/ en Thu, 31 Jul 2025 04:21:13 -0500 Fri, 18 Jul 25 14:32:40 -0500 /news/headline/2025-07-18-analysis-finds-aca-marketplace-insurers-propose-15-median-premium-increase-2026 <p>Health Insurance Marketplace insurers will propose a median premium increase of 15% for 2026, according to an <a href="https://www.healthsystemtracker.org/brief/individual-market-insurers-requesting-largest-premium-increases-in-more-than-5-years/" target="_blank">analysis</a> of preliminary rate filings published July 18 by the Peterson Center on Healthcare and KFF. It would be the largest hike in premiums since 2018, the report said. Factors cited for the increase include the scheduled expiration of enhanced premium tax credits and impacts from tariffs. The analysis found that the expiring tax credits would increase out-of-pocket premium payments by more than 75% on average, while tariffs could increase the cost of certain drugs, medical equipment and supplies.</p> Fri, 18 Jul 2025 14:32:40 -0500 Marketplace Issues/Stability /news/chairpersons-file/2025-07-16-chair-file-leadership-dialogue-continuing-work-strengthen-health-america-aha-president-and <p>This month Congress enacted the One Big Beautiful Bill Act — a sweeping package that contained many of President Trump’s legislative priorities on taxes, border security, energy and deficit reduction, as well as significant policy changes to Medicaid and the Health Insurance Marketplaces.</p><p>This legislation will have a significant impact on hospitals and health systems as the changes are enacted. AHA President and CEO Rick Pollack joined me for a Leadership Dialogue conversation to help us understand the key provisions that apply to health care. We discuss how the AHA is helping the field prepare for some of the law’s changes, as well as our ongoing efforts to mitigate some of the policies. No matter what, we are here for you so you can continue to provide the care and services that our communities depend on.</p><p>During the conversation, Rick and I also look ahead to the many key advocacy priorities that are still on the table for the remainder of the year, including several provisions that the AHA hopes to get enacted as part of a government funding bill at the end of September.</p><p>Grassroots advocacy and sharing stories with your legislators about the real-world impact the policies they enact will have on patients and communities remain vital, and we close our conversation by exploring what this looks like for hospitals and health systems.</p><p>I hope you find our conversation insightful and strategic. Look for future conversations with health care, business and community leaders on making health better as part of the Chair File in 2025.</p><p><em>* Note that this conversation was recorded on July 11, 2025.</em></p><p></p><p> </p><div></div><p> </p> Wed, 16 Jul 2025 10:53:03 -0500 Marketplace Issues/Stability /advisory/2025-06-23-cms-finalizes-2025-marketplace-integrity-and-affordability-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) June 20 finalized its <a href="https://www.cms.gov/files/document/cms-9884-f-2025-pi-rule-master-5cr-062025.pdf">2025 Marketplace Integrity and Affordability rule</a>, intended to establish new standards for the health insurance marketplaces and address improper and fraudulent enrollments. Among other changes, the rule shortens the open enrollment period for the federal marketplace, limits open enrollment periods for state-based marketplaces to a nine-week period and makes changes that will increase the maximum annual cost-sharing limitation. While most of these provisions go into effect 60 days after publication in the Federal Register, CMS sunsets many of these changes after plan year 2026, noting that the marketplaces will face less risk of improper enrollments after the enhanced premium tax credits expire.</p><h2>MAJOR PROVISIONS</h2><p><strong>Open Enrollment.</strong> CMS changes the open enrollment parameters for individual market coverage both on and off the marketplaces, including those for marketplaces operated by individual states. Beginning in 2026 for the 2027 plan year, all open enrollment periods must begin by Nov. 1, end by Dec. 31 and not exceed nine calendar weeks. In addition, all plans purchased during open enrollment must begin on Jan. 1. For on- and off-marketplace plans sold in states operating on the federal platform, the 2027 plan year open enrollment will be Nov. 1-Dec. 15. </p><p>Previously, open enrollment periods for marketplaces on the federal platform ran from Nov. 1-Jan. 15; state-based marketplaces had flexibility to extend open enrollment beyond that window. </p><p><strong>Low-income Monthly Special Enrollment Period (SEP). </strong>CMS temporarily ends the monthly SEP for those with projected household incomes at or below 150% of the federal poverty level (FPL), effective 60 days after enactment of the final rule through the 2026 plan year. </p><p><strong>Agent, Broker and Web-broker Termination.</strong> CMS finalized its proposal to improve transparency of agent, broker and web-broker compliance reviews by adopting a “preponderance of the evidence” standard. CMS expects this will reduce noncompliant behavior, including improper and unauthorized enrollment.</p><p><strong>Premium Adjustment Percentage Methodology.</strong> CMS re-adopts the premium adjustment percentage methodology finalized in the 2020 Notice of Benefit and Payment Parameters, which uses private health insurance premiums to estimate future premium growth. This calculation is used to determine cost-sharing parameters, such as the maximum annual limitation on cost sharing.</p><p>Based on the finalized methodology, CMS sets a maximum annual limitation on cost sharing for the 2026 plan year of $10,600 for self-only coverage and $21,200 for family coverage. These amounts are roughly 15 percent higher than the 2025 plan year cost-sharing limits.</p><p><strong>Eligibility Verification for SEP. </strong>CMS reestablishes pre-enrollment eligibility verification for all types of SEPs on the federal marketplace. Since the 2023 Notice of Benefit and Payment Parameters, pre-enrollment verification was limited to the loss of minimum essential coverage SEP. In addition, all federally facilitated marketplaces must conduct pre-enrollment eligibility verification for at least 75% of all new enrollees. CMS did not finalize these changes for state-based marketplaces. These changes sunset at the end of the 2026 plan year.    </p><p><strong>De Minimis Thresholds.</strong> CMS finalizes its proposal to widen the “de minimis range” for most individual and small group market plans subject to the actuarial value requirements to +2/-4 percentage points. For expanded bronze plans, the new de minimis range will be +5/-4 percentage points. CMS also removed the de minimis range requirements of +2/0 percentage points for individual market silver plans and changed the de minimis range for silver cost-sharing reduction plans to +1/-1 percentage point. </p><p><strong>Deferred Action for Childhood Arrivals (DACA) Recipients.</strong> CMS changes the definition of “lawfully present” such that DACA recipients are no longer eligible to enroll in marketplace or basic health plans or receive premium tax credits or cost-sharing reductions. DACA recipients gained eligibility through the 2024 DACA Rule.</p><p><strong>Essential Health Benefits.</strong> CMS prohibits classifying gender-affirming care as an essential health benefit beginning in plan year 2026. Plans can still cover gender-affirming care if they choose to.</p><p><strong>Program Integrity. </strong>CMS finalizes several policies intended to ensure that individuals are only enrolling in plans and receiving premium tax credits that they are eligible for, including:</p><ul><li>Temporarily requiring all enrollees who attest to projected household income between 100-400% FPL but whose income verification results in a household income below 100% FPL to answer additional verification questions and provide supporting documentation. This policy is intended to ensure only eligible individuals above 100% FPL receive premium tax credits. This policy was finalized in the 2019 Notice of Benefit and Payment Parameters but was vacated by the courts. This policy sunsets after the 2026 plan year.</li><li>Temporarily reinstating a policy deeming an individual ineligible for future premium tax credits if they fail to file their federal income tax return and reconcile premium tax credits for one year. This policy was changed to two consecutive tax years in the 2024 Notice of Benefit and Payment Parameters. This policy sunsets after the 2026 plan year.</li><li>Temporarily requiring marketplaces to verify income with other trusted data sources if IRS data is not available, including requiring additional supporting documentation or other actions by enrollees. Previously, marketplaces accepted enrollees’ self-attestation of projected household income if IRS income verification was not possible. This policy sunsets after the 2026 plan year.</li><li>Removing the 60-day extension of the statutorily required 90-day window during which enrollees must resolve income inconsistencies.</li></ul><p><strong>Additional Policies</strong>. CMS finalizes several additional policies, including:</p><ul><li>Allowing issuers to require enrollees to pay past-due premiums before enrolling in new coverage.</li><li>Temporarily eliminating the fixed-dollar and gross percentage-based premium thresholds finalized in the 2026 Notice of Benefit and Payment Parameters and requiring issuers to adopt a net percentage-based threshold, which will require enrollees to pay more of their premium to maintain coverage. This policy sunsets after the 2026 plan year.</li><li>Temporarily changing the eligibility redetermination process for the 2026 plan year for enrollees in zero-dollar premium plans. These enrollees are required to affirm or update their eligibility information or face $5 premiums upon re-enrollment. The premiums will be eliminated once the enrollee confirms eligibility.</li><li>Removing the re-enrollment hierarchy that allows marketplaces to re-enroll low-income bronze plan enrollees into a silver plan if the silver plan is the same product, has the same provider network and has an equal or lower premium.</li></ul><p><strong>Coverage Impacts.</strong> CMS estimates that between 725,000 and 1.8 million individuals will lose marketplace coverage in 2026 as a result of the policies finalized in this rule.