The Energy and Commerce and Ways and Means committees held marathon markups this week to advance Republican legislation containing a number of healthcare provisions, including sweeping cuts to Medicaid. The bill is likely to be tweaked in the full House or Senate.

Advocates for Community Health has compiled a detailed summary of the Medicaid-related provisions in the House Energy & Commerce Committee’s reconciliation bill, which would impact community health centers and, according to the Congressional Budget Office, eliminate Medicaid coverage for about 10.3 million people. This includes updates on eligibility redeterminations, provider taxes, PBM transparency, community engagement requirements, and more.

As drafted, the package puts the health care safety net at significant risk, posing insurmountable challenges for health centers and their patients. While changes in eligibility reduce coverage levels, a host of new administrative requirements squeeze state budgets. Simply put, health centers will have more uninsured patients to care for with less funding.

On behalf of their constituents, so many of whom will suffer under this bill, ACH urges members of the House of Representatives to reject this legislation.

Reference: H. Con. Res. 14, FY 2025 budget resolution – House Energy & Commerce Committee Reconciliation Text (Subtitle D—Health of Title IV)

Key Provisions of Interest to CHCs (as of May 16, 2025)

  1. Work requirements for able-bodied adults without dependents
  • Effective January 1, 2029
  • Participants must spend at least 80 hours per month working, engaging in community service, participating in a work program, and/or participating in an educational program.
  • State must verify an individual’s compliance with the requirements:
    • For at least one month preceding their enrollment in Medicaid, and
    • For at least one month preceding the individual’s eligibility redetermination (which, under Sec. 44108, will occur every six months.) An individual’s compliance must be verified before their enrollment can be renewed.
  • States will be required to inform individuals about the requirements, to “streamline and simplify” compliance verification, and to provide individuals with due process before denying or dropping them from coverage.
  • Exemptions:
    • person under 19 or over 64.
    • pregnant women. o foster youth and former foster youth under the age of 26.
    • medically frail persons (including, but not limited to, persons who are blind, disabled, have a chronic substance use disorder, or have a serious and complex medical condition).
    • individuals who are already complying with TANF or SNAP work requirements.
    • parents or caregivers of a dependent child or an individual with a disability.
    • persons who are incarcerated or released within the past 90 days.
  • The Community Engagement requirements may not be waived, under Section 1115 or any other authority.
  • We are hearing that individuals who lose Medicaid due to failure to demonstrate compliance with the Community Engagement requirements may face some challenges enrolling in an ACA plan. However, we are still seeking to confirm this.
  1. Delay of Biden-era eligibility rules until 2035
  • The first rule, Medicare Savings Program Eligibility Determination and Enrollment, finalized September 21, 2023, simplifies and streamlines the process for low-income seniors and people with disabilities who receive Medicare to access Medicare Savings Programs (MSPs). MSPs are part of state Medicaid programs and pay for Medicare premiums and often cost-sharing charges, lowering costs for enrollees. Many of the provisions make it easier for low-income people who have applied to the Social Security Administration for help paying for prescription drugs to enroll in MSPs.
  • The second rule, Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes, finalized April 2, 2024, simplifies the eligibility and enrollment process for Medicaid, the Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP), reducing administrative barriers for individuals applying for and renewing their health coverage.
  • CBO estimates that repeal of these rules would reduce federal Medicaid spending by $170 billion over ten years and reduce Medicaid coverage by 2.3 million by 2034.
  1. Freeze on current provider tax rates/no new provider taxes
  • Places a moratorium on any new or increased provider taxes, but allows states to retain their current provider taxes.
  • For current provider taxes, changes the rules for determining whether they meet the requirement to be “generally redistributive.”
  1. Elimination of presumptive eligibility for undocumented
  • No federal match for individuals whose citizenship, nationality, or immigration status has not been verified, including during reasonable opportunity periods when an individual has not yet verified citizenship, nationality, or immigration status
  1. Eligibility determination for expansion population every 6 months (currently 12)
  2. Decrease in FMAP of 10% for Medicaid Expansion States that have undocumented coverage programs using “Medicaid infrastructure”
  • Anticipated impacted states: California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and D.C.
  1. Limits retroactive coverage in Medicaid to one month prior to an individual’s application date (currently 3 months)
  2. Permits states to allow CHCs (and other covered entities) to retain 340B savings on drugs reimbursed under Medicaid managed care.
  • Requires covered entities to report these savings to HHS annually; HHS will post this data on-line.
  • Data will be broken out by state, and within each state, there will be subtotals for CHCs, each hospital category, and all other grantees lumped together.
  1. Possible changes to MCO taxes in certain states.
  • Changes the rules on what is considered redistributive; some states may have to re-submit waivers.

Additional Provisions

  • Limit on state directed payments
    • Limits the total Medicaid payments to a provider (through standard reimbursement systems and state-directed payments) to the total amount Medicare would pay for those services.
  • Sunsets the ARPA 5% FMAP for expansion states – only applies to new expansion states
  • Require states to establish a process for preventing individuals from being enrolled in 2 state Medicaid programs at once
  • Process for removing enrollment of deceased individuals
  • Increased provider screening
  • Penalties for states with “erroneous excess payments”
  • Reduction in asset limit for long term care
  • Repeal of nursing home staffing rule
  • Requires pharmacies to participate in acquisition cost survey (may lead to more carve outs)
  • Ban spread pricing in Medicaid
  • No Medicaid funding for gender affirming care (very specific list of procedures/services)
  • No Medicaid funding for Planned Parenthood – Prohibits Medicaid funds to be paid to providers that are nonprofit organizations, that are essential community providers that are primarily engaged in family planning services or reproductive services, provide for abortions other than for Hyde Amendment exceptions, and which received $1,000,000 or more (to either the provider or the provider’s affiliates) in payments from Medicaid payments in 2024.
    • 1115 waivers must be budget neutral
  • Cost sharing on Medicaid Expansion adults with incomes over 100 percent of the federal poverty level (FPL)
    • May not exceed $35 per service – does not apply to primary care, prenatal care, pediatric care, or emergency room care (except for nonemergency care provided in an emergency room).

Sandy Applebee

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