WEBVTT 1 00:00:06.950 --> 00:00:14.480 Joan Alker: Hi! Everybody! Welcome to our Georgetown University, Webinar. We're just gonna give it another 2 00:00:14.710 --> 00:00:20.150 Joan Alker: 30 seconds here while people are still joining, and we'll be right back. 3 00:00:40.530 --> 00:00:45.023 Joan Alker: Okay, I am gonna start and 4 00:00:45.770 --> 00:00:51.900 Joan Alker: we still have folks joining, but looks like it's slowing down a little bit. And 5 00:00:52.000 --> 00:00:57.419 Joan Alker: before we get into the slides. I want to give a few introductory remarks. 6 00:00:58.266 --> 00:01:08.489 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. 7 00:01:08.760 --> 00:01:17.789 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. 8 00:01:18.300 --> 00:01:27.130 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. 9 00:01:27.370 --> 00:01:39.050 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. 10 00:01:39.340 --> 00:01:50.829 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. 11 00:01:50.970 --> 00:02:05.760 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 12 00:02:06.020 --> 00:02:12.810 Joan Alker: that, as you know, passed Congress and was signed into law on July 4th by President Trump. 13 00:02:13.760 --> 00:02:24.719 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. 14 00:02:25.430 --> 00:02:34.700 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. 15 00:02:35.353 --> 00:02:43.110 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. 16 00:02:43.580 --> 00:02:54.960 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. 17 00:02:55.350 --> 00:02:59.770 Joan Alker: As many of you know, the process itself was extremely chaotic. 18 00:03:00.270 --> 00:03:03.689 Joan Alker: with much of the actual committee work in the House 19 00:03:03.890 --> 00:03:16.890 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. 20 00:03:17.230 --> 00:03:27.079 Joan Alker: and of course, at the Senate on the Senate side, because this was a privileged bill under the budget. Reconciliation rules 21 00:03:27.290 --> 00:03:41.639 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. 22 00:03:42.200 --> 00:03:48.200 Joan Alker: few members had an exact handle on what was exactly in the bill. And so we've been spending some time 23 00:03:48.330 --> 00:03:52.460 Joan Alker: kind of recovering from that crazy time, and also just trying to 24 00:03:52.680 --> 00:04:04.849 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 25 00:04:05.030 --> 00:04:06.530 Joan Alker: made law this way. 26 00:04:07.377 --> 00:04:15.680 Joan Alker: A couple of housekeeping notes. This is a webinar. This will be recorded, it will be in a listen. Only mode. 27 00:04:16.254 --> 00:04:23.180 Joan Alker: We will take questions for the last 20 min or so, and you can submit questions in the Q&A. Box. 28 00:04:23.580 --> 00:04:29.909 Joan Alker: and we will be posting the webinar recording as well as the slides on our website. 29 00:04:30.830 --> 00:04:36.128 Joan Alker: So we are scheduled to end at 2 45 Eastern 30 00:04:37.370 --> 00:04:47.234 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 31 00:04:47.790 --> 00:04:56.039 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 32 00:04:56.290 --> 00:04:59.460 Joan Alker: and Sabrina, who's going to talk about the marketplace. 33 00:04:59.710 --> 00:05:06.669 Joan Alker: So before I get to my chip slides I want to just say a few sort of big picture thoughts. 34 00:05:07.396 --> 00:05:15.889 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. 35 00:05:16.240 --> 00:05:31.720 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 36 00:05:31.920 --> 00:05:39.089 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. 37 00:05:39.510 --> 00:05:49.299 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. 38 00:05:49.550 --> 00:06:02.220 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. 39 00:06:02.890 --> 00:06:08.950 Joan Alker: Hr. One also restricts the way States can raise their funds for their share of Medicaid. 40 00:06:09.100 --> 00:06:13.060 Joan Alker: and dramatically increases red tape for people and providers. 41 00:06:13.230 --> 00:06:26.640 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. 42 00:06:27.480 --> 00:06:28.480 Joan Alker: Okay. 43 00:06:28.620 --> 00:06:32.979 Joan Alker: So now I'm going to get to Chip, we can move to the 1st slide. 44 00:06:33.190 --> 00:06:41.530 Joan Alker: and, as I mentioned generally, Chip was not a subject or active focus on the legislation of the legislation. 