Division J — HEALTH CARE EXTENDERS
Division Overview
1. Overview
Division J, titled "Health Care Extenders," funds and extends programs primarily administered by the Department of Health and Human Services (HHS), including Medicaid, Medicare, human services, public health initiatives, and Food and Drug Administration (FDA) activities. Its overall purpose is to extend expiring authorities, make targeted policy changes, and provide limited new funding for health care access, quality improvement, telehealth flexibilities, and drug pricing transparency, with a focus on vulnerable populations like children, rural hospitals, military families, and 9/11 responders.
2. Total Spending
No overall total appropriation is specified in the text. Individual appropriations include $1 million (FY2026-2030) for Medicaid military family implementation, $10 million (FY2026) for maternity cost study grants to small hospitals, $3 million (FY2026) for maternity study implementation, $2.5 million (FY2026) for acute hospital care at home study, $1.2 million (FY2026) for durable medical equipment fraud report, $4 million (FY2026) for Medicare Advantage provider directory accuracy, and $2 million (FY2026) for multi-cancer early detection screening implementation. Many provisions are extensions of existing funding without new dollar amounts.
3. Key Funding Areas
- Medicaid Military Family Implementation: $1 million (FY2026-2030) — Funds HHS to implement residency rules and coverage for active duty military families relocating states.
- Maternity/Labor/Delivery Cost Studies for Small Hospitals: $10 million (FY2026) — Grants and technical assistance to rural/low-volume hospitals compiling cost data for state studies.
- Maternity Study Implementation: $3 million (FY2026) — HHS support for state studies and national reports on maternity service costs.
- Acute Hospital Care at Home Study: $2.5 million (FY2026) — Funds additional study/report on quality, costs, and outcomes of hospital-at-home waiver.
- DME Program Integrity OIG Report: $1.2 million (FY2026) — Inspector General assessment of fraud risks in Medicare durable medical equipment.
- Medicare Advantage Provider Directory Accuracy: $4 million (FY2026) — CMS implementation of accuracy audits and reporting for network plans.
- Multi-Cancer Early Detection Tests Implementation: $2 million (FY2026) — CMS support for new Medicare coverage of blood-based screening tests starting 2029.
4. Notable Provisions
- Medicaid Changes: Streamlines out-of-state provider enrollment for kids under 21 (effective 3 years post-enactment); removes age limits for working disabled adults' Medicaid buy-in; ensures military families retain residency/coverage when relocating; funds state studies on maternity service costs with HHS reports.
- Medicare Extensions: Extends low-volume hospital payments, Medicare-dependent hospitals, ambulance add-ons, alternative payment models, quality measures, low-income outreach, hospice surveys, work geographic floor through FY2027/FY2028; expands telehealth flexibilities (no geographic limits, mental health, audio-only, hospice recertification) through 2027; new coverage for multi-cancer screening (2029, phased age eligibility), external infusion pumps, virtual diabetes prevention.
- DSH Hospital Payments: Modifies allotments/reductions for Tennessee and others through FY2027/FY2028; revises uncompensated care limits.
- PBM/Drug Reforms: Requires PBM transparency reports, pass-through rebates, generic app transparency; assures pharmacy access/choice; new Medicare coverage rules.
- Human Services/Public Health: Extends sexual risk avoidance/personal responsibility education, family centers, TANF through Dec 2026; community health centers/NHSC/THCs through FY2026; special diabetes programs; national health security.
- FDA/Pediatric: Extends pediatric drug study incentives; limits orphan drug exclusivity for same indication; new Abraham Accords Office.
- Other: Off-campus outpatient dept IDs/attestations; lab test payment phase-in revision; sequestration adjustment; Medicare Improvement Fund increase to $2.062 billion.
5. Who Benefits
- Primary Beneficiaries: Medicaid/CHIP children (out-of-state providers), working disabled adults (age expansion), military families (residency/coverage continuity); Medicare rural/low-volume hospitals, ambulance services, low-income seniors (outreach), telehealth users, hospice/low-income Part D; 9/11 responders/survivors (funding formula); community health centers, NHSC clinicians, teaching hospitals (GME); sickle cell patients, living organ donors, preterm infants/moms, health providers (mental health).