</p><h2>FURTHER QUESTIONS</h2><p>For more information, contact Ariel Levin, AHA’s director of coverage policy, at <a href="mailto:alevin@aha.org">alevin@aha.org</a>.</p><p> </p></div><div class="col-md-4> <a href=" org system files media file target="_blank" title="Click here to download the Regulatory Advisory: CMS Finalizes 2025 Marketplace Integrity and Affordability Rule PDF."><img src="/sites/default/files/2025-06/cover-from%20cms-finalizes-2025-marketplace-integrity-and-affordability-rule-advisory-6-23-2025.png" data-entity-uuid data-entity-type="file" alt="Regulatory Advisory: CMS Finalizes 2025 Marketplace Integrity and Affordability Rule" width="NaN" height="NaN"></div></div></div> Mon, 23 Jun 2025 15:45:13 -0500 Marketplace Issues/Stability /advisory/2025-06-16-senate-finance-committee-releases-legislative-text-reconciliation-bill <div class="container"><div class="row"><div class="col-md-8"><p>The Senate Committee on Finance has released <a href="https://www.finance.senate.gov/chairmans-news/chairman-crapo-releases-finance-committee-reconciliation-text" target="_blank" title="United States Senate Committee on Finance: Chairman Crapo Releases Finance Committee Reconciliation Text">bill text</a> for its portion of the budget reconciliation bill. The committee has jurisdiction over taxes and significant portions of the health care system, including the Medicare and Medicaid programs.</p><p>While the AHA continues to review the bill's text, below are some key provisions of importance to hospitals and health systems, as well as a statement AHA shared with the media. While many of the provisions are the same or similar to <a href="/advisory/2025-05-22-aha-summary-one-big-beautiful-bill-acts-provisions-impacting-hospitals-and-health-systems">The One Big Beautiful Bill Act (H.R. 1)</a>, there are several notable changes, especially with respect to Medicaid provider taxes and state directed payments.</p><p>In addition, AHA members can still <a href="https://aha-advocacy.ispresenting.live/register/" target="_blank" title="AHA Virtual Advocacy Webcast registration">register</a> to participate virtually in AHA’s Advocacy Day briefing on June 17 at 10 a.m. ET.</p><h2>AHA Statement</h2><p>In a <a href="/press-releases/2025-06-16-aha-statement-senate-finance-committee-bill">statement shared with the media</a> this evening, AHA President and CEO Rick Pollack said, “We continue to review the Senate Finance Committee’s proposal. However, it appears that the provisions further undermine the ability for hospitals to provide care to Medicaid patients. This bill moves in the wrong direction.</p><p>“The magnitude of Medicaid reductions and changes to health insurance marketplaces will shift millions of Americans from insured to uninsured status.</p><p>“Additionally, the proposal further erodes the legitimate use of provider taxes and state directed payment programs that help bridge the gap of chronic and historic Medicaid underpayments.</p><p>“These harmful proposals will impact access to all patients who are served by our nation’s hospitals and health systems. These cuts will strain emergency departments as they become the family doctor to millions of newly uninsured people. Finally, the proposal will force hospitals to reconsider services or potentially close, particularly in rural areas.</p><p>“As the Senate continues its deliberation, we urge consideration of the far-ranging negative consequences to our nation’s patients and hospitals.”</p><h2>Key Provisions of Interest to Hospitals and Health Systems</h2><h3>Medicaid Provider Taxes (Section 71120)</h3><p>The legislation would freeze in place provider taxes states use to help fund their Medicaid programs as of the date of enactment, after which states could not increase either the amount of the tax or the base to which the tax applies (i.e., by adding new classes or items of services to be subject to the tax). In addition, beginning in fiscal year (FY) 2027 and continuing through 2031, states that have expanded Medicaid and have provider taxes above 3.5% will see their “hold harmless threshold” reduced by 0.5% annually until the threshold reaches 3.5% except for taxes on nursing homes and intermediate care facilities. This provision differs from that in H.R. 1, which did not include provisions that would reduce the safe harbor threshold for expansion states.</p><h3>Medicaid State Directed Payments (71121)</h3><p>The legislation would establish the payment limit for state directed payments (SDPs) at 100% of Medicare in expansion states and 110% of Medicare in non-expansion states. For SDPs approved before May 1, 2025, for the rating period occurring within 180 days of enactment, or with a completed preprint submitted before enactment, beginning with the rating period on or after Jan. 1, 2027, the total SDP amount would be reduced by 10 percentage points annually until the specified Medicare payment rate limit is achieved. In contrast, H.R. 1 did not require the annual reduction of grandfathered SDPs or appropriate funding for implementation.</p><h3>Medicaid Community Engagement Requirements (Section 71124)</h3><p>The legislation would require certain nonpregnant, nondisabled adult Medicaid beneficiaries to meet certain community engagement requirements (“work requirements”) beginning Dec. 31, 2026. Individuals must work or engage in qualifying activities (e.g., community service, educational programs, job training) for no less than 80 hours/month. The legislation would exempt, among other groups, parents, guardians and caretaker relatives of children aged 14 or under, or a disabled individual. States would be permitted to receive temporary exemptions with Department of Health and Human Services (HHS) approval. The legislation would limit the types of entities that can contract with states to help implement this provision, effectively barring Medicaid managed care plans from assisting. The bill provides $200 million in FY 2026 grants for state implementation and $50 million for federal administration. In contrast, H.R. 1 exempted parents and caretakers of a disabled individual or dependent child (18 or under), did not explicitly prohibit contractors with financial interests, and provided $100 million for state implementation of the provisions.</p><h3>Increase Frequency of Redeterminations for Medicaid Expansion Enrollees (Section 71107)</h3><p>Consistent with H.R. 1, the legislation would require states to redetermine eligibility once every six months for beneficiaries enrolled through the Medicaid expansion eligibility pathway, beginning in calendar year 2027.</p><h3>Modifying Retroactive Eligibility under the Medicaid and CHIP Programs (Section 71114)</h3><p>Consistent with H.R. 1, the legislation would limit the timeframe for retroactive Medicaid and CHIP eligibility to 30 days prior to the application date, as opposed to the current 90-day period.</p><h3>Medicaid Cost-Sharing Requirements for Certain Expansion Individuals (Section 71125)</h3><p>Consistent with H.R. 1, the legislation would require Medicaid expansion enrollees with incomes above 100% of the federal poverty level (FPL) to pay up to $35 in cost sharing per service. The provision would exclude certain services including primary care, pregnancy-related services, mental health or substance use disorder services. Total cost sharing may not exceed 5% of family income.</p><h3>Prohibition on Implementation of Certain Regulations (Sections 71101, 71102, and 71113)</h3><p>Consistent with H.R. 1, the legislation would prohibit the HHS Secretary from implementing certain rules, including the final staffing rule for nursing facilities, final Medicaid eligibility and enrollment rules, and final Medicare savings program eligibility and enrollment rule.</p><h3>Public Program Eligibility for Certain Non-citizens (Sections 71110, 71201 and 71301)</h3><p>The legislation would restrict eligibility for Medicare, Medicaid and premium tax credits for marketplace coverage for non-citizens to the following groups: legal permanent residents, certain Cuban immigrants, and Compact of Free Association migrants lawfully residing in the United States. This expands on provisions included in H.R. 1.</p><h3>FMAP for Emergency Medicaid in Expansion States (Section 71102)</h3><p>Beginning Oct. 1, 2026, the legislation would limit the Federal Medical Assistance Percentage (FMAP) for emergency Medicaid services provided to unlawfully present aliens who, except for their immigration status, would qualify for expansion to the state’s traditional FMAP. In contrast, H.R. 1 did not include provisions limiting the FMAP for emergency Medicaid.</p><h3>Disallowing Premium Tax Credits during Periods of Medicaid Ineligibility due to Alien Status (Section 71302)</h3><p>Consistent with H.R. 1, the legislation would disallow undocumented immigrants who report income below 100% of the federal poverty level and are in their five-year Medicaid waiting period (due to immigration status) to receive premium tax credits to purchase health insurance on the marketplaces.</p><h3>Requiring Marketplace Verification of Eligibility for Health Plan (Section 71303)</h3><p>Consistent with H.R. 1, the legislation would prohibit an individual from claiming the premium tax credit if the individual’s eligibility related to income, enrollment and other requirements is not actively verified annually. This would prohibit automatic reenrollment for enrollees receiving premium tax credits by requiring them to actively prove tax credit eligibility each year. Over half of all returning enrollees in 2025 enrolled through automatic reenrollment.</p><h3>Disallowing Premium Tax Credit in Case of Certain Coverage Enrolled in during the Special Enrollment Period (Section 71304)</h3><p>Consistent with H.R. 1, the legislation would prohibit individuals from receiving premium tax credits if they enroll in health coverage on the marketplace through a special enrollment period associated with their income.</p><h3>Eliminating Limitation on Recapture of Advance Payment of Premium Tax Credit (Section 71305)</h3><p>Mostly consistent with H.R. 1, the legislation would remove the repayment limits and require affected individuals to reimburse the Internal Revenue Service for the full amount of excess tax credit received. The Senate language includes a special rule for those with incomes that unexpectedly fall below 100% of federal poverty level so that they do not need to repay the full amount of their premium tax credits.