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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.  

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California:

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.

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Colorado

2019 Activity: Legislation moving.

State Summary: Two pieces of legislation (HB19-1004 / SB19-004) have been introduced and are in committee.

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: Crossed over the Senate Health & Human Services Committee Hearing (3/13/19).

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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: Senate Health & Human Services Committee Hearing scheduled for 3/29/2019

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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.   

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Connecticut: 

2019 Activity: Legislation moving.

State Summary: Four bills (HB 6894 / HB 5722 / HB 5855 / SB 32) have been introduced and are currently in committee.

Summary - H.B. No. 7267: Establishes the ConnectHealth Program (a public insurance option). The purpose of the program is to offer high-quality, low-cost health insurance coverage. Eligibility and other program criteria will be developed by the Comptroller, Advisory Council, and Office of Health Strategy. The bill would also offer coverage under the state employee plan to small employers and their employees.  

Current Status: Referred to Joint Committee on Insurance and Real Estate. Committee voted 11-8 on March 19th to report HB7267 favorably.  

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Summary - S.B.134 / S.B.1004: A bill to enable small businesses and small business employees to participate in the state employee health plan.

Current Status: SB 134 referred to Joint Committee on Insurance and Real Estate. Hearing held on March 7th. Committee voted 11-8 on March 19th to report SB134 favorably

SB 1004 referred to the Joint Committee on Labor and Public Employees. Hearing held on March 12th. Committee voted 11-3, in a bipartisan vote, on March 14th to report SB1004 favorably

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Summary - H.B. No. 7339: Requires a work group to to make recommendations concerning the establishment of a public health insurance coverage option not later than January 1, 2021.

Current Status: Referred to Joint Committee on Human Services. Hearing held on March 19th. Committee voted 11-7 on March 21st to report HB7339 favorably.

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Summary - H.B. No. 6894: Requires the Office of Health Strategy to develop a Medicaid Public Option plan.

Current Status: Referred to Joint Committee on Human Services

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Summary - H.B. No. 5722: Establishes a public health insurance option

Current Status: Referred to Joint Committee on Insurance and Real Estate

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Summary - H.B. No. 5855: Would establish a task force to study the feasibility, and best method, of implementing a public health insurance option in this state.

Current Status: Referred to Joint Committee on Insurance and Real Estate

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Summary - S.B. No. 32: Would establish a public health insurance option available through the Connecticut Health Insurance Exchange.

Current Status: Referred to Joint Committee on Insurance and Real Estate

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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. 

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Delaware

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.

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Iowa: 

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. 

The standardized plans must be designed to reduce deductibles, make more services available before the deductible, provide predictable cost sharing, maximize subsidies, limit adverse premium impacts, reduce barriers to maintaining and improving health, and encourage choice based on value, while limiting increases in health plan premium rates.

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MARYLAND

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. 

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Massachusetts

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 for offering 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.

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Minnesota:

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.

HF3 / SF 1080: Would allow all Minnesotans to buy into the state’s MinnesotaCare program. HF3 was amended by replacing 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.

Current status: HF 3 was heard in the Commerce Committee on March 13, 2019 and then re-referred to the Government Operations Committee.

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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: HF 273 was heard in the House Health and Human Services Policy Committee on March 6, 2019. The committee voted 9-7 to advance the bill to the House Ways and Means Committee. SF 90 was introduced and referred to the Senate Health and Human Services Finance and Policy Committee.

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Summary - HF27 / SF719: Would establish a purchase option allowing residents to buy into coverage through MinnesotaCare (the state’s Basic Health Program). The bill requires the commissioners of Human Services and Commerce to submit a proposal for the purchase option by March 2020. The bill authorizes the administration to seek a federal waiver allowing individuals with incomes above 200% FPL to use federal tax credits to purchase buy into coverage through MinnesotaCare.

Current status: HF 27 introduced, referred to House Health and Human Services Policy Committee. SF 719 introduced, referred to Senate Health and Human Services Finance and Policy Committee.

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Summary - SF720: Beginning January 2021 (or after approval of a federal waiver) the bill would establish a MinnesotaCare Buy-In Option health plans to be sold through MNsure (the state-based Marketplace). Individuals eligible to purchase a qualified health plan (QHP) and with an income over 400% FPL would be eligible to purchase these plans.

Current status: Referred to Senate Health and Human Services Finance and Policy Committee.

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Summary - SF684: As in SF720, beginning January 2021, this bill establishes MinnesotaCare Buy-In Option health plans to be sold through MNsure but limits availability to counties without adequate coverage options. Plans may be purchased by anyone eligible to purchase a QHP including individuals earning less than 400% FPL. Individuals with incomes below 400% FPL may qualify for federal premium tax credits and cost-sharing reductions toward purchase of these plans.

Current status: Referred to 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 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. 

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MISSOURI: 

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

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Nevada

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.

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NEW HAMPSHIRE: 

2019 Activity: Study legislation introduced.

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

Current status: The House Commerce and Consumer Affairs Committee held a hearing on January 23rd. The bill is due out of committee by March 14th 

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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.

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Oregon

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.  

HB 2012 has the same previsions, but excludes the State Shared Responsibility Penalty.

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: All three bills had a public hearing in the House Committee on Health Care on March 14 and remain in committee.

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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.

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Washington: 

2019 Activity: Legislation moving.

State Summary: Two corresponding bills (HB 1523 / SB 5526) have been introduced in the State House and Senate and are currently in committee.

Summary - HB 1523 / SB 5526 Requires the state health care authority to contract with one or more health carriers to offer silver and gold qualified health plans on the state health benefit exchange for plan years beginning in 2021. The plans offered must be ‘standardized health plans’ and pay fee-for-service provider rates that do not exceed Medicare rates.

Standardized health plans are plans that offer coverage subject to specified coverage requirements, such as actuarial values, cost sharing, and benefits. Pursuant to state and federal law, standardized Medicare supplemental insurance plans are offered in Washington.
Standardized individual market health plans are offered on the health benefit exchanges in several states.

Current Status: On March 13, SB 5526 passed the Senate by a 36 to 13 vote. The House counterpart bill is scheduled for a public hearing on March 26 and an executive session on March 27 in House Committee on Health Care & Wellness.

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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.

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Wisconsin: 

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.   

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WYOMING: 

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.