Joan Alker: Hi! Everybody! Welcome to our Georgetown University, Webinar. We're just gonna give it another
Joan Alker: 30 seconds here while people are still joining, and we'll be right back.
Joan Alker: Okay, I am gonna start and
Joan Alker: we still have folks joining, but looks like it's slowing down a little bit. And
Joan Alker: before we get into the slides. I want to give a few introductory remarks.
Joan Alker: Welcome everybody to our child. Medicaid Policy Institute, Webinar. It's not just about children, but that's what this series is called.
Joan Alker: and thank you to the Annie Casey Foundation for support of this project, which is really to build knowledge and leadership around Medicaid.
Joan Alker: My name is Joan Alker. I'm the Executive Director of the Center for Children and Families at Georgetown University's Mccourt School of Public policy.
Joan Alker: and I'm a research professor also at Mccourt, and I'm joined by 2 colleagues, Edwin Park, who is also a research professor at Mccourt and at Ccf.
Joan Alker: And our colleague, Sabrina Corlett, who is also a research professor at Mccourt and one of the executive directors of the Center on health insurance reforms just down the hall.
Joan Alker: Our sister Center. So we are very pleased to be together today to present some information about Hr. One also known as the one big, beautiful bill
Joan Alker: that, as you know, passed Congress and was signed into law on July 4th by President Trump.
Joan Alker: So we started this series in December. We talked about some of the proposals that we expected Congressional Republicans to advance. And we're here today to review for you what is in the bill.
Joan Alker: We do have an explainer on this, and we will pop the link to that in the chat. Some of you have probably seen that, but there is a lot in this bill.
Joan Alker: And we're not going to be able to cover all of it today. But the explainer is terrific. Edwin and Sabrina wrote it.
Joan Alker: and we also have a number of blogs at Ccf. That we have been posting where we are unpacking and analyzing various aspects of the new law.
Joan Alker: As many of you know, the process itself was extremely chaotic.
Joan Alker: with much of the actual committee work in the House
Joan Alker: and floor time on the Senate, where they skipped the committees and went straight to the floor, happening in the middle of the night with very little notice, very little advance notice of what was in the legislative language.
Joan Alker: and of course, at the Senate on the Senate side, because this was a privileged bill under the budget. Reconciliation rules
Joan Alker: the Senate. Parliamentarian was making rulings about compliance with the bird roll, you know, pretty much right up to close to passage. So things were changing very rapidly, and I think it's fair to say.
Joan Alker: few members had an exact handle on what was exactly in the bill. And so we've been spending some time
Joan Alker: kind of recovering from that crazy time, and also just trying to
Joan Alker: parse out what happened. So, of course, for such a complex and far reaching law, which, as you'll hear, has over a trillion dollars in health care cuts mostly from Medicaid. It's really troubling that Congress
Joan Alker: made law this way.
Joan Alker: A couple of housekeeping notes. This is a webinar. This will be recorded, it will be in a listen. Only mode.
Joan Alker: We will take questions for the last 20 min or so, and you can submit questions in the Q&A. Box.
Joan Alker: and we will be posting the webinar recording as well as the slides on our website.
Joan Alker: So we are scheduled to end at 2 45 Eastern
Joan Alker: and like, I said, we'll hold all the questions till the end. And so now I'm gonna start just as a few kind of table setting comments
Joan Alker: and also to quickly review the impact on the children's health Insurance program before I hand it to Edwin, who's going to talk about Medicaid
Joan Alker: and Sabrina, who's going to talk about the marketplace.
Joan Alker: So before I get to my chip slides I want to just say a few sort of big picture thoughts.
Joan Alker: For those of us who who were working together on this for a long time, and and perhaps some of you attended our earlier webinars.
Joan Alker: Hr. One does not cap Federal medicaid spending, nor does it reduce the higher match rate for the aca medicaid expansion rate for adults, with one exception, that Edwin will cover with respect to emergency Medicaid. So
Joan Alker: so that is good news. There were certainly those in Congress who wanted to do that. But the bill does not do that.
Joan Alker: However. Hr. One does make many, many cuts to Medicaid, many, but not all of them are focused on the Aca Medicaid Expansion group.
Joan Alker: and these cuts and changes will make it considerably harder for new States to adopt this expansion in the future and harder for States who have them today to maintain them.
Joan Alker: Hr. One also restricts the way States can raise their funds for their share of Medicaid.
Joan Alker: and dramatically increases red tape for people and providers.
Joan Alker: And lastly, we'll talk about Hr. One has restrictions on immigrant eligibility, mostly for lawfully resigning immigrants, and we'll cover a little bit of that, and then Sabrina will cover the marketplace changes that the bill makes.
Joan Alker: Okay.
Joan Alker: So now I'm going to get to Chip, we can move to the 1st slide.
Joan Alker: and, as I mentioned generally, Chip was not a subject or active focus on the legislation of the legislation.
Joan Alker: But there are a few important provisions to highlight. And before we get into those I want to say that technically
Joan Alker: the Rural Health Transformation Fund for those of you watching the debate, you'll you'll know. Remember that there was a lot of concern about rural hospitals.
Joan Alker: and a Rural health transformation fund was added. We'll we'll touch on that briefly later, but it's actually written into Chip, even though it really has nothing to do with chip
Joan Alker: but we have a good section in the explainer on on that Rural Health Transformation Fund, and we'll touch on that in a minute.
Joan Alker: So very quickly. Let's go to the 1st slide on Chip, and just a quick, quick overview of Chip. I'm not going to get into all of these. I think most of you know this.
Joan Alker: But Chip is a children's health insurance program. It sits sort of on the shoulders of Medicaid for children whose income is over the Medicaid level, and it's a block. Grant and States have a choice whether they establish a separate chip program, or they simply expand their Medicaid with enhanced financing.
Joan Alker: So the changes I'm about to talk about
Joan Alker: are changes that will apply to separate chip programs. So not all States have those. Let's go to the next slide.
Joan Alker: So hr, one had a lot of
Joan Alker: provisions in it that repealed regulations that were promulgated during the Biden administration relating to lots of things in Medicaid, and you can see them here. The House repealed the entire eligibility enrollment.
Joan Alker: Regulation that had been promulgated.
Joan Alker: And that was in section 7, 1, 1, 0 2. But because we believe and we don't know for sure. But we kind of do know for sure, because they're they're not public
Joan Alker: because of Parliamentarian rulings.
Joan Alker: The trip policies were not repealed in the final version of the bill.
Joan Alker: So what does that mean? What that means is that separate stateship programs are no longer allowed, as of June 3, rd 2025.
