Last Updated- July 2015:

Health Insurance Affordability Programs

How does eligibility vary across states by family size and income?

Overview

Under the Affordable Care Act (ACA), individuals and families may have access to one or more of the following health insurance affordability programs: Medicaid, the Children’s Health Insurance Program (CHIP), and subsidies for Qualified Health Plans purchased through health insurance marketplaces (also known as exchanges). The subsidies include premium tax credits (PTC) that lower monthly coverage costs and cost-sharing reductions (CSR) that lower costs at the time patients get health care. While the Supreme Court has confirmed that subsidies are available in all states, the eligibility for Medicaid and CHIP vary across states. Therefore, the specific insurance affordability program(s) available to an individual or family depends on where they live.


This ACA Spotlight illustrates the insurance affordability options that are available to individuals and families based on their income and their state of residence. The “eligibility profile” maps show the effects of state variations in Medicaid and CHIP eligibility for non-disabled childless adults and for children and parents. The “program threshold” maps show the income limits each state has established for Medicaid and CHIP for the relevant household, expressed as a percentage of the federal poverty level. The data reflected in the maps are also available to view, print, or download in the Data Sets section below. For more information about the maps, please refer to the Methodology section below.

At-A-Glance: State ACA Decisions

State Marketplace Type* Implemented Medicaid Expansion**
Alabama Federally-facilitated Marketplace No
Alaska Federally-facilitated Marketplace No
Arizona Federally-facilitated Marketplace Yes
Arkansas State-Partnership Marketplace Yes
California State-based Marketplace Yes
Colorado State-based Marketplace Yes
Connecticut State-based Marketplace Yes
Delaware State-Partnership Marketplace Yes
District of Columbia State-based Marketplace Yes
Florida Federally-facilitated Marketplace No
Georgia Federally-facilitated Marketplace No
Hawaii Federally-supported State-based Marketplace Yes
Idaho State-based Marketplace No
Illinois State-Partnership Marketplace Yes
Indiana Federally-facilitated Marketplace Yes
Iowa State-Partnership Marketplace Yes
Kansas Federally-facilitated Marketplace No
Kentucky State-based Marketplace Yes
Louisiana Federally-facilitated Marketplace No
Maine Federally-facilitated Marketplace No
Maryland State-based Marketplace Yes
Massachusetts State-based Marketplace Yes
Michigan State-Partnership Marketplace Yes
Minnesota State-based Marketplace Yes
Mississippi Federally-facilitated Marketplace No
Missouri Federally-facilitated Marketplace No
Montana Federally-facilitated Marketplace Yes
Nebraska Federally-facilitated Marketplace No
Nevada Federally-supported State-based Marketplace Yes
New Hampshire State-Partnership Marketplace Yes
New Jersey Federally-facilitated Marketplace Yes
New Mexico Federally-supported State-based Marketplace Yes
New York State-based Marketplace Yes
North Carolina Federally-facilitated Marketplace No
North Dakota Federally-facilitated Marketplace Yes
Ohio Federally-facilitated Marketplace Yes
Oklahoma Federally-facilitated Marketplace No
Oregon Federally-supported State-based Marketplace Yes
Pennsylvania Federally-facilitated Marketplace Yes
Rhode Island State-based Marketplace Yes
South Carolina Federally-facilitated Marketplace No
South Dakota Federally-facilitated Marketplace No
Tennessee Federally-facilitated Marketplace No
Texas Federally-facilitated Marketplace No
Utah Federally-facilitated Marketplace No
Vermont State-based Marketplace Yes
Virginia Federally-facilitated Marketplace No
Washington State-based Marketplace Yes
West Virginia State-Partnership Marketplace Yes
Wisconsin Federally-facilitated Marketplace No
Wyoming Federally-facilitated Marketplace No

* See Kaiser Family Foundation here

** See Kaiser Family Foundation here

Background

The Affordable Care Act (ACA) provides a set of insurance affordability programs that lower the cost of health coverage for uninsured individuals and families. States have considerable flexibility to determine the income eligibility thresholds for two of the insurance affordability programs: Medicaid and the Children’s Health Insurance Program (CHIP). The other insurance affordability programs -- premium tax credits (PTC) and cost-sharing reductions (CSR) -- are subsidies designed to help individuals and families with incomes above the Medicaid and CHIP thresholds and between 100% and 400% of the federal poverty level purchase private insurance. Thus, while the specific insurance affordability programs available to an individual or family depend on where they live, the ACA was intended to provide affordable coverage options for all Americans with incomes below 400% of the poverty level ($97,000 for a family of four in 2015).


The ACA originally mandated states to expand Medicaid for adults with incomes below 138% of the federal poverty level, to provide coverage for those with incomes too low to qualify for the PTC and CSR subsidies. However, the U.S. Supreme Court, in its June 2012 decision in National Federation of Independent Business (NFIB) v. Sebelius, ruled that states were not required to implement the Medicaid expansion. As of June 2015, 22 states have chosen not to expand Medicaid. As a result, adults in those states who earn too much to qualify for Medicaid but not enough to qualify for the PTC and CSR subsidies are left without affordable coverage options.

Methodology

The infographics presented in this ACA Spotlight focus on eligibility for health insurance affordability programs under federal and state law. Social Interest Solutions (SIS) produced the data and maps using the MAGI Cloud platform, which includes a comprehensive rules engine that can generate ACA eligibility results across all states and across the full spectrum of health insurance options, including Medicaid, the Children’s Health Insurance Program (CHIP), and Qualified Health Plans (QHPs) with and without premium tax credits and cost-sharing reduction subsidies. To learn more about the MAGI Cloud platform, click here.


Eighteen reference household types were incorporated into this ACA Spotlight analysis. They include:

Childless Adult Households FPL Families of 4* FPL
$2,942.00 25% $6,062.50 25%
$8,827.50 75% $18,187.50 75%
$14,712.50 125% $30,312.50 125%
$20,597.50 175% $42,437.50 175%
$26,482.50 225% $54,562.50 225%
$32,367.50 275% $66,687.50 275%
$38,252.00 325% $78,812.50 325%
$44,137.50 375% $90,937.50 375%
$50,022.50 425% $103,062.50 425%

*Family of 4 includes 2 parents and 2 children, aged 10 and 12.

These household types were chosen to demonstrate how the programs for which a household is eligible vary across states and change as a household’s income changes. The analysis assumes that the individuals are not disabled or pregnant and otherwise qualify for an insurance affordability program but for the household and income variables (e.g., they meet requirements for citizenship and immigration status, are not incarcerated, and do not have affordable coverage from another source).


To determine eligibility, the MAGI Cloud platform uses income eligibility thresholds for single adults, children, and parents for Medicaid and CHIP based on data from the Kaiser Family Foundation (see here and here). These income eligibility thresholds are available in the Data Sets section. The MAGI Cloud platform also provides eligibility results for subsidies – premium tax credits (PTC) and cost-sharing reductions (CSR) – toward the purchase of QHPs through a health insurance marketplace. A premium tax credit is available to individuals with income above the relevant Medicaid/CHIP threshold and between 100% and 400% of the federal poverty level. Cost-sharing reductions are available to individuals with income between 100% and 250% of the poverty level who also qualify for a premium tax credit.

Data Set

Additional Resources