I 
116TH CONGRESS 
1ST SESSION H. R. 1277 
To establish a State public option through Medicaid to provide Americans 
with the choice of a high-quality, low-cost health insurance plan. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 14, 2019 
Mr. LUJA´N (for himself, Mr. BLUMENAUER, Mr. CARSON of Indiana, Mr. 
CICILLINE, Ms. CLARK of Massachusetts, Ms. CLARKE of New York, Mr. 
COHEN, Mr. DESAULNIER, Mr. MICHAEL F. DOYLE of Pennsylvania, Mr. 
ENGEL, Ms. FUDGE, Mr. GALLEGO, Mr. GARAMENDI, Ms. HILL of Cali-
fornia, Ms. JAYAPAL, Mr. KHANNA, Mr. KRISHNAMOORTHI, Ms. MATSUI, 
Ms. MCCOLLUM, Mrs. NAPOLITANO, Mr. NEGUSE, Ms. NORTON, Ms. 
OMAR, Mr. PERLMUTTER, Mr. POCAN, Mr. ROUDA, Ms. ROYBAL- 
ALLARD, Mr. SCHIFF, Ms. SCHRIER, Mr. TAKANO, Ms. TITUS, Mr. 
TONKO, Mrs. WATSON COLEMAN, Mr. WELCH, Ms. VELA´ZQUEZ, Ms. 
MOORE, Mr. COX of California, Ms. WILD, Ms. KUSTER of New Hamp-
shire, Ms. SCHAKOWSKY, and Mr. CLAY) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committee on Ways and Means, for a period to be subse-
quently determined by the Speaker, in each case for consideration of such 
provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To establish a State public option through Medicaid to pro-
vide Americans with the choice of a high-quality, low- 
cost health insurance plan. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘State Public Option 
Act’’. 
SEC. 2. MEDICAID BUY-IN OPTION. 
(a) IN GENERAL.—Section 1902 of the Social Secu-
rity Act (42 U.S.C. 1396a) is amended— 
(1) in subsection (a)(10)— 
(A) in subparagraph (A)(ii)— 
(i) in subclause (XXI), by striking ‘‘; 
or’’ and inserting a semicolon; 
(ii) in subclause (XXII), by adding 
‘‘or’’ at the end; and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(XXIII) beginning January 1, 
2020, who are residents of the State 
and are not concurrently enrolled in 
another health insurance coverage 
plan, subject, in the case of individ-
uals described in subsection (qq) and 
notwithstanding section 1916 (except 
for subsection (k) of such section), to 
payment of premiums or other cost- 
sharing charges;’’; and 
(B) in the matter following subparagraph 
(G), in clause (XV), by inserting ‘‘or subsection 
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(qq)’’ 
after 
‘‘described 
in 
subparagraph 
(A)(i)(VIII)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(qq) PREVIOUSLY UNDESCRIBED INDIVIDUALS.— 
Individuals described in this subsection are individuals 
who are— 
‘‘(1) described in subclause (XXIII) of sub-
section (a)(10)(A)(ii); and 
‘‘(2) are not described in any other subclause of 
such subsection or any other provision in this Act 
which provides for eligibility for medical assist-
ance.’’. 
(b) PROVISION OF AT LEAST MINIMUM COVERAGE.— 
(1) IN GENERAL.—Section 1902(k)(1) of the 
Social Security Act (42 U.S.C. 1396a(k)(1)) is 
amended by inserting ‘‘or an individual described in 
subsection (qq)’’ after ‘‘an individual described in 
subclause (VIII) of subsection (a)(10)(A)(i)’’ each 
place it appears. 
(2) 
CONFORMING
AMENDMENT.—Section 
1903(i)(26) of the Social Security Act (42 U.S.C. 
1396b(i)(26)) is amended by striking ‘‘individuals 
described 
in 
subclause 
(VIII) 
of 
subsection 
(a)(10)(A)(i)’’ and inserting ‘‘individuals described 
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in subsection (a)(10)(A)(i)(VIII) or (qq) of section 
1902’’. 
