Medicaid – Cuts & Changes – The Big Ugly Bill – Part IV

Cost Sharing (Co-payments, deductibles, co-insurance you pay), Home & Community-based Care, Rural Hospitals, and more! Please share everywhere!

Welcome to Part IV (the last one on Medicaid) of the Changes and Cuts to Medicaid that were enacted on July 4, 2025, but will trickle in over the next 4-5 years. The real impacts will not really be felt by anyone until after the Midterms in 2026 in the hopes that the “R’s” will get re-elected before anyone finds out exactly what they did. Well, I am here to tell you what they did and when each part of it is going to begin.

Part IV covers No Waiver for Work Requirements; Special implementation rule; Rules regarding States’ Managed Care partners; Grants to States to implement these changes; Cost Share Requirements (you will have to pay); Changes to Home or Community-Based care; One item on Medicare payments to providers; The Rural Hospital Fund program; and some articles on how cuts to Medicaid impact Rural Medical Care.

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Work Requirements/Community Engagement Cannot Be Waived!

While other parts of the implementation of the new cuts and changes to Medicaid can be waived by the HHS Secretary, the work requirements cannot. Congress wants to make sure that no “able-bodied” person is sitting on the couch in the basement of their parent’s home playing video games and going to the doctor every day, taking copious amounts of prescription medication, and seeing specialists, because that is what “able-bodied” people do when they live with their parents and play video games in the basement {sarcasm beyond sarcasm.}

AND, if such a model citizen exists, it is their doctors and providers that are getting all the Medicaid money, not them. I still wonder if any of the “R’s” {Rubes} know anything about how Medicaid works or who it is for… they just went in there, saw the dollar signs, and said “cut it!”

Special Implementation Rule for Medicaid

A State that has obstacles and barriers to implementing these new rules can request an exemption as long as they explain and provide proof that one is needed.

If such an exemption is granted, it can only last until December 31, 2028, at which point the exempted State must have corrected all of the obstacles and barriers and have their program up and running.

Also, if the HHS Secretary is of a mind, he/she can cancel the exemption at any time if they feel that the State has not complied with reporting requirements or failed to correct any issues. States have to report quarterly on their progress.

Conforming Amendment to the Social Security Act

(Opinion: I don’t think they should allowed to change existing laws in a reconciliation bill regardless of any ties to the budget. That seems wrong to me.)

You have seen this subsection referenced in yesterday’s coverage.

(42 U.S.C. 1396(a)(10)(A)(i)(VIII))

“(VIII) beginning January 1, 2014, who are under 65 years of age, not pregnant, not entitled to, or enrolled for, benefits under part A of subchapter XVIII, or enrolled for benefits under part B of subchapter XVIII, and are not described in a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in section 1397jj(c)(5) of this title) applicable to a family of the size involved, subject to subsection (k) subject to subsection (k) and (xx);

States’ Managed Care Partners Cannot Determine Benefit Eligibility or Compliance

“A State shall not use a Medicaid managed care entity or other specified entity (as such terms are defined in section 1903(m)(9)(D)), or other contractor to determine beneficiary compliance under such section unless the contractor has no direct or indirect financial relationship with any Medicaid managed care entity or other specified entity that is responsible for providing or arranging for coverage of medical assistance for individuals enrolled with the entity pursuant to a contract with such State.”

Grants Available To States To Implement Changes & Cuts

States will be able to access grant money proportionate to a rate schedule for funding to their state. Congress budgeted $200 million dollars to this grant fund.

Cost Sharing Requirements – You Will Help Pay For Your Medical Care

Begins October 1, 2028 (after the Midterms so it does not hurt the “rubes” chances of getting re-elected), no eligible person shall have to pay a premium or enrollment fee.

However, on that same date, States are to decide what amount of dollars greater than $0 but cannot exceed $35 to charge for whatever services (like Co-pays or Co-insurance) for their care except for those services that are excluded.

“In no case may a deduction, cost sharing, or similar charge be imposed under the State plan with respect to care, items, or services described in any of subparagraphs (B) through (J) of subsection (a)(2), or any primary care services, mental health care services, substance use disorder services, or services provided by a Federally qualified health center (as defined in 1905(l)(2)), certified community behavioral health clinic (as defined in section 1905(jj)(2)), or rural 21 health clinic (as defined in 1905(l)(1)), furnished to a specified individual.”

