This bill amends 42 U.S.C. 1396d(a)(24) to require that personal care services under Medicaid be furnished only to an individual "who is unable to perform 3 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986) and". In short, it inserts a functional eligibility threshold into the statutory description of covered personal care services.
Why it matters: the change creates a single, numerically defined gate for access to personal care services by tying Medicaid eligibility to a tax-code definition of ADLs. That will affect how states set assessment standards, how providers document need, and which beneficiaries qualify for in-home assistance — with predictable administrative and operational consequences for state Medicaid agencies, managed care plans, and home- and community-based service providers.
At a Glance
What It Does
The bill inserts language into the Medicaid statute making personal care services available only to people who cannot perform three or more activities of daily living, using the IRS definition referenced. It does not change payment formulas or other Title XIX authorities.
Who It Affects
State Medicaid programs, Medicaid beneficiaries seeking personal care or home- and community-based services, home care providers, and managed care organizations that administer or authorize those services. CMS will also need to interpret and issue guidance on implementation.
Why It Matters
Tying eligibility to a specific 3+ ADL threshold standardizes a functional gate across Medicaid at the federal statutory level, shifting where decisions about access are made and likely prompting updates to state assessment tools, provider documentation practices, and appeals processes.
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What This Bill Actually Does
The bill makes one focused change to the Medicaid statute: it adds a functional eligibility requirement to the clause that authorizes personal care services under Title XIX. Instead of the existing statutory text standing alone, the new language requires that the recipient be someone who is unable to perform three or more activities of daily living, with the ADL list defined by reference to section 7702B(c)(2)(B) of the Internal Revenue Code.
Because the bill imports the IRS cross-reference rather than defining ADLs in the Social Security Act, Medicaid administrators will need to consult that tax-code definition when assessing eligibility. The change is purely substantive about who may receive personal care services; it does not, on its face, alter payment rates, matching funds, or the list of services states may cover beyond personal care.The statute sets an effective date for medical assistance furnished on or after January 12, 2027.
Practically, that gives states a window to revise assessment instruments, enrollment criteria, and prior authorization rules, and to train assessors and managed-care contractors on the new functional threshold. It also opens immediate questions about how states will document "unable to perform," how cognitive impairments and ADL support needs will be measured, and whether existing waiver populations will be grandfathered or re-evaluated under the new standard.Finally, by using an external tax-code definition, the bill creates a dependency on a non-Medicaid statutory source; any future changes to that tax provision could affect Medicaid eligibility unless Congress or regulations later decouple the definitions.
The Five Things You Need to Know
The bill amends 42 U.S.C. 1396d(a)(24) by inserting the phrase requiring inability to perform 3 or more activities of daily living into the personal care services provision.
The ADL threshold is defined by reference to Internal Revenue Code section 7702B(c)(2)(B), not by new language in the Social Security Act itself.
The eligibility change applies to medical assistance furnished on or after January 12, 2027.
The amendment addresses only the eligibility criterion for personal care services; it does not amend payment rates, federal matching (FMAP), or the scope of covered services beyond adding the ADL requirement.
Because the bill cross-references the tax code for the ADL definition, future changes to that tax provision could change who qualifies for Medicaid personal care without separate changes to the Social Security Act.
Section-by-Section Breakdown
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Short title
Declares the Act’s short name as the "Combating Deceptive Practices in Assistance Programs Act of 2026." The title signals sponsor intent but carries no operative effect on Medicaid policy; it matters mainly for citation and bill-tracking.
Adds a 3+ ADL functional eligibility requirement for personal care services
This is the operative provision: it inserts language into the statutory authorization for personal care services that limits those services to individuals "who is unable to perform 3 or more activities of daily living" and ties that phrase to the IRS definition. Practically, the insertion converts a permissive service description into a conditional one, so states must apply the new functional gate when determining eligibility for personal care. The cross-reference means states and practitioners will rely on the tax-code ADL list when performing assessments and documenting medical necessity.
Applies the amendment prospectively from January 12, 2027
The amendment applies to medical assistance furnished on or after January 12, 2027. That creates a clear prospective cutoff for implementation: services delivered before that date are unaffected. States will need to complete any systems and policy changes before the effective date to avoid coverage interruptions, but the provision does not grandfather existing eligibility determinations or specify transition mechanics.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Beneficiaries with high-intensity needs (those unable to perform 3+ ADLs): the statutory threshold prioritizes and clarifies access for people with the most substantial functional impairments, potentially reducing disputes over baseline eligibility for these individuals.
- State Medicaid programs and payors: a single numeric threshold provides a clearer standard for eligibility determinations, which can reduce administrative uncertainty and improve consistency across assessments and appeals.
- Home- and community-based service (HCBS) program planners and budget analysts: a tighter, defined gate can make utilization forecasting and budget planning more predictable, aiding program design and resource allocation.
Who Bears the Cost
- Medicaid beneficiaries who need less-intensive assistance (fewer than 3 ADLs): they risk losing access to personal care services under the new statutory gate unless states preserve coverage through waivers or other authorities.
- Home care and personal care providers: reduced eligiblity pools or additional prior authorization and documentation requirements could reduce service volume and increase administrative burdens for provider billing and care planning.
- State Medicaid agencies and CMS: implementing the new eligibility standard will require revising assessment tools, training caseworkers and contractors, creating guidance, and potentially handling increased appeals and re-assessments without an explicit appropriation.
- Managed care organizations: plans that administer long-term services and supports will need to update medical eligibility criteria, utilization management rules, and provider contracts to reflect the statutory change.
Key Issues
The Core Tension
The bill pits a federal desire to standardize and limit access to personal care services (to focus resources on those who cannot perform three or more ADLs) against the need for individualized, clinically nuanced determinations of care needs and the flexibility states currently use to serve people with less obvious but still significant supports needs.
Two implementation frictions stand out. First, the bill references an IRS provision for the ADL definition rather than defining ADLs within Medicaid law.
Tax-code definitions were drafted for tax-treatment purposes (for example, long-term care insurance tax benefits) and may not align precisely with clinical or functional assessment practices used by Medicaid. That mismatch creates interpretive work for CMS and states: which professional judgments count as "unable to perform," how to handle borderline cases, and how to reconcile the tax definition with clinical assessment tools already in use.
Second, the 3+ threshold is a blunt numeric cutoff. Functional need exists on a continuum: people who require supervision, cueing, or intermittent help for two ADLs may still have high overall care needs and costs.
The statute does not expressly address cognitive impairments, instrumental activities of daily living (IADLs), or how waiver programs interact with the new gate. The result could be coverage cliffs, increased appeals, and pressure on states to create exceptions or use waivers to maintain services for people who fall below the numeric threshold.
Finally, the bill provides no implementation funding; states and CMS must absorb the administrative work of changing eligibility systems and training assessors, which may delay or complicate a smooth transition by the fixed effective date.
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