The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on May 12, 2025, that would impose additional requirements on health care-related taxes used to finance state Medicaid programs, targeting what it considers a statistical loophole that allows states to shift costs inappropriately to the federal government.
CMS proposed new regulations that would disqualify eight current health care-related tax programs across seven states by adding an extra requirement for non-broad-based and uniform health care-related taxes to qualify for federal matching funds. The agency identified California, Michigan, Massachusetts, and New York among the seven states with problematic tax programs. These programs primarily impose higher taxes on Medicaid business of managed care organizations, with one targeting hospitals. CMS estimates the affected programs currently collect approximately $23.6 billion annually in taxes. The proposed rule targets states that CMS believes manipulate statistical tests by selectively excluding large providers with high Medicaid utilization from taxes while including them in regression calculations, allowing them to pass required tests while imposing a disproportionate burden on the Medicaid program.
Federal regulations currently use statistical tests called the "P1/P2 test" and "B1/B2 test" to determine whether non-broad-based or non-uniform state tax programs are "generally redistributive." States can obtain waivers from broad-based and uniform requirements if their tax programs pass these tests. CMS has historically interpreted "generally redistributive" to mean deriving revenues from taxes on non-Medicaid services and using these revenues as the state's share of Medicaid payments. However, CMS now believes states have found ways to manipulate the B1/B2 test by imposing tax rates on Medicaid-taxable units much higher than comparable commercial taxable units while still passing the statistical requirements.
The new requirement would apply to each permissible class and includes provisions testing both taxes that explicitly refer to Medicaid and those that do not. For taxes explicitly referencing Medicaid, a program would not be generally redistributive if the tax rate on any taxpayer based on Medicaid taxable units exceeds the rate on non-Medicaid taxable units. For taxes not explicitly referencing Medicaid, programs would fail if they impose lower tax rates on taxpayers with relatively lower Medicaid volume compared to those with higher Medicaid volume. CMS also targets programs using substitute definitions as proxies for Medicaid to impose higher rates on Medicaid taxable units. The agency proposes a transition period only for states that obtained waivers more than two years before the final rule's effective date, excluding recently approved programs whose states were warned about potential rulemaking.
CMS explained that it advised states of its concerns about exploiting statistical loopholes through "companion letters" explaining why tax programs did not meet the spirit of the law and warning that it was contemplating rulemaking. CMS emphasized that "a state's responsibility for a substantial portion of the non-federal Medicaid program expenditures incentivizes the state to monitor and operate its program competently and efficiently." In its fact sheet, CMS claimed these tax programs "free up state money that is used for other purposes, pointing specifically to California's funding to expand health care coverage for illegal immigrants." The agency stated it will accept public comments until July 14, 2025.
This proposed rule represents CMS's latest effort to curtail what it views as inappropriate cost-shifting to the federal government, coming at a time when Congress considers Medicaid cuts through budget reconciliation. The House-passed reconciliation bill on May 22, 2025, includes provisions targeting the same statistical loophole, creating potential dual pressure on state Medicaid financing. The rule would limit all states' flexibility to design new health care-related tax programs, potentially preventing adequate provider reimbursement and jeopardizing provider sustainability. For the seven affected states, losing these financing mechanisms could severely impact their ability to maintain Medicaid services, particularly problematic given the programs currently generate $23.6 billion annually that helps support provider payments.
A broad-based tax applies to all providers within a class, while a non-broad-based tax targets only a subset of providers.
It may reduce the amount of Medicaid funding these organizations receive if states fail to redesign tax programs to meet the new criteria.
Yes, states might shift more of the tax burden to non-Medicaid providers to comply with the new redistributive requirements.
States will need to redesign their tax programs or find alternative revenue sources to maintain Medicaid funding levels.
Providers can submit feedback electronically via regulations.gov by July 14, 2025, using the docket number listed in the CMS proposal.