Head's up: Over half the MAGA Murder Bill's healthcare carnage will kick in BEFORE the midterms.

Ever since the MAGA Murder Bill (officially H.R. 1, the so-called "One Big Beautiful Bill Act") was passed by Republicans in the U.S. Senate & House and signed into law by Donald Trump a few days ago, I've seen a growing conventional wisdom taking hold on social media: People keep claiming that either all, "nearly all"or at least "most of" the budget cuts & other gutting of various programs and departments won't actually kick in until after the November 2026 midterms.

Now, don't get me wrong--most of those making these claims are well-intentioned; they're saying this cynically, to underscore how disingenuous Congressional Republicans are by back-loading the pain until the midterms are safely in their rearview mirrors. And, to be fair, much of the damage won't being until well after next November.

Over at The New Republic, Greg Sargent has taken this thinking one step further, noting that by delaying so much of the ugliness of the new law until 2027 or beyond...

Republicans know how unpopular all this will be. So they’ve structured the bill so the tax cuts land immediately, while many of the Medicaid cuts get going in 2027 and 2028. That’s meant to spare them in the midterms.

But there’s a wrinkle here worth appreciating. Those policies will start hitting right when JD Vance’s bid to succeed Trump is getting underway. For Vance—perhaps the most prominent evangelist for Trumpism’s supposed promise for the working class—to have to defend all of that carnage while running for president could yet prove a form of poetic justice.

Again, this is a fair statement, as far as it goes.

However, while I'm not an expert on any of the non-healthcare provisions, when it comes to the sections related to healthcare policy, a whole lot of the ugly will actually hit well before the midterms.

KFF has an excellent breakout of all of the various healthcare policy changes in both the House and Senate versions of the bill as they relate to Medicaid, Medicare, the ACA and even a few connected to Health Savings Accounts.

Overall, they break it out into 26 about Medicaid, 19 about ACA, 9 about Medicare and 11 about HSAs. However, 2 of the Medicare/Medicaid sections are identical since they impact both programs, and the Senate version (the one actually signed into law) didn't include a lot of the House-passed provisions, so the grand total is actually:

• Medicaid: 19 total, 2 of which overlap w/Medicare
• Medicare: 5, 2 of which overlap w/Medicaid
• HSAs: 3
• ACA: 5

In addition, however, there's also half-dozen other significant changes to the ACA via CMS's recently-finalized "Integrity Rule", as well as the expiration of the improved ACA subsidies provided under the American Rescue Plan Act & Inlfation Reduction Act. Oh, and there's also the automatic Medicare cuts triggered by PAYGO legislation.

All told, that's around 40 different major policy changes impacting the U.S. healthcare industry...over half of which will either be fully or at least partially implemented before November 3rd, 2026:

NOTE: I'm using a blend of KFF's language and my own below; please visit their site for more comprehensive decriptions of some of these.

MEDICAID:

• January 1, 2026: Elimination of ARPA financial incentive to get non-expansion states to expand

The American Rescue Plan Act (ARPA) added a financial incentive for states that newly adopt expansion. To date, only two states have taken up this funding (Missouri & Oklahoma). It would provide anywhere between $70 million - $5.0 billion to the remaining 10 states if they expanded Medicaid under the ACA.

Under H.R. 1, that funding is now gone (not that any of the remaining states have been tempted so far anyway).

• October 1, 2026: Limit on ER FMAP payments for immigrants

Undocumented immigrants and some lawfully present immigrants are not eligible for federally funded Medicaid coverage. Emergency Medicaid reimburses hospitals for the costs of emergency care provided to immigrants who would qualify for Medicaid except for their immigration status, which hospitals are required to provide under federal law.

Under H.R. 1, starting next fall, these payments would be limited to the FMAP of each state.

• October 1, 2026: Dramatic reduction in definition of "Qualified Immigrant" for purposes of Medicaid eligibility

In addition to meeting other eligibility requirements, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP. Qualified immigrants include:

• Lawful permanent residents (LPRs);
• refugees;
• individuals granted parole for at least one year;
• individuals granted asylum or related relief;
• certain abused spouses and children
• certain victims of trafficking;
• Cuban and Haitian entrants;
• citizens of the Freely Associated States (COFA migrants) residing in states and territories.

