ONE BIG BEAUTIFUL ACT (OBBA) MEDICAID FUNDING CHANGES IMPACT ON MEDICAID VOLUMES IN CLAIMS DATA; A STUDY OF IMPACT FROM REENROLLMENT REQUIREMENTS OF 2024
Author(s)
Virginia Gleason, BS, MPH, JD1, Edward J. Burleigh, MBA2.
1Principle Clinical Expert, FinThrive, Ronan, MT, USA, 2FinThrive, Newtown, GA, USA.
1Principle Clinical Expert, FinThrive, Ronan, MT, USA, 2FinThrive, Newtown, GA, USA.
OBJECTIVES: The One Big Beautiful Bill Act(OBBBA)was signed into law on 7/4/2025. OBBBA introduced a variety of changes to government healthcare payers. These changes impact eligibility for Medicare and Medicaid, as well as tax credits and subsidies for Marketplace plan premiums. This research explores if these OBBBA changes affect the percentage of commercial, marketplace and government payers.
METHODS: Claims clearinghouses streamline electronic exchange of medical claims data between providers and payers. An 837 electronic claim is created regardless of whether a commercial is payer involved. The 837 (“claim”) is generated to bill insurance or the patient in self-pay scenarios. Claims submitted through the Clearinghouse by payer type were identified for a five-year period (FY 2021- 2025). If more than one payer was present for a unique claim ID, the primary payer was utilized. Statistical comparisons were performed to establish the baseline payer percentages by commercial insurance, Medicare, Medicaid, other payer and self-insured.
RESULTS: The percentage of Medicaid claims remained steady until FY 2024 at which time the rate dropped by five percentage points. This drop coincides with the timeframe in which CMS required all Medicaid programs to reenroll members through eligibility verification. If verification was not completed by FY 2025, the beneficiary’s Medicaid was terminated. At this same time, the percentage of self-pay accounts increased by eight percentage points.
CONCLUSIONS: The additional administrative burden placed on States following the Public Health Emergency which required all Medicaid beneficiaries to undergo eligibility verification resulted in a decline in Medicaid as a payer for healthcare services. The decline in Medicaid as a payer did not change the number of patients seeking care. The additional administrative burden and eligibility requirements under OBBBA will increase the percentage of patients without a payer for their care; thus, placing a financial burden on healthcare providers
METHODS: Claims clearinghouses streamline electronic exchange of medical claims data between providers and payers. An 837 electronic claim is created regardless of whether a commercial is payer involved. The 837 (“claim”) is generated to bill insurance or the patient in self-pay scenarios. Claims submitted through the Clearinghouse by payer type were identified for a five-year period (FY 2021- 2025). If more than one payer was present for a unique claim ID, the primary payer was utilized. Statistical comparisons were performed to establish the baseline payer percentages by commercial insurance, Medicare, Medicaid, other payer and self-insured.
RESULTS: The percentage of Medicaid claims remained steady until FY 2024 at which time the rate dropped by five percentage points. This drop coincides with the timeframe in which CMS required all Medicaid programs to reenroll members through eligibility verification. If verification was not completed by FY 2025, the beneficiary’s Medicaid was terminated. At this same time, the percentage of self-pay accounts increased by eight percentage points.
CONCLUSIONS: The additional administrative burden placed on States following the Public Health Emergency which required all Medicaid beneficiaries to undergo eligibility verification resulted in a decline in Medicaid as a payer for healthcare services. The decline in Medicaid as a payer did not change the number of patients seeking care. The additional administrative burden and eligibility requirements under OBBBA will increase the percentage of patients without a payer for their care; thus, placing a financial burden on healthcare providers
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR67
Topic
Health Policy & Regulatory
Topic Subcategory
Health Disparities & Equity, Reimbursement & Access Policy
Disease
No Additional Disease & Conditions/Specialized Treatment Areas