State Action on Medicaid and other State Buy-in Initiatives

Momentum continues to build behind Medicaid buy-in proposals in many different states. State are at different points in the policy development and political process, with some completing formal studies, while others are still broadly exploring the policy as one of many options to improve affordability and access.  



2019 Activity: No activity.

Previous Activity: The state’s newly established Council on Health Care Delivery Systems is tasked with preparing a feasibility analysis on a public health insurance plan option to increase competition and choice for health care consumers. While the Council is not specifically studying Medicaid buy-in, it establishes a formal process through
which policymakers can consider pathways to creating a public option. The Council became effective on January 1, 2019.



2019 Activity: Legislation signed into law.

State Summary: Two pieces of legislation (HB19-1004 / SB19-004) have been signed into law.

Summary - HB19-1004: Requires the Department of health care policy to develop and submit a proposal concerning the design, costs, benefits, and implementation of a state option for health care coverage that leverages existing state infrastructure.

Current status: Signed by Governor Polis on Friday, May 17.

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Summary - SB19-004: Upon completion of a feasibility study, authorizes a pilot program allowing select individuals in counties with high premiums to participate in the group medical benefit plans offered to state employees. The plan would be open to individuals earning between 400-500% FPL.

Current status: Signed by the Governor on Friday, May 17.

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Previous Activity: Legislation to require the state’s Department of Health Care Policy and Financing and the Division of Insurance to study three options for health care coverage, including a Medicaid Buy-in, was introduced but not enacted. Manatt Health Strategies produced an initial report on buy-in options for the state in December 2018.   



2019 Activity: Legislation moving.

State Summary: Five bills (H.B. No. 7267/S.B.134, S.B.1004, H.B. No. 7339, and HB 7360) related to a public option were introduced in the Connecticut legislature this session.

Current Status: All bills were heard in their respective committees and reported favorably to the General Assembly. H.B. No. 7267 housed the public option language taken from the other four bills.

While legislation containing a public option served as a jumping off point for negotiations among legislators and the executive branch, state leaders ultimately developed a new type of public-private partnership that will offer Connecticut residents a lower cost plan starting in 2022.  H.B. No 7267 will be amended to include the final language for Connecticut’s health reform package, which no longer contains a public option.

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Previous Activity: Legislation to create a Medicaid public option called the “Husky E plan” available to people not otherwise eligible for Medicaid was introduced in the General Assembly but did not advance.  Husky E would have included Affordable Care Act Essential Health Benefits, and the legislation directed state officials to study whether to apply for a waiver to allow consumers to utilize premium tax credits and cost sharing reductions to purchase this coverage.  Husky E would be funded by premiums assessed based on the results of an actuarial analysis, with excess funding over plan cost used to increase provider reimbursement rates. 



2019 Activity: Study Group Final Report completed.

Previous Activity: In June 2018, Delaware approved a Senate Concurrent Resolution authorizing the creation of a Medicaid Buy-in Study Group to study allowing residents earning more than 138% of the FPL to purchase coverage through the Medicaid program. The group was  co-chaired by majority members of the State House and Senate and consists of other legislative leaders along with representatives of the Department of Health and Human Services, the Medical Society of Delaware, the Delaware Healthcare Association, and the insurance industry.



2019 Activity: No activity.

Previous MBI Activity: State Senate legislation to create “Healthy Iowans for a public option” for those not otherwise eligible for Medicaid and without affordable employer insurance was introduced in January 2018 and did not advance.   The coverage would be available on the state’s Exchange and people could use premium tax credits and cost sharing reductions, and would be administered through the Iowa Medicaid Enterprise.  A separate section of the legislation would have terminated the state’s Medicaid managed care contracts. 

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2019 Activity: Legislation Introduced

State Summary: Legislation has been introduced and referred to committee.

Summary: L.D. 109 / H.P. 91: Would establish a public health insurance option available through the State Employee Health Insurance Program.

