SWI Protects

🚨 Big news for anyone who buys health insurance on their own! 🚨

The government just finalized a new rule that’s expected to lower premiums by about 5% in 2025. 🙌

Why? Because they’re cracking down on fraud and making sure only people who actually qualify are getting taxpayer-funded health plans. In 2024 alone, up to 5 million people were improperly enrolled, costing billions. 😳

This new rule will:
✅ Help hardworking families save money
✅ Make coverage more secure and fair
✅ Stop people from abusing the system

More info from CMS 👉
📄 Press Release: https://www.cms.gov/newsroom/press-releases/cms-finalizes-major-rule-lower-individual-health-insurance-premiums-americans
📄 Final Rule:https://www.cms.gov/files/document/cms-9884-f-2025-pi-rule-master-5cr-062025.pdf

www.cms.gov

While we’re at it here are the provisions reforming Medicaid beyond my previous post

Let me know If you want more factual information on anything else in the insurance world.

The “One Big Beautiful Bill Act of 2025” (OBBBA), passed by the House on May 22, 2025, includes several provisions reforming Medicaid beyond the previously discussed reduction in the federal matching rate for certain immigrant populations, restrictions on state-directed payments, and limits on provider taxes. Below, I outline the bill’s broader Medicaid reforms as specified in the legislative text and Congressional Budget Office (CBO) summaries, focusing strictly on what the bill states without speculating on potential impacts.
Medicaid Reforms in the OBBBA
1. Work Requirements for Medicaid Eligibility:
• The bill introduces mandatory “community engagement” requirements for able-bodied adults aged 19–64 enrolled in Medicaid, effective January 1, 2026.
• Eligible individuals must engage in at least 80 hours per month of work, education, job training, or community service to maintain coverage.
• Exemptions apply to:
• Pregnant women.
• Primary caregivers of a dependent child under 6 years old.
• Individuals with disabilities, as defined under the Social Security Act.
• Full-time students.
• Individuals in medical treatment programs (e.g., substance abuse treatment).
• States are required to verify compliance and disenroll non-compliant individuals, with a 90-day grace period for re-enrollment upon meeting requirements.
2. More Frequent Eligibility Redeterminations:
• The bill mandates that states conduct Medicaid eligibility redeterminations every six months instead of annually, effective January 1, 2026.
• It suspends a 2024 Centers for Medicare & Medicaid Services (CMS) regulation that streamlined enrollment processes and reduced administrative barriers for Medicaid eligibility verification.
3. Repeal of Continuous Eligibility for Adults:
• The bill eliminates continuous eligibility for adults in Medicaid, which previously allowed certain adults to remain enrolled for a full year regardless of changes in income or circumstances.
• This provision takes effect in 2026, requiring states to reassess eligibility more frequently based on current income and status.
4. Restrictions on State Funding Mechanisms:
• In addition to limiting provider taxes and state-directed payments (as previously detailed), the bill prohibits states from using certain intergovernmental transfers (IGTs) to draw down federal Medicaid matching funds.
• IGTs are funds transferred between state and local government entities (e.g., public hospitals) to finance Medicaid. The bill caps or restricts these transfers to reduce federal matching payments.
5. Block Grant Option for States:
• The bill allows states to opt into a Medicaid block grant program starting in fiscal year 2027.
• Under this option, states receive a fixed amount of federal funding for Medicaid, adjusted annually based on population growth and inflation, rather than the open-ended federal matching funds currently provided.
• States choosing block grants must submit plans detailing how they will use funds to provide healthcare to low-income populations, with flexibility to design benefits and eligibility criteria, subject to federal approval.
6. Suspension of Enhanced Federal Funding for Certain Programs:
• The bill reduces or eliminates enhanced federal matching rates for specific Medicaid programs, including:
• Community-based long-term care services (e.g., home and community-based services for seniors and individuals with disabilities), reducing the enhanced match rate to the standard federal medical assistance percentage (FMAP).
• Certain public health initiatives, such as those tied to preventive care or maternal health programs, where enhanced funding is phased out by 2028.
7. Limits on Coverage for Non-Qualified Aliens:
• As previously detailed, the bill reduces the federal matching rate from 90% to 80% for states providing Medicaid coverage to non-qualified aliens (e.g., undocumented immigrants) who are not lawfully residing children or pregnant women. This applies to state-funded programs offering comprehensive health benefits to these populations.
8. Repeal of Medicaid Expansion Mandates:
• The bill removes the requirement for states to maintain Medicaid expansion under the Affordable Care Act (ACA) to receive certain federal funds.
• States can opt out of covering the expansion population (adults aged 19–64 with incomes up to 138% of the federal poverty level) without losing other Medicaid funding, effective 2026.
9. Changes to Medicaid Drug Rebate Program:
• The bill modifies the Medicaid Drug Rebate Program by capping the maximum rebate amount manufacturers must pay for certain high-cost drugs.
• It also allows states to negotiate supplemental rebates directly with manufacturers, giving states more flexibility in managing prescription drug costs.
Source Information
These provisions are drawn from the CBO’s analysis of the OBBBA (available at https://www.cbo.gov) and summaries of the bill’s text as revised before House passage. The full legislative text can be accessed via https://www.congress.gov. Note that the bill is currently under Senate review, and these provisions may be modified before final passage.

