Creates an optional Medicaid "buy-in" that lets certain state residents purchase Medicaid starting January 1, 2026, and lets states collect limited premiums and cost‑sharing from those enrollees. It directs HHS to update Medicaid quality measures and provides $50 million in FY2026 to help states implement the updates. The bill also expands a Medicaid primary‑care payment floor to more provider types and requires managed‑care contracts to document those payments, changes how temporary enhanced FMAPs are timed (from calendar years to consecutive 12‑month periods tied to state implementation), and requires state Medicaid plans to cover comprehensive sexual and reproductive health care, including abortion services, effective January 1, 2026.