No Medicare Clawbacks Act of 2026
Officially: “No Medicare Clawbacks Act of 2026” Read the full text
What it does
Read it in plain language
1Short title
This section would let the Act be officially called the No Medicare Clawbacks Act of 2026.
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1. Short title This Act may be cited as the No Medicare Clawbacks Act of 2026 .
2Prohibiting group health plan payment clawbacks in certain circumstances
This section would amend section 1862(b) of the Social Security Act (42 U.S.C. 1395y(b)) in two ways. First, it would restructure the existing text of paragraph (1)(A)(ii), which is a separate provision from clause (i) and can prevent clause (i) from applying in some cases, by giving that existing text a new label, subclause (I), headed "In general," without changing its substance. This makes room for a new subclause (II) to be added alongside it. Clause (i) itself is a separate, unchanged provision and is not the part being relabeled. Second, this section would add a new subclause (II) that limits when a group health plan can take back a payment it already made. Under this new subclause, the protection against clawback applies if an individual is entitled to Medicare benefits under section 226(a) of the Social Security Act and is also enrolled in a group health plan, if clause (i) would otherwise apply to that individual and plan except that subclause (I) is the only reason it does not apply, and if the plan initially paid for an item or service furnished to that individual without regard to the individual's Medicare entitlement. Where those conditions are met, the plan may not later recoup that payment, in whole or in part, on the ground that the individual was entitled to Medicare benefits. This protection further applies only if both of the following are true: the item or service was furnished during a period of retroactive Medicare Part A coverage that applied to the individual, and at the time the item or service was furnished, the individual was not behind on any employee contribution owed for enrollment in the group health plan. This section would also amend paragraph (3)(A) of section 1862(b), which addresses claims under that paragraph, to state that a claim under paragraph (3)(A) also applies when a group health plan recoups payment in violation of the new prohibition added in paragraph (1)(A)(ii)(II).
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2. Prohibiting group health plan payment clawbacks in certain circumstances Section 1862(b) of the Social Security Act ( 42 U.S.C. 1395y(b) ) is amended— (1) in paragraph (1)(A)(ii)— (A) by striking Clause (i) and inserting the following: (I) In general Clause (i) ; and (B) by adding at the end the following new subclause: (II) Prohibition on payment clawbacks in certain circumstances In the case of an item or service furnished to an individual entitled to benefits under this title under section 226(a) who is also enrolled in a group health plan, if clause (i) would otherwise apply to such individual and plan but for application of subclause (I) and if such plan initially makes payment for such item or service without regard to such entitlement, such plan may not later recoup such payment, in whole or part, on the basis that such individual was so entitled to such benefits, provided that— (aa) such item or service was furnished during a period of retroactive coverage of part A benefits applicable to such individual; and (bb) at the time such item or service was furnished, such individual was not behind on any employee contribution owed by such individual with respect to enrollment in such plan. ; and (2) in paragraph (3)(A), by inserting or in the case of a group health plan that recoups payment in violation of paragraph (1)(A)(ii)(II) before the period.
Where it is
In the House.