Current Status:
Referred to Committee on Health Coverage, Services and Financial Services.



2019 Activity: No activity.

Previous Activity: Legislation was introduced in the state Assembly to create a Task Force to make recommendations about the feasibility of a Medicaid Buy-in.  The state Senate amended companion legislation to instead create a Maryland Health Insurance Coverage Protection Commission, which, among other duties,  would make recommendations on the feasibility of a Medicaid Buy-in. Neither version of the legislation was enacted. 



2019 Activity: Legislation introduced.

State Summary: A bill (S.697) has been introduced and referred to the Joint Committee on Health Care Financing.

Summary - S.697: Provides a public health insurance option through the CommonWealth Connector (state-based Marketplace). The plan would be open to all residents without affordable employer insurance and would be required to meet the same standards for quality and value as other plans sold on the Connector. The state would contract with Medicaid managed care organizations or other such health benefits administrators to administer the plan. Premiums would be set at a level sufficient to fully finance the cost of offering the plan. The plan would reimburse providers at Medicare rates. The bill allows for a risk-adjustment payment to the public option plan and all other plans offered through Connector.

Current Status: Introduced and referred to the Joint Committee on Health Care Financing on Feb 28, 2019. No hearing date scheduled yet.

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Previous Activity: The Massachusetts Senate passed wide ranging health care legislation (S.2211) in November 2017, which included a provision allowing for employers and individuals to buy into the state’s MassHealth plan as part of a larger effort to address health care affordability. This bill also called on the state’s Office of Medicaid to issue a report by October, 1 2018 discussing whether or not an expanded plan will be implemented.  Companion state House legislation, Bill H.4617, introduced late in June 2018, did not include a MassHealth buy-in program, and business leaders and insurance providers expressed discomfort with the idea of a public option for fear of hurting private insurance markets and raising state costs. Efforts to reconcile the House and Senate proposals were ultimately unsuccessful.



2019 Activity: Legislation Moving.

State Summary: Eight bills (HF 3 / SF 1080, HF27 / SF719, SF720 SF684) have been introduced and are currently in committee. Two of those bills (HF 3 and HF 273) have been heard in committee.

Summary - HF 3 / SF 1080: Establishes a MinnesotaCare buy-in program open to all Minnesotans. HF3 was amended in committee to replace a MinnesotaCare buy-in with the Governor Walz’s “OneCare” buy-in plan. OneCare would provide a platinum buy-in product in all areas of the state starting in 2023 and silver and gold products in areas without adequate plan coverage starting in 2024. The omnibus bill passed by the House did include dollars for ONECare.

Summary - HF 273/SF 90: Exempts spouses of individuals with access to affordable employer-sponsored insurance from restrictions that prohibit them from enrolling in MinnesotaCare if the cost of the employer’s insurance exceeds 9.86% of the employee’s income to cover both the employee and any dependents.

Current status: Although HF 3 and HF 273 were heard in multiple committees in the House, their Senate companion bills (SF 1080 and SF 90) did not receive a hearing in the Senate. Neither piece of legislation was passed on its own or as a part of the Health and Human Services Omnibus bill.

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Other legislation summaries: The other bills introduced in Minnesota are slightly different variations of a MinnesotaCare buy-in. HF 27 / SF 719 would allow individuals with incomes above 200% FPL to use federal tax credits to purchase buy into coverage through MinnesotaCare. SF 720 would be open to individuals who are eligible for QHPs or with incomes above 400% FPL. SF 684 limits buy-in plans to counties without adequate coverage options while allowing individuals above 400% FPL to use federal tax credits and cost-sharing reductions to purchase plans.

Current status: All bills have been introduced, with House bills referred to the House Health and Human Services Policy Committee and Senate bills referred to the Senate Health and Human Services Finance and Policy Committee. None of these bills passed on their own or as a part of the Health and Human Services Omnibus bill.

