July 4, 2025

• Implementation and enforcement of the Medicare Savings Program (MSP) eligibility, Medicaid and CHIP eligibility and enrollment, and nursing home staffing rules blocked until September 30, 2034. (OBBBA §§ 71101, 71102, 71111) 
• Criteria changed for determining whether provider taxes are “generally redistributive.” (OBBBA § 71117)
• The payment limit for state-directed payments is set to 100% of Medicare for expansion states.  (OBBBA § 71116)
• Federal funding is blocked for one year (until July 3, 2026) for specified family planning and abortion service providers. (OBBBA § 71113) (WA State has committed to back-fill)
• Except for those with US citizenship, green card holders, certain Cubans and Haitians, and COFA residents, individuals who would have become entitled to Medicare after July 4, 2025, lose their Medicare entitlement/eligibility. (OBBBA § 71201)

August 25, 2025

• Deferred Action for Childhood Arrivals (DACA) recipients are no longer eligible for ACA Marketplace coverage (including Premium Tax Credits and Cost Sharing Reductions). (45 CFR § 155.20)
• States may allow Marketplace issuers to require that people pay past-due premiums (with no limits on the look-back period) before they can renew coverage with that issuer. (45 CFR § 147.104) (State option) 
• The low-income monthly special enrollment period for people who have a household income at or below 150% of the Federal Poverty Line and who are eligible for Advance Premium Tax Credits is eliminated until December 31, 2026. After that, Marketplaces may begin offering income-based special enrollment periods. (45 CFR §147.104) But see OBBBA § 71304, making those who enroll through income-based special enrollment periods ineligible for premium tax credits. (Unclear if this impacts WA)
• Automatic 60-day application extension is eliminated for Qualified Health Plan, Advance Premium Tax Credit, or Cost Sharing Reduction applicants whose information cannot be verified by the Exchange and who are therefore required to submit supporting documentation to verify their household income. (45 CFR § 155.315)
• Until December 31, 2026, income verification is required of people applying for Advance Premium Tax Credits and Cost Sharing Reductions who report an income above 100% FPL but for whom federal databases indicate an income below 100% FPL. (45 CFR § 155.320(c)(3))
• Until Plan Year 2027, an applicant’s attestation of their income and family size will no longer be accepted as sufficient when the applicant’s prior tax return and family size data is unavailable from the Secretary of Treasury. Income verification will be required. (45 CFR § 155.320(c)(5))

December 31, 2025

• $50B in Rural Provider Relief Fund awards will be approved for funding allocated to states FY 2026-2030. (OBBBA § 71401)
• Enhanced Premium Tax Credits expire. (ePTCs not reauthorized in OBBBA)
• For taxable years beginning after December 31, 2025, limits are eliminated on the amount of advance premium tax credit that must be paid back (reconciled) if someone underestimates their annual income. (OBBBA § 71305)

January 1, 2026

• Individuals who enroll through an income-based SEP are ineligible for Premium Tax Credits. (OBBBA § 71304) (Unclear if this impacts WA)
• For taxable years beginning after December 31, 2025, individuals who did not file taxes and reconcile Advance Premium Tax Credits for the prior tax year become ineligible for premium tax credits. (OBBBA § 71305) Beginning in plan year 2026, a person is no longer eligible for Premium Tax Credits if HHS notifies the Exchange that the person failed to file taxes and reconcile their Advance Premium Tax Credits for the single tax year that is being used to determine subsequent eligibility. Note that this provision will affect 2026 plan year determinations, which start November 1, 2025. (45 CFR § 155.305) This provision sunsets on December 31, 2026, but see OBBBA § 71305, reinstating the one-year failure-to-file-and-reconcile policy starting in plan year 2028. 
• Exchange premium tax credits are eliminated for non-citizens under 100% FPL subject to the Medicaid 5-year bar. (OBBBA § 71302)
• Beginning in plan year 2026, automatic transfer of people eligible for cost sharing reductions from bronze plans to silver plans with the same coverage, same provider networks, and the same or lower post-APTC premiums is eliminated. (45 CFR § 155.335(j))
• Beginning in plan year 2026, “Specified sex-trait modification procedures” cannot be classified as an essential health benefit. (45 CFR § 156.115) (States may still require coverage, but as non-EHB.) (WA currently has funding to maintain gender-affirming care as an essential health benefit) 
• Beginning in plan year 2026, de minimis ranges for each of the actuarial values of all the metal plans other than expanded bronze plans are changed to +2/ -4 percentage points. Expanded bronze plans have a de minimis range of +5/ -4 percentage points. (45 CFR § 156.140)
• Beginning in plan year 2026, “de minimis variation” means a de minimis range of +1/ -1 percentage point for income-based silver cost sharing reduction plan variations. (45 CFR § 156.400)
• Beginning in plan year 2026, changes to the premium adjustment percentage methodology increase the maximum out-of-pocket limit and net premiums and reduce the number of people who will qualify for fully subsidized plans. (45 CFR § 156.130)