- Agencies/Programs: HHS/CMS (implementation/studies), FDA (pediatric/orphan drugs), CDC (maternal mortality), HRSA (diabetes/respite care).
- Communities/Demographics: Rural/low-income Americans, pediatric cancer patients, diabetics (esp. Indians/Type I), sickle cell communities, military, 9/11 victims.
6. Plain English Summary
Hey neighbor, this part of the big spending bill keeps a bunch of health programs running a bit longer—like extra pay for small rural hospitals under Medicare, more telehealth options without location limits, and easier Medicaid for military families moving states or disabled workers past age 65. It adds new stuff too, like Medicare covering multi-cancer blood tests starting 2029 (with age phases), studies on maternity care costs, and rules forcing pharmacy middlemen (PBMs) to report fees/rebates transparently to plans so they can shop better. Small pots of cash, like $10 million for hospital studies and $4 million for Medicare directory fixes, help roll it out, mostly benefiting kids, seniors, rural folks, and military without big new bucks overall—just extensions to avoid cliffs.
Titles
Title Summary
This title enacts policy reforms to the Medicaid and CHIP programs under the Social Security Act, focusing on provider enrollment, eligibility expansions, military family residency rules, maternity care cost studies, and disproportionate share hospital (DSH) payment adjustments. It targets CMS and state Medicaid agencies, with specific implementation funding to HHS. No broad Medicaid funding is appropriated.
Spending Breakdown
| Line Item | Amount | Purpose |
| Military families implementation (SEC. 6103(b)) | $1,000,000 per fiscal year 2026–2030 ($5M total) | HHS for changes to residency, coverage, and HCBS waiting lists for active duty relocated individuals. |
| Small hospital grants/technical assistance (SEC. 6104(a)(4)) | $10,000,000 (FY2026) | Aid rural low-volume hospitals in compiling maternity/labor/delivery cost data for state studies. |
| Maternity studies implementation (SEC. 6104(c)) | $3,000,000 (FY2026) | HHS for state study requirements, reports, and national data analysis on maternity care costs. |
| Tennessee DSH allotment (SEC. 6105(a)) | $35,351,507 (portion of FY2026); $53,100,000 (FY2027) | Extended statutory DSH payments to Tennessee hospitals for uncompensated care. |
Notable Sections
- SEC. 6101: Establishes streamlined 5-year enrollment for low-risk out-of-state providers (Medicare-enrolled or screened in home state, no exclusions) serving Medicaid/CHIP children under 21; effective 3 years post-enactment.
- SEC. 6102: Removes age-65 cap on Medicaid buy-in eligibility for working adults with disabilities (≥16 years, excess SSI earnings); grace period to 2028 for existing state programs.
- SEC. 6103: Requires states (from 2030) to treat relocated active-duty military families as residents for eligibility/continuity, preserve HCBS waitlist status, and cover services in new state.
- SEC. 6104: Mandates states to study/every 5 years report maternity care costs in high-Medicaid (>50% births) or rural low-volume (<300 births/year) hospitals; HHS issues reports and national analysis.
- SEC. 6105–6106: Extends/adjusts DSH allotments (e.g., Tennessee), eliminates some reductions through FY2028, modifies uncompensated care limits to include Medicare/plan payments, allows states to use prior unspent allotments.
Plain English
This title streamlines Medicaid access for kids via out-of-state doctors, covers more working disabled adults and military families during moves, studies maternity care costs to inform payments, and tweaks extra funding for safety-net hospitals.
Title Summary
Title II amends the Social Security Act to extend Medicare payment adjustments for low-volume and Medicare-dependent hospitals, ambulance services, alternative payment models, the work geographic index floor, and telehealth flexibilities through 2027-2028; it also provides funding for quality measures, low-income outreach, hospice surveys, and studies on programs like Acute Hospital Care at Home. These changes primarily affect the Centers for Medicare & Medicaid Services (CMS), hospitals, providers, and Part D plans, with new requirements for pharmacy benefit managers (PBMs), multi-cancer early detection tests, and Medicare Advantage provider directories.