Cost Sharing On Drugs

States can assess cost sharing on prescription drugs but it cannot exceed a certain limit. When this is finally implemented, if it is implemented since 10/1/2028 is a long ways off, check with your State on what this amount will be.

Cost Sharing Maximum

So the government does not take all of your money away in this new plan, they have put a cap on total out of pocket cost, calculated quarterly or monthly, to 5% of the “family income of the family involved.”

States may permit providers to require that you pay the “deductions, cost-sharing, or similar charges authorized to be imposed” for care, services care items or whatever you receive. States can also permit providers to waive or reduce these deductions or cost-sharing charges on a “case-by-case basis.”

Changes to Home or Community-Based Care Using Medicaid

Beginning July 1, 2028 (After the mid-terms, but before the next presidential election), the HHS Secretary can waive part or all the cost of home or community based services (other than room and board) which are provided through a written plan of care to individuals. The waiver can be for an initial term of 3 years, then every 5 years unless the HHS Secretary cancels it.

The State has to request the waiver. The State has to establish a community-based or home care program and process to determine eligibility, need, assessment of care needed, where the care will be needed (hospital, nursing facility, immediate care facility, or whatever).

There is a monetary cap on the amount that can be expended on this type of care and it is State specific.

The State has to report everything about how many people are receiving such care, the cost of such care, the length of time that such care has been provided to each individual receiving such care, and a comparison report. The government is still collecting as much data on individuals as it possibly can.

No money set aside for this type of care can be used for anything but this care, including paying premiums, payments to third parties, skills training, or any other benefits to employers.

Federal dollars will be set aside for this program and States will receive amounts “on the basis of the proportion of the population of the State that is receiving home or community-based services.”

More On Medicare – People Losing Medicare Coverage

I may have already covered this in the Medicare article, but it is stated with the Medical Care section later in the bill, so I wanted to make sure I did not miss anything.

Who is entitled to receive Medicare? - ``SEC. 1899C. LIMITING MEDICARE COVERAGE OF CERTAIN INDIVIDUALS.

``(a) In General.--Subject to subsection (b), an individual may be

entitled to, or enrolled for, benefits under this title only if the

individual is--

``(1) a citizen or national of the United States;

``(2) an alien who is lawfully admitted for permanent residence

under the Immigration and Nationality Act;

``(3) an alien who has been granted the status of Cuban and

Haitian entrant, as defined in section 501(e) of the Refugee

Education Assistance Act of 1980 (Public Law 96-422); or

``(4) an individual who lawfully resides in the United States

in accordance with a Compact of Free Association referred to in

section 402(b)(2)(G) of the Personal Responsibility and Work

Opportunity Reconciliation Act of 1996.”

Beginning 18 months after date of enactment (7/4/2025), so, December 1 or 4, 2026, (after the mid-terms so the “rubes” in Congress think they can get re-elected) these new eligibility rules will be in force.

Beginning not later than 1 year after enactment, so July 1- or 4 , 2026, The Commissioner of Social Security, Frank Bisignano, will complete a review of who is entitled to or enrolled for Medicare benefits and who is NOT. Any persons not described above as “entitled to” Medicare will receive a notification that their benefits will be terminated 18 months after enactment, so December 1 or 4, 2026 anyone now receiving Medicare that does not meet the new eligibility requirements will have their Medicare canceled.

Medicare Payments to Providers Going Up By 2.5%

Beginning January 1, 2026 and ending on January 1, 2027, Providers will get a bump in Medicare payments of 2.5% with no plans after the end date. So if they are now getting $50 per visit, they will get $51.25. Depending on inflation, which is now at 2.35% and Tariffs have not even kicked in yet, I can see providers dropping Medicare patients as it does not pay enough to keep their doors open. Of course, we shall see. I have already run into providers who do not and will not accept Medicare. I expect this list will get larger as the new law kicks in next year.

The Rural Hospital Fund

Congress set aside $50 Billion to support rural medical care. If it were only supporting rural hospitals, then it might be enough to help. Of course, there are some conditions and restrictions.

