Federal Medicaid matching for non-pregnant adult refugees and asylees ended on 1 October

The statute lists who the federal government will pay for

Section 71109 of Public Law 119-21, the 2025 reconciliation law, took effect on 1 October 2026. It adds a paragraph to the Social Security Act saying that "in no event shall payment be made to a State under this section for medical assistance furnished to an individual unless" that person is on a short list. The list is citizens and nationals, lawful permanent residents, Cuban and Haitian entrants, and people who lawfully reside in the United States under a Compact of Free Association.¹ The payment is the federal share of what a state spends on Medicaid and, under a parallel amendment, on the Children's Health Insurance Program (CHIP). CMS, the federal agency that runs both, calls that share federal financial participation. This article calls it the federal match.

The statute names no excluded group. The groups that lose the match are found by subtraction, and CMS's implementing letter gives examples: "asylees, refugees, parolees, or victims of trafficking."² The text restricts payment to the state. It contains no sentence that ends anyone's eligibility or requires a state to stop covering anyone.¹

That gap matters for the common summary, "immigrants lose Medicaid on 1 October." The summary is right about the money. For a refugee, asylee, parolee or trafficking survivor who is an adult and not pregnant, the federal government stops paying for full Medicaid coverage on that date.² Whether the person stops being covered depends on whether the state keeps paying. CMS wrote that it "will not require states to provide state-only funded health coverage" to the groups that lose the match.² California's Medicaid agency says the same thing about its children's program in a filing to CMS: section 71109 "does not limit who can enroll in CHIP. It only changes the level of federal benefits for some Qualified Non-Citizens."³

One word needs fixing before the rest. CMS "would not consider health coverage that a state opts to continue to provide with 100 percent state-only funds to be Medicaid."² So where a state keeps paying, these adults stay covered, but not by Medicaid, which is the coverage that draws the federal match.

Who keeps the federal match

The table sorts the groups by what happens to the match on 1 October. A lawful permanent resident, a green-card holder, keeps it, with a condition. Section 71109 did not change the five-year waiting period that already applies to most lawful permanent residents, and CMS tells states to keep applying it.² "Retained" for this group means a green-card holder who is past the waiting period or exempt from it.

The loss falls on adults who are not pregnant. The statute's opening words, "except as provided in paragraphs (2) and (4)," carve out emergency-condition care and the option to cover lawfully residing children and pregnant women.¹ That option comes from section 214 of the Children's Health Insurance Program Reauthorization Act of 2009. A state elects it, and CMS counted 39 states, DC and three territories that had by 8 April 2026. Section 71109 "did not make any changes" to it.² A refugee child in a state that elected the option sees no change in the match on 1 October. Georgetown University's Center for Children and Families gave the scope in October 2025. "In all states, lawfully residing adults who are not pregnant will lose coverage unless the state chooses to cover them with state-only funds."⁴

Emergency Medicaid keeps a federal match, at a lower rate for some. Section 71110 caps the match for emergency-condition care at the state's regular rate from 1 October, which removes the 90 percent rate that care for expansion-group members had.¹ CMS expects states "may, in fact, experience an overall total increase" in emergency-only spending.²

What CMS told states to do on 1 October

CMS issued its guidance on 8 April 2026 as State Health Official letter #26-001, a 29-page document signed by Dan Brillman, CMS's deputy administrator and the director of its Center for Medicaid and CHIP Services. The letter calls P.L. 119-21 the "Working Families Tax Cut" legislation, and its Appendix A tabulates the match group by group.²

For anyone enrolled on 1 October, the letter says states "must promptly act." A state identifies potentially affected enrollees and re-verifies their status through the Department of Homeland Security's SAVE system without involving the enrollee, and only then asks the person. If status cannot be verified, the enrollee gets a 90-day reasonable opportunity period. Before ending coverage the state must check whether another basis applies, such as the 214 option or emergency Medicaid, and must give advance notice with hearing rights, at least ten days in Medicaid.²

So 1 October is the date the federal match stops, and each person's coverage ends later, by a process. KFF notes that coverage during the reasonable opportunity period "may extend beyond October 1, 2026."⁵ Washington's provider toolkit goes further: "Most people will not experience changes immediately - most changes will occur at the next coverage renewal after the new requirements take effect."⁶ CMS's "promptly act" and Washington's renewal timing point different ways, and neither document says which one fixes when an individual's coverage in Washington ends.