(c) FEDERAL FINANCIAL PARTICIPATION IN BUY-IN 
PROGRAM.— 
(1) ENHANCED
MATCH
FOR
ADMINISTRATIVE 
EXPENSES.—Section 1903(a) of the Social Security 
Act (42 U.S.C. 1396b(a)) is amended— 
(A) by redesignating paragraph (7) as 
paragraph (8); and 
(B) by inserting after paragraph (6) the 
following new paragraph: 
‘‘(7) an amount equal to 90 percent of the 
sums expended during such quarter which are at-
tributable to reasonable administrative expenses re-
lated to the administration of a Medicaid buy-in pro-
gram 
for 
individuals 
described 
in 
section 
1902(a)(10)(A)(ii)(XXIII); plus’’. 
(2) TREATMENT OF PREMIUM AND COST-SHAR-
ING REVENUES FROM MEDICAID BUY-IN PROGRAM.— 
(A) IN GENERAL.—For purposes of section 
1903(a)(1) of the Social Security Act (42 
U.S.C. 1396b(a)(1)), for any fiscal quarter dur-
ing which a State collects premiums, cost-shar-
ing, or similar charges under subsection (k) of 
section 1916 of such Act (42 U.S.C. 1396o) (as 
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added by this Act), including any advance pay-
ments of premium tax credits under section 
1412 of the Patient Protection and Affordable 
Care Act or payments for cost-sharing reduc-
tions under section 1402 of such Act that are 
received by the State, the total amount ex-
pended during such quarter as medical assist-
ance for individuals who buy into Medicaid cov-
erage under subclause (XXIII) of section 
1902(a)(10)(A)(ii) of the Social Security Act 
(as added by this Act) shall be reduced by the 
amount of such premiums or charges. 
(B) TREATMENT OF EXCESS PREMIUMS.— 
Each State that collects premiums or similar 
charges under subsection (k) of section 1916 of 
the Social Security Act (42 U.S.C. 1396o) (as 
added by this Act) in a fiscal year shall pay to 
the Secretary of Health and Human Services, 
at such time and in such form and manner as 
the Secretary shall specify, an amount equal to 
50 percent of the amount, if any, by which— 
(i) the total amount of such premiums 
and charges collected by the State for such 
year; exceeds 
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(ii) the total amount expended by the 
State during such year as medical assist-
ance for individuals who buy into Medicaid 
coverage under subclause (XXIII) of sec-
tion 1902(a)(10)(A)(ii) of such Act (as 
added by this Act). 
(d) COST-SHARING REQUIREMENT.—Section 1916 of 
the Social Security Act (42 U.S.C. 1396o) is amended by 
adding at the end the following new subsection: 
‘‘(k) PREMIUMS AND COST-SHARING FOR INDIVID-
UALS PARTICIPATING IN MEDICAID BUY-IN PROGRAM.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
with respect to individuals who are eligible for med-
ical 
assistance 
under 
subsection 
(a)(10)(A)(ii)(XXIII) of section 1902 and are de-
scribed in subsection (qq) of such section, a State 
may— 
‘‘(A) impose premiums, deductibles, cost- 
sharing, or other similar charges that are actu-
arially fair; and 
‘‘(B) vary the premium rate imposed on an 
individual based only on the factors described in 
section 2701(a)(1)(A) of the Public Health 
Service Act and subject to the same limitations 
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on the weight which may be given to such fac-
tors under such section. 
‘‘(2) LIMITATIONS.— 
‘‘(A) PREMIUMS.—The total amount of 
premiums imposed for a year under this sub-
section with respect to all individuals described 
in paragraph (1) in a family shall not exceed an 
amount equal to 9.5 percent of the family’s 
household 
income 
(as 
defined 
in 
section 
36B(d)(2) of the Internal Revenue Code of 
1986) for the year involved. 