Spending Breakdown
| Line Item | Amount | Purpose |
| Quality measure endorsement, input, selection (Sec. 6205) | $15,100,000 | FY2027 funding for Medicare quality measure activities. |
| State Health Insurance Assistance Programs (SHIP) outreach (Sec. 6206(a)) | $30,000,000 | Period beginning Jan. 31, 2026, ending Dec. 31, 2027. |
| Area Agencies on Aging outreach (Sec. 6206(b)) | $30,000,000 | Period beginning Jan. 31, 2026, ending Dec. 31, 2027. |
| Aging and Disability Resource Centers outreach (Sec. 6206(c)) | $10,000,000 | Period beginning Jan. 31, 2026, ending Dec. 31, 2027. |
| Coordination of efforts for older Americans (Sec. 6206(d)) | $30,000,000 | Period beginning Jan. 31, 2026, ending Dec. 31, 2027. |
| Medicare hospice surveys (Sec. 6207) | $4,400,000 | Period beginning Jan. 31, 2026, ending Dec. 31, 2026; available until expended. |
| Acute Hospital Care at Home study/report (Sec. 6210(b)(4)) | $2,500,000 | FY2026 CMS Program Management Account; available until expended. |
| IG report on lab test fraud (Sec. 6212(c)) | $1,200,000 | FY2026 HHS IG; available until expended. |
| MA provider directory accuracy (Sec. 6220(b)(2)(C)) | $4,000,000 | FY2026 CMS Program Management Account; available until expended. |
| Multi-cancer early detection implementation (Sec. 6221(d)) | $2,000,000 | FY2026 CMS Program Management Account; available until expended. |
| Pharmacy access/choice enforcement (Sec. 6223(f)) | $188,000,000 | FY2026 CMS Program Management Account; available until expended. |
| PBM accountability (Sec. 6224(a)(4)) | $113,000,000 | FY2026 CMS Program Management Account; available until expended. |
| PBM accountability OIG (Sec. 6224(a)(4)) | $20,000,000 | FY2026 HHS IG; available until expended. |
| MedPAC PBM reports (Sec. 6224(c)(2)) | $1,000,000 | FY2026 MedPAC; available until expended. |
| Off-campus OPD attestation process (Sec. 6225(a), 1833(t)(23)(B)(ii)) | $20,000,000 | FY2026 CMS Program Management Account; available until expended. |
| Medicare Improvement Fund (Sec. 6228) | $2,062,000,000 | Revised total available for Medicare improvements. |
Notable Sections
- Extensions: Secs. 6201-6204, 6208-6209 extend payments for low-volume hospitals, MDH program, ambulance add-ons, APM incentives, geographic index floor, and telehealth (e.g., no geographic limits, audio-only through 2027).
- New programs/funding: Sec. 6221 creates Medicare coverage for multi-cancer early detection tests starting 2029 (payment tied to stool DNA test rates initially); Sec. 6210 extends Acute Hospital Care at Home waiver to 2030 with new study requirements; Secs. 6213-6216 add guidance, virtual DPP inclusion, outreach, and reports on telehealth/LEP, wearables.
- Restrictions/accountability: Secs. 6223-6224 impose PBM transparency/reporting, "any willing pharmacy" access, anti-retaliation, and enforcement (e.g., disgorgement, audits); Sec. 6220 requires MA plans to maintain accurate directories with cost-sharing protections; Sec. 6225 mandates separate NPI/attestations for off-campus outpatient departments.
- Controversial: PBM reforms (e.g., no spread pricing, detailed reporting) and MA directory accuracy with penalties; sequestration reduced to 2% through FY2032, 0% in late FY2033 (Sec. 6227).
Plain English
This title extends Medicare supports for rural hospitals and telehealth while boosting transparency in Part D drug pricing and adding coverage for multi-cancer blood tests, helping providers and seniors access care without major new cuts.