1) Beginning January 1, 2026, only $10 Billion will be available for each fiscal year and there will be no roll over if there is any extra funding. Any money not spent out of the fund will roll into the Treasury (I am guessing the General Fund so this government can spend it any way they want.)

2) Anything left over by October 1, 2032 will be returned to the national treasury to be reappropriated for something else.

3) States will get an allotment and can have it to spend the year it is allotted through the next fiscal year end, so if they do not spend it in the first 12 months, they can use it into the next fiscal year too except for the last year of 2032. In the last allotment, it has to be spent by September 30, 2032. I am guessing that if it is not, the left overs will have to be returned and will be added to the General Fund of the Treasury to be spent on whatever this government wants to spend it on.

If funds are misused in the opinion of the administrator of the fund, then the State may have their funds cut off, reduced, and/or have to repay any funds they have received.

All Applications for funding from States who want to participate have to be in by December 31, 2025 as funding begins in 2026. They have to provide

· A “detailed’ rural health transformation plan

· That will improve access to hospitals and other health care providers and health care items and services furnished to rural residents of the State

· The plan must outline that it is going to improve health care outcomes of rural residents

· It must prioritize the use of new and emerging technologies that emphasize prevention and chronic disease management

· Initiate, foster, and strengthen partnerships between rural hospitals and other health care providers to meet certain goals (See the bill)

· Must enhance economic opportunity for and supply health care clinicians through enhanced recruitment and training

· Prioritize data and technology driving solutions and take place as close to the patient’s home as possible

· Outline strategies to mange long term financial solvency and operational models

· Must identify specific causes driving the acceleration of these hospitals to close, reduce services, or convert

States only have to apply one time. If they are approved after December 31, 2025, they are eligible for the all five allotments.

The Administrator of this fund will determine the actual amount of each allotment. The administrator will allot “50 percent of the amounts appropriated for each such fiscal year equally among all states with an approved application” and “50 percent of the amounts appropriated for each such fiscal year among all such States in an amount to be determined by the Administrator” based on some additional criteria.

· Not less than ¼ of the States with an approved application shall get an allotment based on the following:

· “The percentage of the State population that is located in a rural census tract of a metropolitan statistical area

· The proportion of rural health facilities in the State relative to the number of rural health facilities nationwide

· The situation of hospitals in the State

· Any other factors the Administrator decides to include

What is a Rural Health Facility

· Is located in a rural area

· Is treated as being located in a rural area

· Is located in a rural census tract of a metropolitan statistical area

· A critical access hospital

· A sole community hospital

· A Medicare-dependent, small rural hospital

· A low-volume hospital

· A rural emergency hospital

· A rural health clinic

· A Federally qualified health center

· A community health center that is receiving grant money from the Public Health Service Act

· An Opiod treatment program that is located in a rural census tract of a metropolitan statistical area

· A certified community behavioral health clinic that is located in a rural census tract of a metropolitan statistical area

States receiving money from this fund will NOT have to provide matching funds.

There will be reporting requirements as the government loves their documentation as long as it is coming from you – not so much if they have to be transparent.

Administrative fees cannot exceed 10% of the funding.

What are they supposed to do with the money?

Do at least three things out of this list:

“``(A) Promoting evidence-based, measurable interventions to

improve prevention and chronic disease management.

``(B) Providing payments to health care providers for the

provision of health care items or services, as specified by the

Administrator.

``(C) Promoting consumer-facing, technology-driven

solutions for the prevention and management of chronic

diseases.

``(D) Providing training and technical assistance for the

development and adoption of technology-enabled solutions that

improve care delivery in rural hospitals, including remote

monitoring, robotics, artificial intelligence, and other

advanced technologies.

``(E) Recruiting and retaining clinical workforce talent to

rural areas, with commitments to serve rural communities for a

minimum of 5 years.

``(F) Providing technical assistance, software, and

hardware for significant information technology advances

designed to improve efficiency, enhance cybersecurity

capability development, and improve patient health outcomes.

``(G) Assisting rural communities to right size their

health care delivery systems by identifying needed

preventative, ambulatory, pre-hospital, emergency, acute

inpatient care, outpatient care, and post-acute care service

lines.

``(H) Supporting access to opioid use disorder treatment

services (as defined in section 1861(jjj)(1)), other substance

use disorder treatment services, and mental health services.