‘‘(B) OTHER COST-SHARING.— 
‘‘(i) IN GENERAL.—The cost-sharing 
limitations described in section 1302(c) of 
the Patient Protection and Affordable Care 
Act shall apply to cost-sharing (as defined 
in such section) for medical assistance pro-
vided 
under 
section 
1902(a)(10)(A)(ii)(XXIII) in the same 
manner as such limitations apply to cost- 
sharing under qualified health plans under 
title I of such Act. 
‘‘(ii) AVAILABILITY OF COST-SHARING 
REDUCTIONS.—Individuals provided med-
ical 
assistance 
under 
section 
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1902(a)(10)(A)(ii)(XXIII) and subject to 
cost-sharing under this subsection are eli-
gible for cost-sharing reductions under sec-
tion 1402 of the Patient Protection and 
Affordable Care Act (subject to the income 
eligibility threshold in subsection (b)(2) of 
such section), and in applying such sec-
tion— 
‘‘(I) enrollment in a State plan 
under 
section 
1902(a)(10)(A)(ii)(XXIII) 
shall 
be 
treated as coverage under a qualified 
health plan in the silver level of cov-
erage in the individual market offered 
through an Exchange established for 
or by the State under title I of the 
Patient Protection and Affordable 
Care Act; and 
‘‘(II) the State agency admin-
istering such plan shall be treated as 
the issuer of such plan. 
‘‘(3) PREMIUMS AND COST-SHARING FOR CER-
TAIN OTHER INDIVIDUALS.—If an individual is eligi-
ble 
for 
medical 
assistance 
under 
subsection 
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(a)(10)(A)(ii)(XXIII) of section 1902 and is not de-
scribed in subsection (qq) of such section, a State— 
‘‘(A) shall not impose premiums and cost- 
sharing on the individual under this subsection; 
and 
‘‘(B) may impose premiums and cost-shar-
ing on the individual to the extent allowed by 
another provision of this Act (other than sec-
tion 1902(a)(10)(A)(ii)(XXIII)) which provides 
for eligibility for medical assistance, but only if 
the individual is described in such other provi-
sion. 
‘‘(4) APPLICATION
OF
PREMIUM
ASSISTANCE 
TAX CREDITS.—An individual who is required to pay 
premiums under this subsection for a year for med-
ical assistance shall be eligible for a premium assist-
ance credit under section 36B of the Internal Rev-
enue Code to the same extent that such individual 
would be eligible for a premium assistance credit 
under such section if such individual had paid the 
same amount in premiums for coverage under a 
qualified health plan for such year.’’. 
(e) MANAGED CARE.—Section 1932(a)(1)(A)(i) of 
the Social Security Act (42 U.S.C. 1396u–2(a)(1)(A)(i)) 
is amended by inserting ‘‘, including an individual who is 
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eligible for such assistance after buying into such coverage 
under section 1902(a)(10)(A)(ii)(XXIII),’’ after ‘‘the 
State plan under this title’’. 
(f) OFFERING BUY-IN PROGRAM
ON STATE EX-
CHANGE; ENROLLMENT PERIODS.— 
(1) IN GENERAL.—A State that has elected to 
allow individuals to buy into Medicaid coverage 
under section 1902(a)(10)(A)(ii)(XXIII) of the So-
cial Security Act (as added by this Act) shall allow 
individuals to enroll in such coverage through the 
Federal, federally facilitated, or State Exchange es-
tablished pursuant to title I of the Patient Protec-
tion and Affordable Care Act. 
(2) ENROLLMENT PERIODS.—A State may limit 
the enrollment of individuals into Medicaid coverage 
under section 1902(a)(10)(A)(ii)(XXIII) of the So-
cial Security Act (as added by this Act) to the en-
rollment 
periods 
provided 
for 
under 
section 
1311(c)(6) of the Patient Protection and Affordable 
Care Act. 
