I 
117TH CONGRESS 
1ST SESSION H. R. 2881 
To amend title XVIII of the Social Security Act to provide for an option 
for individuals who are ages 50 to 64 to buy into Medicare, to provide 
for health insurance market stabilization, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 28, 2021 
Mr. HIGGINS of New York (for himself, Mr. LARSON of Connecticut, Mr. 
COURTNEY, and Mr. WELCH) introduced the following bill; which was re-
ferred to the Committee on Energy and Commerce, and in addition to 
the Committee on Ways and Means, for a period to be subsequently de-
termined by the Speaker, in each case for consideration of such provisions 
as fall within the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for an option for individuals who are ages 50 to 64 
to buy into Medicare, to provide for health insurance 
market stabilization, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Buy-In and 
Health Care Stabilization Act of 2021’’. 
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SEC. 2. FINDINGS. 
Congress finds as follows: 
(1) Medicare has coverage gaps and should pro-
vide more comprehensive coverage, including increas-
ing coverage for the medical needs of beneficiaries 
relating to hearing, dental, and vision care. 
(2) Special needs populations face financial 
challenges to secure coverage for Medicare’s out of 
pocket costs and other hurdles. 
(3) Medicare Buy-In is a step in the right di-
rection as Congress considers additional needed leg-
islation to address these and other coverage issues 
and beneficiary financial challenges in Medicare and 
Medicare Buy-In. 
SEC. 3. MEDICARE BUY-IN OPTION. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act (42 U.S.C. 1395c et seq.) is amended by adding at 
the end the following new section: 
‘‘MEDICARE BUY-IN OPTION 
‘‘SEC. 1899C. (a) OPTION.— 
‘‘(1) IN GENERAL.—Every individual who meets 
the requirements described in paragraph (2) shall be 
eligible to enroll under this section. 
‘‘(2) ELIGIBILITY.—An individual who meets 
the following requirements is eligible to enroll under 
this section: 
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‘‘(A) AGE.—The individual has attained 50 
years of age, but has not attained 65 years of 
age. 
‘‘(B) MEDICARE
ELIGIBILITY
(BUT
FOR 
AGE).—The individual is not otherwise entitled 
to benefits under part A or eligible to enroll 
under part A or part B but would be eligible for 
benefits under part A or part B if the indi-
vidual were 65 years of age. 
‘‘(3) PART A, B, AND D BENEFITS AND PROTEC-
TIONS.—An individual enrolled under this section is 
entitled to the same benefits (and shall receive the 
same protections) under this title as an individual 
who is entitled to benefits under part A and enrolled 
under parts B and D, including the ability to enroll 
in a Medicare Advantage plan that provides qualified 
prescription drug coverage (an MA–PD plan) and 
including access to the Medicare Beneficiary Om-
budsman under section 1808(c). 
‘‘(b) ENROLLMENT AND COVERAGE PERIODS.—The 
Secretary shall establish enrollment and coverage periods 
for individuals who enroll under this section. Such periods 
shall be established in coordination with the enrollment 
and coverage periods for plans offered under an Exchange 
established under title I of the Patient Protection and Af-
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fordable Care Act. The Secretary shall establish such peri-
ods so that coverage under this section shall first begin 
on January 1 of the first year beginning at least one year 
after the date of the enactment of this section and shall 
include special enrollment periods, in accordance with sec-
tion 155.420 of title 45 of the Code of Federal Regula-
tions, that are applicable to qualified health plans offered 
through an Exchange. 
‘‘(c) BUY-IN PREMIUM.— 
‘‘(1) AMOUNT OF MONTHLY PREMIUMS.—The 
Secretary shall (beginning for the first year that be-
gins more than 1 year after the date of the enact-
ment of this section), during September of the pre-
ceding year, determine a monthly premium for indi-
viduals enrolled under this section. Such monthly 
premium shall be equal to 1⁄12 of the annual pre-
mium computed under paragraph (2)(B), which 
shall apply with respect to coverage provided under 
this section for any month in such year. 