On who pays, the letter is direct. CMS reads the statute and its legislative history as showing no "clear Congressional intent to require that states provide full Medicaid benefits to qualified noncitizens without receiving federal matching funds," and applies the same reasoning to CHIP.² The letter is CMS's reading. The sources cited here include no court ruling on it. A footnote concedes that two of CMS's own regulations, which require coverage of qualified noncitizens, "will not be aligned" with the statute from 1 October, and CMS says it plans rulemaking.²

A state that continues coverage has to keep it away from the federal claim. State-only services must sit under "a separate and distinct contract and payment" from Medicaid managed-care contracts, and states with state-only programs must control claiming so that only emergency Medicaid is billed to the federal government.² States must also file the changes. Medicaid state plan amendments are due by 31 December 2026 for an effective date of 1 October, and separate-CHIP amendments that restrict eligibility are due by 30 November 2026.²

The reason on the record is federal money

The enrolled statute has no findings or purpose clause, so the stated reason from a primary source comes from the agency.¹ CMS's 8 April press release quotes Administrator Mehmet Oz: "The Trump Administration has a public mandate, a statutory obligation, and a moral duty to safeguard our federal healthcare programs. Today, we're honoring all three by providing clear guidelines to help states follow the law and safeguard taxpayer dollars."⁷ The release describes the change as limiting "the ability to claim federal matching funds" and cites no figure.⁷

Two figures bear on that reason. CMS's letter reports "focused financial oversight of eight states" with state-only programs for noncitizens and "approximately $1.8B in questionable expenditures," which it ties to claims for people for whom the federal match was available only for emergency Medicaid. It gives no period for the figure.² The Congressional Research Service reports the Congressional Budget Office's estimate for section 71109 as a reduction of $6,211 million in federal outlays, about $6.2 billion, and its summary gives the window as fiscal 2025 to 2034.⁸

Both are federal dollars, which is what the stated reason and the statute's instrument, the federal match, address. Neither figure bears on state dollars, and state dollars are what the statute leaves open.

Six states, four kinds of answer

Six states published documents specific enough to compare. They show four outcomes for an adult refugee or asylee: a cutoff written into state statute, a lapse with no state replacement announced, a continuation, and a continuation with an end date.

North Carolina decided in advance, in statute. Session Law 2026-1, section 3C.4, amends G.S. 108A-54.3A to add: "Medicaid coverage for individuals who are not citizens of the United States shall be limited to coverage that is federally required for the State's participation in the Medicaid program," effective 1 October 2026.⁹ Because CMS says no state-only coverage is required, "federally required" leaves no state money for the dropped groups. As enacted in April the section also removed lawfully present children and pregnant people. Governor Josh Stein, signing it on 30 April, said it would eliminate coverage for "nearly 27,000 pregnant women and children who are lawfully present," and asked the General Assembly to fix it.¹⁶ Session Law 2026-41, the budget signed on 7 July, reinstated that group by adding the CHIPRA 214 option to the statute, effective 1 October. Refugees, asylees and the other adult groups were not restored.¹⁰ NC Medicaid's notice tells beneficiaries that "Many people who are not U.S. citizens will lose their Medicaid" and that "If your situation is not listed here, you might lose your Medicaid starting October 1, 2026."¹⁷

South Carolina and Washington follow the federal cutoff in documents that announce no state-funded replacement. South Carolina's Department of Health and Human Services published a notice of final action on 31 August 2026, effective 1 October. It lists the groups that stay: lawful permanent residents who have met the five-year wait plus 40 qualifying work quarters, Cuban and Haitian entrants, Compact of Free Association citizens, and lawfully present pregnant women and children. It says "SCDHHS has not determined a budgetary impact" and that people whose status no longer qualifies "may still access Emergency Services coverage."¹¹ Washington's Health Care Authority says "approximately 14,000 lawfully present non-U.S. citizens in Washington will no longer be eligible for Apple Health," the state's Medicaid program. It lists where they can go instead: Qualified Health Plans on Washington Healthplanfinder, Emergency Medical, Family Planning Only, Medical Care Services and, when enrollment resumes on 1 January 2027, Apple Health Expansion.⁶ Neither document says in terms that the state will spend no money on these adults. They say who keeps Medicaid.

New Mexico keeps paying. Its Health Care Authority says "New Mexico is creating its own program to cover non-citizens who now get Medicaid but may lose coverage after October 1, 2026," naming refugees, asylees, victims of trafficking and humanitarian parolees. Then it adds: "For these individuals, their health coverage will not change, and they do not need to take any action to continue their coverage."¹² The same document says affected members would receive "a written notice that their Medicaid coverage is ending" in the first week of August 2026. Read with CMS's definition, both statements hold: the coverage continues, and it is no longer Medicaid. The summary gives no program name, funding amount or appropriation. KFF reports that New Mexico and New York are planning fully state-funded coverage for lawfully present immigrants who lose Medicaid.¹⁸

New York's page for enrollees says that refugees, asylees, parolees and survivors of domestic violence or human trafficking may find that "your health plan coverage may change from Medicaid to the Essential Plan. You will not experience a change in your benefits as a result," and that "There will be no changes to coverage for children and pregnant people."¹³ The page does not name the funding source. KFF reports that, under a longstanding court ruling, New York "is required to provide state-funded coverage to lawfully present immigrants who would be eligible for Medicaid if not for their immigration status."¹⁸ The ruling is not among the sources cited here, and New York's page does not mention it.

