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 and will run until January 1, 2022.



2019 Activity: Legislation signed into law.

State Summary: Legislation (HB19-1004) has been signed into law.

Summary - HB19-1004: Requires the Department of Health Care Policy and Financing and the Division of Insurance 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. The proposal is due November 15, 2019. Signed by Governor Polis on May 17, 2019.

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Previous Activity: In 2018, legislation (HB18-1384) was introduced but not signed into law, 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. Manatt Health Strategies produced an initial report on buy-in options for the state in December 2018.  



2019 Activity: Legislation introduced.

State Summary: Five bills (H.B. No. 7267/S.B.134, S.B.1004, H.B. No. 7339, and HB 7360) were introduced and responded to favorably, but did not advance further.

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Summary - H.B. No. 7267/ S.B. No. 134: Would establish the ConnectHealth Programa public insurance option). The purpose of the program was to offer high-quality, low-cost health insurance coverage. Eligibility and other program criteria would be developed by the Comptroller, Advisory Council, and the Office of Health Strategy. The bill would also have offered coverage under the state employee plan to small employers and their employees.  

HB7267 was voted favorably and tabled for the calendar in the Senate. SB134 was voted favorably and tabled for the calendar in the Senate.  Due to concerns raised by some stakeholders, the Comptroller, Governor Lamont and legislative leaders negotiated an alternative proposal called the “Connecticut Option.”  It was a public-private partnership that would have lowered premium costs by 20%.  The “Connecticut Option” ran out of time to pass this session, but Connecticut did pass an appropriation to expand its Medicaid program, Husky Health, to 4,000 parents and caregivers.  Governor Lamont and legislative leaders have committed to working on the “Connecticut Option” next year.

Summary - S.B. No. 1004: Would enable small businesses and small business employees to participate in the state employee health plan. S.B.1004 was clone to portions of H.B. 7267/S.B. 134. On April 2, 2019, it was voted favorably and tabled for calendar in the Senate. 

Summary - H.B. No. 7339: Would create a working group to study a public option for individuals with income below 400% FPL. Would require recommendations no later than January 1, 2022. H.B.7339 was clone to portions of H.B. 7267/S.B. 134. Voted favorably and tabled for calendar in House on April 4, 2019.

Summary - H.B. No. 7360: Would expand the types of health care plans that the comptroller must offer to non-state public employers. H.B.7360 was clone to portions of H.B. 7267/S.B. 134. Voted joint favorably by the Appropriations Committee on May 13th, and tabled for the calendar in the House on May 15, 2019.

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Previous Activity: In 2018, legislation (H.B. No. 5463) was introduced to create a Medicaid public option called the “Husky E plan” that would be available to people not otherwise eligible for Medicaid. H.B. No. 5463 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 how a waiver application may allow consumers to utilize premium tax credits and cost sharing reductions to purchase this coverage.  Husky E would be funded by premiums based on the results of an actuarial analysis, with excess funding over plan cost used to increase provider reimbursement rates. 



2019 Activity: Study 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: In January 2018, State Senate introduced legislation (SF 2035) to create Healthy Iowans as a public option for individuals not otherwise eligible for Medicaid and without affordable employer insurance, but it did not advance. The coverage would have been available on the state’s Exchange, where people could have used premium tax credits and cost sharing reductions, and would have been 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: L.D. 109 / H.P. 91, an act to create a public option, was introduced and referred to committee.

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Summary: L.D. 109 / H.P. 91: Would establish a public health insurance option available through the State Employee Health Insurance Program. Received opposition by the Committee on Health Coverage, Insurance and Financial Services on May 16, 2019.

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2019 Activity: No activity.

Previous Activity: In 2018, legislation (HB 1312) 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 (SB 0878) to instead create a Maryland Health Insurance Coverage Protection Commission, which would make recommendations on the feasibility of a Medicaid Buy-in, among other duties. Neither version of the legislation was signed into law.



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: Would provide 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 would allow for a risk-adjustment payment to the public option plan and all other plans offered through Connector. Introduced and referred to the Joint Committee on Health Care Financing on January 22, 2019. No hearing date scheduled.

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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 (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 Introduced.

State Summary: Eight bills (HF 3 / SF 1080, HF27 / SF719, SF720 SF684) were introduced and sent to committee. Two of those bills (HF 3 and HF 273) were heard in committee.

Summary - HF 3 / SF 1080: Would establish a MinnesotaCare buy-in program open to all Minnesotans. HF 3 was amended in committee to replace a MinnesotaCare buy-in with the Governor Walz’s “OneCare” buy-in plan. OneCare would have provided 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. HF 3 moved through the House, with hearings on the bill held in the Health and Human Services Policy Committee, the Commerce Committee, the Government Operations Committee, and most recently in the Health and Human Services Finance Committee on March 29, 2019. OneCare passed the House in the omnibus health and human services bill, but was not included in the final budget bill.

