This side‑by‑side shows how the proposal modernizes Medicaid with clear rules, stronger integrity, and better access — while preserving budget discipline.
| Topic | Current Law | Proposed Change (Bill) |
|---|---|---|
| Eligibility verification | States verify eligibility at application and renewal, often using self‑attestation and periodic data checks. Frequency and rigor vary by state. | Mandates real‑time electronic verification using federal/state databases (wages, death records, other benefits) at application and renewal; requires monthly cross‑checks and immutable audit logs. |
| Fraud & error reporting | No uniform requirement for public reporting of redetermination outcomes or error rates. | Requires monthly public reports on redeterminations, terminations, and error rates, posted on a state dashboard. |
| Work & skills engagement | Some states have CMS‑approved work requirements; rules vary, and exemptions are inconsistent. | Authorizes an “engage or exempt” model via 1115 waivers: auto‑exempts for medical, caregiving, postpartum, and students; good‑cause protections; funded job training/recovery supports. |
| Primary care payment | Many states pay below Medicare rates, contributing to provider shortages. | Sets a floor at 100% of Medicare Part B rates for primary care; bonuses for timely access; covers CHWs and behavioral health integration. |
| Value‑based payments | Optional for states; adoption is uneven. | Authorizes shared‑savings contracts tied to quality benchmarks (chronic disease control, preventive care, reduced ER use). |
| Pharmacy benefit management (PBM) | PBMs may use spread pricing; rebate pass‑through not always required; limited audit rights. | Bans spread pricing; mandates full pass‑through of rebates to Medicaid; grants state audit rights; requires 48‑hour approval for generics/biosimilars when clinically appropriate. |
| Rural access | Rural hospitals face unstable funding; telehealth coverage varies; mobile clinics are rare. | Allows global budgets for rural providers; mandates telehealth parity (including audio‑only where appropriate); funds mobile dental, vision, and primary care clinics. |
| Behavioral health | Same‑day billing for primary + behavioral often prohibited; crisis services coverage inconsistent. | Requires same‑day billing allowance; mandates coverage for mobile crisis teams, stabilization facilities, MAT, IOP, and peer support without arbitrary caps. |
| Transparency | Public reporting and contract disclosure vary widely by state. | Requires monthly public dashboards with KPIs; publishes all managed care and PBM contracts; creates a public complaint tracker with resolution timelines. |
| Evaluation & sunset | No automatic sunset for reforms; evaluations vary. | Independent evaluation at 5 years; reforms sunset unless benchmarks for access, quality, and budget neutrality are met. |
| Savings reinvestment | No federal requirement to reinvest savings into care. | At least 50% of verified savings reinvested in primary care, workforce supports, and rural access. |