The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) made a number of
reforms intended to promote health insurance coverage and affordability, including giving states the option
to expand Medicaid to adults with incomes up to 133 percent of the federal poverty level, and expanding
access to coverage through exchange plans that provide minimum essential coverage with subsidies for
those with incomes up to 400 percent FPL.
Despite this progress, however, many low- and middle-income families still lack affordable health coverage
choices, and concerns about rising out-of-pocket costs remain. State and federal policymakers have
proposed various strategies to improve overall coverage and affordability using the flexibility allowed under
the ACA to create new state-administered options to supplement existing exchange coverage. The term
Medicaid buy-in is often used to describe such proposals because the programs would be administered by
the state or rely on existing Medicaid infrastructure and would require individuals to pay a premium to
purchase, or buy into, coverage.
This brief provides background information on how current law affects state ability to set up buy-in programs,
discusses various proposals at the state and federal levels, and raises key policy considerations.