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Introduced June 12, 2025 by Kim Schrier · Last progress June 12, 2025
Creates a new option for people to buy into Medicaid starting January 1, 2026, lets states collect limited premiums and cost‑sharing tied to household income, and allows those premium payments to qualify for premium tax credits and cost‑sharing reductions. It also expands a Medicaid primary care payment floor to more provider types, requires updated quality measures and reporting, changes timing rules for enhanced FMAP, and makes comprehensive sexual and reproductive health care (including abortion services) a required Medicaid benefit. The bill sets federal rules for enrollment (including Exchange enrollment), federal support for some administrative costs, a $50 million appropriation for quality‑measure updates, and several cross‑statute edits to align Medicaid rules, tax credit treatment, and managed‑care payment and reporting requirements. Some provisions take effect in 2026; others require rulemaking and phased implementation through 2032.
The bill expands and standardizes Medicaid coverage and affordability (including a buy‑in, higher primary‑care payments, and guaranteed reproductive services) to improve access and provider participation, but it increases program costs and administrative complexity and creates legal and distributional challenges that could slow or unevenly distribute the benefits.
Uninsured and low-income individuals can enroll in a Medicaid buy-in (starting Jan 1, 2026) with premiums capped at 8.5% of household income and eligibility for ACA premium tax credits and cost‑sharing reductions, expanding affordable coverage options.
Medicaid beneficiaries will have better access to primary care because payment for specified primary care services is raised to at least Medicare Part B levels (and MCO contracts must verify payments), encouraging more providers to accept Medicaid and supporting value‑based payment arrangements.
States gain stronger federal funding support and predictability — enhanced FMAP tied to each state's expansion start (including retroactive adjustments) and a 90% federal match for reasonable administrative expenses to operate the buy‑in — reducing net state setup and transition costs.
State governments and taxpayers will face higher Medicaid costs because raising primary care payment floors to Medicare levels and requiring coverage of abortion and related services increases program spending and may lead to higher premiums or capitation rates.
States, providers, and federal agencies will face substantial administrative complexity and implementation burdens — from new enrollment and tax‑credit processes to FMAP recalculations, updated contracts, and measure implementation — which could delay benefits or increase compliance costs.
Buy‑in enrollees could still face out‑of‑pocket costs because states may impose premiums, deductibles, and cost‑sharing; additionally, states must remit 50% of premiums collected that exceed medical assistance spending, creating potential fiscal transfers and enrollment incentives misalignment.