Many lawfully present immigrants must wait five years after obtaining qualified status before they may enroll in Medicaid; states may waive the five-year wait for children and pregnant individuals. Some states have state-only funded coverage programs for undocumented immigrants.

Under H.R. 1, starting next fall, the definition of "qualified immigrant" will be restricted to:

• LPRs;
• Certain Cuban and Haitian immigrants;
• Citizens of the Freely Associated States (COFA migrants) lawfully residing in the US;
• Lawfully-residing children and pregnant adults in states that cover them under the ICHIA option.

In other words, refugees, parollees, those granted asylum and even victims of domestic abuse and human trafficking are SOL.

• July 4, 2025 (Expansion States) or January 1, 2028 (Non-Expansion States): Restriction on State-Directed Payments

States may use “state directed payments” (SDPs) to require MCOs to pay providers certain rates, make uniform rate increases, or to use certain payment methods.

A 2024 rule on access to care in Medicaid managed care codified that the upper limit for SDPs is the average commercial rate for hospitals and nursing facilities, which is generally higher than the Medicare payment ceiling used for other Medicaid fee-for-service supplemental payments.

Under H.R. 1, the total payment rate would be capped at Medicare rates for states which have expanded Medicaid under the ACA, and at 110% of Medicare rates for non-expansion states.

States with existing arrangements would have to start reducing their payment rates down 10% per year starting in 2028.

• July 4, 2025: Prohibition of Medicaid payments to Planned Parenthood & other community service providers

Medicaid is prohibited from paying nonprofit providers, essential community providers primarily engaged in family planning services or reproductive services, provide for abortions outside of the Hyde exceptions and received $800,000 or more in payments from Medicaid in 2023.

This basically means Planned Parenthood is screwed, along with other Medicaid essential community providers.

I admit being a bit confused by KFF's wording--they say the effective date is "Upon enactment for one year" which I assume means payments to PP/etc would only be cut off for a year? If so, this would still be devastating but not as horrible as a permanent ban.

Note: Just hours ago a federal judge has blocked this provision...although that could easily change by the time you read this...

• IMPORTANT: Even the controversial & much-debated Medicaid work reporting requirements which have sucked up so much political & media attention, which everyone keeps saying "won't be implemented until after the midterms," could potentially go into effect before Election Day 2026 after all.

The actual wording of the relevant legislative text is:

"...the first day of the first quarter that begins after December 31, 2026, or, at the option of the State under a waiver or demonstration project under section 1115 or the State plan, such earlier date as the State may specify."

In other words, some states COULD potentially launch them BEFORE the midterms via a waiver if granted by the HHS Dept. This most likely refers to states like Arkansas, Indiana, New Hampshire & Ohio, where waivers were already approved by the first Trump Admin but were shut down by federal judges.

On the other hand, there will be a lot of political pressure from Republican leaders for those states not to implement them before the midterms to avoid the blowback, so they're still unlikely to do so before December 2026.

Next, there's two provisions which won't be implemented until October 1, 2034... but that's actually a bad thing because both of these are rules put into place under the Biden Administration:

MEDICAID *AND* MEDICARE:

• Delayed by a Decade: Biden Admin Nursing Home Staffing Final Rule

A 2024 Biden-administration final rule requires long-term care facilities (LTC) to meet minimum staffing levels (including a 24/7 RN on-site and a minimum of 3.48 total nurse staffing hours per resident day (HPRD)), requires state Medicaid agencies to report the share of Medicaid payments for institutional LTC that are spent on worker compensation, and provides funding for people to enter careers in nursing homes.

H.R. 1 prohibits the Secretary of Health and Human Services from implementing, administering, or enforcing the minimum staffing levels required by the final rule until October 1, 2034.

• Delayed by a Decade: Biden Admin Medicaid Eligibility and Enrollment Final Rules

The first rule reduces barriers to enrollment in Medicare Savings Programs (MSPs), which provides Medicaid coverage of Medicare premiums and cost sharing for low-income Medicare beneficiaries. The second rule streamlines application and enrollment processes in Medicaid, aligns renewal policies for all Medicaid enrollees, facilitates transitions between Medicaid, CHIP, and subsidized Marketplace coverage, and eliminates certain barriers in CHIP.

H.R. 1 prohibits the Secretary from implementing, administering, or enforcing certain provisions in both rules until October 1, 2034.