</p><h3>Endowment Tax for Universities (Section 70415)</h3><p>The legislation would amend the excise tax rate for universities based on student endowments. The rates are as follows: 1.4% for student endowments ranging from $500,000-$750,000 (current law), 4% for student endowments ranging from $750,000-$2 million, and 8% for all student endowments above $2 million. In contrast, H.R. 1 had a maximum excise tax rate of 21% for student endowments above $2 million.</p><h3>Executive Compensation (Section 70416)</h3><p>The legislation would limit tax-exempt organizations’ ability to deduct compensation over $1 million.</p><h3>Charitable Contributions for Non-itemizers (Section 70424)</h3><p>The legislation would create a permanent deduction on charitable contributions for taxpayers who do not elect to itemize.</p><h3>Floor on Charitable Contributions (Section 70425)</h3><p>The legislation would impose a 0.5% floor on charitable contributions for taxpayers who elect to itemize for taxable years after Dec. 31, 2025.</p><h3>1% Floor on Deduction of Charitable Contributions Made by Corporations (Section 70426)</h3><p>The legislation would allow a deduction for corporate charitable contributions only to the extent that the aggregate of corporate charitable contributions exceeds 1% of a taxpayer’s taxable income and does not exceed 10% of the taxpayer’s taxable income.</p><h2>Provisions Not Included in Senate Proposal</h2><ul><li>Delay to the cuts to Medicaid Disproportionate Share Hospital payments.</li><li>Increase Medicare payments for physicians.</li><li>Certain changes to health savings accounts.</li><li>Increase in the excise tax rate for tax-exempt private foundations.</li><li>Increase of the unrelated business taxable income of a tax-exempt organization by including the amount paid or incurred for any qualified transportation fringe benefit (provision included in House bill would have impacted non-profit hospitals’ ability to collect revenue from parking fees).</li><li>Provisions codifying the proposed Marketplace Integrity and Affordability rule.</li></ul><h2>Further Questions</h2><p>If you have further questions, please contact AHA at <a href="tel:1-800-424-4301">800-424-4301</a>.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/06/Senate-Finance-Committee-Releases-Legislative-Text-for-Reconciliation-Bill.pdf" target="_blank" title="Click here to download the Legislative Advisory: Senate Finance Committee Releases Legislative Text for Reconciliation Bill PDF."><img src="/sites/default/files/inline-images/Page-1-Senate-Finance-Committee-Releases-Legislative-Text-for-Reconciliation-Bill.png" data-entity-uuid="c479588d-1ad4-4e00-9016-a9330165f5b4" data-entity-type="file" alt="Legislative Advisory: Senate Finance Committee Releases Legislative Text for Reconciliation Bill page 1." width="695" height="900"></a></div></div></div> Mon, 16 Jun 2025 23:00:00 -0500 Marketplace Issues/Stability /fact-sheets/2025-06-05-fact-sheet-one-big-beautiful-bill-act-would-significantly-reduce-availability-coverage-health-insurance <div class="container"><div class="row"><div class="col-md-8"><h2>The Issue</h2><p><span><strong>The House-passed One Big Beautiful Bill Act (OBBBA, H.R. 1) makes significant changes to the Affordable Care Act (ACA) marketplaces that would lead to millions of people losing their coverage and becoming uninsured.</strong></span> These policies would make it more challenging for individuals to enroll and could result in higher premiums by reducing the amount of available tax credits. As a result, the Congressional Budget Office estimates that at least 3 million current marketplace enrollees would lose coverage.<a href="#fn1"><sup>1</sup></a> These coverage losses would be in addition to the estimated coverage losses due to the expiration of the enhanced premium tax credits.</p><h2>AHA Take</h2><p>The marketplaces are a vital piece of the U.S. health insurance coverage framework, providing access to quality health care for millions of Americans. When individuals lose health insurance coverage, they ultimately turn to their local hospital when they need care. This affects everyone, not only the uninsured, leading to overcrowded emergency departments, longer wait times and increased costs for care, which acts as a “hidden tax” on all. <span><strong>The AHA urges the Senate to reject the changes to the marketplaces in the House bill that will result in millions of people becoming uninsured.</strong></span></p><h2>Background</h2><p>For more than a decade, tens of millions of Americans who do not have access to affordable coverage through their employer or a government program (e.g., Medicare, Medicaid) have relied on the marketplaces to access comprehensive coverage. Marketplace enrollees are often small business owners, self-employed or those with multiple part-time jobs or jobs that pay hourly. Nearly three out of four enrollees have incomes that are between 100-250% of the Federal Poverty Level.<a href="#fn2"><sup>2</sup></a><sup>,</sup><a href="#fn3"><sup>3</sup></a></p><p>In 2025, over 24 million people enrolled in coverage through the marketplaces. Over 90% of those enrollees receive federal tax credits that lower their monthly premiums for marketplace coverage, with amounts based on their income.<a href="#fn4"><sup>4</sup></a> In 2021, Congress established enhanced tax credits by increasing and expanding eligibility; however, those policies are scheduled to expire at the end of 2025.<a href="#fn5"><sup>5</sup></a></p><h2>One Big Beautiful Bill Marketplace Provisions</h2><p>The OBBBA includes many provisions that, when taken together, will result in over 3 million marketplace enrollees becoming uninsured. Notably, the bill:</p><ul class="red"><li class="red"><span><strong>Eliminates automatic reenrollment for individuals receiving premium tax credits by requiring annual re-verification of tax credit eligibility.</strong></span> Nearly 11 million people enrolled through automatic, or passive, reenrollment in 2025, which is over half of all returning enrollees.<a href="#fn6"><sup>6</sup></a> Currently, the marketplaces use prior information from the enrollees’ original application along with updated tax data acquired through an automated process to complete reenrollment and updated tax credit eligibility verification without the returning enrollee submitting updated information or paperwork. Under the OBBBA, enrollees would be required to submit updated information on an annual basis to receive tax credits, resulting in a new administrative burden for enrollees and significantly higher premiums for those who fail to reenroll promptly.</li><li class="red"><span><strong>Eliminates provisional eligibility for premium tax credits while applicants are awaiting eligibility determinations.</strong></span> This would require Marketplace enrollees to pay the full, unsubsidized premiums for weeks or months while their applications are being verified.</li><li class="red"><span><strong>Removes the cap on the amount of tax credits that enrollees must repay to the government if their income changes during the year.</strong></span> Tax credit amounts are based on income expectations for the enrollment period. Currently, if an enrollee receives excess premium tax credits due to their actual income exceeding their expectations, they must repay the excess during the tax filing process. For most enrollees, there is a repayment cap based on household income. Under the OBBBA, all premium tax credit recipients would be required to pay the full amount of the excess, regardless of their income. This would add additional financial risk to subsidized enrollees who often experience unpredictable incomes, especially those with the lowest incomes.<a href="#fn7"><sup>7</sup></a></li><li class="red"><span><strong>Shortens the annual open enrollment period.</strong></span> Currently, open enrollment periods for federally facilitated marketplaces run from Nov. 1-Jan. 15 and state-based marketplaces have the flexibility to extend open enrollment beyond that window. The OBBBA would shorten the open enrollment period to Nov. 1-Dec. 15 for all marketplaces. In 2025, roughly 40% of enrollees enrolled after Dec. 15.<a href="#fn8"><sup>8</sup></a></li><li class="red"><span><strong>Ends the monthly low-income special enrollment period and state-based marketplaces’ special enrollment periods based on income.</strong></span> Income-based special enrollment periods offer lower-income people additional opportunities to enroll in health insurance coverage throughout the year. Losing these enrollment opportunities is particularly problematic when coupled with other OBBBA provisions that add barriers to enrollment through more burdensome eligibility and enrollment processes.</li><li class="red"><span><strong>Imposes new administrative burden on enrollees</strong></span> by adding additional income verification processes for individuals with incomes between 100-400% of the Federal Poverty Level.</li><li class="red"><span><strong>Funds the cost-sharing reduction payments,</strong></span> which will result in less generous tax credit amounts and increased premiums for subsidized enrollees. This policy will be challenging for insurers to implement beginning in 2026, potentially resulting in insurers exiting the markets.</li></ul><p><span><strong>Additionally, the bill does not extend the marketplace enhanced premium tax credits</strong></span><strong>.</strong> These tax credits have enabled millions of additional low and middle-income working individuals and families to purchase affordable health care coverage through the marketplaces. The expiration of these credits would effectively be a tax increase of $700 on average for millions of people across the nation and result in an additional 4.2 million people becoming uninsured.<a href="#fn9"><sup>9</sup></a></p><p><span><strong>Taken together, the cumulative impact of the changes to the ACA marketplaces in the OBBBA and the expiration of the enhanced premium tax credits would result in nearly one-third of all current marketplace enrollees losing access to affordable health care coverage.</strong></span> In addition, these policies are likely to destabilize the marketplaces, reducing access to health insurance coverage and increasing the number of uninsured and the amount of uncompensated care provided by hospitals.</p><hr><h3>End Notes</h3><ol class="fnred"><li class="fnred" id="fn1"><a href="https://www.cbo.gov/system/files/2025-06/Wyden-Pallone-Neal_Letter_6-4-25.pdf" target="_blank">cbo.gov/system/files/2025-06/Wyden-Pallone-Neal_Letter_6-4-25.pdf</a></li><li class="fnred" id="fn2"><a href="https://www.cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf" target="_blank">cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf</a></li><li class="fnred" id="fn3">In 2025, this equals $15,650-$39,125 per year for an individual and $32,150-$80,375 for a family of four.