Order Code RS22843
March 21, 2008
Medicaid Provider Taxes
Jean Hearne
Specialist in Social Legislation
Domestic Social Policy
Summary
Provider-specific taxes have been used by many states over the last two decades to
help pay for the costs of the Medicaid program. Such taxes are required to meet a
number of federal laws and regulations, some of which have been in flux recently. This
report provides background information on provider-specific taxes and describes recent
legislative and administrative action on the tax programs.
States have the authority to establish taxes to fund various activities. Sometimes
states establish taxes to fund specific purposes. Other times, taxes may be credited to the
states’ general treasury to be used for any state purpose. One type of tax that is commonly
relied on by many states to fund a portion of their share of Medicaid program costs is a
tax on health care providers. These taxes, called provider taxes, are required to comport
with certain federal laws established by Congress in 1991 and modified in 2005 and 2006.
The 1991 law set rules for provider taxes and for two other Medicaid funding
mechanisms to minimize state practices that were viewed as ways for states to circumvent
their state/federal shared responsibility for funding the Medicaid program. Subsequent
changes to federal law and to the administrative procedures governing the use of provider
taxes have represented a continuing struggle between ensuring the shared financing
responsibility for Medicaid while balancing states’ rights and need to raise funds for state
programs and Medicaid providers.1 New rules issued in February of 2008 conform the
administrative regulations to the legislative changes made by Congress in 2005 and 2006,
as well as make other changes to the procedures for approving provider taxes. The rule
changes become effective in April of 2008.
1 U.S. Government Accountability Office, State Medicaid Financing Practices, HEHS-96-76R,
date; Medicaid Financing: Federal Oversight Initiative Is Consistent with Medicaid Payment
Principles but Needs Greater Transparency, GAO-07-214, April 30, 2007; Medicaid: States Use
Illusory Approaches to Shift Program Costs to Federal Government, GAO/HEHS-94-133,
August 1, 1994.

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Medicaid Provider Tax Legislation
In 1991, Congress passed the Medicaid Voluntary Contribution and
Provider-Specific Tax Amendments (P.L. 102-234). This bill grappled with several
Medicaid funding mechanisms that were sometimes used to circumvent the state/federal
shared responsibility for funding the cost of the Medicaid program. Under these funding
methods, states collect funds (through taxes or other means) from providers and pay the
money back to those providers as Medicaid payments, while claiming the federal
matching share of those payments. States were essentially “borrowing” their required
state matching amounts from the providers. Once the state share was netted out, the
federal matching funds claimed could be used to raise provider payment rates, to fund
other portions of the Medicaid program, or for other non-Medicaid purposes. In some
cases, provider groups initiated the process by approaching the state and requesting that
one of the financing programs be implemented in exchange for improved payment rates
funded by the federal matching amounts.
At the time that the 1991 law was deliberated, many of the provider taxes on the
books specifically targeted only those providers that accepted Medicaid payments
because those were the only providers for whom it would be routine and legal to pay back
the borrowed funds through Medicaid payments. The 1991 law sought to address some
of the mechanisms that allowed these arrangements to work.
With respect to provider-specific taxes, the 1991 law
! requires provider taxes be “broad based” and uniformly applied to all
providers within specified classes of providers — in other words, states
cannot limit the provider taxes only to Medicaid providers;
! prohibits taxes that exceed 25% of the state (or non-federal) share of
Medicaid expenditures; and
! prohibits states from a direct or indirect guarantee that providers receive
their money back (or be “held harmless”)
for the purpose of claiming federal matching payments. The specified classes of providers
used to ensure that tax programs are “broad-based” are those that provide the following:
! Inpatient hospital services.
! Outpatient hospital services.
! Nursing facility services (other than services of intermediate care
facilities for the mentally retarded).
! Services of intermediate care facilities for the mentally retarded.
! Physicians’ services.
! Home health care services.
! Outpatient prescription drugs.
! Services of Medicaid managed care organizations (including health
maintenance organizations, preferred provider organizations, and such
other similar organizations as the Secretary may specify by regulation).2
2 The Deficit Reduction Act of 2005 (DRA, P.L. 109-171) modified this class of providers by
(continued...)