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Previous Activity: In early 2017, bills were introduced in the Minnesota House and Senate calling for state legislators to expand access to MinnesotaCare, the state’s basic health program (BHP), to all Minnesota residents regardless of income. Supported by Gov. Mark Dayton, the MinnesotaCare buy-in would be funded through monthly premiums paid by enrollees, limiting the financial burden on taxpayers. MinnesotaCare would offer a Gold and Silver plan through the state’s health insurance marketplace, MNsure, and all health plans currently offering managed care services for Medicaid and the BHP would also be required to provide at least one buy-in option for consumers. To alleviate concerns from Minnesota hospitals and doctors about receiving lower payments for their services from those on MinnesotaCare plans, they would instead be reimbursed at federal Medicare rates, which are typically higher than those for Medicaid.

Minnesota’s proposal underwent a detailed actuarial analysis, allowing proponents to estimate average premiums and potential savings for families across the state. However, the Republican-controlled legislature adjourned without holding a hearing or advancing the bill. 



2019 Activity: Legislation introduced.

State Summary: Legislation (HB 544) has been introduced to “investigate the merits of Medicaid Buy-in program”. The bill requires the joint committee on legislative research to investigate the merits of a Medicaid buy-in program including:

• Medicaid-like product sold off the exchange for those not eligible for Medicare, Medicaid, or ACA premium tax credits

• Medicaid-like product sold off he exchange for everyone not eligible for Medicaid

• Low-cost state option sold on the exchange

• Offering a basic health program

Current status: Introduced



2019 Activity: Study completed.

Current Status:  Collaboration between legislators and stakeholders is ongoing regarding the development of legislation for introduction in 2019.

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Previous Activity: Sprinklecare” passed and was vetoed in 2017. Senate Bill 374 was enacted in 2017, creating a study with a deadline of Sept. 1, 2018. The study has since been completed.

New Jersey

New Jersey

2019 Activity: Legislation Introduced

State Summary: A bill (S3380) has been introduced and is currently in committee.

Summary - S3380: Expands availability of NJ FamilyCare Advantage program. Coverage would be known as the NJ FamilyCare
Advantage health care plan and would be a QHP available through the Federal Exchange, with premiums and copayments assessed on a sliding scale. The plan could be purchased using federal tax credits.

Current Status: Referred to Senate Health, Human Services and Senior Citizens Committee

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Previous Activity: A1343 / S561: “New Jersey Public Option Health Care Act” was introduced in the NJ House and Senate in January 2018, but neither chamber held a vote.



2019 Activity: Study legislation moving.

State Summary: Legislation (HB277) has been introduced that would establish a commission to study a public option program

Current status: March 19th - Passed the House 211-141. Senate Commerce committee held a hearing on May 7th.


New Mexico

2019 Activity: Study enacted.

State Summary: The legislature approved funding for a Medicaid buy-in study and development of a buy-in plan that seeks any federal waiver necessary.

Summary - The legislature voted to appropriate funds (through SB 536 and HB 548) to the Human Services Department to study and begin “administrative development” of a Medicaid Buy-in plan, including pursuing federal funding through a 1332 waiver. This study builds on the initial study done in early 2019 showing the merits of different Medicaid buy-in options for the state.  

Current Status - Funding for the study is allocated for FY 2020.

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Previous Activity: Last year, a bipartisan majority of the New Mexico state legislature passed a Memorial calling on the Legislative Health and Human Services Committee to study the potential for a Medicaid buy-in in the state. Mannatt Health Strategies is conducting a two phase analysis of policy options.  Mannatt expects to complete their work, which will include an actuarial analysis, by the end of 2018. In the meantime, momentum for Medicaid buy-in in the state continues to build, with five different local councils and governments, representing roughly 50 percent of the states’ overall population, passing resolutions in support of the initiative.