MEDICARE:

• 2026 - 2027 fiscal year: $45 billion in PAYGO-induced automatic Medicare cuts

via House Budget Committee Democrats:

House-Passed FY25 Reconciliation Bill Triggers $535 Billion in Medicare Cuts

The nonpartisan CBO’s analysis confirms that the House-passed reconciliation bill (H.R. 1) will trigger $535 billion in Medicare cuts over a decade. The automatic cuts to Medicare result from an end of year sequester under the Statutory Pay-As-You-Go Act (PAYGO).

What is Statutory PAYGO?

PAYGO is a rule requiring that new authorizing legislation not increase the federal budget deficit unless it is offset by other legislation.

How is Statutory PAYGO enforced?

OMB tracks budgetary effects of enacted legislation on five- and ten-year “scorecards” to enforce this rule. At the end of each year, if either one of these scorecards shows a net deficit balance, OMB must execute the sequester to offset it, unless an act of Congress prevents or postpones the sequester.

How is sequestration calculated?

OMB calculates a "uniform percentage" – meaning a percentage that applies to all applicable programs equally – that would result in savings from an across the board cut in the budget year equal to the net cost on the PAYGO scorecard for that year. However, Statutory PAYGO exempts numerous programs from sequestration, including Social Security, veterans' benefits, Medicaid, the Supplemental Nutrition Assistance Program, and Supplemental Security Income. Most Medicare payments are subject to sequestration, but under the law, they cannot be reduced by more than four percent.

CBO estimates that under PAYGO, the Republican bill will cause a $45 billion cut to Medicare in 2026, growing to $75 billion in 2034 and totaling $535 billion over the 2026 through 2034 period.

It's conceivable that the Republican-controlled Congress will take legislative action before the end of the fiscal year to prevent some or all fo these cuts, and I honestly don't know the details of how the cuts would actually be implemented (Higher premiums for enrollees? Cuts in services? Reduced provider reimbursement?), but $45 billion isn't chump change.

• January 1, 2026: One-year bump in Physician Fee Schedule Conversion Factor Adjustment

Currently Medicare payment rates to physicians and other clinicians under the Physician Fee Schedule are determined in part by a scaling factor, known as the conversion factor, which is updated each year. Under current law, conversion factor updates are based on statutory factors and other budgetary requirements, and do not vary based on changes in inflation in medical practice costs.

Under H.R. 1, there will be a temporary one-year increase of 2.5% to the PFS for services performed during calendar year 2026. Again, this one may not be a bad thing.

AFFORDABLE CARE ACT:

• December 31, 2025: IRA SUBSIDY EXPIRATION

If you've been reading ACA Signups for any length of time you know what a Big F*cking Deal this is and how devastating it will be to ~24 million ACA exchange enrollees (and indirectly to up to 1.8 million Basic Health Plan enrollees). I'm not gonna bother with a lengthy description here, but it's gonna be ugly as hell.

• Immediate Effect: APTC/CSR/BHP enrollment eligibility for DACA recipients RESCINDED (via CMS rule)

This one isn't via the H.R. 1 bill itself, but is instead due to the recent "2025 Marketplace Integrity and Affordability Final Rule" issued by CMS back in June:

CMS is finalizing amendments to the definition of “lawfully present” to exclude DACA recipients, returning to the interpretation adopted in the 2012 Interim Final Rule (77 FR 52614). This change will make DACA recipients ineligible to enroll in a Qualified Health Plan (QHP) through the Marketplace, for premium tax credits, APTC, and cost-sharing reductions (CSRs), and for Basic Health Programs (BHPs) in states that elect to operate a BHP, reversing the 2024 DACA Rule. This policy aligns with statutory requirements and ensures that subsidies are reserved for eligible individuals.

This screws over up to 580,000 DACA recipients (although more realistically only around 100,000 of them were likely to be eligible for various reasons) for...absolutely no good reason whatsoever, other than Trump/MAGA hating immigrants...even those who have lived here virtually their entire lives.

