STOP FRAUD in Medicaid Act
- Bill Number
- H.R. 5364
- Origin Chamber
- House
- Congress
- 119th Congress, Session 1
- Policy Area
- Health
- Status
- Introduced
- Latest Action
- 2025-09-15: Referred to the House Committee on Energy and Commerce.
- Last Updated
- 2026-07-07T08:05:54Z
AI-Generated Summary
Purpose
The "STOP FRAUD in Medicaid Act" (H.R. 5364) aims to strengthen efforts against fraud in the Medicaid program by expanding the responsibilities of state units that investigate fraud. Specifically, it directs these units to also target fraud committed by individuals applying for or receiving Medicaid benefits, in addition to fraud by healthcare providers.
Key Provisions
- Expansion of Investigative Authority: Amends Section 1903(q)(3) of the Social Security Act to require State Medicaid Fraud Control Units (MFCUs)—specialized teams in state attorney general offices that handle Medicaid fraud—to investigate and prosecute fraud related to the application for or receipt of Medicaid services by individuals, not just the provision of services by providers.
- Conforming Amendments: Updates Section 1902(a)(61) of the Social Security Act to align state Medicaid plans with this broader definition of fraud, ensuring consistency across the program.
- Implementation Timeline: The changes take effect 180 days after the bill's enactment, giving states time to adjust operations.
Significant Changes to Existing Law
- Under current law, MFCUs primarily focus on fraud by healthcare providers (e.g., billing scams). This bill broadens their mandate to include "beneficiary fraud," such as individuals lying on applications to qualify for benefits or improperly receiving payments.
- The amendments insert specific phrases like "application for, or receipt of" into existing statutes to explicitly cover individuals applying for or receiving Medicaid, closing a gap in prior enforcement focused mainly on providers.
Potential Impacts
- On Government Agencies: State MFCUs and Medicaid agencies will need to handle more investigations, potentially increasing workloads and requiring additional resources or training. The federal government (via the Centers for Medicare & Medicaid Services) may see reduced improper payments, leading to cost savings in the Medicaid program, which serves low-income individuals for healthcare.
- On Citizens: Medicaid beneficiaries (primarily low-income families, elderly, and disabled people) could face heightened scrutiny and risk of prosecution for unintentional errors or intentional fraud in applications, possibly deterring eligible people from applying while recovering misused funds.
- On International Relations: No direct impacts, as this is a domestic healthcare program.
Main Stakeholders Affected
- State Governments and MFCUs: Directly tasked with expanded enforcement, affecting attorney general offices and state budgets.
- Medicaid Beneficiaries: Individuals eligible for or receiving benefits, who may now be subject to investigations for fraud.
- Federal Government: Oversees Medicaid funding and could benefit from lower fraud rates, reducing the program's $600+ billion annual cost.
- Healthcare Providers: Indirectly affected, as the focus shifts partially from provider fraud, though they remain a priority.
Notable Legal, Constitutional, or Political Implications
- Legal: Strengthens anti-fraud tools under the Social Security Act without creating new crimes; prosecutions would follow existing state laws on fraud. It promotes uniformity in how states address Medicaid abuse but requires states to update their plans accordingly.
- Constitutional: No apparent challenges, as it aligns with Congress's authority to regulate federal spending programs like Medicaid (under the Spending Clause of the U.S. Constitution). It respects state roles in administration while mandating federal standards.
- Political: Highlights bipartisan interest in curbing waste in entitlement programs, potentially appealing to fiscal conservatives by targeting "abuse" without cutting benefits. Could spark debates on balancing fraud prevention with access to care for vulnerable populations.
This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.
Sponsor
Cosponsors (9)
Rep. Fry, Russell [R-SC-7], Rep. Mann, Tracey [R-KS-1], Rep. Cline, Ben [R-VA-6], Rep. Wilson, Joe [R-SC-2], Rep. Jack, Brian [R-GA-3], Rep. Haridopolos, Mike [R-FL-8], Rep. Taylor, David J. [R-OH-2], Rep. Moore, Tim [R-NC-14], Rep. Rouzer, David [R-NC-7]
Recent Actions
- 2025-09-15: Referred to the House Committee on Energy and Commerce.
- 2025-09-15: Introduced in House
- 2025-09-15: Introduced in House
Bill Versions
- States Taking On Power For Redressing All Unlawful Deceits in Medicaid Act — issued 2025-09-15 — PDF (2 pages)