Medicaid Cuts & New Rules Could Affect Those on Home Dialysis

Medicaid is a health insurance program that covers millions of Americans who have limited income and assets, including pregnant women, families with children, the elderly, and those with disabilities who get Supplemental Security Income (SSI). States have leeway in setting financial eligibility guidelines but must follow federal rules to administer Medicaid. Federal law allows federal funds to be used only for U.S. citizens and those legally present in the U.S. A few states have used state-only funds to cover those not legally present who require dialysis under emergency Medicaid.

People Who Benefit from Medicaid

In May 2025, 70.8 million people in the U.S. had health insurance coverage under Medicaid. Of those, 40.9 million were adults.¹ The United States Renal Data System collects and reports data on people with ESRD. The Home Dialysis chapter in the 2024 Annual Data Report showed that:

• In 2022, 10.8% of home dialysis patients had Traditional Medicare with Medicaid as a second payer and 9% had a Medicare Advantage plan with Medicaid paying second.

• About 19.1% of patients ages 18-44 and 13.7% ages 45-64 were on home dialysis in 2022.

• 19.8% of patients on home dialysis had Medicaid as a primary or secondary payer in 2022.

Some patients may get Medicaid under state expansion. But, those with Medicaid were the least likely to be on home dialysis and had higher social deprivation.² The USRDS did not report the number of patients with Medicaid-only. The National Kidney Foundation reports that 75% of people with kidney disease rely on Medicaid.³

Medicaid by any Other Name…

States may call their Medicaid program something other than Medicaid, and about half do. Here is a list of names for each state Medicaid program. Click on the state in this list to learn more.

Medicaid Funding Then and Now

Over the years, Medicaid has been funded by federal and state tax dollars.⁵ The minimum the federal government provides each state is 50% and the maximum is 83%. The federal match depends on the state’s per capita income. States with average incomes below the national average get a higher federal match. You can see your state’s federal match for Medicaid in FY 2026 here.

According to the Congressional Budget Office, the OBBBA will cut $990 billion from Medicaid and CHIP over the next 10 years, which will leave 10 million Americans uninsured. The Administration is trying to soften the blow to rural areas by creating a $50 billion “rural hospital emergency fund” that legislators say will go to hospitals at risk of closure, but states are not required to use the money that way.⁶ How far will $50 billion go toward a cut of $990 billion? How many home dialysis patients live in rural areas and get care at hospitals at risk of closure?

Medicaid Expansion Under the ACA

The Affordable Care Act (ACA) passed in 2010 had a provision for states to expand Medicaid to cover those with incomes between 100% and 138% of federal poverty. The ACA said the government would reimburse states for 90% of the added costs for those people and provided advance premium tax credits that reduced premiums for those with an income between 100% and 400% of federal poverty. It provided extra savings to reduce out-of-pocket costs for those who chose a Silver Plan. Drafters of the ACA assumed that states would provide Medicaid for those with incomes up to 100% of federal poverty, then those with incomes up to 138% of federal poverty would get Medicaid under expansion. In 2012, though, the Supreme Court ruled that expecting states to expand Medicaid was coercing them to cover more people and allowed states to opt out of expanding Medicaid. By 2025, 41 states and the District of Columbia had expanded Medicaid.⁷ In 2025, individuals living in expansion states who have an income of $21,597 (more if living in Alaska or Hawaii) qualify for Medicaid under expansion. Ten states that did not expand Medicaid are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming.

Effects of OBBBA on Medicaid and Medicaid Expansion^8,9

When on July 4, 2025, President Trump signed H.R. 1 or “One Big Beautiful Bill Act” (OBBBA) into law, concerns were expressed about how this could affect people with Medicaid. Here are some dates and provisions to know about:

• October 1, 2026: Citizens and specific categories of immigrants can get Medicaid, Children’s Health Insurance Program, and ACA premium tax credits, including lawful permanent residents, Cuban/Haitian entrants, and those living in the U.S. under a Compact of Free Association with Palau, Micronesia, and the Marshall Islands. But, refugees, asylees, survivors of domestic violence under the Violence against Women Act, trafficking survivors, and those with temporary protected status will not be eligible for Medicaid. How many of them are on home dialysis or serve as care partners to home patients?

• December 31, 2026: States redetermine eligibility annually for most of those with Medicaid. This Act requires states to redetermine eligibility for adults covered under Medicaid expansion every 6 months. Medicaid applications and required documentation create a paperwork burden. Late notices to reapply due to slow mail delivery can cause missed deadlines and Medicaid case closure. CMS allows dialysis clinics to involuntarily discharge patients for nonpayment. Patients who miss deadlines and lose Medicaid as a primary or secondary payer could be at risk.