45 00:06:41.800 --> 00:06:49.189 Joan Alker: But there are a few important provisions to highlight. And before we get into those I want to say that technically 46 00:06:49.644 --> 00:06:58.070 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. 47 00:06:58.330 --> 00:07:12.009 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 48 00:07:12.580 --> 00:07:19.849 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. 49 00:07:20.645 --> 00:07:31.999 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. 50 00:07:32.220 --> 00:07:54.619 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. 51 00:07:54.870 --> 00:07:57.390 Joan Alker: So the changes I'm about to talk about 52 00:07:57.550 --> 00:08:05.769 Joan Alker: are changes that will apply to separate chip programs. So not all States have those. Let's go to the next slide. 53 00:08:06.480 --> 00:08:10.742 Joan Alker: So hr, one had a lot of 54 00:08:11.360 --> 00:08:30.669 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. 55 00:08:31.430 --> 00:08:34.330 Joan Alker: Regulation that had been promulgated. 56 00:08:34.659 --> 00:08:47.640 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 57 00:08:47.850 --> 00:08:50.390 Joan Alker: because of Parliamentarian rulings. 58 00:08:50.490 --> 00:08:56.379 Joan Alker: The trip policies were not repealed in the final version of the bill. 59 00:08:56.940 --> 00:09:05.869 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. 60 00:09:06.010 --> 00:09:12.920 Joan Alker: To have waiting periods, lockouts for nonpayment or premiums, lifetime or annual limits 61 00:09:13.090 --> 00:09:24.409 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 62 00:09:24.890 --> 00:09:33.920 Joan Alker: emanate from when ship was 1st passed in 1997, when there was concern about proud out, proud out of employer, sponsored insurance 63 00:09:34.465 --> 00:09:46.150 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 64 00:09:46.390 --> 00:09:59.059 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. 65 00:09:59.270 --> 00:10:03.849 Joan Alker: So not many states still have these policies, but some do. 66 00:10:04.020 --> 00:10:12.540 Joan Alker: And they they're harmful for children. They keep them uninsured, or they limit their benefits. They promote gaps in coverage. 67 00:10:12.660 --> 00:10:19.059 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 68 00:10:19.778 --> 00:10:35.561 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. 69 00:10:36.290 --> 00:11:02.819 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. 70 00:11:03.080 --> 00:11:14.090 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 71 00:11:14.240 --> 00:11:18.539 Joan Alker: their Medicaid and chip programs with 60 day retro. And that would certainly address 72 00:11:18.670 --> 00:11:23.509 Joan Alker: some of these issues that exist about smooth transfers from Medicaid to chip. 73 00:11:23.730 --> 00:11:36.320 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. 74 00:11:37.120 --> 00:11:47.640 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. 75 00:11:48.600 --> 00:12:11.669 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. 76 00:12:12.230 --> 00:12:37.319 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 77 00:12:37.770 --> 00:12:40.400 Edwin Park: at at the end of the webinar next slide. 78 00:12:41.680 --> 00:12:48.840 Edwin Park: So the top line Cbo estimates Cbo just came out with estimates last week. 79 00:12:48.930 --> 00:12:56.540 Edwin Park: The reconciliation law based on those numbers show that Medicaid and Chip will be cut 80 00:12:56.630 --> 00:13:24.040 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. 81 00:13:24.130 --> 00:13:28.490 Edwin Park: This will lead to an increase in the uninsured by 82 00:13:29.420 --> 00:13:44.530 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. 83 00:13:44.720 --> 00:14:14.110 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. 84 00:14:14.290 --> 00:14:25.639 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 85 00:14:26.230 --> 00:14:27.580 Edwin Park: next slide, please. 86 00:14:28.610 --> 00:14:43.250 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. 87 00:14:43.810 --> 00:15:03.549 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 88 00:15:03.580 --> 00:15:16.640 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 89 00:15:17.170 --> 00:15:29.190 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 90 00:15:29.310 --> 00:15:42.749 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. 