June 1, 2026

• HHS Secretary is required to promulgate guidance on community engagement requirements by this date. (OBBBA § 71119)

October 1, 2026

• Emergency Medicaid services FMAP is reduced to standard Medicaid FMAP for services provided to those “not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law.” (OBBBA § 71110) (Does not impact WA)
• Medicaid & CHIP eligibility is limited to those with US citizenship, green card holders, certain Cubans and Haitians, and COFA residents, with an exception at state option for children under age 21 and pregnant women. (OBBBA § 71109) (State option for children & pregnant women) 

November 1, 2026

• Beginning with plan year 2027, the annual open enrollment period for all exchanges must begin no later than November 1 and end by December 31 of the calendar year preceding the benefit year and must not last longer than 9 weeks. (45 CFR § 155.410).

January 1, 2027

• Semi-annual redeterminations are required for the Medicaid expansion population. (OBBBA § 71107)
• States must establish community engagement requirements (work reporting requirements) as a condition of eligibility for “able-bodied” expansion population adults between 19 and 64 years old, with a one-year hardship exception for good-faith efforts if granted by HHS Secretary. (OBBBA § 71119) (State option to request delay) 
• No later than the first of the first quarter beginning after Dec. 31, 2026, or earlier at state option, individuals who are not enrolled in Medicaid due to failure to meet community engagement reporting requirements are no longer eligible for Advance Premium Tax Credits or Cost Sharing Reductions for Marketplace plans. (OBBBA § 71119)
• Exchange premium tax credits are no longer available to lawfully present immigrants other than green card holders, certain Cubans and Haitians, and COFA residents. (OBBBA § 71301)
• Retroactive coverage is reduced to two months preceding enrollment in traditional Medicaid and the month preceding enrollment for the Medicaid Expansion population. (OBBBA § 71112)
• States must perform quarterly deceased beneficiary status checks and disenrollment. (OBBBA § 71104)
• HHS must create a system to prevent individuals from being enrolled in Medicaid in multiple states. (OBBBA § 71103)
• All applications for new or renewed 1115 Demonstration waivers must be certified budget neutral by the CMS Chief Actuary to be approved. (OBBBA § 71118)

January 4, 2027

• For those entitled to or enrolled in Medicare as of July 4, 2025, eligibility is terminated except for those with US citizenship, green card holders, certain Cubans and Haitians, and COFA residents. (OBBBA § 71201) Individuals without these specified immigration statuses who would have become entitled to Medicare after July 4, 2025, lost their entitlement/eligibility as of July 4, 2025.   

January 1, 2028

• Existing state-directed payment limits are reduced by 10% annually to reach the allowable Medicaid rate (100% of Medicare for expansion states) beginning with the rating period on or after Jan. 1, 2028. (OBBBA § 71116)
• Beginning in plan year 2028, a person is no longer eligible for Premium Tax Credits if they failed to file taxes and reconcile their Advance Premium Tax Credits for the single tax year that is being used to determine subsequent eligibility. (OBBBA § 71305)
• Passive enrollment and provisional eligibility for Premium Tax Credits ends; state Marketplaces must pre-verify eligibility for Advance Premium Tax Credits and cost-sharing reductions using applicant documentation of income, immigration status, health coverage status, place of residence, and family size. (OBBBA § 71303)
• Passive Marketplace plan reenrollment ends; all must reverify eligibility annually for taxable years beginning after December 31, 2027. (OBBBA § 71303)
• States must perform quarterly deceased provider status checks and disenrollment. (OBBBA § 71105)
• Home equity value limit is set at $1M (non-waivable) for purposes of determining allowable assets for long-term care eligibility. (OBBBA § 71106) (WA current limit is over $1M)

July 1, 2028

• New 1915(c) waiver option for HCBS coverage opens. (OBBBA § 71121) (State option) 

October 1, 2028

• Current provider tax thresholds are frozen for two years; the allowable level of provider taxes for expansion states will then be reduced by 0.5% each year until it reaches 3.5% by FY 2032. (OBBBA § 71115)
• States are required to impose cost-sharing on certain services for Medicaid expansion adults with incomes above 100% FPL. (OBBBA § 71120) (State option to select amount up to $35)

October 1, 2029

• States must submit enrollee Social Security Numbers to federal system for preventing individuals from being enrolled in Medicaid in multiple states, and must verify addresses and act to end the multi-state enrollment. (OBBBA § 71103)

October 1, 2030

• “Good faith” waiver of reduction for erroneous excess state payments identified though the Payment Error Rate Measurement (PERM) program is reduced for states with error rates above 3%. (OBBBA § 71106)

Questions or additions? Please contact Vanessa Saavedra at vanessa@nohla.org.