Joan Alker: To have waiting periods, lockouts for nonpayment or premiums, lifetime or annual limits
Joan Alker: on benefits and states must ensure smoother transfers from Medicaid to Chip, where they have a separate chip program. Now, these policies are really outdated policies that
Joan Alker: emanate from when ship was 1st passed in 1997, when there was concern about proud out, proud out of employer, sponsored insurance
Joan Alker: and that was a long time ago. The Affordable Care Act has passed, of course, since then, and radically changed the landscape of employer coverage and private insurance. And there's really
Joan Alker: no evidence at all to suggest that separate State trip programs which only cover 3 million children nationwide are having any impact on employer decisions about dependent coverage.
Joan Alker: So not many states still have these policies, but some do.
Joan Alker: And they they're harmful for children. They keep them uninsured, or they limit their benefits. They promote gaps in coverage.
Joan Alker: and now they're no longer allowed, as of June 3, rd 2025, and likely a lot of folks don't realize this
Joan Alker: and we have a blog that is, goes into a lot of detail. We just put it up. Friday. We we name names about the States. So if you are from a state with a separate ship program, check out the blog.
Joan Alker: the link is in the chat. It'll be on the next slide. And but before we get to that, I just want to say that separately, in another section of Hr. One retroactive eligibility for everybody in Medicaid was limited. It had been 90 days for many, many years for the Expansion group. It was limited 30 days, but for children in particular it was limited from 90 days to 60 days.
Joan Alker: but a little silver lining. There is that chip now add a 60 day retro period at state option so they could line up
Joan Alker: their Medicaid and chip programs with 60 day retro. And that would certainly address
Joan Alker: some of these issues that exist about smooth transfers from Medicaid to chip.
Joan Alker: So we'll go to the next slide. This just has again more information. Please check out this blog, that Tricia Brooks and I wrote, and now I'm going to hand it off to Edwin to talk about Medicaid.
Edwin Park: Thanks, Joan. So I'm going to talk about some of the Medicaid chip cuts obviously can't cover everything. But I'll try to cover 3 major areas. So next slide, please.
Edwin Park: So I'll 1st talk about the new Congressional Budget Office estimates on both spending as well as some very limited coverage numbers. And, as I mentioned, focus on 3 areas of cuts in the budget reconciliation law, there are actually more than 20 provisions related to Medicaid and Chip, and the final reconciliation law.
Edwin Park: We're going to cover these 3 areas, those related to provider taxes, those targeting medicaid expansion adults and those targeting immigrant coverage. They constitute about 2 thirds of the total spending cuts. But there are many other provisions in the legislation that's covered in the Explainer, and we're happy to take questions on those provisions
Edwin Park: at at the end of the webinar next slide.
Edwin Park: So the top line Cbo estimates Cbo just came out with estimates last week.
Edwin Park: The reconciliation law based on those numbers show that Medicaid and Chip will be cut
Edwin Park: on a gross basis by nearly one trillion dollars over the next 10 years. So 990 billion dollars. Now, if you combine that with the marketplace cuts that Sabrina will cover, including interactions between Medicaid and Chip revisions, and between Medicaid chip and marketplace provisions. The total net Federal cuts to Medicaid Chip, and the marketplace will equal 1.1 trillion dollars over 10 years.
Edwin Park: This will lead to an increase in the uninsured by
Edwin Park: 10 million by 2034. So this is 10 million relative to the Congressional Budget Office baseline. The number of people who would be uninsured without enactment of this legislation.
Edwin Park: This does not include the failure to extend the expiring, enhanced premium tax credits for the marketplace as well as the full impact of marketplace restrictions that were already assumed in the Cbo baseline that were codified by this legislation, but also in a rule that was finalized by the centers for Medicare and Medicaid services. But if you add those effects in that resulted in an uninsured increase of about 15 million by 2034.
Edwin Park: Unfortunately, more detailed Cbo coverage estimates are still not available, but it's likely that the large majority of this this coverage loss is due to the Medicaid and Chip revisions
Edwin Park: next slide, please.
Edwin Park: So the 1st bucket of cuts I'll talk about are restrictions on state use of provider taxes, and this slide talks about the some of the rules that go into that are currently in effect related provider taxes.
Edwin Park: These are longstanding rules that have been placed where States can finance their share of the cost of the Medicaid program, in part through taxes and assessments on healthcare providers, including hospitals, nursing homes, managed care plans. This has been allowed under rules that have been in place since 1991
Edwin Park: and the general requirements are taxes have to be uniform across the provider type, broad base across the provider type and not hold taxpayers harmless, that is, there can't be a 1 for one in terms of
Edwin Park: ensuring that everything they pay in taxes is returned to them in the form of Medicaid payments. To satisfy this, no whole harmless requirement. States can rely on what's called a safe harbor threshold
Edwin Park: and under prior law, that, save our harbor threshold was such that the size of the taxes cannot exceed 6% of net. Patient revenues. Provider taxes are a critical growing source of state funding for Medicaid.
Edwin Park: though you know general fund dollars raised by income taxes, sales, taxes, other taxes like corporate or business taxes are the primary source of State funding for Medicaid
Edwin Park: States can use provider taxes for a variety of purposes to help finance improvements like the Medicaid expansion, increase provider payment rates increase access to home and community services and closing general budget shortfalls. And that's been particularly the case during recent recessions next slide.
Edwin Park: So what does the budget reconciliation law do with regard to provider taxes? The 1st is a restriction that affects all States.
Edwin Park: So there's a permanent prohibition on any new Provider taxes or any increases in existing provider taxes upon date of enactment. So that's July 4th of this year.
Edwin Park: Whether there's an increase in existing tax depends on the size of the existing tax. It's measured as a percentage of net patient revenue. So if a tax is at 4%,
Edwin Park: a patient revenues, it can't be increased to 4.1% 4.5%, and so forth.
Edwin Park: This means the States cannot add new taxes or increase current taxes to help close budget shortfalls or finance various medicaid improvements. And again, this affects all states.
Edwin Park: So that's the 1st major provider tax restriction. Next slide.
Edwin Park: So the next restriction is affects a limited number of States, and it involves a highly technical subset of provider taxes called uniformity waiver taxes.
Edwin Park: As I mentioned, one of the requirements for provider tax is they have to be uniform across the provider class or type States can vary it. The application of the tax across providers within a provider class or type, and still satisfy the uniformity requirement if they are able to pass a mathematical test. That's been in place also since 1992,
Edwin Park: and if they can, if they can't pass that math test, then they can get a uniformity waiver.
Edwin Park: The majority of States
Edwin Park: have uniformity waivers of some type for their provider taxes. But this is a restriction on a certain group of uniformity waiver provider taxes. This takes effect on date of enactment.
Edwin Park: And it's basically about taxes where there's a wide difference, significant variation between the tax on a group of providers. That's more Medicaid, based versus a tax on those that are more commercially based. For example, some States have managed care organization provider taxes
Edwin Park: where there's a different tax rate for Medicaid managed care plans versus commercial Mcos in the State.
