I 
115TH CONGRESS 
1ST SESSION H. R. 4128 
To amend title XIX of the Social Security Act to allow States with Exchanges 
with low-insurer participation to offer a Medicaid buy-in plan, and for 
other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
OCTOBER 25, 2017 
Ms. MICHELLE LUJAN GRISHAM of New Mexico 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 amend title XIX of the Social Security Act to allow 
States with Exchanges with low-insurer participation to 
offer a Medicaid buy-in plan, 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 at the ‘‘Health Care Choice 
and Affordability Act’’. 
SEC. 2. MEDICAID BUY-IN PLANS. 
(a) IN GENERAL.— 
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(1) OFFERING ON AN EXCHANGE.—For a plan 
year beginning on or after January 1, 2018, not-
withstanding any other provision of law, a Medicaid 
buy-in State may offer to eligible individuals with re-
spect to a plan year a Medicaid buy-in plan in the 
individual market through an Exchange established 
under title I of the Patient Protection and Afford-
able Care Act for such plan year. 
(2) PREMIUM RATES.— 
(A) IN
GENERAL.—A Medicaid buy-in 
State that offers a Medicaid buy-in plan under 
paragraph (1) shall establish premium rates 
under such plan at a level calculated to produce 
revenue equal to the sum of— 
(i) the costs of health benefits pro-
vided by the plan; plus 
(ii) 10 percent of the administrative 
costs related to operating the plan. 
(B) PROHIBITING
DISCRIMINATORY
PRE-
MIUMS.—In the case of a Medicaid buy-in plan, 
premiums may only vary to the extent per-
mitted under section 2701(a)(1) of the Public 
Health Service Act. 
(3) ENROLLMENT.—The enrollment period for 
a Medicaid buy-in plan offered under paragraph (1) 
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shall, to the extent practicable, conform with the en-
rollment period for qualified health plans offered 
through an Exchange. 
(4) FEDERAL PAYMENT FOR ADMINISTRATIVE 
EXPENSES.—In the case of a Medicaid buy-in State 
that offers a Medicaid buy-in plan under paragraph 
(1), the Secretary of Health and Human Services 
shall pay to such State for each calendar quarter be-
ginning on or after January 1, 2018, an amount 
equal to 90 percent of so much of the sums ex-
pended during such quarter as are attributable to 
administering the Medicaid buy-in plan in such 
State. 
(b) PREMIUM TAX CREDITS.— 
(1) IN GENERAL.—Section 36B of the Internal 
Revenue Code of 1986 is amended by adding at the 
end the following new subsection: 
‘‘(h) APPLICATION
TO INDIVIDUALS PURCHASING 
MEDICAID COVERAGE.—In the case of any individual en-
rolled in a Medicaid buy-in plan subsection (a) shall be 
applied by substituting for ‘premium assistance credit 
amount of the taxpayer for the taxable year’ the following: 
‘the lesser of— 
‘‘ ‘(1) the monthly premiums charged by a Med-
icaid buy-in State for a Medicaid buy-in plan that 
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covers the taxpayer, the taxpayer’s spouse, or any 
dependent (as defined in section 152) of the tax-
payer, or 
‘‘ ‘(2) the excess (if any) of— 
‘‘ ‘(A) such monthly premium, over 
‘‘ ‘(B) an amount equal to 1/12 of the 
product of the applicable percentage and the 
taxpayer’s household income for the taxable 
year.’.’’. 
(2) EXCEPTION FOR MINIMUM ESSENTIAL COV-
ERAGE.—Subparagraph (B) of section 36B(c)(2) of 
the Internal Revenue Code of 1986 is amended by 
inserting before the period at the end the following: 
‘‘or eligibility for coverage under a Medicaid buy-in 
plan (as defined in section 2(c) of the Health Care 
Choice and Affordability Act)’’. 
(3) INDIVIDUAL MANDATE.—Clause (ii) of sec-
tion 5000A(f)(1)(A) of the Internal Revenue Code of 
1986 is amended by inserting before the comma the 
following: ‘‘including under a Medicaid buy-in plan 
(as defined in section 2(c) of the Health Care Choice 
and Affordability Act)’’. 
(4) ADVANCE PAYMENT OF CREDIT.— 
(A) IN
GENERAL.—Advance determina-
tions and payments of premium tax credits al-
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lowable under section 36B of the Internal Rev-
enue Code of 1986 with respect to an individual 
enrolled in a Medicaid buy-in plan shall be al-
lowed, subject to rules similar to the rules in 
section 1412 of the Patient Protection and Af-
fordable Care Act (applied without regard to 
whether such plan is a qualified health plan). 
(B) COORDINATION
WITH
CREDIT.—Sec-
tion 36B(f) is amended by adding at the end 
the following new paragraph: 
‘‘(4) MEDICAID BUY-IN PLANS.—For purposes 
of this subsection, advance payments under section 
2(b)(4)(A) of the Health Care Choice and Afford-
ability Act shall be treated as advance payments 
under section 1412 of the Patient Protection and 
Affordable Care Act.’’. 
(5) CONFORMING
AMENDMENT
RELATING
TO 
EMPLOYER
RESPONSIBILITY.—Section 4980H(c)(6) 
of the Internal Revenue Code of 1986 is amended by 
inserting ‘‘, except that for purposes of subsections 
(a)(2) and (b)(1)(B), the term ‘qualified health plan’ 
shall include a Medicaid buy-in plan (as defined in 
section 2(c) of the Health Care Choice and Afford-
ability Act’’ after ‘‘such Act’’. 
(c) DEFINITIONS.—In this section: 
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(1) ELIGIBLE INDIVIDUAL.—The term ‘‘eligible 
individual’’ means an individual who will have access 
to only qualified health plans issued by one health 
insurance issuer (as defined in section 2791 of the 
Public Health Service Act (42 U.S.C. 300gg–91)) or 
will have access to no qualified health plans with re-
spect to a plan year. 
(2) MEDICAID BUY-IN STATE.—The term ‘‘Med-
icaid buy-in State’’ means a State that has at least 
one political subdivision in which fewer than two 
health insurance issuers participate in the Federal, 
Federally facilitated, or State Exchange established 
under title I of the Patient Protection and Afford-
able Care Act (Public Law 111–148) for such polit-
ical subdivision. 
(3) MEDICAID BUY-IN PLAN.—The term ‘‘Med-
icaid buy-in plan’’ means a health insurance plan 
that— 
(A) is administered by the State agency 
administering the State plan under title XIX of 
the Social Security Act (42 U.S.C. 1396 et 
seq.) (or a waiver of such plan); and 
(B) consists of benchmark coverage de-
scribed in subsection (b)(1) of section 1937 of 
such Act (42 U.S.C. 1396u–7(b)(1)) or bench-
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mark-equivalent coverage described in sub-
section (b)(2) of such section. 
(4) QUALIFIED
HEALTH
PLAN.—The term 
‘‘qualified health plan’’ has the meaning given such 
term in section 1301 of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18021). 
Æ 
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