• December 31, 2025: Gender-Affirming Care can no longer be considered an Essential Health Benefit (via CMS rule)

Again, this is via the CMS "Integrity Rule" rather than via H.R. 1 itself:

CMS is finalizing that, effective beginning in plan year 2026, issuers subject to EHB requirements (that is, non-grandfathered individual and small group market plans) may not cover specified sex-trait modification procedures, as an EHB. In the final rule, CMS is also adding a definition of the term “specified sex-trait modification procedure” in response to comments and specifying that certain services would not qualify as a “specified sex-trait modification procedure” under this definition.

This policy will not prohibit issuers of coverage subject to EHB requirements from voluntarily covering specified sex-trait modification procedures, nor will it prohibit states from requiring coverage of such services, subject to the rules related to state-mandated benefits at 45 CFR § 155.170. This policy will align EHB with the benefits covered by typical employer-sponsored plans, as required by the applicable statute.

It doesn't mean that insurance carriers can't cover gender-affirming services, but it does mean those services can't have APTC subsidies applied towards them if they're included in the policy...which not only means that a lot more transgender folks will have to pay more for such services, it also means carriers will be less likely to choose to include them as part of their policies at all.

• January 1, 2026: Elimination of APTC for all lawfully-present immigrants under 100% FPL

Under current law, U.S. citizens and lawfully present immigrants are eligible to enroll in ACA Marketplace coverage and receive premium subsidies and cost-sharing reductions. Lawfully present immigrants with incomes under 100% of the federal poverty level (FPL) who do not qualify for Medicaid coverage due to their immigration status also are eligible for ACA Marketplace coverage.

Under H.R. 1, "lawfully present immigrants" has been reduced to LPRs/green card holders, COFA migrants, "certain immigrants from Cuba & Haiti" which means many other groups are screwed including refugees, asylees & those with TPS starting in 2027.

However, it also eliminates all federal subsidies (APTC) for "lawfully present immigrants" with incomes below 100% FPL starting January 1, 2026.

This basically means that recent documented immigrants who aren't eligible for Medicaid because they've lived here for less than 5 years also aren't eligible for ACA subsidies if they earn less than 100% FPL whether they live in an expansion state or not.

• January 1, 2026: Elimination of Special Enrollment Period for enrollees earning less than 150% FPL (via CMS Rule)

People in states that use Federally-Facilitated Marketplaces (FFM) and make no more than 150% of the federal poverty level can apply for a year-round SEP to sign up for coverage. Some state-based exchanges also offer SEPs that are based on the relationship of people's income to the poverty line.

Nearly half of all ACA exchange enrollees on the federal exchange earned less than 150% FPL this year.

The CMS rule eliminates the < 150% FPL Special Enrollment Period.

• January 1, 2026: Enrollees via Non-QLE SEP barred from receiving APTC or CSR (NA/AN screwed?)

Bars any consumer who enrolls in a plan via a non-QLE SEP from receiving either premium tax credits or CSRs.

QLE = Qualifying Life Experience (ie, losing existing coverage; getting married/divorced; giving birth/adopting; getting out of prison; turning 26; etc)

SEP = Special Enrollment Period (ie, a time window during which you're allowed to enroll in an ACA exchange plan & receive financial help if eligible outside of the official Open Enrollment Period)

Under the ACA, Native Americans and Alaska Natives are eligible to enroll via a year-round Special Enrollment Period...but, as my colleague Louise Norris noted, technically "being a Native American/Alaska Native" isn't a Qualifying Life Experience, so it's possible that they may not be eligible for federal subsidies if they enroll outside of the official Open Enrollment Period.

• January 1, 2026: PAPI formula change to make MOOP higher ($450/$900/yr) (via CMS rule)

CMS is finalizing updates to the methodology for calculating the premium adjustment percentage to establish a premium growth measure that captures premium changes in both the individual and employer-sponsored insurance markets for the 2026 plan year and beyond. CMS is also finalizing the plan year 2026 maximum annual limitation on cost sharing, reduced maximum annual limitations on cost sharing, and required contribution percentage using the finalized premium adjustment percentage methodology.

Maximum out of Pocket (MOOP) is the maximum amount that any ACA plan enrollee has to pay in deductibles, co-pays or coinsurance combined for in-network care over the course of the year.

Via my colleague Louise Norris:

• The 2025 Maximum Out of Pocket cap: $9,200 for an individual or $18,400 for the household
• Under the old rule: 2026 MOOP would be $10,150 / $20,300 (10.3% higher)
• Under the new rule: 2026 MOOP would be $10,600 / $21,200 (15.2% higher)

In other words, under the old formula the MOOP would increase by $950 or $1,900 next year, which would be bad enough...but under the new formula, it's gonna go up by an additional $450 person / $900 per household.