91 00:15:43.270 --> 00:15:56.749 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 92 00:15:56.790 --> 00:16:14.859 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. 93 00:16:15.560 --> 00:16:27.709 Edwin Park: So what does the budget reconciliation law do with regard to provider taxes? The 1st is a restriction that affects all States. 94 00:16:27.840 --> 00:16:38.850 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. 95 00:16:39.110 --> 00:16:49.560 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%, 96 00:16:50.040 --> 00:16:55.600 Edwin Park: a patient revenues, it can't be increased to 4.1% 4.5%, and so forth. 97 00:16:55.790 --> 00:17:05.960 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. 98 00:17:06.980 --> 00:17:11.039 Edwin Park: So that's the 1st major provider tax restriction. Next slide. 99 00:17:12.369 --> 00:17:27.489 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. 100 00:17:28.790 --> 00:17:53.870 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, 101 00:17:54.100 --> 00:18:02.039 Edwin Park: and if they can, if they can't pass that math test, then they can get a uniformity waiver. 102 00:18:03.010 --> 00:18:04.890 Edwin Park: The majority of States 103 00:18:05.020 --> 00:18:17.990 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. 104 00:18:18.300 --> 00:18:43.280 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 105 00:18:43.840 --> 00:18:51.560 Edwin Park: where there's a different tax rate for Medicaid managed care plans versus commercial Mcos in the State. 106 00:18:52.060 --> 00:19:21.300 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 107 00:19:21.340 --> 00:19:27.590 Edwin Park: can grant a transition period of up to 3 years. But there's no guarantee of such a period. It could be 0 108 00:19:27.800 --> 00:19:33.829 Edwin Park: takes effect. This prohibition takes effect immediately. It could be one month, a year, or up to 3 years. 109 00:19:34.750 --> 00:19:52.490 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 110 00:19:52.660 --> 00:20:06.170 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. 111 00:20:06.250 --> 00:20:13.030 Edwin Park: According to the Congressional Budget Office, this would cut Federal spending by 34.6 billion dollars over 10 years. 112 00:20:13.090 --> 00:20:36.389 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. 113 00:20:37.000 --> 00:20:43.929 Edwin Park: Cbo already assumed that about half the impact was in the baseline already before enactment of this legislation. 114 00:20:44.630 --> 00:20:46.250 Edwin Park: Next slide, please. 115 00:20:47.120 --> 00:20:56.470 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. 116 00:20:57.080 --> 00:21:13.929 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. 117 00:21:13.930 --> 00:21:27.169 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, 118 00:21:27.800 --> 00:21:41.889 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. 119 00:21:42.200 --> 00:21:50.810 Edwin Park: The safe harbor again starting October 1, st 2027 will be reduced by half a percentage point each fiscal year. 120 00:21:52.760 --> 00:22:02.380 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, 121 00:22:02.570 --> 00:22:28.249 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 122 00:22:28.720 --> 00:22:37.350 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 123 00:22:37.870 --> 00:22:49.220 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. 124 00:22:49.560 --> 00:23:11.730 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. 125 00:23:11.790 --> 00:23:30.549 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 126 00:23:31.170 --> 00:23:32.170 Edwin Park: next slide. 127 00:23:33.130 --> 00:23:53.229 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. 128 00:23:53.610 --> 00:24:06.719 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 129 00:24:08.270 --> 00:24:24.409 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. 130 00:24:25.620 --> 00:24:31.472 Edwin Park: So work reporting requirements this provision that got a lot of attention in 131 00:24:32.060 --> 00:24:43.750 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. 132 00:24:44.280 --> 00:25:09.629 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. 