‘‘(2) ANNUAL PREMIUM.— 
‘‘(A) COMBINED
NATIONAL, PER
CAPITA 
AVERAGE FOR PARTS A, B, AND D BENEFITS.— 
The Secretary shall estimate the average, an-
nual per capita amount for benefits and admin-
istrative expenses that will be payable under 
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parts A, B, and D in the year for all individuals 
enrolled under this section. 
‘‘(B) ANNUAL PREMIUM.—Subject to sub-
paragraphs (C) and (D), the annual premium 
under this subsection for months in a year is 
equal to the average, annual per capita amount 
estimated under subparagraph (A) for the year. 
‘‘(C) ADJUSTMENTS.—The Secretary shall 
adjust the annual premium under this sub-
section as necessary— 
‘‘(i) to ensure that expenditures under 
this title for any year are not increased by 
reason of this section; and 
‘‘(ii) by a geographic adjustment fac-
tor to address regional affordability con-
cerns. 
‘‘(D) 
AUTHORITY
TO
CALCULATE 
AMOUNTS OF MONTHLY PREMIUMS SEPARATELY 
FOR DIFFERENT AGES.—In determining the an-
nual premium amount under this paragraph for 
months in a year, the Secretary may make sep-
arate determinations of such amount for indi-
viduals by age, if the Secretary determines that 
making such separate determinations would in-
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crease enrollment under this section and reduce 
the risk of adverse selection. 
‘‘(3) ADDITIONAL PREMIUM FOR CERTAIN PART 
D PLANS.—Nothing in this section shall preclude an 
individual from choosing a prescription drug plan 
which requires the individual to pay an additional 
amount (because of the inclusion of supplemental 
prescription drug benefits or because the plan is a 
more expensive plan, pursuant to section 1860D– 
13(a)(1)). In such case, the monthly premium under 
paragraph (1) shall be increased with respect to 
such individual. 
‘‘(d) PAYMENT OF PREMIUMS.— 
‘‘(1) 
PAYMENT.—Premiums 
for 
enrollment 
under this section shall be paid to the Secretary at 
such times, and in such manner, as the Secretary 
determines appropriate. 
‘‘(2) DEPOSIT.—Amounts collected by the Sec-
retary under this section shall be deposited in the 
Medicare Buy-In Trust Fund established under sub-
section (e). 
‘‘(e) MEDICARE BUY-IN TRUST FUND.— 
‘‘(1) IN GENERAL.—There is hereby created on 
the books of the Treasury of the United States a 
trust fund to be known as the ‘Medicare Buy-In 
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Trust Fund’ (in this subsection referred to as the 
‘Trust Fund’). The Trust Fund shall consist of such 
gifts and bequests as may be made as provided in 
section 201(i)(1) and such amounts as may be de-
posited in, or appropriated to, such fund as provided 
in this title. 
‘‘(2) PREMIUMS.—Premiums collected under 
subsection (d) shall be transferred to the Trust 
Fund. 
‘‘(3) INCORPORATION
OF
PROVISIONS.—Sub-
sections (b) through (i) of section 1841 shall apply 
with respect to the Trust Fund and this title in the 
same manner as they apply with respect to the Fed-
eral Supplementary Medical Insurance Trust Fund 
and part B, respectively, except that in applying 
such section 1841, any reference in such section to 
‘this part’ shall be construed to be a reference to 
this section and any reference in section 1841(h) to 
section 1840(d) and in section 1841(i) to sections 
1840(b)(1) and 1842(g) are deemed to be references 
to comparable authority exercised under this section. 
‘‘(f) CLARIFICATION.—Nothing in this section shall 
affect the benefits or eligibility under this title of individ-
uals who would otherwise be entitled to or eligible for ben-
efits under this title or title XIX, or both. 