• January 1, 2026: Widening de minimus thresholds (via CMS Rule)

CMS is finalizing widening the de minimis ranges to +2/-4 percentage points for all individual and small group market plans subject to the AV requirements under the EHB package, other than for expanded bronze plans, for which CMS is finalizing a de minimis range of +5/-4 percentage points. CMS is also finalizing removing from the conditions of QHP certification the de minimis range of +2/0 percentage points for individual market silver QHPs and specifying a de minimis range of +1/-1 percentage points for income-based silver CSR plan variations.

This is basically blurring the lines between Bronze, Silver, Gold and Platinum-level ACA plans, making the distinctions vaguer, more confusing to enrollees and completely defeating the point of having separate "Metal Levels" in the first place. It also means that the benchmark Silver plan, which is the one used to calculate APTC subsidies, will likely be lower-priced but also less comprehensive...which means that ACA subsidies will be less generous for all enrollees.

• January 1, 2026: $5/mo subsidy penalty for $0 auto-renewals until verification (via CMS Rule)

CMS is finalizing modifications to the annual eligibility redetermination process by requiring Marketplaces on the Federal platform to ensure that consumers who are automatically re-enrolled with no premium responsibility following application of APTC and without affirming or updating their eligibility information, are automatically re-enrolled with a $5 monthly premium beginning in plan year 2026.

Once consumers confirm or update their information, the $5 monthly bill will be eliminated if they continue to be eligible for a $0 premium after application of APTC. As with all enrollees, they may receive a refund or reduction on the taxes they owe (or may owe) when they file and reconcile their APTC on their federal income tax return.

...This policy will sunset at the end of the 2026 plan year.

Normally, if an existing ACA enrollee takes no action whatsoever (ie, they never contact their ACA exchange by phone or by logging into their account) during OEP, the exchange will either automatically re-enroll them into their existing plan for another year or they'll "map" the enrollee to the closest equivalent plan in the event that their current one is being discontinued by the insurance carrier.

This rule states that in cases where the enrollee is fully subsidized (ie, 100% of their premiums are covered by APTC subsidies), they'd have those subsidies reduced by $5/month...which means they'd go from paying nothing to $5/month in premiums.

During the 2024 OEP, 42% of federal exchange enrollees (6.8 million people) were enrolled in $0-premium policies. I don't have that number for 2025 yet, but I'm assuming it's higher since total enrollment is 13% higher.

Assuming that extrapolated across every state, that'd be up to over 10 million ACA exchange enrollees who could potentially be hit with a $5/month hike in their monthly premium. They'd be charged the $5/mo until they actively confirmed that they wanted to remain enrolled in that policy or that their income had changed.

$5/mo may not sound like much but it's a pretty big deal to low-income folks and will no doubt cause a lot of confusion. I should also note that if the point was truly to eliminate fraud and make sure enrollees were aware of being auto-renewed, they could have made the reduction $1.00 or even $0.01 instead of $5.00 for the same effect.

• November 1, 2026: Shortened Open Enrollment Period (via CMS Rule)

CMS is finalizing changes to the annual OEP beginning with the OEP for plan year 2027. This adjustment will apply to both on- and off-Marketplace individual market coverage. The final rule allows all Exchanges flexibility to set their own OEPs within set parameters for timing and duration. Each OEP must start no later than November 1 and end no later than December 31, and the OEP may not exceed 9 calendar weeks. Finally, all enrollments pursuant to Open Enrollment Period must begin on January 1.

Currently, the annual Open Enrollment Period runs 76 days, from November 1st to January 15th. This would shorten it considerably. While it's being implemented for the 2027 calendar year, that means the policy still goes into effect before the midterms...2 days before, to be precise, on November 1, 2026.

• December 31, 2025: Discontinuation of Bronze plan enrollees eligible for $0-premiums CSR Silver plans being auto-reenrolled into them (via CMS Rule)

CMS is finalizing the repeal of a regulation that allows Marketplaces to automatically re-enroll CSR-eligible bronze QHP enrollees in a silver QHP if the silver QHP is in the same product, has the same provider network, and has a lower or equivalent net premium as the bronze plan into which the enrollee would otherwise have been re-enrolled.