133 00:25:10.527 --> 00:25:15.150 Edwin Park: Includes parents of children, ages 14. And above 134 00:25:15.810 --> 00:25:30.219 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 135 00:25:30.380 --> 00:25:41.080 Edwin Park: effective. January 1, 2027 States have to have a work reporting requirement, though there is authority. 136 00:25:41.680 --> 00:25:48.310 Edwin Park: discretion given to the Secretary of health and human services, or the Cms. Administrator on his behalf. 137 00:25:48.500 --> 00:25:53.310 Edwin Park: to grant a good faith, effort, delay to States. 138 00:25:54.270 --> 00:26:04.730 Edwin Park: but that delay can go no later than December 31, st 2028, and States may implement this work requirement earlier. 139 00:26:04.920 --> 00:26:09.699 Edwin Park: but if they do so, they have to comply with all the requirements of this provision. 140 00:26:10.450 --> 00:26:19.469 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. 141 00:26:20.300 --> 00:26:21.920 Edwin Park: especially adults. 142 00:26:22.010 --> 00:26:51.170 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. 143 00:26:51.920 --> 00:27:13.789 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. 144 00:27:14.870 --> 00:27:16.290 Edwin Park: Next slide, please. 145 00:27:17.540 --> 00:27:30.289 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. 146 00:27:31.370 --> 00:27:52.769 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. 147 00:27:52.970 --> 00:27:55.210 Edwin Park: States do not have to require 148 00:27:55.860 --> 00:28:15.880 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. 149 00:28:16.600 --> 00:28:22.980 Edwin Park: if the State is experiencing a very high unemployment rate, or has experienced a natural disaster. 150 00:28:23.120 --> 00:28:38.820 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 151 00:28:38.980 --> 00:28:40.430 Edwin Park: next slide, please. 152 00:28:43.910 --> 00:28:59.300 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 153 00:28:59.610 --> 00:29:03.780 Edwin Park: provider tax restrictions target to all expansion states. 154 00:29:04.440 --> 00:29:16.859 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 155 00:29:17.080 --> 00:29:36.720 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 156 00:29:38.304 --> 00:29:43.549 Edwin Park: for the final provision. But, for example, in the original House Bill. 157 00:29:44.580 --> 00:29:51.120 Edwin Park: There was going to be a reduction in enrollment, about 5.2 million, of which 4.8 million would end up uninsured. 158 00:29:52.530 --> 00:30:10.080 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 159 00:30:10.240 --> 00:30:15.709 Edwin Park: the experience with prior Medicaid work reporting requirements in states like Arkansas and others. 160 00:30:16.340 --> 00:30:36.340 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 161 00:30:36.510 --> 00:30:43.940 Edwin Park: being disenrolled with the large majority ending up uninsured, most likely next slide. 162 00:30:44.630 --> 00:30:50.799 Edwin Park: So I'm going to talk about 2 other provisions that target the Medicaid Expansion group 163 00:30:51.402 --> 00:30:56.820 Edwin Park: and this the second pro. The 1st provision I'll mention, is 164 00:30:57.080 --> 00:31:13.070 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. 165 00:31:14.170 --> 00:31:29.810 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 166 00:31:30.730 --> 00:31:51.340 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 167 00:31:51.550 --> 00:31:52.580 Edwin Park: next slide. 168 00:31:54.590 --> 00:32:13.620 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. 169 00:32:14.730 --> 00:32:25.390 Edwin Park: If individuals or services were previously exempt from cost sharing, they continue to be exempt. In addition, this provision, under the law 170 00:32:26.110 --> 00:32:42.430 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. 171 00:32:43.230 --> 00:32:46.790 Edwin Park: The cost sharing has to be of some amount. 172 00:32:46.980 --> 00:32:59.410 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. 173 00:33:00.140 --> 00:33:09.240 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. 174 00:33:09.390 --> 00:33:26.680 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 175 00:33:28.050 --> 00:33:39.209 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. 176 00:33:40.100 --> 00:33:46.569 Edwin Park: and these are cuts reducing access to health coverage among immigrants. 