This part caps what a state may direct health plans to pay providers. In an expansion state the cap is the Medicare rate. Elsewhere it is 110 percent of that rate. Payments already approved wind down by 10 points a year from 2028.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 71116 in the PDF
What the document says
“the total payment rate for such service is limited to--”
The section requires the Secretary of Health and Human Services to revise section 438.6(c)(2)(iii) of title 42 of the Code of Federal Regulations so that for a payment for a service in a rating period beginning on or after enactment the total payment rate is capped at 100 percent of the specified total published Medicare payment rate for a State giving coverage to everyone in the expansion group equivalent to minimum essential coverage, and at 110 percent of that rate for any other State. Where no published Medicare rate exists, the State plan rate is used.
What the document actually says
“the total payment rate for such service is limited to--”
That sentence, in plain words
The total rate for a service is capped. The two figures that follow set it.
What this is about
A state that expanded Medicaid is held to the Medicare rate. Any other state may go to 110 percent of it. If there is no Medicare rate, the state plan rate is used.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 71116 in the PDF
What the document says
“beginning with the rating period on or after January 1, 2028, the total amount of such payment shall be reduced by 10 percentage points each year until the total payment rate for such service is equal to the rate for such service specified in subsection (a).”
The section keeps the old rate for a payment with written prior approval, or a good faith effort to get it, before May 1, 2025, for a rural hospital payment so approved by enactment for a rating period within 180 days of enactment, and for one where a completed preprint was sent in before enactment. From the rating period on or after January 1, 2028 those payments fall by 10 percentage points a year until they reach the new cap.
What the document actually says
“beginning with the rating period on or after January 1, 2028, the total amount of such payment shall be reduced by 10 percentage points each year until the total payment rate for such service is equal to the rate for such service specified in subsection (a).”
That sentence, in plain words
From January 1, 2028 the payment starts to fall. It drops 10 points each year. It falls until it hits the new cap.
What this is about
That covers payments already approved. It also covers some rural hospital payments. The wind down is gradual, not at once.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 71116 in the PDF
What the document says
“the limitation described in such paragraph shall apply to such State with respect to a payment described in section 438.6(c)(2)(iii) of title 42, Code of Federal Regulations (or a successor regulation) for a service furnished during a rating period beginning on or after the date of enactment of this Act.”
The section provides that a State which starts giving the expansion coverage on or after enactment comes under the lower cap for a payment for a service in a rating period beginning on or after enactment.
What the document actually says
“the limitation described in such paragraph shall apply to such State with respect to a payment described in section 438.6(c)(2)(iii) of title 42, Code of Federal Regulations (or a successor regulation) for a service furnished during a rating period beginning on or after the date of enactment of this Act.”
That sentence, in plain words
The lower cap applies to that state as well. It covers payments for care in a rating period from this law on.
What this is about
So a state cannot escape it by expanding late. The cap follows the coverage. It bites from the same date.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
The document says “shall”Who acts: Secretary of Health and Human ServicesHow: statuteSec. 71116 in the PDF
What the document says
“There are appropriated out of any monies in the Treasury not otherwise appropriated $7,000,000 for each of fiscal years 2026 through 2033 for purposes of carrying out this section, to remain available until expended.”
The section appropriates $7,000,000 for each of fiscal years 2026 through 2033 to carry out the section, to remain available until expended. It also defines rating period, rural hospital, State, total published Medicare payment rate and written prior approval by reference to the Social Security Act and the regulations.
What the document actually says
“There are appropriated out of any monies in the Treasury not otherwise appropriated $7,000,000 for each of fiscal years 2026 through 2033 for purposes of carrying out this section, to remain available until expended.”
That sentence, in plain words
Seven million dollars is set aside each year. That runs from fiscal year 2026 through 2033. The money stays there until it is spent.
What this is about
It pays to carry out this part. The part also defines five terms. Those come from an older law and the rules.
No action is recorded against this proposal. That is not evidence that none has been taken, and nobody has yet read it against the record. See what the tracker does not yet cover.
Each distinct thing the section does: require the Secretary to revise the regulation and set the two caps, wind down grandfathered payments, apply the lower cap to a State that expands later, define the terms used, and appropriate funding.
The six kinds of rural hospital and the four cross referenced definitions, which are carried in a summary.
The section directs a change to section 438.6 of title 42 of the Code of Federal Regulations and points to the Social Security Act and the Internal Revenue Code of 1986, none of which is indexed here.