</li><li class="fnred" id="fn4"><a href="https://www.cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf" target="_blank">cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf</a></li><li class="fnred" id="fn5"><a href="/system/files/media/file/2025/02/Fact-Sheet-Enhanced-Premium-Tax-Credits-20250207.pdf" target="_blank">aha.org/system/files/media/file/2025/02/Fact-Sheet-Enhanced-Premium-Tax-Credits-20250207.pdf</a></li><li class="fnred" id="fn6"><a href="https://www.cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf" target="_blank">cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf</a></li><li class="fnred" id="fn7"><a href="https://www.kff.org/affordable-care-act/issue-brief/marketplace-enrollees-with-unpredictable-incomes-could-face-bigger-penalties-under-house-reconciliation-bill-provision/" target="_blank">kff.org/affordable-care-act/issue-brief/marketplace-enrollees-with-unpredictable-incomes-could-face-bigger-penalties-under-house-reconciliation-bill-provision/</a></li><li class="fnred" id="fn8"><a href="https://www.cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf" target="_blank">cms.gov/files/document/health-insurance-exchanges-2025-open-enrollment-report.pdf</a></li><li class="fnred" id="fn9"><a href="https://www.cbo.gov/system/files/2025-06/Wyden-Pallone-Neal_Letter_6-4-25.pdf" target="_blank">cbo.gov/system/files/2025-06/Wyden-Pallone-Neal_Letter_6-4-25.pdf</a></li></ol></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/06/Fact-Sheet-One-Big-Beautiful-Bill-Act-Would-Significantly-Reduce-Availability-of-Coverage.pdf" target="_blank" title="Click here to download the Fact Sheet: One Big Beautiful Bill Act Would Significantly Reduce Availability of Coverage in the Health Insurance Marketplaces PDF.">Download the Fact Sheet PDF</a></div><a href="/system/files/media/file/2025/06/Fact-Sheet-One-Big-Beautiful-Bill-Act-Would-Significantly-Reduce-Availability-of-Coverage.pdf"><img src="/sites/default/files/inline-images/Page-1-Fact-Sheet-One-Big-Beautiful-Bill-Act-Would-Significantly-Reduce-Availability-of-Coverage.png" data-entity-uuid="364043ab-7de4-4b4a-9051-03b3f18fc7a8" data-entity-type="file" alt="Fact Sheet: One Big Beautiful Bill Act Would Significantly Reduce Availability of Coverage in the Health Insurance Marketplaces page 1." width="695" height="900"></a></div></div></div> h2 { color: #003087; } h3 { color: #9d2235; } ul.red li.red::marker { color: #9d2235; font-weight: bold; } ol.fnred li.fnred::marker { color: #9d2235; font-weight: bold; } Thu, 05 Jun 2025 13:09:04 -0500 Marketplace Issues/Stability /news/headline/2025-05-22-house-passes-reconciliation-bill-significant-impacts-medicaid-health-insurance-marketplaces <p>The House May 22 passed the fiscal year 2025 budget reconciliation bill, the <a href="https://www.congress.gov/bill/119th-congress/house-bill/1" target="_blank">One Big Beautiful Bill Act</a> by a <a href="https://clerk.house.gov/evs/2025/roll145.xml" target="_blank">215-214 vote</a>. The legislation includes significant impacts to Medicaid and the Health Insurance Marketplaces. <br><br>In a <a href="/press-releases/2025-05-21-aha-statement-house-reconciliation-legislation" target="_blank">statement</a> shared with Congress and the media last night prior to the vote, AHA President and CEO Rick Pollack said, “Our hospitals and health systems have significant concerns regarding the harmful Medicaid and Health Insurance Marketplace provisions currently included in the bill. The sheer magnitude of the level of reductions to the Medicaid program alone will impact all patients, not just Medicaid beneficiaries, in every community across the nation. Hospitals — especially in rural and underserved areas — will be forced to make difficult decisions about whether they will have to reduce services, reduce staff and potentially consider closing their doors. Other impacts could include longer waiting times to receive care, more crowded emergency departments, and hospitals not being able to invest in technology and innovations for clinical care.</p><p>“In particular, the Medicaid legislative proposals severely restrict the use of legitimate state funding resources and supplemental payment programs, including provider taxes and state directed payments, under the guise of eliminating waste, fraud and abuse. We reject this notion as these critical, legitimate and well-established Medicaid financing programs are essential to offset decades of chronic underpayments of the cost of care provided to Medicaid patients. These new policies are estimated to decimate federal support for the Medicaid program by more than $700 billion over 10 years and will displace health care coverage for millions of Americans, moving them from insured to uninsured status.</p><p>“In addition to jeopardizing access to patient care and services, these abrupt policy changes would upend state government budgets and threaten the viability of the health care system to provide essential services to this population. Since these changes are effective immediately upon enactment of the legislation, states will have little or no time to prepare for the significant financial impact on state budgets.</p><p>“Given the substantial reduction in Medicaid payments and cuts to the Health Insurance Marketplaces, including allowing the enhanced premium tax credits to expire, millions will lose health care coverage. Therefore, the AHA urges the House to reject efforts to dismantle these vital programs in the OBBBA and preserve health care access for our nation’s vulnerable and working families.”</p><p>The bill will now be considered by the Senate, where it is likely to undergo a series of changes before a vote is held. <br><br>The AHA sent a <a href="/special-bulletin/2025-05-22-house-passes-reconciliation-bill-significant-policy-changes-and-reductions-medicaid-other-health" target="_blank">Special Bulletin</a> to members that includes the AHA’s statement and highlights changes made to the bill prior to its passage, along with resources to assist with advocacy efforts. A <a href="/advisory/2025-05-22-aha-summary-one-big-beautiful-bill-acts-provisions-impacting-hospitals-and-health-systems" target="_blank">Legislative Advisory</a> was also sent to members that summarizes provisions in the bill impacting hospitals and health systems.</p> Thu, 22 May 2025 16:26:59 -0500 Marketplace Issues/Stability /advisory/2025-05-22-aha-summary-one-big-beautiful-bill-acts-provisions-impacting-hospitals-and-health-systems <div class="container"><div class="row"><div class="col-md-8"><p>The House of Representatives May 22 passed by a 215-214 vote H.R. 1, the <a href="https://rules.house.gov/sites/evo-subsites/rules.house.gov/files/documents/rcp_119-3_final.pdf" target="_blank">One Big Beautiful Bill Act</a>, a sweeping package that would enact many of President Trump’s legislative priorities on taxes, border security, energy and deficit reduction. The bill, which Republicans are attempting to pass through reconciliation, includes significant policy changes to Medicaid and the Health Insurance Marketplaces. See AHA’s <a href="/press-releases/2025-05-21-aha-statement-house-reconciliation-legislation">statement</a> from AHA President and CEO Rick Pollack, sent late yesterday to congressional offices prior to the House vote. The action now moves to the Senate, which is expected to make changes to the bill.</p><p>Before House passage, the bill was <a href="https://amendments-rules.house.gov/amendments/RCP_119-3_Managers_xml (002)250521201648156.pdf" target="_blank">amended</a>, including several changes that were made on May 21. The following is a summary of provisions included in the bill that affect hospitals and health systems, as well as some resources from the Congressional Budget Office regarding the impact of the bill.</p><h2>Congressional Budget Office Resources</h2><ul><li><a href="https://www.cbo.gov/publication/61420" target="_blank">Estimated Budget Effects</a></li><li><a href="https://www.cbo.gov/system/files/2025-05/61423-PAYGO.pdf" target="_blank">Potential Statutory Pay-As-You-Go Effects</a></li><li><a href="https://www.cbo.gov/system/files/2025-05/61422-Reconciliation-Distributional-Analysis.pdf" target="_blank">Preliminary Analysis of the Distributional Effects</a></li></ul><h2>AHA Summary of Provisions Impacting Hospitals and Health Systems</h2><h3>Title III — Committee on Education and Workforce</h3><h4>Section 30011: Loan limits</h4><p>Terminates the Grad PLUS loan program effective July 1, 2026, and would prohibit any new Grad PLUS loans during the 2026-2027 school year, including a three-year exception for students who were enrolled in a program of study as of June 30, 2026, and had previously received a Grad PLUS loan.</p><p>Amends the maximum annual loan limit for unsubsidized loans disbursed to graduate students to $100,000 and for professional programs, including medical school, to $150,000.</p><h4>Section 30024: Public service loan forgiveness</h4><p>Clarifies that payments made by new borrowers on or after July 1, 2025, who are serving in a medical or dental residency would not count as qualifying payments toward public service loan forgiveness.</p><h3>Title IV — Energy and Commerce</h3><h4>Subtitle D — Health</h4><h4>SUBPART A: REDUCING FRAUD AND IMPROVING ENROLLMENT PROCESSES</h4><h4>Section 44101: Moratorium on implementation of rule relating to eligibility and enrollment in Medicare Savings Programs (Effective from enactment through Jan. 1, 2035)</h4><p>Prohibits the Department of Health and Human Services (HHS) Secretary from implementing, administering or enforcing the Medicare Savings Program (MSP) rule for 10 years. This would rollback requirements that states 1) automatically enroll certain Supplemental Security Income recipients in the qualified Medicare beneficiary eligibility group of the MSP program, 2) use data from the low-income subsidy program as an application for MSPs and align the family size definitions between the MSP and Low Income Subsidy programs, and 3) accept self-attestation for certain types of income and resources.