177 00:33:46.970 --> 00:33:51.399 Edwin Park: So the biggest provision or the most 178 00:33:52.420 --> 00:34:00.840 Edwin Park: Draconian provision in this area is a provision eliminating medicated ship eligibility for many lawfully present immigrants. 179 00:34:01.760 --> 00:34:19.989 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 180 00:34:20.540 --> 00:34:23.340 Edwin Park: certain entrants from Cuba and Haiti. 181 00:34:24.060 --> 00:34:28.389 Edwin Park: migrants from the compact of free association nations of the Pacific 182 00:34:28.710 --> 00:34:31.699 Edwin Park: and children pregnant women who are covered under 183 00:34:32.540 --> 00:34:54.100 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 184 00:34:54.250 --> 00:34:59.640 Edwin Park: for only these groups will be available. Starting October 1, st 2026. 185 00:35:00.500 --> 00:35:16.099 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. 186 00:35:16.350 --> 00:35:25.270 Edwin Park: so-called parolees, who are admitted for humanitarian reasons, people who are admitted under special immigrant Visas, including those from 187 00:35:26.310 --> 00:35:31.810 Edwin Park: Iraq and Afghanistan, native American tribal members born in Canada. 188 00:35:31.970 --> 00:35:48.930 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 189 00:35:49.650 --> 00:35:56.949 Edwin Park: these groups of State only dollars, but would no longer be able to be covered by federally funded Medicaid and chip 190 00:35:57.540 --> 00:35:58.950 Edwin Park: next slide. 191 00:35:59.800 --> 00:36:09.810 Edwin Park: So the last provision I'll cover is a provision that would cut Federal funding 192 00:36:10.420 --> 00:36:23.789 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. 193 00:36:23.980 --> 00:36:25.760 Edwin Park: So under prior law 194 00:36:26.260 --> 00:36:35.000 Edwin Park: payments to hospitals, purchasing emergency services to certain immigrants include people who are undocumented, people who are lawfully present. 195 00:36:35.240 --> 00:37:02.630 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 196 00:37:02.770 --> 00:37:07.200 Edwin Park: effective again, October 1, st 2026. So October of next year. 197 00:37:08.030 --> 00:37:21.560 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. 198 00:37:22.670 --> 00:37:51.090 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 199 00:37:51.830 --> 00:37:52.310 Edwin Park: oh. 200 00:37:52.920 --> 00:38:16.870 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 100 201 00:38:16.960 --> 00:38:30.669 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. 202 00:38:31.730 --> 00:38:56.720 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 203 00:38:56.720 --> 00:39:02.330 Sabrina Corlette: insurance market, including the Affordable Care Act marketplaces next slide, please. 204 00:39:03.090 --> 00:39:26.369 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 205 00:39:26.370 --> 00:39:37.480 Sabrina Corlette: June. Most of the provisions in that rule take effect. in August of 2025, or in january 1, st 2026, 206 00:39:37.490 --> 00:39:49.920 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 207 00:39:50.000 --> 00:39:54.179 Sabrina Corlette: paperwork burdens on marketplace enrollees 208 00:39:55.690 --> 00:40:17.950 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. 209 00:40:17.950 --> 00:40:34.080 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. 210 00:40:35.285 --> 00:40:37.009 Sabrina Corlette: Next slide, please. 211 00:40:37.990 --> 00:41:05.380 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 212 00:41:05.420 --> 00:41:24.359 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. 213 00:41:25.032 --> 00:41:41.210 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 214 00:41:41.210 --> 00:42:05.390 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. 215 00:42:05.390 --> 00:42:14.209 Sabrina Corlette: including an estimate that ending the Ptc enhancements couldn't reduce marketplace enrollment by 7.2 million people 216 00:42:14.530 --> 00:42:16.070 Sabrina Corlette: next slide, please. 217 00:42:16.410 --> 00:42:23.399 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 218 00:42:23.400 --> 00:42:47.050 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. 219 00:42:47.050 --> 00:43:01.455 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, 220 00:43:01.790 --> 00:43:25.840 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 221 00:43:26.470 --> 00:43:36.860 Sabrina Corlette: of money that that flows from the Federal Government to consumers in the form of the premium tax credits. Next slide, please. 