New York’s Medicaid financing strategy—particularly its use of a managed care organization (MCO) tax—has come under renewed federal scrutiny amid recent legislative proposals and regulatory developments. The federal reconciliation bill, known as the One Big Beautiful Bill Act (OBBBA), alongside newly proposed guidance from the Centers for Medicare & Medicaid Services (CMS), could significantly influence how New York and other states structure healthcare-related tax mechanisms used to draw down federal Medicaid matching funds.

Section 44132 of the OBBBA would establish a ten-year moratorium on the creation or expansion of provider and MCO taxes. Under this proposal, states would be prohibited from adopting new healthcare-related taxes or increasing existing ones unless they were enacted before the effective date of the legislation. Even if a tax complies with federal requirements—such as being broad-based, uniformly applied, and not directly redistributive—it would remain frozen at its current structure for the duration of the moratorium.[1]

This legislative action is reinforced by CMS’s proposed rule issued in April 2025, which would increase scrutiny of waiver requests for narrowly tailored provider taxes. The CMS fact sheet outlines how the rule aims to ensure that such taxes do not disproportionately benefit the providers who fund them and that they meaningfully redistribute costs across a provider class. CMS signaled that future approvals would be based not only on statistical compliance with redistribution formulas, but also on substantive evidence that the taxes are not structured to guarantee repayments through Medicaid.

New York’s FY 2025 budget projected approximately $3.7 billion in revenue from its MCO tax, intended to support Medicaid program enhancements, including base rate adjustments and targeted payments to providers. However, according to CMS correspondence and discussions shared at the May 2025 MACPAC meeting, the federal government is expected to approve only about $2.1 billion in matching funds under current policy standards.

This shortfall has triggered a review by New York State officials, with reports indicating that the state may need to restructure or replace components of the MCO tax mechanism. As of June 2025, the New York State Department of Health has not issued updated guidance or notifications to providers regarding potential changes to reimbursement or supplemental funding. However, news coverage and budget briefing materials confirm that the Governor’s Office is working with CMS and legislative leaders to evaluate options for FY 2026 and beyond.

New York is not alone. States such as California, Michigan, and Pennsylvania are also assessing their provider tax frameworks in response to tighter federal standards and the proposed legislative freeze. Many of these states have historically used targeted healthcare-related taxes as tools to secure additional federal funding for Medicaid. Under the OBBBA and new CMS rules, these strategies will require greater alignment with redistributive principles and transparency requirements.

For context, the foundational rules governing provider taxes appear in 42 U.S.C. § 1396b(w) and are implemented through 42 C.F.R. § 433.68. These rules require taxes to apply across a broad base of providers, to be uniformly imposed, and not to disproportionately benefit any one group of taxpayers. The reconciliation bill does not change those standards—it simply imposes a statutory moratorium on modifications that could otherwise have been evaluated under the existing waiver process.

For providers operating in New York, the practical effects of these developments are not yet fully known, but preparation is prudent. Providers may wish to monitor announcements from the New York Department of Health, reassess their current funding assumptions, and evaluate how federal match uncertainty could affect supplemental payments. While reimbursement changes have yet to be implemented, the alignment of federal legislation and administrative rulemaking indicates that states may soon face binding constraints on Medicaid financing flexibility.

As guidance evolves and legislative proposals move forward, healthcare providers, Medicaid plans, and other stakeholders should prepare to navigate these changes.

FOOTNOTES

[1] Proposed in legislative summaries; pending bill text.