When Do the One Big Beautiful Bill Act’s Health Care Provisions Go Into Effect?

The OBBBA eliminates enforcement of a CMS rule that makes it easier for Medicare beneficiaries to enroll in Medicaid, CHIP, and the Basic Health Program. As a result, a May 2025 estimate from the Congressional Budget Office (CBO) finds that roughly 2.3 million people could lose their coverage by 2034.

The OBBBA institutes this deadline for CMS to issue guidance on bi–annual Medicaid redeterminations.

The OBBBA institutes this deadline for the CMS administrator to approve or deny state applications for $50 billion in funding intended to cushion the $1 trillion blow to Medicaid spending.

To incentivize states to adopt the ACA’s Medicaid expansion, the American Rescue Plan Act offered additional financial support, increasing the federal government’s Medicaid contribution by 5 percentage points for two years after expansion. The OBBBA will end this incentive, on January 1.

The Department of Health and Human Services will release an interim final rule with implementation requirements for Medicaid work reporting requirements.

States that implement Medicaid work reporting requirements by December 31, 2026 (in accordance with the OBBBA), are required to notify enrollees by September that they will be subject to the requirement.

The OBBBA eliminates Medicaid eligibility for some groups of legal immigrants by removing refugees, asylees, and humanitarian parolees from the definition of “qualified immigrants”—or noncitizens eligible for Medicaid.

The OBBBA requires Medicaid expansion enrollees ages 19 to 64 to report 80 hours of community engagement activities (work, community service, or half-time student enrollment) or demonstrate that they meet the requirements for a qualifying exemption, to maintain their Medicaid coverage.

A CBO analysis of the May 22, 2025, version of the OBBBA found that 4.8 million Medicaid enrollees will become uninsured by 2034 as a result. That number is expected to increase when the CBO releases final estimates of the bill’s impacts.

States with approved Section 1115 waivers may implement work requirements prior to December 31, 2026. The secretary of health and human services may also grant states a one-time compliance exemption until December 31, 2028.

The OBBBA requires states to redetermine eligibility for Medicaid expansion enrollees every six months instead of annually. This change is expected to cause 700,000 people to lose their Medicaid coverage by 2034.

The OBBBA limits retroactive Medicaid coverage from 90 days prior to application to one month prior to application for expansion enrollees and two months prior to application for coverage for traditional enrollees.

The OBBBA generally reduces provider tax rates for expansion states by 0.5 percent each year until they reach a maximum of 3.5 percent in fiscal year 2032.

This change is expected to cost states $89 billion in federal Medicaid investments by 2034.

The OBBBA allocates $50 million in grant funding for one year and $100 million for the second year to states that wish to apply to create a separate track for disabled people who do not meet the usual requirement of needing institutional-level care to receive HCBS. States will only be eligible if their proposed program does not increase the wait for services for the existing HCBS group, a condition that CAP analysis finds it unlikely states will meet.

The OBBBA requires states to impose cost- sharing requirements of up to $35 per service for Medicaid expansion enrollees with incomes above 100 percent of the federal poverty level (up to a maximum of 5 percent of household income).

This change could cost a family of four living on only $33,000 per year up to $1,650 in new, mandatory out-of-pocket costs.