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‘‘(g) ELIGIBILITY FOR FINANCIAL ASSISTANCE.— 
‘‘(1) IN GENERAL.—Individuals enrolled in cov-
erage under this section shall, from amounts trans-
ferred under paragraph (2), receive financial assist-
ance for such coverage that is substantially similar 
to the assistance the individual would have received 
if the individual were enrolled in a qualified health 
plan through an Exchange. 
‘‘(2) TRANSFER OF FUNDS TO MEDICARE BUY- 
IN TRUST FUND.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
transfer to the Medicare Buy-In Trust Fund 
under subsection (d) for each plan year the 
amount determined under paragraph (C) for 
such year. 
‘‘(B) USE
OF
FUNDS.—The amounts 
transferred to the Medicare Buy-In Trust Fund 
under subparagraph (A) shall only be used to 
reduce the premiums and cost-sharing for cov-
erage under this section of individuals enrolled 
under such coverage who would be eligible for 
cost-sharing reductions under section 1402 of 
the Patient Protection and Affordable Care Act 
and premium assistance under section 36B of 
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the Internal Revenue Code of 1986 if such indi-
vidual were enrolled in a qualified health plan. 
‘‘(C) AMOUNT OF TRANSFER.— 
‘‘(i) IN GENERAL.—The amount de-
termined under this subparagraph for any 
plan year is the aggregate amount the Sec-
retary determines is equal to 100 percent 
of the premium tax credits under section 
36B of the Internal Revenue Code of 
1986, and 100 percent of the cost-sharing 
reductions under section 1402 of the Pa-
tient Protection and Affordable Care Act, 
that would have been provided for the plan 
year to eligible individuals who meet speci-
fied income criteria and are enrolled for 
such plan year in coverage provided 
through enrollment under this section if 
such individuals were enrolled for such 
year in a qualified health plan through an 
Exchange. 
‘‘(ii) SPECIFIC REQUIREMENTS.—The 
Secretary shall make the determination 
under clause (i) on a per enrollee basis and 
shall take into account all relevant factors 
necessary to determine the value of the 
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premium tax credits and cost-sharing re-
ductions that would have been provided to 
eligible individuals described in section 
1331 of the Patient Protection and Afford-
able Care Act, including the age and in-
come of the enrollee, geographic differences 
in average spending for health care across 
rating areas, the health status of the en-
rollee for purposes of determining risk ad-
justment payments and reinsurance pay-
ments that would have been made if the 
enrollee had enrolled in a qualified health 
plan through an Exchange, and whether 
any reconciliation of the credit or cost- 
sharing reductions would have occurred if 
the enrollee had been so enrolled. This de-
termination shall take into consideration 
the experience of other States with respect 
to participation in an Exchange and such 
credits and reductions provided to resi-
dents of the other States, with a special 
focus on enrollees with income below 200 
percent of poverty. 
‘‘(D) CERTIFICATION.— 
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‘‘(i) IN GENERAL.—The Chief Actuary 
of the Centers for Medicare & Medicaid 
Services, in consultation with the Office of 
Tax Analysis of the Department of the 
Treasury, shall certify whether the method-
ology used to make determinations under 
subparagraph (C), and such determina-
tions, meet the requirements of this para-
graph. Such certifications shall be based 
on sufficient data from the federal ex-
change and from comparable States about 
their experience with programs created by 
the Basic Health Plan. 
‘‘(ii) CORRECTIONS.—The Secretary 
shall adjust the payment to the Trust 
Fund for any plan year to reflect any error 
in the determinations under subparagraph 
(C) for any preceding plan year. 
‘‘(iii) APPLICATION.—Coverage pro-
vided through enrollment under this part 
and parts B and D pursuant to this sec-
tion shall be treated as coverage under a 
qualified health plan in the silver level of 
coverage in the individual market offered 
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through an Exchange and the Secretary 
shall be treated as the issuer of such plan. 
‘‘(h) TREATMENT IN RELATION TO THE AFFORD-
ABLE CARE ACT.— 
‘‘(1) TREATMENT AS MINIMUM ESSENTIAL COV-
ERAGE.—For purposes of applying section 5000A of 
the Internal Revenue Code of 1986, the coverage 
provided through enrollment under this section con-
stitutes minimum essential coverage under sub-
section (f)(1)(A)(i) of such section. 