Title Summary
Title III extends the authorization and funding for human services programs under the Social Security Act, including Sexual Risk Avoidance Education (Sec. 510), Personal Responsibility Education (Sec. 513), Family-to-Family Health Information Centers (Sec. 501(c)), and the Temporary Assistance for Needy Families (TANF) program (Part A of Title IV). These amendments push expiration dates from early 2026 to fiscal year 2026 and through December 31, 2026, with pro rata funding where applicable. No new agencies or programs are funded; it continues existing HHS-administered initiatives.
Spending Breakdown
No specific new dollar amounts are appropriated; funding extends prior levels on a pro rata basis where noted.
| Line Item | Amount | Purpose |
| Sexual Risk Avoidance Education (Sec. 6301, amending 42 U.S.C. 710) | Extension through FY 2026 + pro rata Oct. 1–Dec. 31, 2026 | Continues grants for education exclusively on abstaining from sexual activity to prevent pregnancy and STIs |
| Personal Responsibility Education (Sec. 6302, amending 42 U.S.C. 713) | Extension through FY 2026 + pro rata Oct. 1–Dec. 31, 2026 | Continues grants for education on reducing teen pregnancy and STIs, including skills like healthy relationships |
| Family-to-Family Health Information Centers (Sec. 6303, amending 42 U.S.C. 701(c)(1)(A)) | Extension through FY 2026 + pro rata Oct. 1–Dec. 31, 2026 | Continues centers providing information on health services for families of children with disabilities or special needs |
| Temporary Assistance for Needy Families (TANF) (Sec. 6304, Part A Title IV) | Such sums as necessary through Dec. 31, 2026 | Continues TANF cash assistance, work programs, and related services (excludes sections 403(c) and 418; includes Sec. 1108(b)) |
Notable Sections
- All sections extend program authorizations without new funding levels or restrictions, shifting dates from FY 2025/early 2026 to FY 2026/Dec. 31, 2026.
- Sec. 6304 explicitly appropriates "such sums as may be necessary" for TANF continuation, ensuring no lapse.
- No new programs created; no policy changes beyond extensions.
Plain English
This title prevents funding cliffs for sex education grants, family health info centers, and welfare assistance by extending them through the end of 2026 at current levels.
Title Summary
Title IV extends mandatory funding for key public health programs under the Public Health Service Act and related laws, primarily administered by the Health Resources and Services Administration (HRSA) within HHS. It covers Community Health Centers, National Health Service Corps, Teaching Health Centers' graduate medical education, Special Diabetes Programs (for Type I diabetes and Indians), National Health Security Programs, No Surprises Act implementation, and the World Trade Center Health Program.
Spending Breakdown
| Line Item | Amount | Purpose |
| Community Health Centers (FY2024) | $4,236,712,328 | Funding for health centers serving underserved areas. |
| Community Health Centers (FY2025) | $4,295,287,671 | Funding for health centers serving underserved areas. |
| Community Health Centers (FY2026) | $4,600,000,000 | Funding for health centers serving underserved areas. |
| Community Health Centers (Oct 1–Dec 31, 2026) | $1,159,452,055 | Funding for health centers serving underserved areas. |
| National Health Service Corps (FY2024) | $341,208,605 | Scholarships and loan repayments for providers in underserved areas. |
| National Health Service Corps (FY2025) | $349,736,600 | Scholarships and loan repayments for providers in underserved areas. |
| National Health Service Corps (FY2026) | $350,000,000 | Scholarships and loan repayments for providers in underserved areas. |
| National Health Service Corps (Oct 1–Dec 31, 2026) | $88,219,178 | Scholarships and loan repayments for providers in underserved areas. |
| Teaching Health Centers GME (FY2024) | $168,915,878 | Graduate medical education in community-based settings. |
| Teaching Health Centers GME (FY2025) | $181,563,574 | Graduate medical education in community-based settings. |
| Teaching Health Centers GME (FY2026) | $225,000,000 | Graduate medical education in community-based settings. |
| Teaching Health Centers GME (FY2027) | $250,000,000 | Graduate medical education in community-based settings. |