</p><h4>Section 44102: Moratorium on implementation of rule relating to eligibility and enrollment for Medicaid, CHIP and the Basic Health Program (Effective from enactment through Jan. 1, 2035)</h4><p>Prohibits the HHS secretary from implementing, administering or enforcing the eligibility and enrollment rule for 10 years. This would limit states’ ability to use other data sources (such as payroll or state vital statistics data) to determine an individual’s eligibility for Medicaid and limit states’ use of prepopulated renewal forms. It would also allow states to impose annual and/or lifetime limits on Children’s Health Insurance Program (CHIP) benefits and to disenroll CHIP beneficiaries for failure to pay premiums or enrollment fees.  </p><h4>Section 44103: Ensuring appropriate address verification under the Medicaid and CHIP programs</h4><p>Requires regular (no less than once each month) enrollee address verification and is intended to prevent individuals from enrolling in two state Medicaid or CHIP programs simultaneously. This section would require state Medicaid agencies to establish a process to collect address information for Medicaid enrollees and report certain identifying information to the HHS secretary by Jan. 1, 2027. The secretary would be required to establish a system that would identify when an individual is enrolled in two state programs simultaneously, determine in which state the individual resides, and disenroll the individual from other state Medicaid or CHIP programs. The section appropriates $10 million for fiscal year (FY) 2026 to establish a system and $20 million for FY 2029 to maintain that system.</p><h4>Section 44104: Modifying certain state requirements for ensuring deceased individuals do not remain enrolled (Effective Jan. 1, 2028)</h4><p>Requires states to review the Social Security Administration’s Death Master File to determine whether any enrollees are deceased. If a beneficiary is disenrolled in error, the state must re-enroll them retroactively to the date of disenrollment.</p><h4>Section 44105: Medicaid provider screening requirements (Effective Jan. 1, 2028)</h4><p>Requires states to regularly (no less frequently than monthly) check provider eligibility to determine whether HHS or the state has terminated the provider’s participation.</p><h4>Section 44106: Additional Medicaid provider screening requirements (Effective Jan. 1, 2028)</h4><p>Requires states to regularly (no less than quarterly) check the Death Master File to determine whether providers are deceased.</p><h4>Section 44107: Removing good faith waiver for payment reduction related to certain erroneous excess payments under Medicaid (Effective FY 2030)</h4><p>Limits the authority of the HHS secretary to waive payment reductions and requires HHS to reduce federal funding to states derived from states making erroneous excess payments for ineligible individuals or services. </p><h4>Section 44108: Increasing frequency of eligibility redeterminations for certain individuals (Effective Dec. 31, 2026)</h4><p>Requires states to redetermine eligibility once every six months for beneficiaries enrolled through the Medicaid expansion eligibility pathway.</p><h4>Section 44109: Revising home equity limit for determining eligibility for long-term care services under the Medicaid program (Effective Jan. 1, 2028)</h4><p>Revises the permissible home equity interest limit to $1,000,000 to determine allowable assets for nursing facility services and long-term care. Asset disregards are prohibited. </p><h4>Section 44110: Prohibiting federal financial participation under Medicaid and CHIP for individuals without verified citizenship, nationality or satisfactory immigration status (Effective Oct. 1, 2026)</h4><p>Prohibits federal financial participation for Medicaid and CHIP enrollees in a reasonable opportunity period unless the individual successfully verifies their citizenship or immigration status. It is optional for states to provide coverage during the verification period.</p><h4>Section 44111: Reducing expansion Federal Medical Assistance Percentage for certain states providing payments for health care furnished to certain individuals (Effective Oct. 1, 2027)</h4><p>Reduces the Federal Medical Assistance Percentage (FMAP) to 80% for the expansion population in states that use state funds to cover aliens who are not qualified aliens or lawfully residing pregnant women and children (i.e., undocumented immigrants and certain lawfully residing adults). “Coverage” is not limited to Medicaid and may include other programs established by the state to offer financial assistance to purchase health insurance coverage or to provide comprehensive health benefits coverage.</p><h3>SUBPART B: PREVENTING WASTEFUL SPENDING</h3><h4>Section 44121: Moratorium on Minimum Staffing Rule for long-term care facilities (Effective from enactment through Jan. 1, 2035)</h4><p>Prohibits HHS from implementing the Minimum Staffing Standards for long-term care facilities and the Medicaid Institutional Payment Transparency Reporting regulation for 10 years.</p><h4>Section 44122: Modifying retroactive under the Medicaid and CHIP programs (Effective Dec. 31, 2026)</h4><p>Limits the timeframe for retroactive Medicaid and CHIP eligibility to 30 days prior to the application date, as opposed to the current 90-day period.</p><h4>Section 44123: Ensuring accurate payments to pharmacies under Medicaid (Effective first day of the first quarter that begins six months after enactment)</h4><p>Expands transparency requirements regarding Medicaid payments to pharmacies for covered outpatient drugs. The secretary is required to conduct a survey to determine, and make publicly available, national average drug acquisition prices and cost benchmarks. Monetary penalties may be imposed on retail community pharmacies or non-retail pharmacies for failing to comply with a survey request, providing false information or otherwise failing to comply with requirements.</p><h4>Section 44124: Preventing the use of abusive spread pricing in Medicaid (Effective for contracts that begin 18 months after the date of enactment)</h4><p>This section requires that payment for drugs and related administrative services is based on a transparent prescription drug pass-through pricing model and prohibits any form of spread pricing. Payment made by the entity or pharmacy benefit manager (PBM) is limited to ingredient cost and a professional dispensing fee. The payment must be passed through in its entirety by the entity or PBM to the pharmacy or provider dispensing the drug.</p><h4>Section 44125: Prohibiting federal Medicaid and CHIP funding for gender transition procedures</h4><p>Prohibits states from receiving federal funds for specified gender transition procedures. This does not apply to certain services provided by a health care provider with parental/legal guardian consent, including puberty suppression, blocking prescription drugs to normalize puberty or an individual experiencing precocious puberty, and certain medically necessary procedures.</p><h4>Section 44126: Federal payment to prohibited entities (Effective from enactment for 10 years)</h4><p>Prohibits states from receiving federal matching funds for services rendered by providers that provide abortions (other than Hyde Amendment exceptions) and receive more than $1 million in Medicaid payments in 2024. This applies to not-for-profit, essential community providers primarily engaged in family planning services, reproductive health and related medical care. This provision would apply for 10 years, beginning on the date of enactment.</p><h3>SUBPART C: STOPPING ABUSIVE FINANCING PRACTICES</h3><h4>Section 44131: Sunsetting eligibility for increased FMAP for expansion states (Effective Jan. 1, 2026)</h4><p>Repeals the ability for states that have not yet expanded Medicaid to receive 5% enhanced FMAP funds should they later choose to expand.</p><h4>Section 44132: Moratorium on new or increased provider taxes (Effective from enactment)</h4><p>Disallows federal matching funds for state provider taxes imposed after the date of enactment or any provider taxes that were increased (in amount or rate) after the date of enactment. The draft legislation also includes a provision that prohibits states from increasing the tax base by expanding items or services, or expanding the tax base to include providers that were previously not included. This would effectively cap provider taxes at the amount in place on the date of enactment.</p><h4>Section 44133: Revising the payment limit for certain directed payments (Effective from enactment)</h4><p>Limits state-directed payments (SDPs) to no more than 110% of the published Medicare payment rate for non-expansion states and 100% of the published Medicare payment rate for expansion states, except for previously approved SDPs or preprints submitted to the HHS secretary prior to the date of enactment. However, states with SDPs in place could not increase the amount and would be required to submit grandfathered SDP preprints for CMS approval when seeking renewal. In the absence of a published Medicare rate, an equivalent rate could be used. If a state expands Medicaid after the date of enactment, SDPs would be subject to the 100% Medicare upper payment limit, including preprints for which prior approval was made before the state expanded Medicaid.  </p><h4>Section 44134: Requirements regarding waiver of uniform tax requirement for Medicaid provider tax</h4><p>Modifies the requirements regarding uniformity of provider taxes and, specifically, whether a state’s tax is considered “generally redistributive.” Under the draft legislation, a tax is not considered generally redistributive if:</p><ol type="a"><li>Lower volume Medicaid health care entities are taxed at a lower rate than higher volume Medicaid health care entities.</li><li>High Medicaid volume health care entities are taxed more heavily than non-Medicaid health care entities.</li><li>The tax establishes any target or exclusion related to a health care entity’s Medicaid participation status.</li></ol><h4>Section 44135: Requiring budget neutrality for Medicaid demonstration projects under Section 1115</h4><p>Codifies CMS practice of requiring that Section 1115 waivers not increase federal spending compared to what a state would have spent without the waiver. It also requires the secretary to specify a methodology for using waiver savings for subsequent approvals.