‘‘(2) USE OF EXCHANGES.—Coverage provided 
through enrollment under this section shall be 
deemed to be coverage under a qualified health plan 
for purposes of section 1311(d)(4)(C) of the Patient 
Protection and Affordable Care Act and shall be 
made available for enrollment, information compari-
son, and otherwise as such a plan through any inter-
net website maintained by an Exchange established 
under title I of such Act (as described in such sec-
tion). 
‘‘(3) MEDICAID
MANAGED
CARE.—States are 
prohibited from buying their Medicaid beneficiaries 
ages 50 to 64 into Medicare under this section, and 
individuals otherwise eligible for enrollment under a 
State plan under title XIX are prohibited from cov-
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erage under this title pursuant to enrollment under 
this section. The preceding sentence shall not apply 
to Medicaid beneficiaries whose Medicaid coverage or 
eligibility does not meet the definition of minimum 
essential coverage under a government-sponsored 
program under section 1.5000A–2 of title 26, Code 
of Federal Regulations (or any successor regulation). 
‘‘(4) ACCESS TO MEDIGAP.—Coverage provided 
through medicare supplemental policies certified 
under section 1882 shall be made available to indi-
viduals eligible for enrollment pursuant to this sec-
tion for enrollment, information, comparison, and 
otherwise as such a policy through any internet 
website described in paragraph (2). 
‘‘(i) OVERSIGHT.—There is established an advisory 
committee to be known as the ‘Medicare Buy In Oversight 
Board’ to monitor and oversee the implementation of this 
section, including the experience of the individuals enroll-
ing under this section. The Medicare Buy In Oversight 
Board shall make periodic recommendations for the con-
tinual improvement of the implementation of this section 
as well as the relationship of enrollment under this section 
to other health care programs. 
‘‘(j) OUTREACH AND ENROLLMENT.— 
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‘‘(1) IN GENERAL.—During the period that be-
gins on January 1, 2021, and ends on December 31, 
2023, the Secretary shall award grants to eligible 
entities for the following purposes: 
‘‘(A) OUTREACH AND ENROLLMENT.—To 
carry out outreach, public education activities, 
and enrollment activities to raise awareness of 
the availability of, and encourage, enrollment 
under this section. 
‘‘(B) ASSISTING INDIVIDUALS TRANSITION 
UNDER THIS SECTION.—To provide assistance 
to individuals to enroll under this section. 
‘‘(C) RAISING
AWARENESS
OF
PREMIUM 
ASSISTANCE
AND
COST-SHARING
REDUC-
TIONS.—To distribute fair and impartial infor-
mation concerning enrollment under this section 
and the availability of premium assistance tax 
credits under section 36B of the Internal Rev-
enue Code of 1986 and cost-sharing reductions 
under section 1402 of the Patient Protection 
and Affordable Care Act, and to assist eligible 
individuals in applying for such tax credits and 
cost-sharing reductions. 
‘‘(2) ELIGIBLE ENTITIES.— 
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‘‘(A) IN GENERAL.—In this subsection, the 
term ‘eligible entity’ means— 
‘‘(i) a State; or 
‘‘(ii) a nonprofit community-based or-
ganization. 
‘‘(B) ENROLLMENT AGENTS.—Such term 
includes a licensed independent insurance agent 
or broker that has an arrangement with a State 
or nonprofit community-based organization to 
enroll eligible individuals under this section. 
‘‘(C) EXCLUSIONS.—Such term does not 
include an entity that— 
‘‘(i) is a health insurance issuer; or 
‘‘(ii) receives any consideration, either 
directly or indirectly, from any health in-
surance issuer in connection with the en-
rollment of any individuals under this sec-
tion. 
‘‘(3) PRIORITY.—In awarding grants under this 
subsection, the Secretary shall give priority to 
awarding grants to States or eligible entities in 
States that have geographic rating areas at risk of 
having no qualified health plans in the individual 
market. 