California pays for a stated period. The Department of Finance's enacted budget summary shows "a General Fund cost of $364.9 million in 2026-27 and a General Fund reduction of $381.8 million by 2029-30 for a July 1, 2027 transition to restricted-scope Medi-Cal for individuals impacted by the federal eligibility change for qualified non-citizens." It says the population moves to fee-for-service on 1 January 2027.¹⁴ The Assembly Budget Committee's floor report of 27 June 2026, written before the final votes, "Approves $303.1 million General Fund in 2026-27 to provide full-scope Medi-Cal coverage to Qualified Non-Citizen populations (e.g. refugees, asylees, victims of trafficking) through July 1, 2027," and puts the shift to restricted scope in 2027-28.¹⁵ The enacted summary's line is a net cost of the transition and the floor report's is the cost of full-scope coverage, so the two may measure different things, or the figure may have moved after 27 June. The documents cited here do not reconcile them. The cost to California is $303.1 million in one and $364.9 million in the other. Restricted scope is a narrower benefit package than full scope, and the budget summary does not define it.

California's filings with CMS describe a different layer. Medicaid state plan amendment 26-0040, filed on 11 September 2026 for an effective date of 1 October, changes "all Qualified Non-Citizens" to "LPRs, Cuban/Haitian entrants, and COFA migrants" and is silent on state-only coverage.¹⁹ CHIP amendment 26-0041 says children under 21 and pregnant individuals covered under the CHIPRA 214 option "will continue to qualify for federally-funded Medi-Cal."³ Both were listed as pending when filed. In the budget's words the continuing coverage is full-scope Medi-Cal. By CMS's definition, coverage paid with 100 percent state funds is not Medicaid.

No primary source counts the affected people

CMS's letter gives no national number of people who lose the match, and the Congressional Budget Office documents behind the national estimates are not among the sources cited here. The figures in circulation reach readers through secondary sources, and each counts something different.

The $6.2 billion above is a federal spending estimate. The figure of about 100,000 additional uninsured people by 2034 is the CBO's estimate for the Medicaid and CHIP restriction, as reported by KFF and by Georgetown's Center for Children and Families.⁵⁴ It is the change in the number of uninsured people in the whole country in 2034, and CCF says "that number could go up or down depending on how states respond." It does not count people who lose coverage on 1 October 2026. Washington's estimate of about 14,000 people who will no longer be eligible for Apple Health is a different measure, a count of eligibility in one state, and the state gives no method or reference date for it.⁶

The figure of 1.4 million comes from CCF, which wrote in October 2025 that "an estimated 1.4 million lawfully present immigrants are expected to lose health coverage due to the Budget Reconciliation Law."⁴ It spans Medicaid and CHIP, the Marketplace and Medicare, and names no source inline. The four CBO figures CCF lists in the same post are 100,000 for Medicaid and CHIP, 900,000 and 300,000 for two Marketplace provisions, and 100,000 for Medicare, which add to 1.4 million. Of that total, 100,000 is the Medicaid and CHIP restriction.

North Carolina's 27,000 is the governor's estimate for children and pregnant people, a group the later budget restored, so it does not describe 1 October.¹⁶ The documents cited here give no count for California, New Mexico or New York.

A refugee adult in New Mexico and one in North Carolina

Take two adult refugees who are not pregnant, one in New Mexico and one in North Carolina. Section 71109 treats them the same: neither draws a federal match for full coverage after 1 October 2026.¹ Their states then treat them differently. New Mexico's Health Care Authority tells its member that coverage will not change.¹² North Carolina's statute limits noncitizen Medicaid to what federal law requires, and NC Medicaid says affected people will get a letter explaining why and how to appeal.⁹¹⁷ A refugee in California with the same status stays in full-scope coverage on the state's money until 1 July 2027 and then moves to restricted scope.¹⁴¹⁵ If either adult has a child under 21, the child stays covered in both states under the 214 option, which North Carolina reinstated in July.¹²¹⁰

The conversion from an eligibility question to a budget question happens in identifiable places. In North Carolina it is a subsection of a general statute. In California it is a General Fund line with an end date, priced at $303.1 million in one budget document and $364.9 million in another. In New Mexico it is a program whose funding the state's summary does not state. In New York, KFF reports, it is a court ruling. The federal statute that took effect on 1 October contains none of these.

No document cited here reports what happened on 1 October. The latest dated document cited here is KFF's review of state notices, from 22 September 2026, and none reports terminations, re-verification results or notices sent after 1 October.⁵ California's two plan amendments were pending when filed, and CMS's deadline for Medicaid amendments is 31 December 2026.¹⁹²

The documents settle what a lawfully present adult's coverage depends on, in three steps. The first is the category. Citizens, green-card holders past the waiting period, Cuban and Haitian entrants and Compact of Free Association migrants keep the match. For everyone else the match is gone, so the second step is the state, where a statute or a budget decides. In California there is a third step, the date.