222 00:43:37.670 --> 00:44:02.620 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 223 00:44:02.620 --> 00:44:24.810 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. 224 00:44:24.810 --> 00:44:51.709 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. 225 00:44:52.272 --> 00:45:05.350 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 226 00:45:05.740 --> 00:45:15.889 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. 227 00:45:15.900 --> 00:45:26.770 Sabrina Corlette: and similar to what Edwin summarized on the Medicaid side. The folks who would remain eligible are 228 00:45:26.770 --> 00:45:51.739 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 229 00:45:51.740 --> 00:45:58.610 Sabrina Corlette: almost 70 billion dollars in savings from these 2 provisions. Next slide, please. 230 00:46:00.004 --> 00:46:17.810 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 231 00:46:18.040 --> 00:46:46.159 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. 232 00:46:46.508 --> 00:46:58.700 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. 233 00:46:58.700 --> 00:47:18.539 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. 234 00:47:19.010 --> 00:47:43.260 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 235 00:47:43.260 --> 00:48:05.729 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 236 00:48:05.730 --> 00:48:16.779 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. 237 00:48:17.160 --> 00:48:45.079 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 238 00:48:45.080 --> 00:48:49.660 Sabrina Corlette: that the marketplace integrity rule promulgated by Cms. 239 00:48:49.660 --> 00:49:03.050 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. 240 00:49:03.960 --> 00:49:28.209 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 241 00:49:28.370 --> 00:49:57.239 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 242 00:49:57.740 --> 00:50:08.410 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 243 00:50:08.800 --> 00:50:10.249 Sabrina Corlette: next slide, please. 244 00:50:11.820 --> 00:50:16.020 Sabrina Corlette: So this slide gets at a couple really 245 00:50:16.260 --> 00:50:31.189 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. 246 00:50:31.623 --> 00:50:53.729 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. 247 00:50:53.730 --> 00:51:02.379 Sabrina Corlette: the marketplaces can use 3rd party data sources. And they it can. There can be an extended verification period that starts 248 00:51:02.920 --> 00:51:28.339 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. 249 00:51:28.698 --> 00:51:57.009 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. 250 00:51:57.160 --> 00:52:24.750 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. 251 00:52:24.840 --> 00:52:47.449 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. 252 00:52:47.770 --> 00:53:01.550 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. 253 00:53:02.080 --> 00:53:29.200 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 254 00:53:29.200 --> 00:53:42.470 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. 255 00:53:42.490 --> 00:53:54.710 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. 256 00:53:55.260 --> 00:54:23.200 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 257 00:54:23.200 --> 00:54:48.670 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 258 00:54:48.670 --> 00:55:06.850 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. 259 00:55:07.252 --> 00:55:12.629 Sabrina Corlette: So that's my last slide, and I will turn it back to Joan and look forward to your questions. 260 00:55:13.450 --> 00:55:21.709 Joan Alker: Thank you so much, Sabrina. I'm gonna do a couple of quick questions for Sabrina, and then shift back to Edwin. 261 00:55:22.210 --> 00:55:32.819 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. 262 00:55:33.070 --> 00:55:40.561 Sabrina Corlette: No you can stay covered. You don't lose your eligibility. The marketplace rule that 263 00:55:41.270 --> 00:56:10.670 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. 264 00:56:11.340 --> 00:56:15.119 Joan Alker: Okay, what year does auto re-enrollment end. 265 00:56:15.890 --> 00:56:28.619 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. 266 00:56:29.710 --> 00:56:30.630 Joan Alker: Okay. 267 00:56:31.030 --> 00:56:47.619 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 268 00:56:47.730 --> 00:56:56.509 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. 