At around 7 a.m. on Thursday, May 22, 2025, after an overnight session, the House of Representatives passed H.R. 1, the One Big Beautiful Bill Act, by a vote of 215 to 214. It is a budget reconciliation bill, which means it can pass the Senate with a simple majority, and Republican leaders have said they want it on the President's desk by July 4. The Senate is expected to change it substantially. Nothing in it is law today.
We are writing about it anyway, because the Medicaid provisions are the largest changes to the program proposed in a decade and because the practices we work with are already asking what to do. The honest answer is: not much yet, but understand what is coming and where it would hit your front desk and your accounts receivable.
Key takeaways
- The House-passed bill adds work requirements for expansion adults, six-month redeterminations, cost sharing of up to $35 per service for expansion adults above the poverty line, a shorter retroactive coverage window and limits on provider taxes and state directed payments.
- The provisions with the most practice impact are dated December 31, 2026 and later. Nothing changes at the front desk this year.
- CBO's preliminary estimate of the committee's health provisions was about 8.6 million more uninsured by 2034; a full estimate of the House-passed text is still to come.
- The lesson of the 2023 to 2024 unwinding applies: most coverage losses are procedural, and practices see them as eligibility denials, not as policy.
- Measure your Medicaid exposure and eligibility denial rate now, so you have a baseline whatever the Senate does.
What the House bill would do to Medicaid
The bill's health provisions run to hundreds of pages. The ones that matter most to a physician practice are in the table below, with the effective dates as written in the House-passed text. The Senate may change any of them.
| Provision | What it does | House-passed timing |
|---|---|---|
| Work and community engagement requirement | Adults aged 19 to 64 in the expansion population must show 80 hours a month of work, education, training or community service, with exemptions for pregnancy, disability, caregiving and others | States must implement by December 31, 2026 |
| Six-month redeterminations | Eligibility for expansion adults must be redetermined every six months instead of annually | Begins for renewals after December 31, 2026 |
| Cost sharing for expansion adults | States must charge cost sharing of up to $35 per service for expansion adults with income above the federal poverty level, with exemptions for primary care, mental health and substance use treatment and some other services | Begins October 1, 2028 |
| Retroactive coverage | Retroactive eligibility shortened from three months before application to one month | Applications after December 31, 2026 |
| Provider tax moratorium | States may not create new provider taxes or raise existing ones, limiting a major state financing mechanism | On enactment |
| State directed payments | Caps payments states direct to providers through managed care at Medicare rates (110% in non-expansion states) | Grandfathering for existing arrangements |
The Congressional Budget Office has not yet scored the bill as passed. Its preliminary estimate of the Energy and Commerce Committee's health provisions, circulated before the committee markup on May 13, put the increase in the uninsured at about 8.6 million people by 2034, with the Medicaid changes accounting for most of it and the work requirement the largest single factor. Whatever the final number, the direction is toward fewer people covered and more frequent coverage interruptions.
Who this affects
Primary care, pediatrics (indirectly, through parents' coverage), behavioral health, OB/GYN and any practice in an expansion state with a meaningful Medicaid share. Practices in non-expansion states are less exposed to the work requirement and six-month renewal provisions, which apply to the expansion population, but still affected by the provider tax and directed payment changes, which flow through state budgets and managed care rates.
The work requirement provision deserves a practical note. When Arkansas ran a work requirement in 2018 and 2019, most of the people who lost coverage were not people who failed to work; they were people who failed to report. Practices saw it as patients arriving for scheduled visits with coverage that had ended the previous month, discovered at check-in or, worse, at claim denial.
The directed payment cap is the provision that reaches practices in every state, and it is the least discussed. Many states use directed payments to lift Medicaid managed care rates for particular provider classes toward commercial levels, and a cap at Medicare rates would pull some of those arrangements down over time. If your state has a directed payment program for physician services (your state medical society will know), the rate you are paid by Medicaid MCOs today may depend on it.