</p><h3>SUBPART D: INCREASING PERSONAL ACCOUNTABILITY</h3><h4>Section 44141: Community engagement (work) requirements (Effective December 31, 2026)</h4><p>Establishes work requirements for certain Medicaid beneficiaries. Beginning Dec. 31, 2026, or earlier at the option of the state, states are required to establish work requirements for non-exempt expansion adults aged 19-64. Individuals must work or engage in qualifying activities (e.g., community service, educational programs, job training) for no less than 80 hours/month. Mandatory exceptions include individuals under the age of 19, pregnant or post-partum women, individuals enrolled in Medicare Part A or Part B, and institutionalized individuals. Optional exceptions for short-term hardship events include individuals receiving inpatient hospital services, nursing facility services or inpatient psychiatric services; individuals in disaster zones; and individuals in areas with high unemployment. Compliance is verified during the initial eligibility determination, as well as part of subsequent eligibility redetermination, or more frequently as determined by the state. States may use data sources like payroll data to verify compliance. If the state is unable to verify that the individual has met the community engagement requirements, the individual will have 30 days to demonstrate compliance before they are disenrolled. States must determine whether an individual would qualify for Medicaid under other eligibility pathways before disenrolling. Grants totaling $100 million are provided in FY 2026 for system development. The amended section changes a requirement that the secretary promulgate rules regarding the implementation and instead directs the secretary to issue guidance not later than Dec. 31, 2025.</p><h4>Section 44142: Modifying cost-sharing requirements for certain expansion individuals under the Medicaid program (Effective Oct. 1, 2028)</h4><p>Requires states to impose cost-sharing requirements at an amount greater than $0 and not exceeding $35 on Medicaid expansion enrollees, as determined by the state. Total cost sharing may not exceed 5% of family income. Cost-sharing requirements cannot be imposed on pregnancy-related services, primary care, mental health or substance use disorder services. States may allow providers to require payment as a condition of providing services. Providers may waive cost-sharing requirements on a case-by-case basis. This section also prohibits states from requiring Medicaid expansion enrollees to pay a premium, enrollment fee, or other such charge.</p><h3>Other Provisions Related to Medicaid</h3><h4>Section 44302: Streamlined enrollment process for eligible out-of-state providers under Medicaid and CHIP</h4><p>Streamlines enrollment requirements for eligible out-of-state providers. Eligible out-of-state providers are those who are determined by the secretary or another state Medicaid program to have limited risk of fraud, waste and abuse and have not been excluded from participation in a state Medicaid program or other federal health program.</p><h4>Section 44303: Delaying disproportionate share hospital reductions</h4><p>Delays the Medicaid disproportionate share hospital (DSH) reductions to FYs 2029 through 2031. Under current law, federal allotments for Medicaid DSH would be reduced by $8 billion for FYs 2026 through 2028. The section also extends Tennessee’s DSH allotment through 2028.</p><h3>Other Provisions Unrelated to Medicaid</h3><h4>Section 44304: Modifying update to the conversion factor under the physician fee schedule under the Medicare program</h4><p>Creates a single conversion factor for Physician Fee Schedule services under the Medicare program starting in 2026 (as opposed to the two distinct ones in place today — one for physicians participating in alternative payment models and another for those who are not). For 2026, the update to the single conversion factor would be 75% of the Medicare Economic Index (MEI), and, for 2027, it would be 10% of the MEI. This provision would not be retroactive.</p><h4>Section 44201: Addressing waste, fraud and abuse in the Accountable Care Act exchanges</h4><p>Codifies most of the proposed policies in the 2025 Marketplace Integrity rule, including:</p><ul><li>Shortening the Health Insurance Marketplace open enrollment period.</li><li>Removing the low-income special enrollment period.</li><li>Changes to the premium adjustment percentage methodology.</li><li>Allowing insurers to require that enrollees pay past-due premiums before renewing coverage.</li><li>Disallowing DACA recipients from receiving premium tax credits or cost-sharing reductions.</li><li>Prohibiting gender-affirming care as an essential health benefit.</li><li>Greater eligibility verification processes.</li></ul><p>The draft legislation does not include the proposal to improve transparency of agency, broker and web-broker behavior, and varies in its language regarding the de minimus range, which impacts the value of coverage within each metal tier.</p><h4>Section 44202: Funding cost-sharing reduction payments</h4><p>Restores federal funding for the cost-sharing reduction (CSR) payments, which reduce costs for low-income marketplace enrollees. The federal government stopped funding these payments beginning in the 2018 plan year, as Congress did not appropriate the funds. To address the lack of funding, insurers increased the cost of silver plan premiums in a practice known as "silver-loading." This increased the cost of premium tax credits, which are based on the second-lowest cost silver plan premium. By funding the CSR payments, insurers will no longer need to silver load, which will lower the value of the premium tax credits and generate savings for the federal government.</p><h3>Title XI — Committee on Ways and Means, ‘‘The One, Big, Beautiful Bill’’</h3><h4>SUBPART A: MAKE AMERICAN FAMILIES AND WORKERS THRIVE AGAIN</h4><h4>Section 110112: Reinstatement of partial deduction for charitable contributions of individuals who do not elect to itemize</h4><p>Creates a temporary deduction for non-itemizing taxpayers up to $150 for single filers ($300 for married filing jointly) for charitable cash contributions for tax years 2025 through 2028. The charitable contribution must be made to a qualified charity and cannot be made to Donor-Advised Funds or supporting organizations.</p><h4>Sections 110201-110203: Custom Health Option and Individual Care Expense (CHOICE) arrangements</h4><p>Regulations finalized in 2019 created “individual coverage health reimbursement arrangements (ICHRAs),” which allow employers to offer their employees financial support to purchase health insurance on the individual markets, in addition to other medical expenses. This bill would codify those regulations, rename ICHRAs as Custom Health Option and Individual Care Expense (CHOICE) arrangements, and remove some of the administrative barriers to implementation. In addition, the bill would create a tax credit for businesses with fewer than 50 employees to implement CHOICE arrangements by offering a $100 per employee tax credit in the first year of implementation and a $50 per employee tax credit in the second year.</p><h4>Sections 110204, 110206, 110208-110213: Health savings account provisions</h4><p>Health savings accounts (HSAs) are tax-advantaged savings accounts for high-deductible health plan (HDHP) enrollees. There are strict regulations around who can utilize HSAs and how their funds can be used. This bill would expand HSA access to individuals enrolled in Medicare Part A if they are also still enrolled in their private HDHP, and to individuals enrolled in bronze or catastrophic health plans in the individual market. The bill would also create more flexibility in how individuals contribute, for example, by allowing eligible individuals to contribute even if their spouse has a flexible spending arrangement, and what services can be covered by HSA funds. Finally, the bill would increase HSA contribution limits for individuals with annual income that is less than $75,000 individually or $150,000 for a family.</p><h4>Section 110205: Treatment of direct primary care service arrangements</h4><p>Excludes direct primary care (DPC) service arrangements from classification as a health plan for the purposes of HSA eligibility so long as the primary care arrangement is for only primary care services, the individual pays a fixed monthly fee, and that amount doesn’t exceed $150 for an individual (twice the amount for coverage of more than one person). Would clarify that anesthesia, prescription drugs and lab services would not qualify as DPC services. Would allow for DPC services to be qualified medical expenses by excluding DPC arrangements from the definition of “health insurance” for which HSAs could not be utilized. Would also provide for cost-of-living adjustments for DPC arrangements. In general, this provides additional flexibility for HSAs to be used for DPC arrangements, which may increase beneficiary enrollment in these types of plans.</p><h4>SUBPART B: MAKE RURAL AMERICA AND MAIN STREET GROW AGAIN</h4><h4>Section 111201: Expanding the definition of rural emergency hospital under the Medicare program</h4><p>This provision allows for the conversion to a rural emergency hospital (REH) if state licensure is not currently provided but will be licensed as such within one year of the state providing such licensure. It also allows for a facility located less than 35 miles away from another hospital, critical access hospital (CAH) or REH, to be an REH, provided that annually, the facility must demonstrate more than 50% of the services provided are emergency and observation care for Medicare Part A and B patients. The provision permits eligibility for conversion from CAHs and small rural (<50 beds) hospitals opened between Jan. 1, 2014, and Dec. 26, 2020. Additionally, outpatient prospective payment system plus 5% payment to facilities located less than 35 miles away from another hospital, CAH or REH are disallowed. The provision also disallows a monthly facility payment to facilities located less than 10 miles away from another hospital, CAH or REH.</p><h4>SUBPART C: MAKE AMERICA WIN AGAIN</h4><h4>Section 112003: Termination of qualified commercial clean vehicles credit</h4><p>Eliminates the qualified commercial clean vehicles credit at the end of 2025. Provides an exception for vehicles placed in service before 2033 and under a binding contract entered into before May 2025.</p><h4>Section 112004: Termination of alternative fuel vehicle refueling property credit</h4><p>Eliminates the alternative fuel vehicle refueling property credit at the end of 2025.</p><h4>Section 112009: Restrictions on clean electricity investment credit</h4><p>Restricts the clean electricity investment credit by making zero credit available after Dec. 31, 2028. This provision restricts access to the credit for certain prohibited foreign entities.