269 00:56:56.690 --> 00:57:17.000 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. 270 00:57:17.080 --> 00:57:40.550 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. 271 00:57:40.950 --> 00:57:55.429 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 272 00:57:55.780 --> 00:58:01.009 Joan Alker: clarify if the things you've been talking about apply to state-based marketplaces as well. 273 00:58:01.380 --> 00:58:20.729 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. 274 00:58:21.670 --> 00:58:38.010 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. 275 00:58:38.520 --> 00:58:45.470 Edwin Park: Sure so to respond to the appropriate criticism that the law would 276 00:58:45.570 --> 00:58:52.070 Edwin Park: place huge financial burdens on rural hospitals, forcing them to close cut staffing cut services. 277 00:58:52.210 --> 00:58:56.779 Edwin Park: There is a new Rural Health Transformation Fund that is placed within. Chip 278 00:58:56.900 --> 00:58:58.520 Edwin Park: has nothing to do with Chip. 279 00:58:58.660 --> 00:59:07.420 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 280 00:59:08.129 --> 00:59:19.940 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. 281 00:59:20.790 --> 00:59:23.809 Edwin Park: The Urban Institute estimated that 282 00:59:23.940 --> 00:59:35.613 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. 283 00:59:36.110 --> 00:59:55.999 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 284 00:59:56.781 --> 01:00:07.168 Edwin Park: and then the the fund itself is, pretty remarkably designed in a way to not actually go to rural hospitals, 285 01:00:07.890 --> 01:00:31.510 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 286 01:00:31.660 --> 01:00:34.970 Edwin Park: these applications on the other half 287 01:00:35.530 --> 01:00:54.669 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 288 01:00:55.130 --> 01:01:10.351 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 289 01:01:11.830 --> 01:01:36.050 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 290 01:01:36.080 --> 01:01:42.800 Edwin Park: more difficulties, of course, being able to keep their doors open under this legislation. 291 01:01:44.530 --> 01:02:11.230 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 292 01:02:11.300 --> 01:02:29.660 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. 293 01:02:29.670 --> 01:02:42.799 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 294 01:02:42.950 --> 01:02:58.030 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. 295 01:02:58.610 --> 01:03:04.690 Edwin Park: Yeah. So there's a a big gap, a big abyss between the 296 01:03:04.850 --> 01:03:24.419 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. 297 01:03:24.480 --> 01:03:46.730 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. 298 01:03:47.630 --> 01:03:55.769 Edwin Park: But you know the real goal is to dramatically undermine estate financing. So, as Joan mentioned. 299 01:03:56.170 --> 01:04:13.469 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. 300 01:04:13.650 --> 01:04:28.650 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 301 01:04:28.860 --> 01:04:43.559 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. 302 01:04:44.120 --> 01:04:45.473 Edwin Park: And then 303 01:04:46.170 --> 01:04:59.730 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 304 01:04:59.730 --> 01:05:18.379 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. 305 01:05:19.740 --> 01:05:20.630 Joan Alker: Thanks. 306 01:05:21.249 --> 01:05:27.309 Joan Alker: Edwin. Do we know how many in which States use provider taxes to fund home and community based services. 307 01:05:27.590 --> 01:05:50.770 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. 308 01:05:51.300 --> 01:05:55.300 Edwin Park: raising enrollment caps in 1915 c waivers for example. 309 01:05:57.330 --> 01:06:16.639 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. 310 01:06:16.640 --> 01:06:19.409 Joan Alker: Yeah, definitely. So. 311 01:06:19.620 --> 01:06:41.940 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 312 01:06:42.870 --> 01:06:49.340 Edwin Park: by another half percentage point every year until you get to 3 and a half percent. 313 01:06:49.370 --> 01:07:15.489 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. 314 01:07:15.570 --> 01:07:18.379 Edwin Park: Targeted expansion states to both. 315 01:07:18.640 --> 01:07:31.180 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. 