H.R. 3995: State Public Option Act

The State Public Option Act aims to establish a public health insurance option by allowing individuals to buy into Medicaid coverage. Here are the main components of the bill:

Medicaid Buy-In Option

• The bill amends the Social Security Act to create a structure where eligible individuals can enroll in Medicaid starting January 1, 2026. This includes individuals who are not currently enrolled in any other health insurance plan.
• Individuals will pay premiums and other cost-sharing fees, enabling them access to Medicaid benefits.
• States will be required to offer this buy-in option through their health insurance exchanges.

Coverage Requirements

• The Medicaid buy-in program must provide at least minimum essential health coverage as specified by federal guidelines. This will include coverage for a range of medical services.
• The bill places limits on the premiums charged, capping them at 8.5% of the household income.
• Cost-sharing requirements will align with existing ACA guidelines, ensuring that Medicaid participants are eligible for cost-sharing reductions under the Affordable Care Act.

Financial Incentives

• The bill introduces enhanced federal funding amounts for state administrative costs related to the Medicaid buy-in program, contributing up to 90% for reasonable administrative expenses.
• States that collect premiums will remit a percentage of excess revenues to the federal government.

Managed Care and Quality Measures

• Legislation mandates that states provide updated quality measures for the population opting into the buy-in program.
• States will be empowered to implement managed care solutions for Medicaid buy-in participants, ensuring quality and cost-effectiveness in healthcare delivery.

Coverage for Sexual and Reproductive Health Services

• The bill requires that comprehensive sexual and reproductive health services, including abortion services, are included in the Medicaid coverage offered under the buy-in option.
• States may need to modify their Medicaid plans to ensure that these services are available as part of the health coverage offered to eligible individuals.

Funding for Implementation

• The bill allocates $50 million for the fiscal year 2026 to support states in updating and implementing necessary quality measures and operational adjustments related to the buy-in program.

Impact on Providers

• Medicaid reimbursement rates for primary care services will be updated to ensure they are at least equal to those in Medicare, encouraging participation from healthcare providers.

Enrollment Procedures

• States will have the autonomy to set specific enrollment periods for the Medicaid buy-in program, which may mirror existing ACA exchange enrollment windows.
• The bill allows for the use of advance premium tax credits to offset costs for eligible individuals purchasing Medicaid coverage.

Relevant Companies

• None found