| Teaching Health Centers GME (FY2028) | $275,000,000 | Graduate medical education in community-based settings. |
| Teaching Health Centers GME (FY2029) | $300,000,000 | Graduate medical education in community-based settings. |
| Special Diabetes Program for Type I (FY2024) | $155,619,196 | Research and initiatives for Type I diabetes (to remain available until expended). |
| Special Diabetes Program for Type I (FY2025) | $159,228,188 | Research and initiatives for Type I diabetes (to remain available until expended). |
| Special Diabetes Program for Type I (FY2026) | $200,000,000 | Research and initiatives for Type I diabetes (to remain available until expended). |
| Special Diabetes Program for Type I (Oct 1–Dec 31, 2026) | $50,410,959 | Research and initiatives for Type I diabetes (to remain available until expended). |
| Special Diabetes Program for Indians (FY2024) | $155,619,196 | Prevention and treatment for Native communities (to remain available until expended). |
| Special Diabetes Program for Indians (FY2025) | $159,228,188 | Prevention and treatment for Native communities (to remain available until expended). |
| Special Diabetes Program for Indians (FY2026) | $200,000,000 | Prevention and treatment for Native communities (to remain available until expended). |
| Special Diabetes Program for Indians (Oct 1–Dec 31, 2026) | $50,410,959 | Prevention and treatment for Native communities (to remain available until expended). |
| No Surprises Act Implementation | $42,100,000 | Funding for surprise medical billing protections (increased from $14M; available through Dec 31, 2026). |
| World Trade Center Health Program (FY2026–2040) | Formula-based (prior year × 1.07 × enrollment ratio) | Annual adjustments for 9/11 responders/survivors health care. |
Notable Sections
- SEC. 6401: Extends Community Health Centers, National Health Service Corps, and Teaching Health Centers through 2026 (partial year) or 2029, with escalating amounts; subjects funds to prior law requirements (P.L. 118-47).
- SEC. 6402–6403: Extends Special Diabetes Programs and National Health Security Programs (e.g., medical countermeasures, strategic stockpile) through Dec 31, 2026.
- SEC. 6404: Extends and triples No Surprises Act implementation funding to $42.1M through Dec 31, 2026.
- SEC. 6411: Adds inflation- and enrollment-adjusted funding formula for World Trade Center Health Program through FY2040; requires HHS report within 3 years on needs through FY2090, including modeling comparisons and recommendations.
Plain English
This title renews and boosts funding for community clinics, diabetes research, emergency health preparedness, surprise billing fixes, and 9/11 health care, keeping these services running for underserved and affected Americans through at least 2026.
Title Summary
Title V amends the Public Health Service Act to reauthorize and enhance programs under HHS agencies like CDC, HRSA, and FDA, focusing on maternal mortality prevention, organ procurement and transplantation, living donor support, pediatric drug studies, sickle cell disease treatment, lifespan respite care, preterm birth research (PREEMIE), and health provider mental health protections.
Spending Breakdown
| Line Item | Amount | Purpose |
| Preventing Maternal Deaths (Sec. 6501) | $100,000,000 annually for FY2026-2030 | Funds maternal mortality review committees and CDC dissemination of best practices to health providers |
| Program for Pediatric Studies of Drugs (Sec. 6504) | $25,000,000 annually for FY2026-2028 | Supports FDA research on drugs for pediatric populations |
| Sickle Cell Disease Prevention and Treatment (Sec. 6505) | $8,205,000 annually for FY2026-2030 | Grants/contracts for treatment and complication prevention |
Notable Sections
- Sec. 6501 creates new CDC requirement to annually disseminate maternal mortality best practices.
- Sec. 6502 authorizes temporary (3-year sunset) registration fees on OPTN members to fund network operations, with GAO review and transparency mandates.
- Sec. 6503 prohibits considering organ recipient income in living donor reimbursements and requires annual reports on funding adequacy.
- Sec. 6507 mandates HHS to establish an interagency preterm birth working group within 18 months and commissions a National Academies study on preterm births due within 24 months.