``(I) Developing projects that support innovative models of

care that include value-based care arrangements and alternative

payment models, as appropriate.

``(J) Additional uses designed to promote sustainable

access to high quality rural health care services, as

determined by the Administrator.”

Summary

The “devil is in the details” so if you are on Medicaid or Medicare or SNAP, I recommend you reach out to your Congressional leaders (and if they are MAGAs, reach out to Hakeem Jefferies office) or your State Health Department, or even your State representatives to learn what will happen specifically in YOUR State.

Much of what is in this Big Ugly Bill is not set to begin until after the Mid-Terms. The “rubes” in Congress want to be able to have an opportunity to convince everyone that nothing bad is going to happen and that the Democrats are lying to you about the loss of services. Do Not Believe Them. They like to “spin” whatever lies they are telling into things that “sound good” but are not to sow chaos, confusion, and guilt. If anyone should feel guilty, it should be them.

We can vote the “rubes” out of Congress. We must begin campaigning on the truth. These articles give you an overview of what’s in the Big Ugly Bill, AND they give you all the receipts in the research at the bottom. So if you are trying to help inform someone about these changes, you have everything to prove it to them at your fingertips.

Just a note, but I’m going to take a couple of days off and pick this back up next week. Have a wonderful weekend, try not to worry! There are a lot of people out there who are here to help, to listen, to assist in finding the answers, and to help figure out next steps… Take a breather and come back fighting next week.

And Thank you all for supporting what I do. It’s always free and I enjoy bringing it to everyone. Please share all over the place so everyone can know what you know!

Rural hospitals brace for painful choices after Trump's Medicaid and Obamacare cuts – “More than 300 rural hospitals in the U.S. are at risk of closing down because of the bill, Democratic lawmakers wrote in a letter last month. If more of their patients are uninsured, these hospitals risk not getting paid for their services, the letter said.” - https://www.nbcnews.com/health/health-news/rural-hospitals-brace-painful-choices-trumps-medicaid-obamacare-cuts-rcna217577

What to Know About New Medicaid Cuts: Is Your Local Hospital Closing Soon? – “Some experts predict that cuts to Medicaid will impact nearly every state, with most expected to see more than 25% of their hospitals shut down. In 11 states, the risk is even higher, with 50% or more of hospitals at risk.” - https://www.kiplinger.com/taxes/medicaid-cuts-and-your-local-hospital

What experts think of the $50 billion rural health fund in Trump’s big bill – “But the $50 billion Congress set aside for the Rural Health Transformation Program covers less than a third of the funding rural communities are expected to lose in Medicaid cuts. “It is just a fig leaf,” said Edwin Park, a research professor at Georgetown University’s Center for Children and Families.” - https://www.pbs.org/newshour/health/what-does-the-rural-health-fund-in-trumps-megabill-do

The State I live in has 37 rural hospitals alone and that doesn’t count all the clinics and other programs listed above. Even if we received the maximum allotment of $200 million per year for the next 5 years, it would not be enough to make all the required improvements and run the hospitals. Over ¾’s of our State is rural. Nothing has been said about nursing homes unless they have some weird name that has “hospital” at the end of it. I do not know if that was an oversight or the funding for long term care and nursing facilities is supposed to take care of that.

Democrats Are Already Planning To Repeal Trump's Medicaid Cuts – “If Democrats get the House majority, they can immediately use budget deadlines to demand a repeal of the Medicaid cuts. Trump is trapped in his own delusion that Medicaid isn’t being cut, and there are enough Senators to kill the cuts without a Democratic majority in the Senate to make them happen. All that is needed is for Democrats to have some power and a seat at the table to demand the cuts. -

Democrats Are Already Planning To Repeal Trump's Medicaid Cuts

This Concludes the Medicaid Changes & Cuts – Next week I will cover the changes to the ACA (Obamacare) and more from the Big Ugly Bill!

Vote For The Democrats AND Keep Pounding On Congress!

What they did was wrong. The worst of it won’t take effect until after the Mid-terms and the “R’s” are hoping that they can convince people that they will go back and “fix” what they are destroying, or that all of us 90% are “bad” and taking advantage, moochers and spongers off the government – a government who we paid taxes into all our lives and expect a return on our investment. A government the rich and selfish have NOT paid a lot of taxes into and do not need these services.