• January 1, 2027: This Act requires states that expanded Medicaid to verify at least every 6 months if those 19-64 who get or apply for Medicaid under expansion worked or did community service at least 80 hours a month or attended school part-time. There are some “exemptions” and “temporary hardship,” but definitions aren’t clear. The “medically frail” exemption could exempt home dialysis patients, but not their care partners. States must review at least 1 or up to 3 months prior to the application or renewal to assure compliance.¹⁰ Some home dialysis patients or care partners may miss work or school due to illness that could make them ineligible and the longer the lookback period, the greater the risk.

• January 1, 2027; States must verify addresses for Medicaid recipients with the National Change of Address Database and managed care entities. Do our patients file a change of address card with the USPS to update that database? They don’t always report a change of address to providers.

• January 1, 2027: States must review Social Security’s Master Death File quarterly and disenroll any deceased people. In February 2025, Donald Trump and DOGE claimed tens of millions of dead people were getting benefits. That got people’s attention. A 2024 report found that from 2015-2022, SSA paid less than 1% in erroneous payments, most of which were to living people.¹¹ An SSA blog reports that less than 1/3 of 1% of deaths are misreported to SSA. Being declared dead in that database can affect payment, bank accounts, and more.¹²

• January 1, 2027: This bill limits retroactive coverage of services to 1 month for Medicaid expansion adults and 2 months for all others. In the past, retroactive coverage was for 3 months prior to the month of the application. This could leave home patients with huge bills for hospitalizations and surgery as well as dialysis care.

• July 1, 2028: This bill creates a waiver that allows states to offer Home and Community Based Services (HCBS) to those who may not meet criteria for needing institutional care. States have to meet reporting standards and it must be cost neutral. This could help home patients get help at home for chores other than dialysis—if funding is sufficient.

• October 1, 2028: Adults who get Medicaid under expansion and whose income is over 100% of federal poverty will have to pay part of the cost of their care—$35 per service or 5% of their income. Some providers’ services are exempted; dialysis clinics are not. This could make PD and home HD unaffordable for these patients.

Mandatory and Optional Medicaid Services¹³

These services are mandatory so states must provide them—but how will they do so with funding cuts?

• Transportation to medical care 

• Inpatient and outpatient hospital services

• Rural health clinic services

• Services at Federally qualified health centers

• Home health services

• Labs and X-rays

• Nursing facilities services

• Comprehensive and preventive healthcare for children under 21

• Family planning services

• Tobacco cessation counseling for pregnant women

• Physician services

• Home health services

• Nurse Midwife services

• Certified pediatric and family nurse practitioner services

• Freestanding birth center services licensed/ otherwise recognized by the state

• Medication Assisted Treatment (MAT)

• Routine costs of items and services for those enrolled in qualifying clinical trials

• Concurrent care for children receiving hospice

States have the option to cover these services and may choose not to cover them:

• Other licensed practitioner services

• Private duty nursing services

• Clinic services

• Dental services

• Physical therapy

• Occupational therapy

• Speech, hearing and language disorder services

• Prescription drugs 

• Dentures

• Prosthetics

• Eyeglasses

• Other diagnostic, screening, preventive, and rehabilitative services

• Services for individuals age 65 or older in an Institution for Mental Disease (IMD) 

• Services in an intermediate care facility for Individuals with intellectual disability 

• Inpatient psychiatric services for individuals under age 21 

• Hospice 

• Case management

• TB-related services

• Respiratory care for ventilator-dependent individuals

• Primary care case management

• Primary and secondary medical strategies, treatment, and services for individuals with sickle cell disease

• Certified community behavioral health clinic (CCBHC) services

• State plan home and community based services 

• Self-directed personal assistance services 

• Community First Choice Option (CFC) 

• Medical Assistance For Eligible Individuals Who Are Patients In Eligible Institutions for Mental Diseases

• Alternative Benefit Plan (ABP) – mandatory for Medicaid expansion population

• Health homes for enrollees with chronic conditions 

• Other services approved by the Secretary, including those furnished in a religious nonmedical health care institution, emergency hospital services by a non-Medicare certified hospital, and critical access hospital (CAH).

Medicare vs Medicaid

Most people with kidney failure are U.S. citizens or legally present in the U.S. They must have enough work credits to qualify for Medicare under their own work record or through a spouse or parent (if a child). When someone with kidney failure starts dialysis in a clinic, there’s a 3-month waiting period for Medicare. That waiting period can be waived so Medicare can start the 1st of the month of 1st dialysis if training for home dialysis begins before the end of the waiting period. Some clinics have a waiting list that’s too long for everyone who needs to start training to start that quickly. When a patient has Medicaid, it can pay for dialysis until Medicare starts and then pay second after Medicare. Patients who start dialysis and don’t have enough work credits to qualify for Medicare may qualify for Medicaid, which may be their only payer for dialysis and other healthcare.

Summing it All Up

Medicaid is a program funded by the federal government and state governments. States administer Medicaid in compliance with a state plan, federal rules and waivers. I fear that changes to Medicaid will cause many of our most vulnerable home patients to lose essential health coverage.