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.
|State||Marketplace Type*||Implemented Medicaid Expansion**|
|District of Columbia||State-based Marketplace||Yes|
|Hawaii||Federally-supported State-based Marketplace||Yes|
|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|
|Oregon||Federally-supported State-based Marketplace||Yes|
|Rhode Island||State-based Marketplace||Yes|
|South Carolina||Federally-facilitated Marketplace||No|
|South Dakota||Federally-facilitated Marketplace||No|
|West Virginia||State-Partnership Marketplace||Yes|
* See Kaiser Family Foundation here
** See Kaiser Family Foundation here
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.
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|
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.
- Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services
- Centers for Medicare & Medicaid Services, U.S. Department of Health & Human Services
- The Henry J. Kaiser Family Foundation
- U.S. Census Bureau