed to exist if the investigation remains unresolved after a suspension has been in effect for 18 months.
CMS must also revise specified regulations to provide that an allegation of fraud shall be considered credible only if the allegation has indications of reliability and the state Medicaid agency: (1) has reviewed all allegations, facts, and evidence carefully; (2) acts judiciously on a case-by-case basis; and (3) has considered the potential impact a payment suspension may have on beneficiary access to care.
People & committees
Rep. Luján, Ben Ray [D-NM-3] · D–NM
Legislative record
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Referred to the Subcommittee on Health.
Referred to the House Committee on Energy and Commerce.
Introduced in House
Introduced in House
Primary sources
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Source last updated: Dec 3, 2025. Consult Congress.gov for the current record.
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