Edwin Park: This prohibition affects at least 7 States with 8 taxes. It's our understanding that it's California, Illinois, Massachusetts, Michigan, New York, Ohio, and West Virginia. But additional States may be implicated. We're starting to hear from states that are other states that may have taxes that are subject to this prohibition. Again, this is upon date of enactment, so this could take effect immediately. The one caveat is that the Secretary of Health and Human Services, or the Cms. Administrator on his behalf
Edwin Park: can grant a transition period of up to 3 years. But there's no guarantee of such a period. It could be 0
Edwin Park: takes effect. This prohibition takes effect immediately. It could be one month, a year, or up to 3 years.
Edwin Park: As a result, some States could see an immediate restriction on State Medicaid Funding, and unless they can identify other financing sources, they would have to cut their Medicaid programs, notably because of the provision I just covered previously. Since there's no
Edwin Park: ability for States to add new taxes or increase existing provider taxes. States can't substitute other revenues raised by provider taxes to replace these lost revenues from uniform new waiver provider taxes.
Edwin Park: According to the Congressional Budget Office, this would cut Federal spending by 34.6 billion dollars over 10 years.
Edwin Park: But this actually is only half the expected budgetary impact. So it's actually twice that, because at the same time Cms had issued a proposed rule doing something very similar to this, trying to prohibit certain uniformity waiver taxes, and because of the conventions related to Cbo scoring.
Edwin Park: Cbo already assumed that about half the impact was in the baseline already before enactment of this legislation.
Edwin Park: Next slide, please.
Edwin Park: So the 3rd big change to provider taxes affects only expansion, states only states that have taken up the affordable Care Act's Medicaid expansion.
Edwin Park: and this would be a reduction in the size of most existing provider taxes. Again, just in expansion States. Now, as I mentioned, there's that safe harbor threshold which is effectively a limit on the size of a provider tax that a State can assess.
Edwin Park: and the old safe harbor threshold was 6% of net patient revenues starting fiscal year 2028. So that's the Federal fiscal year which starts October 1, st 2027,
Edwin Park: that limit of 6% of net patient revenue will be reduced. This will affect all provider taxes except taxes on nursing homes and taxes on intermediate care facilities for people with intellectual disabilities.
Edwin Park: The safe harbor again starting October 1, st 2027 will be reduced by half a percentage point each fiscal year.
Edwin Park: and you can see here some of the the numbers fiscal year 2028 is 5 and a half percent. It's down to 3 and a half percent by fiscal year 2023,
Edwin Park: 7 expansion States have hospitals, taxes in excess of 5 and a half percent. According to Kff. 18 expansion States have hospital taxes in excess of 3 and a half percent. So it gives you a sense of how quickly States could be affected. There are other States that are expansion states that have provider taxes outside of hospital taxes that are also likely to be implicated, and as a result
Edwin Park: this will create a cost shift for States. They'll have less State financing available for their Medicaid program, and notably a number of States
Edwin Park: used increases in hospital provider taxes to finance the Medicaid expansion, either explicitly as part of the same legislation or as part of the financing for the expansion.
Edwin Park: The combined effect of this provision, plus the prohibition on any new or increased taxes. Total, a spending cut of 191.1 billion dollars over 10 years. Cbo assumes that states are able to replace some of the revenues related to provider taxes. But there.
Edwin Park: you know, not going to be able to replace all of it. As a result, they're going to have to cut both State spending and also Federal spending related to the matching funds associated with those State dollars and States are going to have less funding for their Medicaid programs. As a result, they're going to have to make cuts across the board, not just to the Medicaid expansion, but to the rest of their program
Edwin Park: next slide.
Edwin Park: So the second area of Medicaid cuts are cuts, targeting medicaid expansion adults. I already talked about provider tax restrictions that apply only to expansion states there's some other financing provisions related to the expansion which I can cover in the Q. And A.
Edwin Park: But while the provider tax restrictions are about trying to undercut financing for the Medicaid program overall in expansion States. There are a number of other provisions that target enrollment
Edwin Park: in the Medicaid expansion as well as access to needed services for expansion adults. So there are work reporting requirements, more frequent renewals and mandatory cost, sharing for many services for expansion. Adults next slide, please.
Edwin Park: So work reporting requirements this provision that got a lot of attention in
Edwin Park: the run up to the final passage of this legislation. This is a major provision. It's 1 of the biggest spending cuts of all the Medicaid and Chip provisions.
Edwin Park: as you can see at the bottom of the slide. It's a cut of 325 billion dollars. And I mentioned before that the gross Medicaid and chip cut in total was 990 billion dollars. So it gives you a sense of how large the impact on spending it is from this work reporting requirement. So this is a mandatory, non-waivable work, requirement for expansion. Adults, age 19 to 64.
Edwin Park: Includes parents of children, ages 14. And above
Edwin Park: it applies, in addition to states that use waivers to partially cover expansion adults, but are not expansion states. So this includes Wisconsin and Georgia, but does not apply to Puerto Rico and the other Territories
Edwin Park: effective. January 1, 2027 States have to have a work reporting requirement, though there is authority.
Edwin Park: discretion given to the Secretary of health and human services, or the Cms. Administrator on his behalf.
Edwin Park: to grant a good faith, effort, delay to States.
Edwin Park: but that delay can go no later than December 31, st 2028, and States may implement this work requirement earlier.
Edwin Park: but if they do so, they have to comply with all the requirements of this provision.
Edwin Park: The work reporting requirement has to be satisfied for at least one month before application, and at least once between every 6 month. Redetermination.
Edwin Park: especially adults.
Edwin Park: can demonstrate compliance with the requirement if they work not less than 80 h. 80 h. Community service participate in a work program of not less than 80 h engage in a combination of such activities for not less than 80 h, or have monthly income not less than the minimum wage multiplied by 80 h, or if a seasonal worker have average monthly income over 6 months of not less than the minimum wage multiplied by 80 h.
Edwin Park: States have to use ex parte processes, such as relying on wage databases to determine compliance. States cannot waive, and they cannot modify requirements of this provision. As I mentioned, a big expected spending cut according to the Congressional Budget office, of 3 25.6 billion dollars over the next 10 years.
Edwin Park: Next slide, please.
Edwin Park: Now there are exemptions from work. Reporting requirements. States have to provide on a mandatory basis exemptions for various groups of individuals, including but not limited. I'm just offering examples.
Edwin Park: Parents, guardians, and caretakers of children, ages 13 and younger, disabled individuals, disabled family members, pregnant people, those receiving postpartum coverage, those who are medically frail otherwise have special medical needs veterans with disability. Former foster use. There are a number of other exempted groups.
Edwin Park: States do not have to require
Edwin Park: verification of eligibility for exemptions, though they can't opt to do so. States are required to use an ex parte process for exemptions. To try to make this process as automatic as possible. States can provide certain short-term exemptions as laid out in the law. For example.
Edwin Park: if the State is experiencing a very high unemployment rate, or has experienced a natural disaster.
Edwin Park: but States cannot provide additional exemptions, but they also cannot be more restrictive. With these mandatory exemptions the Secretary is also barred from allowing additional exemptions under this provision
Edwin Park: next slide, please.