What would change in the practice's workflow
If a version of these provisions becomes law, three things change at the practice level. Eligibility becomes something you check at every visit, not at the first visit of the year, because coverage can end at any six-month boundary and after any missed reporting deadline. Retroactive coverage shrinks, so a patient seen in month one who enrolls in month three will no longer have the visit covered. And a new patient balance category appears: cost sharing for expansion adults, in states that do not already charge it, which the practice must collect and cannot waive routinely.
The redetermination provision also brings back the churn that practices saw during the 2023 and 2024 unwinding, when over 25 million people were disenrolled and about 69% of those lost coverage for procedural reasons rather than ineligibility. Many of them re-enrolled within months. Every one of those gaps produced denials, rebills and patient statements that should not have been sent.
A worked example of the churn cost
A family practice in an expansion state has 1,800 Medicaid patients, 700 of them expansion adults. Under annual renewals, roughly 700 renewal events a year touch that group. Under six-month renewals it is 1,400. During the unwinding, the practice saw about 8% of renewals end in a procedural disenrollment. If that rate held, six-month renewals would produce around 112 coverage gaps a year among expansion adults instead of 56, and each gap that coincides with a visit is a denied claim (CO-27, expenses incurred after coverage terminated) that has to be held, re-checked for reinstatement, rebilled or written off. At an average allowed amount of $110 for a primary care visit, that is roughly $6,000 a year of claims in limbo for this one practice, plus the staff time to work them, before counting the patients who simply stop coming.
Measuring your exposure
Do not change your financial policy or retrain staff on a bill that has not passed the Senate. Do use the next few months to measure your exposure and fix the things that would hurt under any version of the law. Start with Medicaid revenue by plan and by eligibility category, if your state's 271 responses or portal identify expansion adults. Then your current eligibility denial rate for Medicaid and Medicaid managed care (CARC CO-27, CO-31, CO-26); if it is meaningful today, it will get worse under six-month renewals. Then confirm real-time eligibility is actually run for every Medicaid visit, including established patients, and that the response is read for the managed care plan assignment, not just the yes or no.
Finally, check your state's presumptive eligibility and retroactive coverage rules as they stand now, so you have a baseline for what changes, and write down how the practice would handle a Medicaid patient who arrives without coverage: self-pay rate, sliding scale, referral to enrollment assistance, or reschedule. Most practices have no written answer, and the ones that do wrote it during the unwinding.
Our view
We think the six-month redetermination provision will do more damage to practice revenue than the work requirement itself, because it doubles the number of opportunities for procedural disenrollment for every expansion adult, whether they are working or not. Practices that built good eligibility habits during the unwinding will be fine. Practices that let those habits lapse when the unwinding ended should rebuild them this year, regardless of what the Senate does. Our medical billing team runs eligibility on every Medicaid visit as standard, and the RCM audit reports eligibility denials as a separate leakage category.
Questions we hear
Is any of this in effect now?
No. The House passed the bill on May 22. The Senate has not acted. Even if the bill were signed this summer, the Medicaid provisions with the greatest practice impact are dated for the end of 2026 and later.
We are in a non-expansion state. Can we ignore it?
The work requirement and six-month renewal provisions apply to the expansion population, so their direct effect on you is small. The provider tax and directed payment provisions affect how your state finances Medicaid and could affect managed care rates in any state. Watch your state's reaction.
Should we stop taking new Medicaid patients?
That is a business decision for each practice and not one to make on proposed legislation. The operational question is whether your front end can handle more frequent eligibility changes, and that is worth fixing whether or not this bill passes.
What to do this month
- Pull your Medicaid revenue by plan and, where the data allows, by eligibility category. Know what share of collections is at risk.
- Measure your Medicaid eligibility denial rate (CO-26, CO-27, CO-31) for January through April and set the report to run monthly.
- Confirm real-time eligibility runs for every Medicaid visit and that staff read the plan assignment on the response.
- Record your state's current retroactive coverage and presumptive eligibility rules as a baseline.
- Write the one-paragraph policy for a Medicaid patient who arrives without active coverage.
- Follow the Senate text. The Finance Committee will produce its own version, and the provisions above may move, soften or harden.