Summary - HF 273 / SF 90: Would exempt 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. HF 273 was heard in the House Health and Human Services Policy Committee on March 6, 2019. The committee voted 7-9 to re-refer the bill to the House Committee on Ways and Means. HF 273 was included in the House health and human services omnibus bill, but it was not a part of the final budget bill. SF 90 was introduced and referred to the Senate Family Care and Aging Committee.

Other Legislation Summaries: The other bills introduced in Minnesota were 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 coverage through MinnesotaCare. SF 720 would open MinnesotaCare to individuals who are eligible for QHPs or with incomes above 400% FPL. SF 684 would limit 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 were 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.

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Previous Activity: In early 2017, bills were introduced in the Minnesota House and Senate that called 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, allowed 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 554) was 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



2019 Activity: New study legislation signed into law.

State Summary:  A resolution (S.C.R. 10) authorizing the Nevada Legislative Commission to further study the feasibility of a public option health plan available to all state residents was introduced and passed in June 2019.

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Previous Activity: Sprinklecare” passed and was vetoed in 2017. SB394 was enacted in 2017, creating a study with a deadline of September 1, 2018. The study has since been completed.



2019 Activity: Study legislation introduced.

State Summary: Legislation (HB277) was introduced that would establish a commission to study a public option program. On March 19, 2019, HB277 passed the House 211-141. Senate Commerce Committee held a hearing on May 7, 2019, which led to the adoption of an amendment. It was engrossed on June 11, 2019.

New Jersey

New Jersey

2019 Activity: Buy-in legislation introduced and study legislation signed into law.

State Summary: Legislation (S3380) was introduced to create a buy-in to the state’s publicly funded insurance program; it went to committee, but has not passed. Other legislation (A5600) authorizes the state to study a buy-in plan through the Fiscal Year 2020 Appropriations Act.

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. S3380 was referred to the Senate Health, Human Services and Senior Citizens Committee on January 24, 2019.

Summary - A5600: Instructs the Commissioner of Banking and Insurance to commission an analysis of options for the state to provide more affordable health coverage in the individual market, to include an option to allow consumers to purchase Medicaid, Medicaid-like, or NJ FamilyCare plans. Governor Murphy signed the Fiscal Year 2020 Appropriations Act (A5600) on June 30, 2019.

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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.


New Mexico

2019 Activity: Study passed.

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 with broad bipartisan support 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. Funding for the study is allocated for FY 2020.

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Previous Activity: In 2018, 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. Manatt Health Strategies conducted a two phase analysis of policy options. Momentum for Medicaid buy-in in the state continues to build. In 2018, five different local councils and governments, representing roughly 50 percent of the states’ overall population, passed resolutions in support of the initiative.



2019 Activity: Buy-in legislation signed into law; previous 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. S.B. 770 creates a Task Force on Universal Health Care and authorizes the Oregon Health Authority to develop a plan for a buy-in program as part of the state’s move toward universal health coverage.

Summary - H.B. 2009: Would have allowed 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 would have imposed a State Shared Responsibility Penalty, or 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: Had the same provisions as H.B. 2009, but excluded the State Shared Responsibility Penalty.

Summary - HB 3185: Would have allowed 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 also allow enrollees to choose a coordinated care organization or services paid on fee-for-service basis.

Summary - S.B. 770: Requires the Oregon Health Authority to develop a plan for a Medicaid Buy-In program. A report is due to the legislature no later than May 1, 2020, regarding eligibility requirements, options for targeting, and recommendations for legislative changes. Federal approval is needed for plan implementation.

Current Status: Public hearings in the House Committee on Health Care were held on H.B. 2009 and H.B. 3185 on March 14, 2019. Both bills were still in committee when the legislature adjourned. H.B. 2012 passed the House Committee on Health Care as amended and was referred to the Joint Committee on Ways and Means, where it remained through adjournment. A public hearing was held on S.B. 770 in the Senate Committee On Health Care on April 1, 2019, and a modified version of the bill was successfully passed on the last day of session.

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Previous Activity: In 2018, 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 another that would align provider networks in Medicaid and the Marketplace to enhance care continuity. The work group’s final report was published in December 2018.



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. S.B. 5526 was ultimately brought to conference committee, passed by the general assembly, and signed by the Governor. H.B. 1523 / S.B. 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. After negotiations in Conference Committee, S.B. 5526 passed 56-41 in the House, and 27-21 in the Senate. The bill was signed by the Governor on May 13, 2019.

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Previous Activity: In 2017, legislation (SB 5984) 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 the 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.

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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.

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Previous Activity: Legislation (SF0088) 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.