Edwin Park: Now, what is the expected impact on the expansion? So I already mentioned, there's restrictions on provider taxes that affect all States. Some States, including expansion states. That's definitely the case with this uniformity waiver. And then there's those
Edwin Park: provider tax restrictions target to all expansion states.
Edwin Park: So I would undercut finance with expansion. But this would like this work. Requirement would affect the ability for people to enroll continues to be enrolled in the expansion
Edwin Park: expansion. Individuals will lose medicaid coverage due to red tape, the inability to navigate the reporting or the exemption process. And it's not because they aren't working or they aren't eligible for an exemption. We have no updated Cbo estimates related to the work requirements
Edwin Park: for the final provision. But, for example, in the original House Bill.
Edwin Park: There was going to be a reduction in enrollment, about 5.2 million, of which 4.8 million would end up uninsured.
Edwin Park: those that disenroll from Medicaid because of failure to meet the work requirements or to obtain an exemption for which they're eligible, are actually made ineligible for marketplace tax credits. If they have, they end up in the income range to qualify
Edwin Park: the experience with prior Medicaid work reporting requirements in states like Arkansas and others.
Edwin Park: and that's been documented by this Congressional Budget Office researchers at Harvard and the Urban Institute is that these work requirements have no increase in hours worked or employment. This is really about cutting enrollment, and this is again targeted to the Medicaid Expansion group. So these are expansion adults who are going to end up
Edwin Park: being disenrolled with the large majority ending up uninsured, most likely next slide.
Edwin Park: So I'm going to talk about 2 other provisions that target the Medicaid Expansion group
Edwin Park: and this the second pro. The 1st provision I'll mention, is
Edwin Park: more frequent redeterminations. So under prior law expansion, adults had to renew their coverage every 12 months effective. January 1, st 2027. All expansion states must conduct renewals for expansion adults every 6 months.
Edwin Park: These more frequent redeterminations increase the risk of procedural disenrollments as we saw during unwinding the more frequent renewals, the more likely that's the case that some individuals who remain eligible
Edwin Park: fall off the program because they're unable to meet the the time frames produce the documents that a State might require as part of the renewal process. This is a spending cut according to Congressional budget office of 62.5 billion dollars over 10 years
Edwin Park: next slide.
Edwin Park: So the last provision I'll discuss related to expansion adults is a new requirement that all expansion States must charge some cost, sharing for most services provided to expansion adults. This is a provision that's effective. October 1, st 2028.
Edwin Park: If individuals or services were previously exempt from cost sharing, they continue to be exempt. In addition, this provision, under the law
Edwin Park: exempts a certain group of additional services from this mandatory cost, sharing primary care, mental health, substance, use, disorder services furnished by, you know, various health centers, rural health clinics, Fqhcs, behavioral health clinics.
Edwin Park: The cost sharing has to be of some amount.
Edwin Park: It can't exceed $35 per service, except for prescription drugs, which would be subject now to mandatory cost, sharing. But the old rules about how high the cost sharing would be.
Edwin Park: or what be allowed, continue to apply. States are also permitted to allow providers to deny services for failure to pay cost sharing.
Edwin Park: Now, research shows, there's a huge body of research showing that cost sharing increases. Even modest ones reduce utilization of needed care among low-income people. And and that's going to be the result. And that's why this produces savings of of 7.4 billion dollars over 10 years
Edwin Park: next slide. So this is the last set of provisions I'll discuss. And again there's many other Medicaid and chip provisions that I'm happy to go through in the Q&A section.
Edwin Park: and these are cuts reducing access to health coverage among immigrants.
Edwin Park: So the biggest provision or the most
Edwin Park: Draconian provision in this area is a provision eliminating medicated ship eligibility for many lawfully present immigrants.
Edwin Park: This will take effect October 1, st 2026, and starting, then Federal funding for health coverage and Medicaid and Chip will only be available for 4 groups, individuals admitted for permanent residence, green card holders, but only after 5 years
Edwin Park: certain entrants from Cuba and Haiti.
Edwin Park: migrants from the compact of free association nations of the Pacific
Edwin Park: and children pregnant women who are covered under
Edwin Park: the Ikea option which allows States to cover lawfully present children and pregnant women and Medicaid or Medicaid and Chip. In the case of Chip separate State chip programs, which about, you know a little more than half the States do that right now, and so Federal funding
Edwin Park: for only these groups will be available. Starting October 1, st 2026.
Edwin Park: Now, among those who are losing eligibility, who currently are eligible for federally funded Medicaid and Chip are some very vulnerable groups of lawfully present immigrants, refugees Asylees, victims of domestic violence and human trafficking.
Edwin Park: so-called parolees, who are admitted for humanitarian reasons, people who are admitted under special immigrant Visas, including those from
Edwin Park: Iraq and Afghanistan, native American tribal members born in Canada.
Edwin Park: This is a cut in Federal spending of 6.2 billion dollars over 10 years. So this is a drastic reduction in Medicaid and chip eligibility for lawfully present immigrants. States can cover
Edwin Park: these groups of State only dollars, but would no longer be able to be covered by federally funded Medicaid and chip
Edwin Park: next slide.
Edwin Park: So the last provision I'll cover is a provision that would cut Federal funding
Edwin Park: related to so-called emergency Medicaid, but only in expansion states. So this is another provision that has been target has been used to target expansion states financing.
Edwin Park: So under prior law
Edwin Park: payments to hospitals, purchasing emergency services to certain immigrants include people who are undocumented, people who are lawfully present.
Edwin Park: who would have been otherwise eligible for medicaid, but for immigration status. Those payments are matched, the applicable Federal matching rate. So if it is someone who would otherwise look like an expansion adult, they'd be matched. The expansion match rate of 90%. If there's a different individual who'd be subject to their coverage would be subject to the regular Medicaid matching rate. A regular matching rate would apply to the emergency. Medicaid services
Edwin Park: effective again, October 1, st 2026. So October of next year.
Edwin Park: Any State cost related to emergency Medicaid for expansion States would be eligible only for the regular medicaid matching rate rather than the 90% expansion expansion match.
Edwin Park: This is a cost shift to expansion States as emergency Medicaid is mandatory, and there also will, of course, be greater demand for emergency Medicaid, because of the eligibility restrictions for many lawfully present immigrants that I just discussed. This is a spending cut of 28.2 billion dollars over 10 years, and, as I mentioned, there are other provisions that target. The Medicaid expansion deter. Take up of the Medicaid expansion among the remaining
Edwin Park: oh.
Edwin Park: non-expansion States provisions related to State directed payments with differential application of rules for State directed payments and how they're phased down between those that are expansion States and those that are non-expansion States and those State directed payments. Those restrictions are a big, you know, cut to Medicaid about 100
Edwin Park: 50 billion dollars over 10 years, but happy to answer questions about those in Q. And a. With that I will stop on the Medicaid section. I will turn it over to Sabrina to talk about the marketplace provisions.