State Marketplaces may continue seeking approval from the Secretary to design and conduct their own annual eligibility redetermination process.

Normally the exchange will re-enroll people into the same policy if it's still available, but a couple years back the Biden Admin realized that there's a lot of people who are leaving thousands of dollars in potential savings on the table by selecting Bronze plans instead of a high-CSR Silver plan with the exact same provider network even when they're eligible for a far better value without paying a dime more.

To benefit enrollees, HealthCare.gov started shifting people in that specific situation over to Silver plans instead in order to provide them with greater savings on deductibles, co-pays & coinsurance fees. The Musk/Trump Administration is pulling the plug on this improvement.

• January 1, 2026: Bronze & Catastrophic plans treated as HDHPs

Currently, not all bronze plans meet the requirement to be paired with an HSA (the out-of-pocket maximum or other design features might not meet IRS rules). Catastrophic plans are ineligible to be paired with an HSA. Bronze plans have the highest cost-sharing and lowest premiums among metal-tier plans, equivalent to 60% of the actuarial value of plan benefit. Catastrophic plans have lower premiums than bronze plans and deductibles are equal to the ACA annual limit on out-of-pocket costs ($9,200 for individual coverage and $18,400 for family coverage in 2025).

Under H.R. 1, bronze and catastrophic plans are treated as HDHPs which can be paired with an Health savings Account. This is the rare provision of the bill which may actually be a positive thing.

And finally, here's one which is technically going into effect before the midterms but which enrollees won't be hit with until they file their taxes in spring 2027:

• January 1, 2026: Elimination on excess APTC recapture limits regardless of income

Currently, if an enrollee receives excess premium tax credits because their estimated income was lower than their actual income, they must repay the excess. However, for most enrollees, there is a repayment cap that varies based on household income.

For enrollees with household incomes over 400% of the federal poverty level (FPL), there is no limit. They must repay the entirety of their excess tax credit.

Other repayment limits vary from $375 for a single person with an income that is less than 200% FPL to $3,150 for families with an income between 300%-400% FPL.

Under H.R. 1, all premium tax credit recipients will now have to repay the full amount of any excess, no matter their income.

This won't impact enrollees who earn more than 400% FPL...but then again, they're already about to be screwed by having all APTC subsidies eliminated anyway. However, it's gonna be a nasty surprise for some enrollees who earn between 100 - 400% FPL who thought they'd only have to pay back a few hundred bucks who instead find they have to pay a lot more back to the IRS.

The only silver lining (no pun intended) here is that I've received reliable confirmation that this will not impact folks who receive APTC but end up earning less than 100% FPL, thank God.

HEALTH SAVINGS ACCOUNTS:

• January 1, 2026: HSA eligibility for Direct Primary Care Arrangements (DPC)

DPC arrangements generally offer unlimited primary care services to patients in exchange for a periodic fee paid to the DPC practice. Current law may treat DPC as a health plan under certain circumstances, making an individual covered by a DPC arrangement ineligible to use an HSA.

Under H.R. 1, some DPCs will not be considered health plans, allowing individuals covered by these arrangements to be eligible for a health savings account. This may sound reasonable on the surface, but it sounds to me like it's mostly another tax dodge for wealthy people, since I suspect they tend to be the only ones who have DPC arrangements.

• Immediate: Permanent HSA coverage of Telehealth & Other Remote Services

HSA-eligible high deductible health plans were allowed to cover telehealth and other remote services before the deductible temporarily via COVID-era legislation, which was supposed to end on December 31, 2024.

Under H.R. 1, this allowances has been extended permanently. Again, this one isn't necessarily a bad thing, depending on your POV.

----------------

OK, so what about healthcare provisions which kick in AFTER the midterms?

MEDICAID:

• October 1, 2028: Mandatory cost sharing for ~half of expansion adult enrollees

States have the option to charge premiums and cost-sharing for Medicaid enrollees within limits, and certain populations and services (emergency, family planning, pregnancy and preventive) are exempt from cost-sharing. Cost-sharing is generally limited to nominal amounts but may be higher for those with income above 100% of the federal poverty level (FPL). Out-of-pocket costs cannot exceed 5% of family income. States may allow providers to deny services for enrollees for nonpayment of copayments.