316 01:07:31.940 --> 01:07:39.600 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 317 01:07:39.870 --> 01:08:09.379 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. 318 01:08:09.460 --> 01:08:21.370 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. 319 01:08:21.520 --> 01:08:38.669 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. 320 01:08:38.830 --> 01:09:02.060 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. 321 01:09:02.440 --> 01:09:04.720 Edwin Park: So it's at least one month 322 01:09:05.010 --> 01:09:23.960 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. 323 01:09:25.149 --> 01:09:25.920 Edwin Park: Let's see. 324 01:09:25.920 --> 01:09:26.350 Joan Alker: And then. 325 01:09:26.359 --> 01:09:36.143 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 326 01:09:37.239 --> 01:09:40.869 Edwin Park: require compliance for up to 3 months. 327 01:09:42.670 --> 01:09:55.530 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 328 01:09:55.590 --> 01:10:16.140 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 329 01:10:16.260 --> 01:10:24.169 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. 330 01:10:24.300 --> 01:10:37.369 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. 331 01:10:37.420 --> 01:10:57.300 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 332 01:10:57.460 --> 01:11:06.520 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. 333 01:11:06.520 --> 01:11:10.279 Edwin Park: Yeah, so for purposes of the 334 01:11:10.480 --> 01:11:19.019 Edwin Park: work, reporting requirement itself, compliance with requirements of hours worked, or, for example, income 335 01:11:19.260 --> 01:11:48.109 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 336 01:11:48.180 --> 01:11:56.790 Edwin Park: the State is supposed to make it, as you know, automated as possible, using these ex parte processes. 337 01:11:58.110 --> 01:12:05.129 Joan Alker: Thanks. So I've got one more for Edwin, and I've got a final one for both of you. Edwin. 338 01:12:05.630 --> 01:12:20.690 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. 339 01:12:20.920 --> 01:12:27.309 Edwin Park: Yeah, so it's at least these 7 States. With the 8 taxes that we mentioned in the Explainer. 340 01:12:28.230 --> 01:12:41.039 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. 341 01:12:41.120 --> 01:13:05.180 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. 342 01:13:06.050 --> 01:13:21.019 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 343 01:13:22.710 --> 01:13:50.970 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. 344 01:13:52.980 --> 01:13:56.240 Sabrina Corlette: I don't know. I can't recall. If 345 01:13:56.890 --> 01:14:02.440 Sabrina Corlette: there's an explicit timeline for that, I will say 346 01:14:03.248 --> 01:14:07.910 Sabrina Corlette: for folks who can show their income is above 347 01:14:08.410 --> 01:14:13.770 Sabrina Corlette: medicaid eligibility. A 138% of poverty and expansion states 348 01:14:13.990 --> 01:14:20.400 Sabrina Corlette: they should be able to get eligibility that way. So if they? 349 01:14:20.590 --> 01:14:30.439 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 350 01:14:30.750 --> 01:14:33.936 Sabrina Corlette: income. So presumably you're working in some fashion. But 351 01:14:34.740 --> 01:14:41.939 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. 352 01:14:41.940 --> 01:14:45.070 Edwin Park: Yeah, I don't think there's any timeline, but if 353 01:14:45.400 --> 01:14:48.270 Edwin Park: I think it's if an individual 354 01:14:48.880 --> 01:14:59.620 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. 355 01:14:59.820 --> 01:15:04.609 Edwin Park: And they have income at a hundred percent of Federal poverty line or above, and 356 01:15:04.710 --> 01:15:09.500 Edwin Park: then they cannot get marketplace subs tax credits 357 01:15:09.870 --> 01:15:37.479 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. 358 01:15:38.940 --> 01:15:52.569 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. 359 01:15:53.260 --> 01:15:58.909 Edwin Park: Oh, sure! So many of the provisions. Have specific language exempting 360 01:15:59.640 --> 01:16:22.780 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. 361 01:16:24.230 --> 01:16:44.350 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. 362 01:16:44.470 --> 01:17:09.359 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.