Congress.gov | Library of Congress U.S. Congress legislation, Congressional Record debates, Members of Congress, legislative process educational resources presented by the Library of Congress

Here is the information on the bullet point in my previous post

- Reduced Federal Funding: The bill lowers the federal matching rate for Medicaid expansion populations from 90% to 80% in states providing coverage to certain lawfully residing immigrants, and it restricts state-directed payments and provider taxes, which could limit funds for healthcare providers. This may reduce access to services, particularly in states with high Medicaid enrollment like Texas, Florida, and Pennsylvania.

The “One Big Beautiful Bill Act of 2025” (OBBBA), passed by the House on May 22, 2025, specifies that the federal matching rate for Medicaid expansion populations is reduced from 90% to 80% for states providing coverage to immigrants who are not “qualified aliens” or “children or pregnant women who are lawfully residing in the United States” under the Medicaid option for these groups. The bill’s text, as revised before passage, defines the affected immigrant groups as follows:
• Non-Qualified Aliens: These are immigrants who do not meet the federal definition of a “qualified alien” under Medicaid rules (as outlined in the Social Security Act, 42 U.S.C.). “Qualified aliens” include:
• Lawful permanent residents (green card holders).
• Refugees, asylees, and certain other humanitarian immigrants.
• Individuals from the Compact of Free Association (COFA) nations (Micronesia, Marshall Islands, Palau).
• Certain Cuban or Haitian entrants.
• Other specific categories, such as victims of trafficking or those with specific parole statuses.
• Non-qualified aliens, therefore, primarily include undocumented immigrants and other non-citizens without a federally recognized immigration status eligible for Medicaid.
• Excluding Lawfully Residing Children and Pregnant Women: The bill exempts states from the penalty if they provide coverage to lawfully residing children or pregnant women under the Medicaid and CHIP Reauthorization Act of 2009 option, which allows coverage for these groups even within their first five years of lawful status. This includes immigrants with statuses like Deferred Action for Childhood Arrivals (DACA) or Temporary Protected Status (TPS) who are children or pregnant.
Specific Groups Affected: The reduction applies to states that use their own funds to provide Medicaid-like coverage to undocumented immigrants or other non-qualified aliens who are not children or pregnant women. As of April 2025, 14 states and the District of Columbia offer state-funded health coverage to some immigrants regardless of status, including:
• Undocumented Immigrants: Adults who lack any lawful immigration status are the primary group targeted by this provision. The bill penalizes states like California, Colorado, Connecticut, Maine, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Vermont, Washington, Illinois, and the District of Columbia, which provide state-funded coverage to some or all undocumented adults.
Clarifications from Legislative Process:
• Earlier drafts of the bill included broader penalties that would have applied to states covering any lawfully residing immigrants (e.g., DACA recipients, TPS holders) not considered “qualified aliens.” However, amendments made before the House vote narrowed the penalty to focus primarily on undocumented immigrants, excluding coverage for lawfully residing children and pregnant women under the 2009 Medicaid/CHIP option.
• The Congressional Budget Office (CBO) notes that this provision affects states providing “any form of financial assistance” or “comprehensive health benefits” to non-qualified aliens, regardless of funding source.
For the exact legislative text, refer to the bill at https://www.congress.gov or the CBO’s analysis at https://www.cbo.gov.