Under H.R. 1, states are required to impose cost sharing of up to $35 per service on expansion adults with incomes 100-138% FPL, with some services exempted, while sticking with the 5% household income maximum cap.

• December 31, 2026: Eligibility redeterminations doubled from every year to every six months

Currently, states must renew eligibility every 12 months for Medicaid enrollees whose eligibility is based on modified adjusted gross income (MAGI), including children, pregnant individuals, parents, and expansion adults, and must renew eligibility at least every 12 months for enrollees whose eligibility is based on age 65+ or disability. States are required to review eligibility within the 12-month period if they receive information about a change in a beneficiary’s circumstances that may affect eligibility.

Under H.R. 1, states have to conduct eligibility redeterminations at least every 6 months for expansion adults only.

• January 1, 2027 / October 1, 2029: Crackdown on enrollee address/other personal info verification

Currently, states are not required to take proactive steps to obtain updated enrollee contact information, although a CMS rule requires states to leverage reliable data sources to update enrollee address information, effective June 2025.

Under H.R. 1, states are required to...

...obtain enrollee address information using reliable data sources, including the National Change of Address Database and managed care entities; the HHS Secretary has to establish a system to share information with states for purposes of preventing individuals from being simultaneously enrolled in two states and requires states to submit monthly enrollee SSNs and other information to the system; and states have to review the Master Death File at least quarterly to determine if any enrolled individuals are deceased.

The contact info requirement kicks in starting in 2027; the dual-state enrollment prevention system starting by October 2029.

• January 1, 2027: Retroactive coverage limited to one or two months instead of three

Under current law, states are required to provide Medicaid coverage for qualified medical expenses incurred up to 90 days prior to the date of application for coverage.

Under H.R. 1, retroactive coverage is limited to one month for expansion enrollees and two months for traditional Medicaid enrollees.

• July 4, 2028: Crackdown on provider tax funding arrangements

Currently, states are permitted to finance the non-federal share of Medicaid spending through multiple sources, including state general funds, health care related taxes (or “provider taxes”), and local government funds. Federal rules specify provider taxes must be broad-based and uniform (i.e., states can’t limit provider taxes to only Medicaid providers) and may not hold providers “harmless” (i.e., guarantee providers receive their money back). The hold harmless requirement does not apply when tax revenues comprise 6% or less of providers' net patient revenues from treating patients (referred to as the “safe harbor” limit).

Under H.R. 1, however, starting 3 years from the bill being signed into law...

• States are prohibited from establishing any new provider taxes or from increasing the rates of existing taxes.
• Some currently permissible taxes won't be allowed in the future, including those on MCOs
• ACA expansion states are penalized even more, with the "safe harbor" limit being gradually reduced to just 3.5%
• The new limit applies to all providers except nursing homes & intermediate care facilities, and even applies to local government taxes in expansion states only

• January 1, 2027: New definition of "Budget Neutrality" for Section 1115 Waivers

Currently, Section 1115 demonstration waivers must be “budget neutral” to the federal government over the course of the waiver. Federal costs under an 1115 waiver may not exceed what they would have been for that state without the waiver. Typically, budget neutrality calculations are determined on a per enrollee basis—so, per enrollee spending over the course of the waiver (usually 5 years) cannot exceed the projected per enrollee spending calculated in the “without-waiver baseline.”

Budget neutrality calculations and the use of “savings” when expenditures decrease on account of the waiver are negotiated between states and CMS & OMB).

Under H.R. 1, however, the CMS Chief Actuary is the one who decides whether or not the waiver "increases federal expenditures compared to federal expenditures without the waiver." I'm not certain about this but it sounds like this may not even be on a "per enrollee" basis; if not, then it would quickly become absurd since any increase in enrollment--presumably one of the major points of having a waiver in the first place--would by definition increase total expenditures.

• October 1, 2030: Reduction in "Good Faith" waiver payments for erroneous Medicaid payments

Currently, federal law directs CMS to recoup federal funds for erroneous payments made for ineligible individuals and overpayments for eligible individuals if the state’s eligibility “error rate” exceeds 3 percent. CMS may waive the recoupment if the Medicaid agency has taken steps to demonstrate a “good faith” effort to get below the 3 percent allowable threshold.