Nothing Is Forever Or Permanent

Remember that nothing is permanent. Legislation can be altered or repealed. So while they made changes and cuts to Medicaid, these changes can be restored or made better by Congress, current or future. Keep pounding on Congress at your displeasure at what they have done and how it will impact you or someone in your family, or even someone you may know.

From Michael Popok and Legal AF - “Can Congress Be Sued? You Bet.

Some might wonder: can you sue Congress over a law they passed? Absolutely. Laws—even budget bills—can be struck down as unconstitutional if they infringe on rights enshrined in the Constitution. It’s happened before, and it’ll happen again.” https://substack.com/home/post/p-167919554

Research & Additional Reading:

The Big Ugly Bill - https://www.congress.gov/bill/119th-congress/house-bill/1/text

Medicaid Program; Streamlining the Medicaid, Children's Health Insurance Program, and Basic Health Program Application, Eligibility Determination, Enrollment, and Renewal Processes - A Rule by the Centers for Medicare & Medicaid Services on 04/02/2024 - https://www.federalregister.gov/documents/2024/04/02/2024-06566/medicaid-program-streamlining-the-medicaid-childrens-health-insurance-program-and-basic-health

The Fair Labor Standards Act Of 1938, As Amended - https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/FairLaborStandAct.pdf

26 U.S. Code § 45R - Employee health insurance expenses of small employers - https://www.law.cornell.edu/uscode/text/26/45R

26 U.S. Code § 5000A - Requirement to maintain minimum essential coverage - https://www.law.cornell.edu/uscode/text/26/5000A

STATE PLANS FOR MEDICAL ASSISTANCE^[6] - https://www.ssa.gov/OP_Home/ssact/title19/1902.htm

RAISE Family Caregivers Act - https://www.congress.gov/bill/115th-congress/house-bill/3759/text)

38 U.S. Code § 1155 - Authority for schedule for rating disabilities - https://www.law.cornell.edu/uscode/text/38/1155

42 U.S.C. 1396p - Liens, adjustments and recoveries, and transfers of assets - https://www.govinfo.gov/app/details/USCODE-2010-title42/USCODE-2010-title42-chap7-subchapXIX-sec1396p

42 U.S. Code § 1396p - Liens, adjustments and recoveries, and transfers of assets - https://www.law.cornell.edu/uscode/text/42/1396p

42 U.S.C. 1396a - State plans for medical assistance - https://www.govinfo.gov/content/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap7-subchapXIX-sec1396a.pdf

TITLE 42—THE PUBLIC HEALTH AND WELFARE - https://www.govinfo.gov/content/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap7-subchapXIX-sec1396a.pdf

STATE PLANS FOR MEDICAL ASSISTANCE^[6] - https://www.ssa.gov/OP_Home/ssact/title19/1902.htm

Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier - https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

Medicaid and CHIP Cuts in the House-Passed Reconciliation Bill Explained - https://ccf.georgetown.edu/2025/05/27/medicaid-and-chip-cuts-in-the-house-passed-reconciliation-bill-explained/

Summary of Health Provisions in the One Big, Beautiful Bill Act (H.R. 1) - https://www.amcp.org/letters-statements-analysis/summary-health-provisions-one-big-beautiful-bill-act-hr-1

Directed Payments in Medicaid Managed Care - https://www.macpac.gov/wp-content/uploads/2024/10/Directed-Payments-in-Medicaid-Managed-Care.pdf

How Will the One Big Beautiful Bill Act Affect the ACA, Medicaid, and the Uninsured Rate? - https://www.kff.org/policy-watch/how-will-the-2025-budget-reconciliation-affect-the-aca-medicaid-and-the-uninsured-rate/

Trump's spending bill cuts Medicaid: Here's what it's called in your state - https://www.axios.com/2025/07/08/medicaid-cuts-states

Trump bill's health effects won't be felt until after midterms - https://www.axios.com/2025/07/07/medicaid-impacts-tax-bill-delayed

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Note: All commentary on my pages are from research and/or my opinion or interpretation of what I read. The opinions of the writers of the articles are their own. I work to find reliable and highly factual content with a “central” bias. Happy researching and reading! Have a Wonderful Rest of Your Day!!!