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! Other classifications of health care services as specified by the Secretary.3
Requiring that all providers within a class be taxed, as opposed to only Medicaid
providers, dampened the ability of states to establish such taxes. The reason is that
Medicaid providers could easily be held harmless by inflating Medicaid payments. Other
providers could not be repaid so simply, and therefore would be more likely to oppose the
imposition of such taxes.
Recent changes to law include a provision in the Deficit Reduction Act of 2005
(DRA, P.L. 109-171), which altered one of the specified classes of providers. The
“Medicaid managed care organizations” class was changed to all “managed care
organizations.” The Tax Relief and Health Care Act of 2006 (TRHCA, P.L. 109-432)
included a provision changing the rules exempting taxes from scrutiny of their hold
harmless provisions. Those rule changes are described more fully below.
Regulations
Federal regulations further define the rules with which Medicaid provider taxes must
comply. Most regulations have been in place since not long after the 1991 law was
enacted.4 Following the passage of TRHCA and DRA, the Center for Medicare and
Medicaid services issued a new rule implementing several changes to comport with those
laws, as well as making a number of other changes.
Hold Harmless
Regulations established in 1992 and 1993 describe three tests that are applied to a
state’s tax to determine whether taxpayers are held harmless: a positive correlation test,
a Medicaid payment test, and a guarantee test. Taxes that fail any of those tests are
determined to have a hold harmless provision in violation of the law.5
! A positive correlation test is used to determine whether a state or other
unit of government imposing the tax provides directly or indirectly for
a non-Medicaid payment to the taxpayers in an amount that is positively
correlated to either the tax amount or the difference between their
Medicaid payment and the tax amount.
! The Medicaid payment test is violated if all or any portion of the
Medicaid payment to the taxpayer varies based only on the amount of the
total tax payments.
! The guarantee test is violated if the state or other unit of government
imposing the tax provides directly or indirectly for any payment, offset,
2 (...continued)
changing “Medicaid managed care organizations” to all “managed care organizations.” This
change further broadened the group upon which a tax could be imposed, thereby reducing the
potential for abusive tax programs.
3 A number of other classifications are described in the regulations at 42 CFR 433.56.
4 The rules regarding provider taxes can be found at 42 CFR Part 433.
5 The law also allows for states to apply for a waiver of the hold harmless requirements.

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or waiver that guarantees to hold taxpayers harmless for all or a portion
of the tax.
Safe Harbor. The administrative rules, however, waive the application of those
hold harmless tests when the tax is applied at a rate that produces revenues that are less
than or equal to between 5.5% and 6% of the revenue received by the taxpayer. This
threshold has been referred to as a “safe harbor.”
TRHCA changed the threshold under which tax programs could avoid being tested
for violations of the hold harmless rule. The rule in effect before THRCA allowed for
taxes on providers of 6% or less of their revenue to forego scrutiny of hold harmless
provisions. THRCA changed the threshold so that for fiscal years beginning on or after
January 1, 2008, through September 30, 2011, taxes at or below 5.5% of revenues could
forego such scrutiny. After that period, the threshold would revert to 6% of revenues.
New Regulation
On February 22, 2008, HHS published a final rule: “Medicaid Program: Health Care
Related Taxes”6 in the Federal Register. The rule describes a number of changes to the
Centers for Medicare and Medicaid’s (CMS’s) policies for reviewing health care-related
taxes. Two of the changes implement provisions enacted in TRHCA and DRA, as
described above. There are a number other changes proposed as well.
The rule would make the following changes: (1) revise the threshold for determining
if a tax program is required to undergo a test to determine whether a provider is being
“held harmless” for the tax payment and clarify use of the term “revenues”; (2) clarify
standards for determining the existence of a hold harmless arrangement; (3) codify one
class of health care services permissible for establishing health care provider taxes; and
(4) remove obsolete language. In addition, a few other notable changes are made, all of
which are described in more detail below.
Revising the hold-harmless threshold. In order to conform CMS regulations
to the statutory changes made by THRCA, the new rule changes the threshold under
which tax programs could avoid scrutiny of hold harmless provisions from 6% of a
taxpayer’s revenue to 5.5% for fiscal years beginning on or after January 1, 2008, through
September 30, 2011. In addition, the regulation further specifies that the revenues against
which the 5.5% threshold should be applied are “net operating revenues.” The former
regulation had not specified the type of revenues against which to apply the threshold test.
Permissible classes of services. As described above, DRA broadened one
permissible class of services from the services of “Medicaid managed care organizations”
to those of all managed care organizations. The regulation makes changes to conform
with the DRA change. It further specifies that all services of MCOs, regardless of payer
source, will be considered a permissible class of health care items or services for the
purpose of the taxes. This is to reduce incentives for MCOs to reorganize to separate their
business lines, thereby isolating Medicaid business, for the purpose of imposing Medicaid
6 Department of Health and Human Services, Centers for Medicare &Medicaid Services,
“Medicaid Program; Health Care-Related Taxes,” 73 Federal Register 9685, February 22, 2008.