</p><p>This provision restricts access to the credit for certain prohibited foreign entities. Specifically:</p><ol type="1"><li>No credit is allowed for a facility that commences construction a year after the enactment of this bill that includes any material assistance from a prohibited foreign entity.</li><li>No credit is allowed for taxable years beginning after enactment if the taxpayer is a specified foreign entity.</li><li>No credit is allowed for tax years that begin two years after the date of enactment for foreign influence entities or if the taxpayer makes fixed, determinable, annual or periodic (FDAP) amount payments to a prohibited foreign entity that are more than 5% of total expenditures related to the credit generating activity or 15% in aggregate</li></ol><h4>Section 112015: Phase-out of credit for certain energy property</h4><p>Aligns the expiration of the investment tax credit for geothermal heat pumps with the clean electricity investment tax credit. There is a 20% credit reduction for facilities placed in service in calendar year 2029, a 40% reduction for facilities placed in service in 2030, a 60% reduction for facilities placed in service in 2031 and no credit available after Dec. 31, 2031.</p><p>This provision restricts access to the credit for certain prohibited foreign entities. Specifically:</p><ol type="1"><li>No credit is allowed for taxable years beginning after enactment if the taxpayer is a specified foreign entity.</li><li>No credit is allowed for tax years that begin two years after the date of enactment for a foreign-influenced entity.</li></ol><h4>Section 112019: Excessive employee renumeration from controlled group members and allocation of deduction</h4><p>Applies aggregation rules for the deduction limitation and allocation of deduction applied under Internal Revenue Code (IRC) section 162(m) as it relates to certain excessive employee remuneration.</p><h4>Section 112021: Modification of excise tax on investment income of certain private colleges and universities</h4><p>Amends the current excise tax on net investment income framework for certain private colleges and universities under IRC section 4968 with a tiered system based on an institution’s student-adjusted endowment (see table below). For purposes of calculating an institution's student-adjusted endowment, this section amends such calculation by excluding students who do not meet the requirements under Section 484(a)(5) of the Higher Education Act of 1965. This section also provides an exemption from being considered an applicable educational institution, provided the institution meets certain requirements related to being a qualified religious institution. Additionally, this section includes student loan interest income and certain royalty income to calculate a school’s net investment income.</p><table><thead><tr><th>Student-Adjusted Endowment</th><th>Excise Tax Rate</th></tr></thead><tbody><tr><td>$500,000-$749,999</td><td>1.4% (current rate)</td></tr><tr><td>$750,000-$1,249,999</td><td>7%</td></tr><tr><td>$1,250,000-$1,999,999</td><td>14%</td></tr><tr><td>$2,000,000+</td><td>21%</td></tr></tbody></table><h4>Section 112022: Increase tax rate on net investment income of certain private foundations</h4><p>Amends the current excise tax on net investment income framework for tax-exempt private foundations under IRC section 4940(a) with a tiered system that maintains the current excise tax rate for private foundations with less than $50 million in total assets but applies higher excise tax rates on private foundations reporting $50 million or more in total assets (see table below).</p><table><thead><tr><th>Size of Private Foundation (in assets)</th><th>Excise Tax Rate</th></tr></thead><tbody><tr><td>$0-$49,999,999</td><td>1.39% (current rate)</td></tr><tr><td>$50,000,000-$249,999,999</td><td>2.78%</td></tr><tr><td>$250,000,000-$4,999,999,999</td><td>5%</td></tr><tr><td>$5,000,000,000+</td><td>10%</td></tr></tbody></table><h4>Section 112024: Unrelated business taxable income increased by the amount of certain fringe benefit expenses for which deduction is disallowed</h4><p>Amends IRC section 512 to increase the unrelated business taxable income of a tax-exempt organization by including the amount paid or incurred for any qualified transportation fringe benefit.</p><h4>Section 112025: Name and logo royalties treated as unrelated business taxable income</h4><p>Amends IRC sections 512 and 513 to increase the unrelated business taxable income of a tax-exempt organization by including the income from any sale or licensing by an organization of its name or logo.</p><h4>Section 112026: Exclusion of research income limited to publicly available research</h4><p>Amends IRC section 512 to increase the unrelated business taxable income of a tax-exempt organization by including the income generated from non-public research for an organization whose tax-exempt purpose is to provide publicly available research as unrelated business income.</p><h4>Section 112101: Permitting premium tax credit only for certain individuals</h4><p>Eliminates premium tax credit eligibility for undocumented immigrants and only allows eligibility for Lawful Permanent Residents, certain Cuban immigrants, and individuals living in the U.S. through a Compact of Free Association.</p><h4>Section 112102: Certain aliens treated as ineligible for premium tax credit</h4><p>Prohibits individuals with immigration status granted by asylum (or pending an asylum application), parole, temporary protected status, deferred enforced departure and withholding of removal from receiving premium tax credits.</p><h4>Section 112103: Disallowing premium tax credit during periods of Medicaid ineligibility due to alien status</h4><p>Strikes the loophole that allows undocumented immigrants who report income below 100 percent of the federal poverty level and are in their five-year Medicaid waiting period (due to immigration status) to receive premium tax credits to purchase health insurance on the Exchange.</p><h4>Section 112201: Requiring Exchange verification of eligibility for health plan</h4><p>Prohibits an individual from claiming the premium tax credit if the individual’s eligibility related to income, enrollment and other requirements is not actively verified annually. This would prohibit automatic reenrollment for enrollees receiving premium tax credits by requiring them to actively prove tax credit eligibility each year. Over half of all returning enrollees in 2025 enrolled through automatic reenrollment.</p><h4>Section 112202: Disallowing premium tax credit in case of certain coverage enrolled in during the special enrollment period</h4><p>Prohibits individuals from receiving premium tax credits if they enroll in health coverage on the Exchange through a special enrollment period associated with their income.</p><h4>Section 112203: Eliminating limitation on recapture of advance payment of premium tax credit</h4><p>Removes the repayment limits and requires affected individuals to reimburse the Internal Revenue Service for the full amount of excess tax credit received.</p><h4>Section 112204: Implementing artificial intelligence tools to reduce and recoup improper payments under Medicare</h4><p>Provides $25 million for the HHS secretary to contract with artificial intelligence contractors and data scientists to examine Medicare improper payments and recoup overpayments. Additionally, the secretary is required to report to Congress on progress in decreasing the number of Medicare improper payments.</p><h4>SUBPART D: INCREASE IN DEBT LIMIT</h4><h4>Section 113001: Modification of limitation on the public debt</h4><p>Increases the statutory debt limit by $4 trillion.</p><h2>Further Questions</h2><p>If you have further questions, please contact AHA at <a href="tel:1-800-424-4301">800-424-4301</a>.</p><p><a href="/system/files/media/file/2025/05/Legislative-Advisory-AHA-Summary-of-One-Big-Beautiful-Bill-Acts-Provisions-Impacting-Hospitals-and-Health-Systems.pdf"><span><em><strong>Read the complete Legislative Advisory.</strong></em></span></a></p></div><div class="col-md-4"><a href="/system/files/media/file/2025/05/Legislative-Advisory-AHA-Summary-of-One-Big-Beautiful-Bill-Acts-Provisions-Impacting-Hospitals-and-Health-Systems.pdf"><img src="/sites/default/files/inline-images/Page-1-Legislative-Advisory-AHA-Summary-of-One-Big-Beautiful-Bill-Acts-Provisions-Impacting-Hospitals-and-Health-Systems.png" data-entity-uuid="7b4d504a-d7a3-4f38-b807-ac4bd58ba5fb" data-entity-type="file" alt="Legislative Advisory: AHA Summary of One Big Beautiful Bill Act’s Provisions Impacting Hospitals and Health Systems page 1." width="696" height="900"></a></div></div></div> table, th, td { border: 1px solid; } Thu, 22 May 2025 15:08:44 -0500 Marketplace Issues/Stability /special-bulletin/2025-05-22-house-passes-reconciliation-bill-significant-policy-changes-and-reductions-medicaid-other-health <div class="container"><div class="row"><div class="col-md-8"><p>The House of Representatives May 22 passed by a 215-214 vote H.R. 1, the <a href="https://rules.house.gov/sites/evo-subsites/rules.house.gov/files/documents/rcp_119-3_final.pdf" target="_blank">One Big Beautiful Bill Act</a>, a sweeping package that would enact many of President Trump’s legislative priorities on taxes, border security, energy and deficit reduction. The bill, which Republicans are attempting to pass through reconciliation — a <a href="/issue-landing-page/2025-02-07-budget-reconciliation-process-resource-page">budget tool</a> that gives Congress a fast-track mechanism to avoid the Senate filibuster and pass legislation with a simple majority — includes significant policy changes to Medicaid and the Health Insurance Marketplaces that will jeopardize access to care for communities. The action now moves to the Senate, which is expected to make changes to the bill.</p><p>This Special Bulletin includes several updates and resources related to the bill, including:</p><ul><li><strong>Changes Made to the Bill.</strong> The House late yesterday made several <a href="https://amendments-rules.house.gov/amendments/RCP_119-3_Managers_xml (002)250521201648156.pdf?_gl=1*1jziwmj*_ga*MTIyNTg0MjE4Ny4xNjg5MTcxMjMz*_ga_N4RTJ5D08B*czE3NDc5MTgyNDIkbzEkZzEkdDE3NDc5MTg1MTYkajAkbDAkaDA" target="_blank">changes</a> to the bill before its passage. See some of the changes below and watch for an updated Legislative Advisory with a summary of provisions included in the bill.