On July 4, 2025, the federal budget reconciliation bill, H.R.1, was signed into law, enacting major structural reforms to Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act Marketplaces. These changes, including a $911 billion reduction in federal Medicaid spending over the next 10 years, significantly reshape the operational and financial landscape of the health coverage system, with far-reaching implications for program enrollment, expenditures, and administration, immediately and in the years ahead.
H.R.1 includes provisions that scale back access to health coverage for many lawfully residing non-citizens, estimated to leave 1.3 million more immigrants uninsured. These resources describe the changes to eligibility for Medicaid and Marketplace programs for non-citizens.
On April 8, the Centers for Medicare & Medicaid Services (CMS) issued a State Health Official Letter interpreting section 71109 of H.R.1, which significantly restricts non-citizen coverage in Medicaid and the Children’s Health Insurance Program (CHIP). This expert perspective provides background on Medicaid and CHIP coverage for non-citizens; highlights key policy issues, implementation and operational considerations, and outstanding areas in CMS’ new guidance; and discusses potential consequences of these new changes on non-citizens, states, and providers.
H.R.1 adds significant new limits on which lawfully present non-citizens will be able to receive health coverage through Medicaid and the Children’s Health Insurance Program as well as subsidized coverage through the Marketplaces. This list of frequently asked questions is intended to serve as an added resource for states as they plan eligibility and systems updates and has been updated to reflect the State Health Official Letter released by CMS on April 8.
On Tuesday, January 20, State Health and Value Strategies hosted a webinar on H.R.1 and the changes it will make to non-citizen eligibility for Medicaid, CHIP, and Marketplace coverage. These changes are expected to cause 1.3 million lawfully present immigrants to become uninsured and have profound consequences for many immigrants’ health and economic wellbeing. During the webinar, experts from Manatt Health provided an overview of H.R.1’s provisions that impact non-citizen coverage through Medicaid, CHIP, and the Marketplaces and highlighted implications and potential state actions to mitigate coverage loss.
H.R.1, signed into law on July 4, makes dramatic changes to the Medicaid and Marketplace coverage landscape. These changes include provisions that scale back access to health coverage for many lawfully residing non-citizens, estimated to leave 1.3 million more immigrants uninsured. This expert perspective describes the provisions, which eliminate the availability of premium tax credits (PTCs) and federally-funded Medicaid and CHIP coverage for many non-citizens who have been eligible for these programs for years, and eliminate PTCs for the lowest income, lawfully present non-citizens who are subject to a waiting period before they qualify for Medicaid or CHIP.
This Excel tool provides an integrated view of implementation dates for Medicaid, the Children’s Health Insurance Program, Marketplace, and Medicare provisions in the budget reconciliation law, H.R.1. Because of interdependencies with the budget reconciliation provisions, policies in the Marketplace Integrity and Affordability final rule of June 25, 2025, are also included in this timeline. This tool is intended to support states in (1) planning for timely implementation of reconciliation-driven health policy changes, and (2) effectively communicating potential impacts to communities and key stakeholders.
On Thursday, July 24, State Health and Value Strategies hosted a webinar on the budget reconciliation legislation (H.R.1) and the sweeping changes to Medicaid that it will make to state Medicaid program expenditures, enrollment, and operations now (with many provisions having already taken effect upon enactment) and in the years to come. It concentrates cuts to the Affordable Care Act’s Medicaid expansion population, limits use of provider taxes and state directed payments, constraining the ways states can raise revenue to finance their share of Medicaid program costs, and adds major restrictions on access to affordable health coverage for noncitizens.
On Thursday, July 10, State Health and Value Strategies hosted a webinar for State-Based Marketplace and Division of Insurance officials. On July 4, the president signed the reconciliation budget bill into law, starting the clock on a number of changes to Marketplace coverage and premium tax credit eligibility. Just two weeks earlier, the Centers for Medicare & Medicaid Services finalized its Program Integrity rule that also creates new requirements for Marketplaces. During the webinar, SHVS’ experts discussed the immediate changes that states are facing and what steps to take in the coming days and weeks.