The Republican-backed “One, Big, Beautiful Bill” has made a lot of headlines in recent weeks. The bill, intended to deliver on some of President Donald Trump’s major campaign promises, includes things like no taxes on tips or overtime pay as well as new rules limiting some immigrants’ access to various types of government aid.
But the sweeping bill doesn’t stop there. It also contains several proposed Medicare changes, including the four below.
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1. Broader access to HSAs for Medicare-eligible seniors
Current law says that you must stop contributing to a health savings account (HSA) once you’re enrolled in Medicare, though you can continue to use your HSA funds. This is true even if you still have a high-deductible health insurance plan (HDHP) — one with a deductible of $1,650 or more for an individual or $3,300 for a family in 2025 — through your employer.
The new bill proposes a change that would allow seniors eligible for Medicare Part A but enrolled in an HDHP to continue contributing to an HSA for as long as they have the HDHP. Normal HSA contribution limits would apply. The 20% penalty on non-medical withdrawals that currently only applies to people under 65 would apply to this population as well. The penalty would disappear when you’re 65 or older and no longer eligible to contribute to an HSA.
2. Expanded definition of a rural emergency hospital
Rural emergency hospitals (REHs) are a type of Medicare-designated facility that operates in areas where bigger hospitals may struggle to stay open. They receive a monthly payment just for remaining open and they also get a 5% increase on outpatient payments to help ensure they’re able to continue providing care for residents in these rural areas.
When Congress created the REH designation in 2020, only hospitals that were already enrolled in Medicare at the time could claim it. This new bill would establish a “lookback period” running from Jan. 1, 2014, to Dec. 26, 2020, that would allow any qualifying rural hospitals operating during that window that have closed to reopen under the REH designation. However, facilities located closer to larger hospitals may not be eligible for some of the incentives that more remote REHs receive.
3. Limited Medicare access for non-citizens
Current law enables seniors 65 and older to sign up for Medicare. You don’t actually have to be a U.S. citizen under current law. You may qualify as long as you’re “lawfully present” in the U.S. However, the “One, Big, Beautiful Bill” seeks to change this by limiting Medicare coverage only to U.S. citizens, lawful permanent residents, certain Cuban immigrants, and individuals living in the U.S. through a Compact of Free Association.
4. AI tools to recoup improper Medicare payments
The new bill would provide $25 million to the Secretary of Health and Human Services, Robert F. Kennedy Jr., to hire AI contractors and data scientists to identify and recoup Medicare overpayments. These occur when a doctor or hospital receives more money from Medicare than they should.
In 2023, Medicare overpayments topped $31 billion with another $16.6 billion in Medicare Part C (Medicare Advantage) overpayments and $3.4 billion in Medicare Part D overpayments.
Nothing’s set in stone
While the “One, Big, Beautiful Bill” passed the House of Representatives by a single vote, that’s not a guarantee it will make it all the way to the president’s desk. Even if it does, it almost certainly won’t get there unedited. Senate Republicans have already made it clear that they plan to make some changes to the bill, so it’s possible that some or all of the items mentioned above could look different in their final form.
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