Sabrina Corlette: Thank you, Edwin, and Hi, everybody! It's it's so great to be with you all today and have an opportunity to team up with our sister center at Georgetown. As Joan said, my name is Sabrina Corlin, and I'm at the center on health insurance reforms, also at the Mccourt School, and my area of expertise. My focus is the commercial
Sabrina Corlette: insurance market, including the Affordable Care Act marketplaces next slide, please.
Sabrina Corlette: So when we're looking at the marketplaces, although the focus of this webinar is pretty much exclusively on the provisions of the Reconciliation Bill. It's important to emphasize that the marketplaces are facing a triple whammy Edwin mentioned something called the marketplace integrity rule, which was finalized in late
Sabrina Corlette: June. Most of the provisions in that rule take effect. in August of 2025, or in january 1, st 2026,
Sabrina Corlette: and they similar to some of the provisions in the Reconciliation Bill. The regulation includes provisions that restrict eligibility, reduce benefits and impose new
Sabrina Corlette: paperwork burdens on marketplace enrollees
Sabrina Corlette: In addition to those to the marketplace rule, the marketplaces are also facing the expiration of the enhanced premium tax credits or Ptcs that were originally included in the 2021 American Rescue Plan Act that significantly boosted the affordability of premiums for marketplace plans.
Sabrina Corlette: and was a large driver of the tremendous growth in enrollment that we have seen in marketplace plans, in fact, doubling between 2020 and 2024. The marketplace has grown from 12 million to 24 million people just in the last 4 years.
Sabrina Corlette: Next slide, please.
Sabrina Corlette: So the effects of this triple whammy are going to be dramatic for the marketplaces. As Edwin mentioned, we are expecting the ranks of the uninsured to grow by 15 million people. That's according to the Congressional Budget Office and wrapped up in that number, are 4.2 million people expected to become uninsured because of the expiration of the enhanced
Sabrina Corlette: Ptcs. And roughly one to 2 million more from the provisions that were in the marketplace rule, although that has not been separately scored, or the interactions of that rule with Hr. One have not been fully scored by the Congressional Budget Office.
Sabrina Corlette: In addition, while we don't have an exact estimate here from Cbo. Yet we have independent estimates that project, that marketplace enrollment could fall by 10 million people or more. So almost cut in half
Sabrina Corlette: Wakely, which is an actuarial forecasting, firm estimates that up to 13.6 million people could lose coverage as a result of the combination of the budget law, the marketplace rule, and the end of the Ptc. Enhancements and Urban Institute has also published some separate estimates of some of the separate provisions.
Sabrina Corlette: including an estimate that ending the Ptc enhancements couldn't reduce marketplace enrollment by 7.2 million people
Sabrina Corlette: next slide, please.
Sabrina Corlette: So I'm not going to spend a lot of time on this slide anytime. You see, font sizes this small you have to sort of
Sabrina Corlette: say, No, no, please, please spare me, and I am going to spare you, but I mainly wanted to share this visual, to help people understand that the marketplace integrity, final rule, and Hr. One, the Budget Bill, are really intertwined, and the the provisions that were in the marketplace rule. Some of them were codified in Hr. One.
Sabrina Corlette: Others were sort of are sort of staggered. So the marketplace rule. Provisions go into effect this year, but we're we're sunset at the end of 2026, and then sort of Hr. One picks up where they left off. But ultimately,
Sabrina Corlette: These 2 things together are, you know, show us that the Trump Administration and Congress were really working hand in glove to meet sort of twin goals of quote, unquote reducing marketplace fraud which really was just to sort of create more frictions for people as they go through the eligibility and enrollment process, but also fundamentally to reduce the amount
Sabrina Corlette: of money that that flows from the Federal Government to consumers in the form of the premium tax credits. Next slide, please.
Sabrina Corlette: So now I'm going to dive into the provisions of Hr. One that affect the marketplaces. However, I am happy during Q. And A to answer any questions you might have about the expiration of the Ptcs. Or the marketplace rule. But just in the interest of time I wanted to focus just on the provisions in Hr. One which that is quite enough
Sabrina Corlette: by themselves, because they are significant. And I saw in the Q. And A. Somebody was asking about the dynamic of the fact that many of the Medicaid provisions aren't going to hit until after the midterms for the marketplaces. A lot of these provisions will be felt pretty quickly.
Sabrina Corlette: So number one, beginning with Plan year 2026. The law limits premium, tax, credit, eligibility for lawfully present immigrants. 1st of all, currently people who are ineligible for medicaid, due to their immigration status can purchase coverage through the marketplace and receive very generous premium tax credits such that they have $0 premiums.
Sabrina Corlette: The bill would prohibit these folks from getting eligibility for premium tax credits. The folks who are under 100% of the Federal poverty line
Sabrina Corlette: and then beginning in 2027, there are going to be new limitations on the immigrant groups who qualify for premium tax credits in the marketplaces.
Sabrina Corlette: and similar to what Edwin summarized on the Medicaid side. The folks who would remain eligible are
Sabrina Corlette: lawful, permanent residents or green card holders, certain Cuban and Haitian migrants and cofa migrants. So similarly, although these folks currently are eligible today for coverage refugees asylees victims of domestic violence and human trafficking, etc. They would no longer be eligible for premium tax credits in the marketplaces, and Cbo has estimated
Sabrina Corlette: almost 70 billion dollars in savings from these 2 provisions. Next slide, please.
Sabrina Corlette: Another provision. That will also begin in 2026 is a provision to remove the limitation on advanced premium tax credit, repayment. And this is likely to lead to
Sabrina Corlette: potentially very large, very unexpected tax liabilities, particularly for low income marketplace enrollees. So under current law if you project your income for marketplace eligibility for the coming year, and it turns out that your estimate is a little bit off, and that you were actually eligible for lower Aptcs than you actually got.
Sabrina Corlette: You are supposed to pay back the Irs. The excess amount of premium tax credits that you received. However, for lower income folks. The amount you have to pay back at tax time is capped.
Sabrina Corlette: So for a single filer, it's capped at $375. If you are under 200% of the Federal poverty line, and it's sort of the cap kind of grows as you go up the income scale. So it's up to $1,575 for a person up to 400% of the Federal poverty line.
Sabrina Corlette: What this law does is essentially remove those repayment caps so essentially regardless of your income, you're facing sort of uncapped liability. If you make a mistake and misestimate your income. And we know that for our lower income marketplace enrollees projecting your income
Sabrina Corlette: 12 years ahead of 12 months ahead of time is really really tough. Many of these folks are hourly workers or shift workers or gig economy workers or freelancers. And so really, having that accurate projection of your income is really tough. So this is likely to have a really chilling effect on enrollment as people
Sabrina Corlette: make decisions about whether or not to apply for premium tax credits. Cbo has estimated that this provision will generate about 17 billion dollars in savings. Next slide, please.