</li><li><strong>AHA Statement Submitted to Congressional Offices.</strong> The AHA, prior to the House vote, shared a <a href="g/press-releases/2025-05-21-aha-statement-house-reconciliation-legislation">statement</a> from AHA President and CEO Rick Pollack with congressional offices and the media.</li><li><strong>Advocacy Resources.</strong> The AHA has many resources that hospital and health system leaders can use as part of their advocacy efforts as attention turns to the Senate.</li></ul><h2>Changes to the Bill</h2><p>The House made several changes to the bill, including provisions that would affect Medicaid and the Health Insurance Marketplaces. Some of the changes include:</p><p>Watch for an updated Legislative Advisory for a detailed summary of provisions that affect hospitals and health systems.</p><h2>AHA Statement Shared with Congressional Offices and Media</h2><p>Prior to the House voting on the bill, AHA shared the following <a href="/press-releases/2025-05-21-aha-statement-house-reconciliation-legislation">statement</a> from AHA President and CEO Rick Pollack with congressional offices and the media.</p><p>“On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) is sharing our concerns about the One Big Beautiful Bill Act (OBBBA) that is being considered on the House floor this week.</p><p>“Our hospitals and health systems have significant concerns regarding the harmful Medicaid and Health Insurance Marketplace provisions currently included in the bill. The sheer magnitude of the level of reductions to the Medicaid program alone will impact all patients, not just Medicaid beneficiaries, in every community across the nation. Hospitals — especially in rural and underserved areas — will be forced to make difficult decisions about whether they will have to reduce services, reduce staff and potentially consider closing their doors. Other impacts could include longer waiting times to receive care, more crowded emergency departments, and hospitals not being able to invest in technology and innovations for clinical care.</p><p>“In particular, the Medicaid legislative proposals severely restrict the use of legitimate state funding resources and supplemental payment programs, including provider taxes and state directed payments, under the guise of eliminating waste, fraud and abuse. We reject this notion as these critical, legitimate and well-established Medicaid financing programs are essential to offset decades of chronic underpayments of the cost of care provided to Medicaid patients. These new policies are estimated to decimate federal support for the Medicaid program by more than $700 billion over 10 years and will displace health care coverage for millions of Americans, moving them from insured to uninsured status.</p><p>“In addition to jeopardizing access to patient care and services, these abrupt policy changes would upend state government budgets and threaten the viability of the health care system to provide essential services to this population. Since these changes are effective immediately upon enactment of the legislation, states will have little or no time to prepare for the significant financial impact on state budgets.</p><p>“Given the substantial reduction in Medicaid payments and cuts to the Health Insurance Marketplaces, including allowing the enhanced premium tax credits to expire, millions will lose health care coverage. Therefore, the AHA urges the House to reject efforts to dismantle these vital programs in the OBBBA and preserve health care access for our nation’s vulnerable and working families.”</p><h2>Advocacy Resources and Engage Your Senators</h2><p>After the House passage of the bill, attention now shifts to the Senate, which is expected to consider changes to the bill. Hospital and health system leaders are encouraged to use the upcoming Memorial Day recess to contact their senators and urge them to reject harmful provisions that would jeopardize access to coverage and care for millions of Americans across the country.</p><p>As you tell the story about what the bill’s impact would mean for your patients and communities and your organization’s ability to provide 24/7 care and services, please use the following AHA resources to assist your efforts.</p><ul><li><strong>Digital Toolkit.</strong> Use this toolkit to engage stakeholders, such as your hospital or health system teams and community leaders, in joining the fight to protect Medicaid. The <a href="/advocacy/advocacy-issues/medicaid">toolkit</a> includes a Medicaid Made Simple video, sample social media posts, stakeholder messages and newsletter copy.</li><li><strong>Fact Sheets and Infographics.</strong> The AHA has developed a series of fact sheets and infographics to inform your advocacy efforts. Visit the <a href="/advocacy/advocacy-issues/medicaid">Medicaid Advocacy Issue</a> page.</li><li><strong>Coalition to Strengthen America’s Health Care Resources.</strong> The <a href="https://strengthenhealthcare.org/" target="_blank">Coalition to Strengthen America’s Healthcare</a>, of which the AHA is a founding member, has many digital resources and tools that can assist your advocacy efforts.</li></ul><h2>Further Questions</h2><p>Visit the <a href="g/advocacy/action-center">AHA Action Center</a> for more resources on these issues and other priorities important to hospitals and health systems. If you have further questions, please contact the AHA at <a href="tel:1-800-424-4301">800-424-4301</a>.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/05/SB-House-Passes-Reconciliation-Bill-with-Significant-Policy-Changes-and-Reductions-to-Medicaid-Other-Health-Care-Programs.pdf"><img src="/sites/default/files/inline-images/Page-1-SB-House-Passes-Reconciliation-Bill-with-Significant-Policy-Changes-and-Reductions-to-Medicaid-Other-Health-Care-Programs.png" data-entity-uuid="6b4a4438-2190-4839-b61f-e7b9d51060e8" data-entity-type="file" alt="Special Bulletin: House Passes Reconciliation Bill with Significant Policy Changes and Reductions to Medicaid, Other Health Care Programs page 1." width="695" height="900"></a></div></div></div> Thu, 22 May 2025 12:31:14 -0500 Marketplace Issues/Stability /press-releases/2025-05-21-aha-statement-house-reconciliation-legislation <div class="row"><div class="col-md-2"><p>Contact:</p></div><div class="col-md-10"><p>Colleen Kincaid, <a href="mailto:ckincaid@aha.org?subject=RE: AHA Statement on House Reconciliation Legislation">ckincaid@aha.org</a><br>Colin Milligan, <a href="mailto:cmilligan@aha.org?subject=RE: AHA Statement on House Reconciliation Legislation">cmilligan@aha.org</a></p></div></div><p><strong>Rick Pollack</strong><br><strong>President and CEO</strong><br><strong>���������� Association</strong></p><p>May 21, 2025</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) is sharing our concerns about the One Big Beautiful Bill Act (OBBBA) that is being considered on the House floor this week.</p><p>Our hospitals and health systems have significant concerns regarding the harmful Medicaid and Health Insurance Marketplace provisions currently included in the bill. The sheer magnitude of the level of reductions to the Medicaid program alone will impact all patients, not just Medicaid beneficiaries, in every community across the nation. Hospitals — especially in rural and underserved areas — will be forced to make difficult decisions about whether they will have to reduce services, reduce staff and potentially consider closing their doors. Other impacts could include longer waiting times to receive care, more crowded emergency departments, and hospitals not being able to invest in technology and innovations for clinical care.</p><p>In particular, the Medicaid legislative proposals severely restrict the use of legitimate state funding resources and supplemental payment programs, including provider taxes and state directed payments, under the guise of eliminating waste, fraud and abuse. We reject this notion as these critical, legitimate and well-established Medicaid financing programs are essential to offset decades of chronic underpayments of the cost of care provided to Medicaid patients. These new policies are estimated to decimate federal support for the Medicaid program by more than $700 billion over 10 years and will displace health care coverage for millions of Americans, moving them from insured to uninsured status.</p><p>In addition to jeopardizing access to patient care and services, these abrupt policy changes would upend state government budgets and threaten the viability of the health care system to provide essential services to this population. Since these changes are effective immediately upon enactment of the legislation, states will have little or no time to prepare for the significant financial impact on state budgets.</p><p>Given the substantial reduction in Medicaid payments and cuts to the Health Insurance Marketplaces, including allowing the enhanced premium tax credits to expire, millions will lose health care coverage. Therefore, the AHA urges the House to reject efforts to dismantle these vital programs in the OBBBA and preserve health care access for our nation’s vulnerable and working families.</p><p>###</p> Wed, 21 May 2025 21:21:48 -0500 Marketplace Issues/Stability /news/headline/2025-04-11-aha-comments-cms-marketplace-integrity-and-affordability-proposed-rule <p>The AHA April 11 <a href="/lettercomment/2025-04-11-aha-comments-cms-marketplace-integrity-and-affordability-rule">commented</a> on the Centers for Medicare & Medicaid Services’ 2025 Marketplace Integrity and Affordability <a href="https://www.federalregister.gov/documents/2025/03/19/2025-04083/patient-protection-and-affordable-care-act-marketplace-integrity-and-affordability">proposed rule</a>. While the AHA expressed appreciation of the agency’s efforts to address concerns of large numbers of low-income individuals being unknowingly enrolled into Health Insurance Marketplace plans by certain brokers, the association expressed worry that some CMS proposals to address the issue could create barriers to care for eligible Marketplace consumers.  <br><br>The AHA said it was concerned with CMS estimates that 750,000 to 2 million consumers could lose their coverage due to the proposals. The association encouraged the agency to pause finalizing many of its proposals to give it and stakeholders additional time to consider the impacts while simultaneously taking action to stop brokers responsible for inappropriate enrollments. </p> Fri, 11 Apr 2025 14:39:33 -0500 Marketplace Issues/Stability