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‘‘(4) FUNDING.—Out of any moneys in the 
Treasury not otherwise appropriated, $500,000,000 
is appropriated to the Secretary for each of calendar 
years 2021 through 2023, to carry out this sub-
section. 
‘‘(k) IMPLEMENTATION.— 
‘‘(1) CONSULTATION.—In carrying out this sec-
tion, the Secretary shall— 
‘‘(A) consult with other Federal agencies, 
including the Department of the Treasury, the 
Department of Labor, the Department of Vet-
erans Affairs, the Department of Defense, and 
the Office of Personnel Management; and 
‘‘(B) incorporate significant public con-
sultation and feedback, through public forums, 
notice and comment rulemaking, and any other 
appropriate mediums. 
‘‘(2) REPORT.—No later than one year after 
the date of the enactment of this section, the Sec-
retary shall submit to Congress a report establishing 
the administrative parameters for the implementa-
tion of this section. 
‘‘(l) FEASIBILITY STUDY.—The Secretary shall con-
duct a study on the feasibility of applying this section with 
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respect to individuals residing in States that are not with-
in the 50 States or the District of Columbia.’’. 
(b) MEDIGAP.—Section 1882 of the Social Security 
Act is amended by adding at the end the following new 
subsection: 
‘‘(aa) DEVELOPMENT OF NEW STANDARDS FOR CER-
TAIN MEDICARE SUPPLEMENTAL POLICIES RELATING TO 
BUY-IN OPTION.—The Secretary shall request the Na-
tional Association of Insurance Commissioners to review 
and revise the standards for benefit packages described 
in subsection (p)(1), to otherwise update standards to in-
clude requirements for each medicare supplemental policy 
that offers such a policy in a State, with respect to each 
year, to accept every individual in the State who is eligible 
for enrollment pursuant to section 1899C and who applies 
for such coverage for such year if the individual applies 
for enrollment in such policy during the 30-day period fol-
lowing the date of enrollment pursuant to section 1899C 
and to accept every such individual during a period of 
transition from enrollment pursuant to such section to en-
rollment under this title pursuant to eligibility other than 
under such section. Such revisions shall be made con-
sistent with the rules applicable under subsection 
(p)(1)(E) with the reference to the ‘1991 NAIC Model 
Regulation’ deemed a reference to the NAIC Model Regu-
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lation as published in the Federal Register on December 
4, 1998, and as subsequently updated by the National As-
sociation of Insurance Commissioners to reflect previous 
changes in law and the reference to ‘date of enactment 
of this subsection’ deemed a reference to the date of enact-
ment of this subsection (aa).’’. 
SEC. 4. MEDICARE DIRECT SUPPLEMENTAL INSURANCE 
OPTION. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended by inserting after section 1882 (42 U.S.C. 
1395ss) the following new section: 
‘‘SEC. 1882A. MEDICARE DIRECT SUPPLEMENTAL INSUR-
ANCE OPTION. 
‘‘(a) IN GENERAL.—The Secretary shall provide for 
the offering under this section of a voluntary program to 
supplement the benefits provided to individuals under 
parts A and B of this title. 
‘‘(b) ELIGIBILITY; ENROLLMENT.—The Secretary 
shall provide procedures for the enrollment under the pro-
gram under this section of individuals who are entitled to 
benefits under part A and enrolled under part B, but who 
are not enrolled in a Medicare Advantage plan (or in a 
plan under section 1876). Such procedures shall be con-
sistent with the following: 
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‘‘(1) There shall be an initial enrollment period 
during the last calendar quarter of 2022 that per-
mits all individuals who are eligible to enroll at that 
time under this subsection to enroll and obtain bene-
fits effective on January 1, 2023. 
‘‘(2) For individuals who are not eligible to en-
roll at such time but who subsequently become eligi-
ble, there shall be an individual enrollment period 
which is the 6-month period described in section 
1882(s)(2)(A). 