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taxes only on the subsidiary of the MCO. The preamble of the proposed regulation notes
that this practice was found to be occurring.7
Clarify Standards for Hold Harmless Tests. Several clarifications are made
in the application of three tests to determine if a tax includes a prohibited hold harmless.
! Positive Correlation Test — One clarification involves the determination
of whether a tax includes a direct or indirect non-Medicaid payment to
the tax payers that is positively correlated to the tax amount or to the
difference between the Medicaid payment and the tax amount. In the
past, the use of the term “positively correlated” raised disagreements
about allowable taxes. Tax programs disallowed by CMS were
subsequently reinstated by an appeals board because the positive
correlation test was not applied in a strict statistical manner. This
regulation would allow a finding of a hold harmless for payments and
taxes that are correlated even when there is not a strict correlation in a
mathematical sense. This change would ensure that CMS is able to apply
the positive correlation test in the broadest manner possible, allowing that
a positive correlation can exist even if the correlation varies over time,
the correlation changes, or if the payment to the taxpayer is conditional
on the payment of the tax. The preamble of the proposed rule argues for
the need for flexibility and subjectivity in the review of tax arrangements
and notes that it is impossible to anticipate all hold harmless plans that
could be created.
! The Medicaid Payment Test — Under the Medicaid payment test, a hold
harmless arrangement exists if all or any portion of a Medicaid payment
varies based only on the amount of the tax payment. The new rule adds
a clarification to allow for a finding that a Medicaid payment varies
based on the tax payment when a payment is conditional on the tax
payment. The preamble of the proposed rule states that because Medicaid
payments are required, by statute, to be based on efficiency, economy,
and quality of care, payments conditioned solely on the payment of a tax
are considered to be in violation of that law.
! The Guarantee Test — Under the existing regulation, tax arrangements
that include a direct or indirect guarantee that holds taxpayers harmless
for any portion of their tax costs are considered to be in violation of the
hold harmless prohibition. The new rule further specifies that the hold
harmless rule is violated if a tax arrangement includes a direct or indirect
guarantee of a direct or indirect payment of any portion of their tax costs.
The new rule includes a number of other changes, as well:
! It removes all references to transition periods that expired in the
early 1990s.
7 A proposed regulation with comment period was published on March 23, 2007, 72 Federal
Register 13726.

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! It standardizes the terminology used for referring to the tax amount and
the payment amount across all of the hold harmless tests. The purpose
of this change seems to be twofold — to reduce confusion raised by using
slightly different terms in different places for the same thing, and to
utilize terms that are sufficiently broad to allow for the maximum amount
of flexibility for the agency in applying the hold harmless tests.
! It makes parallel changes to the provisions implementing the hold
harmless prohibition for bona fide provider donations.
HHS estimates that the imposition of the rule would reduce federal Medicaid outlays
by $0.4 billion over the five-year period beginning in 2008. The Congressional Budget
Office estimates the impact to be a reduction in federal outlays of $0.6 billion over the
same period. States, however, in responding to a survey conducted by the staff of the
House Committee on Oversight and Government Reform, estimate their loss of federal
Medicaid funds to be over $5 billion for the period, an amount more than 10 times the
HHS estimates.8
Opposition to the Rule
Opposition to the rule was expressed in a letter from the American Public Human
Services Association and the National Association of State Medicaid Directors to the
Acting Administrator of CMS.9 The letter raised concerns that the rule reduces
consistency and clarity, that its changes exceed the Secretary’s authority, and that it would
impede a state’s ability to condition Medicaid reimbursements on payment of required
taxes. Other concerns about specific provisions were raised, as well.
Based on their survey of state Medicaid Directors, the majority staff of the House
Committee on Oversight and Government Reform conclude that the fiscal and
programmatic impacts of CMS’s recent regulatory changes — including the provider tax
regulation — are far more extensive than has been understood and warn against making
such changes without fully understanding the impact on Medicaid programs and
beneficiaries. Their results echo the objections of governors and hospital associations
expressing the concern that the Administration’s recent rule changes would have a
significant impact on Medicaid financing that could potentially harm access to Medicaid
services for Medicaid beneficiaries.
Finally, Congress is considering taking action as well. A number of proposals and
at least two bills would halt the implementation of some or all of the provider tax rule.
H.R. 5613, Protecting the Medicaid Safety Net Act of 2008, would halt the
implementation of all provisions, except for those required by the changes to law enacted
as part of TRHCA and DRA, until April, 2009. H.R. 4355, a Bill to Impose a Moratorium
on Certain Medicaid Payment Restrictions, would halt implementation of the entire
regulation for a one-year period beginning on the date of enactment.
8 The Administration’s Medicaid Regulations: State-by-State Impacts, prepared for Chairman
Henry Waxman by the Majority Staff, U.S. House of Representatives, Committee on Oversight
and Government Reform, March 2008.
9 Letter addressed to Leslie Norwalk, Acting Administrator of CMS, dated May 22, 2007.

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