{"abstract":"This proposed rule would revise standards for determining whether an indirect hold harmless arrangement exists for a health care- related tax. This proposed rule is necessary to implement a provision in the \"One Big Beautiful Bill Act,\" herein referred to as the \"Working Families Tax Cut (WFTC) legislation,\" which established new indirect hold harmless thresholds for health care-related taxes. Currently, the threshold for a State's collection of tax revenues is no more than 6 percent of net patient revenue attributable to the assessed permissible class of health care items or services. Effective October 1, 2026, the WFTC legislation generally sets the threshold equal to the applicable percent of net patient revenue attributable to taxes imposed as of July 4, 2025. Effective October 1, 2027, the WFTC legislation also requires a phase down of the hold harmless threshold in expansion States. Apart from establishing the new threshold in regulation and proposing related changes and enhancements to existing processes, we propose to sunset a secondary prong to the indirect hold harmless determination to ensure the thresholds determined as of July 4, 2025, serve as the maximum permissible level. Finally, this rule proposes to add a new permissible class to enhance CMS oversight of health care- related taxes.","action":"Proposed rule.","agencies":[{"raw_name":"DEPARTMENT OF HEALTH AND HUMAN SERVICES","name":"Health and Human Services Department","id":221,"url":"https://www.federalregister.gov/agencies/health-and-human-services-department","json_url":"https://www.federalregister.gov/api/v1/agencies/221","parent_id":null,"slug":"health-and-human-services-department"},{"raw_name":"Centers for Medicare & Medicaid Services","name":"Centers for Medicare & Medicaid Services","id":45,"url":"https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services","json_url":"https://www.federalregister.gov/api/v1/agencies/45","parent_id":221,"slug":"centers-for-medicare-medicaid-services"}],"body_html_url":"https://www.federalregister.gov/documents/full_text/html/2026/07/23/2026-14897.html","cfr_references":[{"chapter":null,"citation_url":null,"part":"433","title":42}],"citation":"91 FR 46562","comment_url":"http://www.regulations.gov/commenton/CMS-2026-2476-0001","comments_close_on":"2026-09-21","correction_of":null,"corrections":[],"dates":"To be assured consideration, comments must be received at one of the addresses provided below, by September 21, 2026.","disposition_notes":null,"docket_ids":["CMS-2452-P"],"dockets":[{"supporting_documents":[],"agency_name":"CMS","documents":[{"comment_count":70,"comment_start_date":"2026-07-23","updated_at":"2026-09-21T01:55:36.074-04:00","comment_url":"https://www.regulations.gov/commenton/CMS-2026-2476-0001","allow_late_comments":false,"id":"CMS-2026-2476-0001","comment_end_date":"2026-09-22","regulations_dot_gov_open_for_comment":true}],"supporting_documents_count":0,"id":"CMS-2026-2476","title":"Amending the Indirect Hold Harmless Threshold of Health Care-Related Taxes. CMS-2452-P"}],"document_number":"2026-14897","effective_on":null,"end_page":46599,"executive_order_notes":null,"executive_order_number":null,"full_text_xml_url":"https://www.federalregister.gov/documents/full_text/xml/2026/07/23/2026-14897.xml","html_url":"https://www.federalregister.gov/documents/2026/07/23/2026-14897/medicaid-program-amending-the-indirect-hold-harmless-threshold-of-health-care-related-taxes","images":{"EN23JY26.000":{"large":"https://img.federalregister.gov/EN23JY26.000/EN23JY26.000_large.png","medium":"https://img.federalregister.gov/EN23JY26.000/EN23JY26.000_medium.png","original_size":"https://img.federalregister.gov/EN23JY26.000/EN23JY26.000_original_size.png"}},"images_metadata":{"EN23JY26.000":{"large":{"identifier":"EN23JY26.000","content_type":"image/png","size":42932,"width":823,"sha":"a19b4b4cd14a9b0489aa0a54000a274f","url":"https://img.federalregister.gov/EN23JY26.000/EN23JY26.000_large.png","height":490},"medium":{"identifier":"EN23JY26.000","content_type":"image/png","size":12656,"width":430,"sha":"78a13ceca8d6603425ac53300574db7d","url":"https://img.federalregister.gov/EN23JY26.000/EN23JY26.000_medium.png","height":256},"original_size":{"identifier":"EN23JY26.000","content_type":"image/png","size":41765,"width":1625,"sha":"1f75d4677dfeee9c46d1271cc312fdff","url":"https://img.federalregister.gov/EN23JY26.000/EN23JY26.000_original_size.png","height":967}}},"json_url":"https://www.federalregister.gov/api/v1/documents/2026-14897?publication_date=2026-07-23","mods_url":"https://www.govinfo.gov/metadata/granule/FR-2026-07-23/2026-14897/mods.xml","not_received_for_publication":null,"page_length":38,"page_views":{"count":9787,"last_updated":"2026-09-21 06:15:03 -0400"},"pdf_url":"https://www.govinfo.gov/content/pkg/FR-2026-07-23/pdf/2026-14897.pdf","presidential_document_number":null,"proclamation_number":null,"public_inspection_pdf_url":"https://public-inspection.federalregister.gov/2026-14897.pdf?1784664910","publication_date":"2026-07-23","raw_text_url":"https://www.federalregister.gov/documents/full_text/text/2026/07/23/2026-14897.txt","regulation_id_number_info":{"0938-AV93":null},"regulation_id_numbers":["0938-AV93"],"regulations_dot_gov_info":{"supporting_documents":[],"comments_count":70,"agency_id":"CMS","comments_url":"https://www.regulations.gov/docketBrowser?rpp=50&so=DESC&sb=postedDate&po=0&dct=PS&D=CMS-2026-2476","supporting_documents_count":0,"docket_id":"CMS-2026-2476","document_id":"CMS-2026-2476-0001","regulation_id_number":"0938-AV93","title":"Amending the Indirect Hold Harmless Threshold of Health Care-Related Taxes. CMS-2452-P","checked_regulationsdotgov_at":"2026-09-21T10:55:04Z"},"regulations_dot_gov_url":"http://www.regulations.gov/commenton/CMS-2026-2476-0001","significant":null,"signing_date":null,"start_page":46562,"subtype":null,"title":"Medicaid Program; Amending the Indirect Hold Harmless Threshold of Health Care-Related Taxes","toc_doc":"Indirect Hold Harmless Threshold of Health Care-Related Taxes","toc_subject":"Medicaid Program","topics":["Administrative practice and procedure","Child support","Claims","Grant programs-health","Medicaid","Reporting and recordkeeping requirements"],"type":"Proposed Rule","volume":91}