Sabrina Corlette: Some other marketplace changes beginning in Plan year 2026. One is that the law gets rid of what we call the low Income Special Enrollment period under the Biden Administration we created a year round, or they created a year round enrollment opportunity for people under 150% of the poverty level. The law gets rid of that beginning in 2026. But it's important to note
Sabrina Corlette: that the marketplace integrity rule promulgated by Cms.
Sabrina Corlette: Has this. These Seps eliminated, beginning in August of this year so effectively there will be no more low income, special enrollment opportunity starting August 2025.
Sabrina Corlette: The other thing the the law does is codify permanently a provision that was also in the marketplace integrity rule, and this is essentially speeding up the timeframe that people have to file their taxes and reconcile the advanced Ptcs that they received previously. Folks had 2 years to kind of catch up and and make sure that their
Sabrina Corlette: their tax filings were submitted and their Aptcs were reconciled. This provision would shorten that time period to one year, at which point, if they haven't reconciled, they would lose eligibility for premium tax credits. And I think here. It's just important to acknowledge that a lot of the delays and errors that occur in this process are due to slowdowns on the Irs side. So not necessarily the fault of the Enrollee
Sabrina Corlette: and this change is also coinciding with some significant reductions in force at the Irs. So less customer support to help people manage this process
Sabrina Corlette: next slide, please.
Sabrina Corlette: So this slide gets at a couple really
Sabrina Corlette: impactful provisions. These won't hit until 2028. But I think, Cbo, it could be underestimating the coverage impacts of these provisions, but a time will tell.
Sabrina Corlette: I think one of the most significant changes is the end of what we call passive re-enrollment or automatic re-enrollment. It requires all enrollees to return to the marketplace every year to verify the information in their application, and and re-enroll in a health plan. Even if nothing has changed.
Sabrina Corlette: the marketplaces can use 3rd party data sources. And they it can. There can be an extended verification period that starts
Sabrina Corlette: August first, st but so just important to note that the marketplaces and and quite frankly, all commercial insurance products heavily rely on automatic re-enrollment both for continuity of coverage purposes, and also just to reduce administrative friction. And, in fact, in some state-based marketplaces, automatic re-enrollment is as high as 75% each year.
Sabrina Corlette: on average, across all the marketplaces, about 45% are automatically re-enrolled. So this change is gonna really require a sort of people to really take active steps to stay and maintain their coverage. At the same time the marketplace rule shortens the open enrollment period. So people are going to have a lot less time to kind of figure out what they want to do here and and come back and update their their applications.
Sabrina Corlette: The another important provision to highlight is something we call presumptive eligibility. Essentially the law bars people from getting advanced payment of premium tax credits until all of the verification is complete on their application. Right now you can actually apply for and enroll in a marketplace plan in one sitting potentially. You don't have to, you know.
Sabrina Corlette: file a bunch of extra paperwork. You can sort of do it all fairly seamlessly, and if there's a discrepancy between something in your application and the data sources that the marketplace has for you. They will allow you to provisionally enroll with Ptc's as you're working through those verifications. This gets rid of that provisional eligibility.
Sabrina Corlette: And so people will have to. If they want to enroll in a plan. They'll have to pay the full premium while the marketplaces are working, working through. The the data in their application or asking them to submit new paperwork.
Sabrina Corlette: There was one helpful change between the House and Senate version of this bill. The House version would have ended. Provisional eligibility for families with newborns, as folks might know it can take a little while to get your birth certificate or social security number. And so this would. The House passed. Bill would have barred people from getting Ptcs. While they wait for that social security number
Sabrina Corlette: under the Senate Bill, and ultimately the Bill President trump signed, if you have a change in family size, such as a newborn. You do not have to lose this provisional eligibility.
Sabrina Corlette: So these 2 provisions, combined with the failure to reconcile provision mentioned on the previous slide would generate about 37 billion dollars in savings. Next slide, please.
Sabrina Corlette: Okay, this is my last slide. And you know, while Hr. One reduces the premium tax credits available for low income people. It creates new tax breaks for higher income people by expanding some health savings account provisions. Essentially the bill sort of expands the types of plans that can be considered
Sabrina Corlette: eligible to be paired with a Health savings account, and also allows people to use their Hsas to pay for the fees charged by direct primary care service arrangements capped at about $150 per individual per month. These provisions will actually cost the Federal Government about 10.7 billion dollars
Sabrina Corlette: in lost revenue, and and for folks who are not familiar, Hsas are essentially tax favored savings account that are tied with a high, deductible health plan and allow people to shelter income from Uncle Sam.
Sabrina Corlette: So that's my last slide, and I will turn it back to Joan and look forward to your questions.
Joan Alker: Thank you so much, Sabrina. I'm gonna do a couple of quick questions for Sabrina, and then shift back to Edwin.
Joan Alker: So Sabrina. If you have current health coverage under the low income scp, will your benefits end in August, or will they continue to the end of the plan year.
Sabrina Corlette: No you can stay covered. You don't lose your eligibility. The marketplace rule that
Sabrina Corlette: ends the low income. Sep, it means that new people coming in will no longer be able to get that scp unless they have another qualifying life event like a move or a new baby or a loss of other coverage. So it, just it ends it prospectively. If you got in previously under the low income step, you will not lose your eligibility. Going forward.
Joan Alker: Okay, what year does auto re-enrollment end.
Sabrina Corlette: 2028. So it's technically 2027, the the open enrollment of 2027 that folks will need to start coming back and updating their applications. And actively re-enrolling.
Joan Alker: Okay.
Joan Alker: For here's another question. A couple of people asked for the marketplace. Current. Regulatory exception talks about people where the marketplace projects a hundred percent income over Fpl, but they have less than 100%. They currently won't have to pay
Joan Alker: back. Would they have to pay? What would? Why would they have to pay back Aptc if they have less income than the marketplace projects them to have.
Sabrina Corlette: Yes, so that safe harbor still exists. It's a regulatory, safe harbor. But the Hr. One did not change that safe harbor so essentially, if you are coming to the marketplace and you project your income, say at 110% of the Federal poverty line. So you're eligible for premium tax credits.
Sabrina Corlette: And then a year later, you file your taxes. And it turns out you actually had 95%. Fpl, you obviously, only folks, 100% of Fpl. And above are eligible for Ptcs. But under this regulatory, safe harbor you would not owe anything back to the Irs if you actually fall below that Federal poverty line, and that has not changed.
Joan Alker: Okay? And this question is about, it says, is the disallowance of Aptc for income based scp for Federal marketplace States only? Or does it also apply to state based marketplaces, and maybe more generally, you could just
Joan Alker: clarify if the things you've been talking about apply to state-based marketplaces as well.
Sabrina Corlette: Yeah. The provisions in Hr. One apply across the board to all marketplaces. There are several provisions in the marketplace rule. Where the State based marketplaces do have some flexibility. But the provisions I covered in my presentation are applicable. Nationwide.