2019 Activity: Legislation moving and Study Completed

State Summary - HB 2009 / HB 2012 / HB 3185, introduced by Representative Salinas, Chair of the Universal Access to Healthcare Workgroup, would establish a Medicaid buy-in option. The Universal Access to Care Work Group generally supports Medicaid buy-in as an incremental step to increasing health coverage. The work group supports a program offered off the exchange that targets lower-income individuals and families not eligible for Medicaid or Marketplace subsidies

Current Study Status: Study complete. The work group may continue its work after the 2019 legislative session at the formal request of the chair of the House Committee on Health Care

Summary - HB 2009 Would allow individuals who don't qualify for medical assistance or premium tax credits under the ACA to enroll in coordinated care organizations by paying premiums that cover the actuarial value of health services. It also imposes a State Shared Responsibility Penalty/individual mandate.

The buy-in would cover any individual between 138%-400% FPL, and those between 400%-600% FPL who are required to pay the full cost of their premium in an employer-sponsored plan.  

Summary - HB 2012 has the same provisions, but excludes the State Shared Responsibility Penalty.

Summary - HB 3185 would allow individuals and employers on behalf of employees to enroll in the state medical assistance program upon payment of premiums prescribed by Oregon Health Authority. It would allow enrollees to choose a coordinated care organization or services paid on fee-for-service basis.

Current Status: HB 2009 and HB 3185 had a public hearing in the House Committee on Health Care on March 14 and remains in committee. HB 2012 passed the House Committee on Health Care as amended and was referred to the joint committee on Ways and Means.

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Previous Activity: Last year, the state’s Universal Access to Health Care work group studied different conceptual proposals, including 3 different approaches to buy-in: one that would make Medicaid available off-Exchange for purchase by those who are not eligible, an option to allow consumers eligible for premium tax credits to use those tax credits to purchase coverage, and one that would align provider networks in Medicaid and the Marketplace to enhance care continuity.



2019 Activity: Legislation signed into law.

State Summary: Two corresponding bills (HB 1523 / SB 5526) were introduced in the State House and Senate this session. SB 5526 was ultimately brought to conference committee, passed by the general assembly, and signed by the Governor.

Summary - HB 1523 / SB 5526 are companion bills that require the state health care authority to contract with one or more health carriers to offer bronze, silver, and gold standardized qualified health plans on the state health benefit exchange for plan years beginning in 2021.

Current Status: SB 5526 went through committee in the Senate and House, it was ultimately compromised on in conference committee and language was passed 56-41 in the House, and 27-21 in the Senate. The bill was signed by the President of the Senate and the Speaker of the House on April 28, and was signed into law by the Governor on May 13th.

HB 1523 passed through the House chamber and remains in committee in the Senate.

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Previous Activity: Legislation to create the Apple health public option was introduced in the state Senate, but did not advance.  The legislation required the apple health option to be offered by managed care plans, and directed the health authority to increase rates for providers participating in both apple health and the apple health public option. Coverage would include essential health benefits, including reproductive care, and be actuarially equivalent to silver Exchange plan.  The legislation also instructed state officials to explore regional risk pools or purchasing options with Oregon and California.



2019 Activity: No activity.

Previous Activity: Legislation to create a Medicaid buy-in was introduced in both the Assembly and Senate in 2017.  The proposals would have allowed people earning too much to be eligible for the state’s Badgercare Plus or childless adult demonstration to purchase this coverage.  The legislation stipulated that coverage would have an actuarial value of at least 87%, with a premium similar to the average paid by the state to managed care. The legislation also directs the state Department of Health Services to “maximize efficiency” and improve continuity of care” and to implement mechanisms to minimize adverse selection, negative impacts on premiums in the individual and group insurance markets, and to minimize the state’s financial risk, but does not provide additional details on what mechanisms the state could employ to achieve these goals.   



2019 Activity: No Activity.

Previous Activity: Legislation introduced in the state Senate in February 2018 to create a Medicaid buy-in as part of a larger health reform package, was defeated by a margin of 7-23 shortly after its introduction.