Under H.R. 1, HHS has to reduce payments to states for erroneous payments and expands the definition of "improper payments" to include cases where insufficient info is available to confirm eligibility.

• January 1, 2028: Reduction in Home Equity limits for Long Term Care eligibility:

Currently, ,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.

Under H.R. 1, the max limit is $1.0 million regardless of inflation, and states will be allowed to change the requirements for farmland homes.

• July 1, 2028: Home and Community Based Services (HCBS) waivers allowed

Currently, states are required to cover nursing facility care under Medicaid, but nearly all home care (HCBS) is optional. Nearly all states provide home care through “1915(c) waivers,” which limit services to people who require an institutional level of care. Because those services are optional, states may limit the amount of care people may have receive and the number of people receiving services. Most states have waiting lists because the number of people seeking services exceeds the amount of care available.

Under H.R. 1, states are allowed to establish waivers for people who do not need an institutional level of care.

• January 1, 2028: Crackdown on provider screening requirements

Currently, provider screening and enrollment is required for all providers in Medicaid fee-for-service or managed care networks. Additionally, the ACA requires states to terminate provider participation in Medicaid if the provider was terminated under Medicare or another state program. CMS has multiple tools to assist states with provider screening and enrollment compliance, including leveraging Medicare data.

Under H.R. 1, states have to run checks at enrollment, re-enrollment and monthly on all providers, as well as having to run quarterly checks to make sure the provider hasn't died.

MEDICARE:

• January 4, 2027: Restriction on Medicare coverage for some classes of documented immigrants

Currently, residents of the United States, including citizens, permanent residents, and other immigrants that are lawfully present in the country, are eligible for premium-free Medicare Part A if they or their spouses have worked in a job for at least 40 quarters where they paid Medicare payroll taxes and are at least 65 years old. People under age 65 with a qualifying disability, end-stage renal disease (ESRD), and amyotrophic lateral sclerosis (ALS) are also generally eligible. Legal immigrants who are age 65 or older who do not have this work history can purchase Medicare Part A after residing legally in the U.S. for five years continuously.

Under H.R. 1, however, starting in 18 months, Medicare eligibility will be restricted to U.S. citizens, green card holders & certain immigrants from Cuba, Haiti and COFA...throwing asylees and those w/Temporary Protected Status under the bus.

• January 1, 2028: Orphan Drug Exclusion changes

he Inflation Reduction Act requires the Secretary of Health and Human Services to negotiate prices with drug companies for certain drugs covered under Medicare. Drugs qualify to be selected for price negotiation if they are high-spending drugs without generic or biosimilar competition and have been on the market for at least 7 years (for small-molecule drugs) or 11 years (for biologics) past the FDA approval or licensure date.

Certain types of drugs are excluded from selection, including drugs designated for only one rare disease or condition and approved for an indication (or indications) only for that disease or condition, known as the orphan drug exclusion.

Under H.R. 1, the "exclusion" is modified to include drugs designated for one or more rare diseases or conditions and where the only approved indication or indications are for one or more rare diseases or conditions, and the time period won't count towards the 7 or 11 year time frame. I have no idea whether this change is positive or negative, honestly.

• 2027 - 2034 Fiscal Year: The balance of the PAYGO-induced automatic Medicare cuts

Since the first $45 billion would kick in during the 2026 FY, that leaves another $490 billion would be spread out over the next nine years.

AFFORDABLE CARE ACT:

• January 1, 2028: Pre-enrollment verification of eligibility for premium tax credit

Currently, new ACA exchange enrollees are granted conditional eligibility if there is a mismatch in the information they provided and federal databases. Enrollees can retain coverage and tax credits for up to 90 days while submitting verification documents. Returning enrollees who take no action during open enrollment are auto-renewed into the same or similar plan. Nearly half of Marketplace enrollees in 2025 auto-renewed.

Under H.R. 1, enrollee household income, "eligible alien" immigration status, health coverage status, place of residence, family size, and any other information that the Secretary of Health and Human Services deems necessary must be verified before coverage. Consumers can still enroll in a plan, but cannot receive premium tax credits until after they verify their eligibility.

THIS WOULD EFFECTIVELY END AUTO-RENEWALS, WHICH NEARLY HALF OF EXCHANGE ENROLLEES CURRENTLY UTILIZE.