Plain English
This title extends federal authorizations for targeted public health efforts to reduce maternal and infant deaths, improve organ transplants and donor support, advance pediatric and sickle cell research, aid caregivers, and protect health workers' mental health.
Title Summary
This title enacts policy changes for the Food and Drug Administration (FDA) under Subtitle A, named the Mikaela Naylon Give Kids a Chance Act, which amends laws to expand pediatric cancer drug research requirements, strengthen enforcement of pediatric studies, require reports on compliance, extend rare pediatric disease priority review vouchers through September 30, 2029, and limit orphan drug exclusivity to specific approved uses or indications. Subtitle B establishes an Abraham Accords Office within FDA to provide technical assistance and facilitate regulatory cooperation with Abraham Accords countries on medical product oversight. No direct appropriations are provided.
Spending Breakdown
| Line Item | Amount | Purpose |
| No direct appropriations specified | $0 | N/A |
Notable Sections
- SEC. 6601: Creates new FDA authorities for molecularly targeted pediatric cancer investigations, including combinations with standard-of-care or same-sponsor adult cancer drugs; requires guidance, reports to Congress, and GAO study; applies to applications submitted 3 years post-enactment.
- SEC. 6602: Strengthens enforcement of pediatric study requirements with due diligence processes, noncompliance letters, and limitations on actions for unmarketed drugs.
- SEC. 6604: Extends rare pediatric disease priority review voucher program to 2029 and mandates GAO report on its effectiveness.
- SEC. 6605: Restricts orphan drug exclusivity to the "same approved use or indication," applying retroactively.
- SEC. 6611: Establishes Abraham Accords Office in an Abraham Accords country within 2 years for technical assistance and regulatory convergence; requires congressional report in 3 years.
Plain English
This title updates FDA rules to speed up pediatric cancer and rare disease drug development, improve study compliance, limit some drug monopolies, and set up an office to boost regulatory ties with Middle East allies under the Abraham Accords.
Title Summary
Title VII amends the Public Health Service Act, ERISA, and Internal Revenue Code to impose transparency requirements on pharmacy benefit managers (PBMs) serving group health plans and insurers, mandating semiannual (or quarterly) reports on drug pricing, claims, rebates, compensation, and formulary details. It primarily targets plans of large employers (100+ employees) or large plans (100+ participants), with summaries for smaller plans, enforced by HHS, DOL, and Treasury. Additional sections require full PBM rebate pass-through to plans and FDA disclosure of inactive ingredient matching for generics.
Spending Breakdown
No direct appropriations; implements regulatory requirements with civil penalties.
| Line Item | Amount | Purpose |
| Civil monetary penalty for failure to report/disclose | $10,000 per day | Violations of reporting, disclosure, or contract rules (Sec. 6701(d)) |
| Civil monetary penalty for false information | Up to $100,000 per item | Knowingly providing false data (Sec. 6701(d)) |
Notable Sections
- Sec. 6701: Creates new sections (PHSA §2799A-11, ERISA §726, IRC §9826) requiring PBMs to report detailed, machine-readable data on per-drug claims (e.g., compensation, rebates, out-of-pocket costs), therapeutic classes, top-spending drugs, and affiliated pharmacies; plans must provide summaries to enrollees upon request; effective 30 months post-enactment; privacy via HIPAA; limited reports for plans tied to drug makers.
- Sec. 6702: Amends ERISA §408(b)(2) to mandate 100% pass-through of PBM rebates/fees to plans quarterly; exception shields "innocent" fiduciaries if they reasonably believed compliance and notify DOL; deems PBM arrangements "indirect" services subject to fiduciary rules.
- Sec. 6703: Amends FD&C Act §505(j)(3) requiring FDA, upon request, to confirm if ANDA drug matches listed drug's inactive ingredients qualitatively/quantitatively; draft guidance due in 1 year.
Plain English
This title forces PBMs to fully disclose drug costs, rebates, and profits to employer health plans and pass along all rebates, while making FDA reveal generic ingredient matches, aiming to help control prescription prices.