‘‘(3) The Secretary shall permit eligible individ-
uals to enroll at other times (and not less frequently 
than annually) in a uniform manner, but such en-
rollment shall be subject to a late enrollment penalty 
under subsection (d)(2)(B). 
‘‘(c) BENEFITS.— 
‘‘(1) IN
GENERAL.—The benefits provided 
under the program under this section shall consist of 
payment of the cost of deductibles, copayments, and 
other cost-sharing amounts (including amounts at-
tributable to and permitted as balance billing) other-
wise imposed or permitted under this title, subject to 
an annual deductible of $100. 
‘‘(2) ADMINISTRATION.—The Secretary shall 
coordinate payment of benefits under this part with 
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those under parts A and B and may, for such pur-
pose, enter into appropriate arrangements with 
qualified entities (which may include fiscal inter-
mediaries and carriers). 
‘‘(3) NO
PRE-EXISTING
CONDITION
LIMITA-
TIONS.—The benefits under this section shall not be 
subject to any pre-existing condition or similar un-
derwriting limitation. 
‘‘(d) PREMIUMS.— 
‘‘(1) ACTUARIAL
COST.—The Secretary shall, 
during September of each year beginning with 2022, 
determine a monthly actuarial rate for all enrollees 
under this section, which rate shall be applicable for 
months in the succeeding calendar year. Such actu-
arial rate shall be the amount the Secretary esti-
mates to be necessary so that the aggregate amount 
for such calendar year with respect to those enrollees 
will equal the total amount which the Secretary esti-
mates will be payable under this section for benefits 
accrued (including services performed and related 
administrative costs incurred) in such calendar year 
under the program under this section. In calculating 
the monthly actuarial rate, the Secretary shall make 
adjustments to take into account errors in esti-
mations under this paragraph for previous years and 
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shall include an appropriate amount for a contin-
gency margin. 
‘‘(2) PREMIUM.— 
‘‘(A) IN GENERAL.—The monthly premium 
of each individual enrolled under this section 
for a month in a year shall be the monthly ac-
tuarial rate determined under paragraph (1) for 
months in such year. Such premium shall be 
community-rated and shall not vary among en-
rollees based upon the age, place of residence, 
or any other factors, except as provided under 
subparagraph (B). 
‘‘(B) PENALTY FOR LATE ENROLLMENT.— 
In the case of an individual who does not enroll 
under this section in a period provided under 
paragraph (1) or (2) of subsection (b), the Sec-
retary shall increase the monthly premium (in 
a manner similar to that applied under part B 
pursuant to section 1839(b)) of 10 percent for 
each full 12 months in which the individual 
could have been but was not so enrolled. In ap-
plying such an increase— 
‘‘(i) the aggregate percentage increase 
may not exceed 100 percent; and 
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(1) USE OF FUNDS.—The Secretary shall use 
amounts in the Fund to establish a reinsurance pro-
gram under which the Secretary shall make reinsur-
ance payments, subject to subsection (a)(3), to 
health insurance issuers with respect to high-cost in-
dividuals enrolled in qualified health plans offered by 
such issuers that are not grandfathered health plans 
or transitional health plans for any plan year begin-
ning with the 2020 plan year. This subsection con-
stitutes budget authority in advance of appropria-
tions Acts and represents the obligation of the Sec-
retary to provide payments from the Fund in ac-
cordance with this subsection. 
(2) AMOUNT
OF
PAYMENT.—The payment 
made to a health insurance issuer under paragraph 
(1) with respect to each high-cost individual enrolled 
in a qualified health plan issued by the issuer that 
is not a grandfathered health plan or a transitional 
health plan shall equal 80 percent of the lesser of— 
(A) the amount (if any) by which the indi-
vidual’s claims incurred during the plan year 
exceeds— 
(i) in the case of the 2021, 2022, or 
2023 plan year, $50,000; and 
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(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply to taxable years beginning after 
December 31, 2020. 
Æ 
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