(g) APPLICATION
OF ADVANCED PREMIUM TAX 
CREDITS TO MEDICAID BUY-IN PLANS.— 
(1) IN GENERAL.—Section 36B of the Internal 
Revenue Code of 1986 is amended— 
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(A) in subsection (b)(3)(B), by adding at 
the end the following new sentence: 
‘‘If an applicable taxpayer resides in a rating 
area in which no silver plan is offered on the 
individual market but the taxpayer buys into 
Medicaid 
coverage 
under 
section 
1902(a)(10)(A)(ii)(XXIII) of the Social Secu-
rity Act, such Medicaid coverage shall be 
deemed to be the applicable second lowest cost 
silver plan with respect to such taxpayer.’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(h) APPLICATION
TO INDIVIDUALS PURCHASING 
MEDICAID COVERAGE.—In the case of any individual who 
buys 
into 
Medicaid 
coverage 
under 
section 
1902(a)(10)(A)(ii)(XXIII) of the Social Security Act, this 
section shall be applied with the following modifications: 
‘‘(1) The amount determined under subsection 
(b)(2)(A) shall be increased by the amount of the 
monthly premiums paid for such coverage. 
‘‘(2) Subsection (c)(2)(A)(i) shall be applied by 
treating coverage under the Medicaid program under 
title XIX of the Social Security Act in the same 
manner as a qualified health plan that was enrolled 
in through an Exchange. 
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‘‘(3) In applying subsection (c)(2)(B)— 
‘‘(A) an individual shall not be considered 
to be eligible for minimum essential coverage 
described in section 5000A(f)(1)(A)(ii) by rea-
son of eligibility for medical assistance under a 
State 
Medicaid 
program 
under 
section 
1902(a)(10)(A)(ii)(XXIII); and 
‘‘(B) an individual who is not covered by 
minimum essential coverage described in section 
5000A(f)(1)(B) shall not be considered to be el-
igible for such coverage.’’. 
(2) ADVANCED PAYMENT OF CREDIT.— 
(A) 
IN
GENERAL.—The 
Secretary 
of 
Health and Human Services, in consultation 
with the Secretary of the Treasury, shall estab-
lish a program under which— 
(i) upon request of a State agency ad-
ministering a State Medicaid program 
under title XIX of the Social Security Act, 
advance determinations are made in a 
manner similar to advanced determinations 
under section 1412 of the Patient Protec-
tion and Affordable Care Act with respect 
to the income eligibility of individuals en-
rolling in such program for the premium 
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tax credit allowable under section 36B of 
the Internal Revenue Code of 1986 and 
the cost-sharing reductions under section 
1402 of the Patient Protection and Afford-
able Care Act; 
(ii) the Secretary notifies— 
(I) the State agency admin-
istering the program and the Sec-
retary of the Treasury of the advance 
determinations; and 
(II) the Secretary of the Treas-
ury of the name and employer identi-
fication number of each employer with 
respect to whom 1 or more employees 
of the employer were determined to be 
eligible for the premium tax credit 
under section 36B of the Internal 
Revenue Code of 1986 and the cost- 
sharing reductions under section 1402 
of the Patient Protection and Afford-
able Care Act because— 
(aa) the employer did not 
provide minimum essential cov-
erage; or 
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(bb) the employer provided 
such minimum essential coverage 
but it was determined under sec-
tion 36B(c)(2)(C) of such Code 
to either be unaffordable to the 
employee or not provide the re-
quired minimum actuarial value; 
and 
(iii) the Secretary of the Treasury 
makes advance payments of such credit or 
reductions to the State agency admin-
istering the program in order to reduce the 
premiums payable by individuals eligible 
for such credit. 
(B) DETERMINATIONS AND PAYMENTS.— 
Rules similar to subsections (b) and (c) of sec-
tion 1412 of the Patient Protection and Afford-
able Care Act shall apply for purposes of this 
subsection. 
