Medicare & Medicaid

Changes to enrollment, eligibility, work requirements, and expansion incentives outlined in the OBBBA will lead to cuts in federal healthcare programs.

Jul. 4, 2025

1. Moratorium on New and Existing Provider Taxes

Prohibits states from establishing any new Medicaid provider taxes or from increasing the rates of existing taxes

2. Lower Cap for State Directed Payments

Directs HHS to revise Medicaid regulations for state-directed payments (SDPs).

For expansion states (states that expanded Medicaid under the Affordable Care Act): Payments for inpatient hospital and nursing facility services cannot exceed 100% of what Medicare would pay for the same service.
For non-expansion states (those that didn’t expand Medicaid): Payments for the same services can go up to 110% of the Medicare rate.

Any payments approved after May 1, 2025, that go over these limits are not allowed, unless they are for rural hospitals, which are exempt from the cap (likely to support their financial sustainability).

3. Moratorium on Implementation of Eligibility and Enrollment Final Rule

Bars the Secretary from implementing, enforcing, or administering specific provisions of the April 2024 CMS final rule — which has not yet taken effect — until October 1, 2034. The rule aims to streamline Medicaid application and enrollment, standardize renewal procedures for all Medicaid enrollees, ease transitions between Medicaid, CHIP, and subsidized Marketplace coverage, and remove certain barriers in CHIP.

4. Moratorium on Implementation of Medicare Savings Program Final Rule

Prohibits the Secretary from implementing, administering, or enforcing provisions that have not yet taken effect in September 2023 CMS final rule that reduces barriers to enrollment for Medicare beneficiaries in Medicare Savings Programs (MSPs) until October 1, 2034.

5. Moratorium on Implementation of Nursing Home Staffing Final Rule

Prohibits the Secretary of Health and Human Services from implementing, administering, or enforcing the minimum staffing levels required for long-term care (LTC) facilities included in an April 2024 CMS final rule until October 1, 2034.

Impact: Rolls back provisions including mandating a total nurse staffing standard of 3.48 hours per resident day (HPRD), a 24/7 on-site registered nurse (RN) requirement and increased transparency related to compensation for workers.

Dec. 31, 2025

1. Rural Health Transformation Program

Deadline to apply to program. The rural health transformation program will provide $50 billion in grants to states between fiscal years 2026 and 2030, to be used for payments to rural health care providers and other purposes. Distributes 50% of payments equally across states with approved applications; the remaining funds will be distributed based on an approach determined by CMS within broad requirements. Uses of funds include promoting care interventions, paying for health care services, expanding the rural health workforce, and providing technical assistance aimed at system transformation.

Jan. 1, 2026

1. Eliminating Temporary Financial Incentive for Medicaid Expansion

Eliminates the temporary incentive for states that newly adopt Medicaid expansion.

2. Recapture of Excess Premium Tax Credits

Removes the cap on how much the IRS may recoup from individuals who receive more in advance premium tax credits than they are ultimately eligible for.
The final Senate version eliminates an earlier exemption for individuals whose projected income exceeded 100% of the FPL but whose actual income did not.
Effective for taxable years beginning after Dec. 31, 2025.
Revenue Estimate: $19.5 billion revenue gain.

3. Special Enrollment Periods and Tax Credit Eligibility

Denies premium tax credits for individuals who enroll through special enrollment

periods based solely on household income.

Credits would only be allowed in cases tied to qualifying life events or changes in circumstances.
Effective for taxable years beginning after Dec. 31, 2025.

Jan. 1, 2027

1. Work Requirements (or Earlier at State Option)

Requires states to implement community engagement requirements for able-bodied adults without dependents as soon as Dec. 31, 2026. An individual can meet the community engagement requirements during a month by working, completing community service, participating in a work program, enrolling in an educational program or a combination of these activities for at least 80 hours.

Provides a broader exemption for any parent of a dependent child, among other exemptions. Only parents of children under age 15 would be exempt from the national requirement. Expands the list of “good cause” exemptions.
Increases implementation funding from $50 million to $200 million for FY 2026 to CMS.

2. Verifying Enrollee Addresses

Requires states to obtain enrollee address information using reliable data sources, including the National Change of Address Database and managed care entities. Date is for states to obtain contact information; October, 2029, to establish a system to prevent enrollment in two states simultaneously.

3. Ensuring Deceased Individuals Do Not Remain Enrolled

Requires states to review the Master Death File at least quarterly and disenroll any enrolled individuals who are deceased.

4. Limiting Retroactive Coverage

Shortens retroactive coverage from 90 days prior to application to one month prior to application for ACA Medicaid expansion beneficiaries, and two months prior to application for traditional Medicaid beneficiaries.

Jan. 1, 2028

1. Reducing State-Directed Payments

Begins reducing existing payments by 10 percentage points each year until they reach the allowable Medicare-related payment limit. Specifies that in the absence of published Medicare payment rates, the limit is set at the Medicaid fee-for-service payment rate.

Effective Date: Upon enactment of a lower limit on new state directed payments; January 1, 2028, for reduction in existing state directed payments above new allowable Medicare-related limit.

2. Medicaid Provider Screening Requirements

Requires states to conduct checks at provider enrollment or re-enrollment and on a quarterly basis of the Social Security Administration’s Death Master File to determine whether providers enrolled in Medicaid are deceased.

3. Reducing Home Equity Limits

Most Medicaid enrollees who qualify for Medicaid because they need long-term care (LTC) are subject to limits on their home equity. In 2025, federal rules specified that states’ limits on home equity must be between $730,000 and $1,097,000, and those amounts are updated each year for inflation.

Reduces the maximum home equity limits to $1,000,000 regardless of inflation.
Allows states to apply different requirements for homes that are located on farms.

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