Joan Alker: Okay, super. I'm going to give Sabrina a break. Hello, hang in there, Edwin. We've got a bunch of Medicaid questions. Let me start by just asking you to speak for a minute about the so-called Rural Health Transformation Fund.
Edwin Park: Sure so to respond to the appropriate criticism that the law would
Edwin Park: place huge financial burdens on rural hospitals, forcing them to close cut staffing cut services.
Edwin Park: There is a new Rural Health Transformation Fund that is placed within. Chip
Edwin Park: has nothing to do with Chip.
Edwin Park: Where there's 50 billion dollars in Federal funding, starting in fiscal year 2026. It's 10 billion dollars a year through fiscal year 2030
Edwin Park: and there's a lot of discretion to the Secretary about how this fund used, and how States would use these funds. But to give you a sense of how inadequate it is.
Edwin Park: The Urban Institute estimated that
Edwin Park: rural hospitals would face an 87 billion dollars hit in reduced revenues under earlier version of the legislation, 23 billion dollars increase in uncompensated care costs.
Edwin Park: Kff has an earlier estimate that rural areas would see a Federal medicaid spending cut of about 155 billion dollars. So the size 50 billion dollars versus these impacts is much smaller. It's also temporary. It's only for 5 years. Obviously, these cuts are current and these cuts are going to get larger and larger every year
Edwin Park: and then the the fund itself is, pretty remarkably designed in a way to not actually go to rural hospitals,
Edwin Park: and not go to States and providers based on needs. So half the funds are divided equally among all states that are given an approved application, but the applications have to have certain criteria. But there's no specific criteria the secretary uses will have to use to prove
Edwin Park: these applications on the other half
Edwin Park: is basically can be allocated, based on, however, the Secretary wants or the Cms. Administrator on his behalf. It only has to go to a quarter of the States with approved applications, so it could be targeted only to a small number of States and States can use these funds
Edwin Park: in ways that reimburse providers or pay providers, but doesn't have to be rural providers, and can go to a bunch of things that have nothing to do with rural providers and health systems, including going to try to combat chronic disease, prevent
Edwin Park: preventive care, cyber security things that have nothing to do with the rural hospitals affected by these Medicaid cuts. So you know it's inadequate. It's temporary. And who knows where the funds will go, and how they'll be used, and there's no guarantee that they'll be used to aid rural hospitals that are already going to be under a lot of fiscal strain today, but will face even
Edwin Park: more difficulties, of course, being able to keep their doors open under this legislation.
Joan Alker: Thanks, Edwin, and I'll just note across the bill. And this seemed to increase as the bill ran through the Congress. There are a number of places where the Trump Administration and specifically Secretary Kennedy or Administrator Oz have discretion. This Rural Health Transformation Fund is is one example of that. The good faith exceptions to the implementation of the work. Reporting requirement is another area that they have significant discretion to pick States. They're going to allow
Joan Alker: to implement this later, and there are. There are a number of places their transition period, as Edwin mentioned on some of the provider tax issues. So so that's troubling given their propensity to reward their friends and punish their enemies. So that'll be something to keep an eye on.
Joan Alker: So keeping on to this provider tax issue a couple of questions, Edwin. 1st of all, someone asked, what is the rationale for limiting provider taxes? And if you could just
Joan Alker: also, in your response address, another question, which is, is this limit something that States are going to be able to litigate about? Is it appropriate for the Federal government to limit States in raising this revenue source.
Edwin Park: Yeah. So there's a a big gap, a big abyss between the
Edwin Park: rationale for the provider tax restrictions and the actual intent. So the rationale is that this is a scam financing scheme that's wholly inappropriate and has to be cracked down upon, and that States are lately violating these longstanding Federal rules that I've discussed.
Edwin Park: There's no evidence that there is widespread noncompliance with the Federal requirements for provider taxes to date. You know, there are certainly issues where States have had their Federal funding disallowed, and they had to repay back, based on inappropriate providers tax arrangements which were out of compliance with the Federal rules.
Edwin Park: But you know the real goal is to dramatically undermine estate financing. So, as Joan mentioned.
Edwin Park: the final law did not include some of the, you know, most radical, most far-reaching reductions in Federal funding for States, such as capping Federal funding through a per capita cap, or limiting Federal funding for the Medicaid expansion.
Edwin Park: But it did succeed in dramatically undermining State financing because it's a Federal State. Financial partnership states have to share the cost of Medicaid. And so these provider tax restrictions will force states to
Edwin Park: scale back their Medicaid programs, make deep cuts in the Medicaid program. In some cases potentially drop the Medicaid expansion as provider taxes were a key financing source for the expansion, and so that clearly was the intent of that.
Edwin Park: And then
Edwin Park: in terms of litigation. It seems highly unlikely. This is a change in in Federal rules. This is not an administrative action. For example, the Trump Administration tried to pursue provider tax restrictions
Edwin Park: through proposed rule called the Mfar rule, which was ultimately dropped before the end of the trump administration. But this is actually a change in the statute, a change in the Federal rules about how States can and cannot use provider taxes to finance their share of Medicaid costs.
Joan Alker: Thanks.
Joan Alker: Edwin. Do we know how many in which States use provider taxes to fund home and community based services.
Edwin Park: There's nothing, you know, comprehensive. This is really going to be a deep dive into state financing and state budgets. But it's our understanding that provider taxes have been used for dedicated purposes, not just the Medicaid expansion, but for behavioral health. Home acade-based service improvements.
Edwin Park: raising enrollment caps in 1915 c waivers for example.
Joan Alker: Okay? And we do one more in provider tax. And then we're going to go to the work requirement for a couple of questions. Matt from Arizona says their hospital associations are concerned, that their 5.9 9% assessment on hospitals will be affected. So I think that the answer is. Yes, there. And that came on your next slide.
Joan Alker: Yeah, definitely. So.
Edwin Park: The 3rd provider tax provision, which affects just expansion, states, you know, lowers the permitted size of those provider taxes, and that includes most provider taxes, including hospital taxes. So that starting at fiscal year 2028, the current limit of 6% of patient revenues, which is the measurement of the size of the tax will be reduced to 5 and a half percent
Edwin Park: by another half percentage point every year until you get to 3 and a half percent.
Edwin Park: So you know, this will definitely affect Arizona's provider tax, and, as I understand it, that Provider tax was enacted as part of the legislation authorizing the Medicaid expansion in the State, so this will force the State to have to identify other revenues. To continue the expansion, which, again, is one of the intents of this particular provider tax restriction.
Edwin Park: Targeted expansion states to both.
Edwin Park: cause some States to potentially drop their expansion, or at least create the risk of that as well as make it harder for non-expansion States to newly adopt the expansion in the future.