(C) COORDINATION WITH CREDIT.— 
(i) IN GENERAL.—Section 36B of the 
Internal Revenue Code of 1986 is amended 
by inserting ‘‘and under section 2(g)(2) of 
the State Public Option Act’’ after ‘‘sec-
tion 1412 of the Patient Protection and 
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Affordable Care Act’’ each place it appears 
in subsections (f)(1), (f)(2), and (g)(1). 
(ii) INFORMATION
REPORTING.—Sec-
tion 36B(f)(3) of such Code is amended by 
adding at the end the following flush sen-
tence: ‘‘In the case of any coverage under 
the Medicaid program under title XIX of 
the Social Security Act for which a credit 
under this section is allowable by reason of 
subsection (h), the State agency admin-
istering the Medicaid program shall be 
treated as an Exchange for purposes of 
this paragraph and subparagraph (A) shall 
not apply.’’. 
(3) CONFORMING
AMENDMENT
RELATING
TO 
EMPLOYER RESPONSIBILITY.—Paragraph (6) of sec-
tion 4980H(c) of the Internal Revenue Code of 1986 
is amended by inserting ‘‘, except that for purposes 
of subsections (a)(2) and (b)(2), the term ‘qualified 
health plan’ shall include any plan described in sec-
tion 36B(h)’’ after ‘‘such Act’’. 
(h) CONFORMING AMENDMENTS.— 
(1) Section 1902(a)(10) of the Social Security 
Act (42 U.S.C. 1396a(a)(10)), as amended by sub-
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section (a), is further amended, in the matter fol-
lowing subparagraph (G)— 
(A) by striking ‘‘and (XVII)’’ and inserting 
‘‘, (XVII)’’; and 
(B) by inserting ‘‘, and (XVIII) the med-
ical assistance made available to an individual 
described in subparagraph (A)(ii)(XXIII) shall 
be limited to medical assistance described in 
subsection (k)(1)’’ before the semicolon. 
(2) Section 1903(f)(4) of the Social Security 
Act (42 U.S.C. 1396b(f)(4)) is amended by inserting 
‘‘1902(a)(10)(A)(ii)(XXIII),’’ 
after 
‘‘1902(a)(10)(A)(ii)(XXII),’’. 
(3) Section 1905(a) of the Social Security Act 
(42 U.S.C. 1396d(a)) is amended, in the matter pre-
ceding paragraph (1)— 
(A) by striking ‘‘or’’ at the end of clause 
(xvi); 
(B) by inserting ‘‘or’’ at the end of clause 
(xvii); and 
(C) by inserting after clause (xvii) the fol-
lowing new clause: 
‘‘(xviii) 
individuals 
described 
in 
section 
1902(a)(10)(A)(ii)(XXIII),’’. 
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(4) Section 1916A(a)(1) of the Social Security 
Act (42 U.S.C. 1396o–1(a)(1)) is amended by strik-
ing ‘‘or (j)’’ and inserting ‘‘(j), or (k)’’. 
(5) Section 1937(a)(1)(B) of the Social Secu-
rity Act (42 U.S.C. 1396u–7(a)(1)(B)) is amended 
by inserting ‘‘, subclause (XXIII) of section 
1902(a)(10)(A)(ii),’’ after ‘‘1902(a)(10)(A)(i)’’. 
SEC. 3. DEVELOPMENT OF STATE-LEVEL METRICS ON MED-
ICAID BENEFICIARY ACCESS AND SATISFAC-
TION. 
(a) IN GENERAL.— 
(1) DEVELOPMENT
OF
METRICS.—Not later 
than 1 year after the date of enactment of this Act, 
the Director of the Agency for Healthcare Research 
and Quality, in consultation with State Medicaid Di-
rectors, 
shall 
develop 
standardized, 
State-level 
metrics of access to, and satisfaction with, providers, 
including primary care and specialist providers, with 
respect to individuals who are enrolled in State Med-
icaid plans under title XIX of the Social Security 
Act. 
(2) PROCESS.—The Director of the Agency for 
Healthcare Research and Quality shall develop the 
metrics described in paragraph (1) through a public 
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