Joan Alker: Yeah. And, as I said in the Q. And a. We should expect the same people who were trying to cut Medicaid at the Federal level and the expansion to
Joan Alker: pick that up at the State level and have some vigorous debates going forward in the coming years ahead. So on the work requirement questions. We have a lot of questions about who they apply to, and I want to just reiterate, as Edwin said, that they only apply to the Medicaid expansion, adult population who are getting the 90% match plus those who are in a lookalike population essentially under a section 1 15 waiver. We believe that's Wisconsin and Georgia.
Joan Alker: So if that's if you're in one of the States that has not expanded Medicaid and getting the 9% match, and you're not Georgia or Wisconsin. The work requirement doesn't apply at all in your State.
Joan Alker: and it doesn't apply to people who are not in that category getting the 90% match. So people who are getting Medicaid because they are receiving SSI very, very poor low income parents should be exempt. But there's going to be a lot of confusion about this.
Joan Alker: Some of the other questions we won't know until Cms issues guidance, and some of them will depend on where a person lives. But let me ask a couple of questions, specific questions, and, Edwin, you can jump in on this one. Do the work requirements at renewal. All also require that it's only one month prior to renewal that you have to prove work.
Edwin Park: So it's at least one month
Edwin Park: at some point between the 6 month renewals that are now required for all expansion. Adults but States unfortunately, have the flexibility to increase that. And so it could be, you know, 1, 2 months, or it could be every month between the redeterminations.
Edwin Park: Let's see.
Joan Alker: And then.
Edwin Park: Oh, sorry, Joe. Similarly, before application, you have to satisfy the the work reporting requirement for at least one month, but states have the option to
Edwin Park: require compliance for up to 3 months.
Joan Alker: So 2 other things to get to one is we've had a number of questions about this. If your State has a work requirement or is seeking a section 1115. Work requirement. Now
Joan Alker: that is tougher than what's in the Federal law. Leo Cue and I wrote a blog about this. It's in the chat. Your State will have to comply with the Federal minimums. Those are not waivable provisions. So, for example, states that have a work requirement, they're trying to put in place for parents, for example, children
Joan Alker: under 14. So children over 6, a lot of States exempt children under 6 when they write these proposals they're going to have to up their game.
Joan Alker: And as Leo and I say in the blog, it's really no point in applying for a waiver that's going to only be, in effect, you know, for a very short period of time. But but that, I think, is also little known.
Joan Alker: Turning to the issue of how income is defined, Edwin, and the requirement that there's an ex parte requirement on termination of income, minimum wage times 80 h. The question arises about what early retirement benefits count
Joan Alker: as that income. I'm not sure we know the answer to that. But could you just say a little bit more about this intersection of income and ex parte, and what the law actually says, there.
Edwin Park: Yeah, so for purposes of the
Edwin Park: work, reporting requirement itself, compliance with requirements of hours worked, or, for example, income
Edwin Park: earned minimum wage times 80 h. The state is required to use automated processes ex parte processes where possible, and that includes potentially things like wage databases and the like. So the State is supposed to automate it. How that would work in practice, of course, will depend on individual States, but that is a requirement that
Edwin Park: the State is supposed to make it, as you know, automated as possible, using these ex parte processes.
Joan Alker: Thanks. So I've got one more for Edwin, and I've got a final one for both of you. Edwin.
Joan Alker: we've got a question about the Cbo score for uniformity waiver changes. Approximately 70 billion is that expected to impact only the 8 states you flagged, which would be a very large and potentially immediate impact for those states.
Edwin Park: Yeah, so it's at least these 7 States. With the 8 taxes that we mentioned in the Explainer.
Edwin Park: there are probably more states that may be implicated, and this has mostly been a discussion about taxes on managed care plans, managed care organizations.
Edwin Park: But you know there are potentially other taxes and going to hospitals and others that could be potentially implicated. So it is something that's a concern all along that this is a more expansive provision, and we don't know yet what Cms. Will say in terms of what taxes are no longer permissible, and, as I mentioned.
Edwin Park: there is a transition period allowed of up to 3 years, but that's at the discretion of the Cfs administrator. And so it is possible that these taxes are immediately prohibited, and they were immediately prohibited upon enactment, which would be July 4.th
Joan Alker: Final question. This came as a surprise, I noticed, to some of the Republican members voting for this in the House markup, but people who are disenrolled from Medicaid for failure to comply with the work requirement are explicitly barred from receiving premium tax credits to enroll on the marketplace? Sabrina? Do you have any idea how long that bar would last? When would they be able to get into the marketplace? Do we know.
Sabrina Corlette: I don't know. I can't recall. If
Sabrina Corlette: there's an explicit timeline for that, I will say
Sabrina Corlette: for folks who can show their income is above
Sabrina Corlette: medicaid eligibility. A 138% of poverty and expansion states
Sabrina Corlette: they should be able to get eligibility that way. So if they?
Sabrina Corlette: I I mean, the whole thing is sort of silly because to be eligible for marketplace tax credits. You have to have 100. You have to be at least 100%. Fpl, you have to have some
Sabrina Corlette: income. So presumably you're working in some fashion. But
Sabrina Corlette: but I don't recall there being any timeline associated with. How long you're locked out of the marketplace, Edwin, do you.
Edwin Park: Yeah, I don't think there's any timeline, but if
Edwin Park: I think it's if an individual
Edwin Park: is, would be otherwise eligible for Medicaid, except for failure to comply with the work, reporting requirements or qualifying for an exemption for which they're eligible.
Edwin Park: And they have income at a hundred percent of Federal poverty line or above, and
Edwin Park: then they cannot get marketplace subs tax credits
Edwin Park: while they're in that situation. But you know, as Sabrina said, if their income rises and they enter the marketplace. Eligibility range above the expansion income range above 138% of the poverty line. Then they'll be able to get premium tax credits, but if they are, they're still considered eligible for Medicaid. Even if they've been disenrolled because of the work reporting requirements, then they would not be eligible for the premium tax credits.
Joan Alker: Okay, so we're gonna have to cut this off. I've got one more question for Edwin that I know he's very passionate about. There have been a few questions about how any of this applies to the Puerto Rico and the Territories. So Edwin.
Edwin Park: Oh, sure! So many of the provisions. Have specific language exempting
Edwin Park: the application of these cuts to Puerto Puerto Rico and the territories, so that includes the work reporting requirements. But I haven't tallied or gone through every provision to see exactly which provisions have that language, but in general they have been exempted. The Territories have been exempted from these cuts.
Joan Alker: Okay. So I want to thank our speakers. We are going to cut it off. We will take note of these questions and do our best to get some answers to them posted when we post the webinar recording a reminder that will be available on our website, Ccfgeorgetownedu along with the slides.
Joan Alker: and thanks so much to all of you for attending and for our wonderful speakers. We covered a lot of ground in a short amount of time, and undoubtedly we'll do another one of these. But do keep an eye on our blog because we are unpacking a lot of these issues on our blog in the cheer blog, and we we cross post a lot of their blogs as well. So thanks so much. Everybody for joining us today. Have a good rest of your day.