Updated February 12, 2013.
Following the U.S. Supreme Court’s decision to uphold the constitutionality of the Patient Protection and Affordable Care Act (ACA), efforts continue at the state and federal levels to prepare for implementation of key provisions of the Act scheduled to take effect in 2014. These provisions, such as the (now optional) Medicaid expansion, the individual mandate to purchase insurance, state insurance exchanges, and employer “play or pay” rules will create new or different pathways to health coverage for many.
This flow chart provides a high-level picture of the ways that people will obtain health coverage in 2014, assuming the Act is implemented as it exists today. The flow chart clearly reflects the complexity of the existing system for health coverage in the U.S., a public/private hybrid the ACA builds upon, but does not fundamentally change.
This diagram is intended as an overview of the pathways to coverage: while individuals may follow the flow chart and determine possible options, it is not intended to be comprehensive for that purpose. Rather, it is offered as a way to look ahead and better understand the many pathways to coverage that will exist in 2014, specifically in states that accept the option to expand Medicaid eligibility to individuals and families with incomes up to 138 percent of the federal poverty level (FPL).
The federal poverty threshold is a different measure, used mainly for statistical purposes such as Census Bureau estimates of the number of Americans in poverty each year. Children’s Health Insurance Program HealthCare.gov Consumers Guide to Health Reform—Q&A (Kaiser Health News, March 2010)
Federal poverty level (FPL) is a term commonly used to reference poverty guidelines issued by the Department of Health and Human Services (HHS) each year in the Federal Register. Poverty guidelines are used for administrative purposes, such as determining financial eligibility for certain federal programs. The 2011 poverty guideline is $10,890 for a single person and $22,350 for a family of four.
The Children’s Health Insurance Program (CHIP) is jointly financed by the federal and state governments and administered by the states. The State Children’s Health Insurance Program (SCHIP) encourages states to provide health coverage for uninsured children in families whose incomes are too high to qualify for Medicaid but too low to afford private insurance. Since 1997, when SCHIP was enacted, states have had the authority to set their SCHIP income eligibility levels, subject to available funding.
The U.S. Department of Health and Human Services HealthCare.gov website is a central database of health coverage options, combining information about public programs with information from private insurance plans. Consumers can receive information about options specific to their life situations and local communities.
Summary of Coverage Provisions in the Patient Protection and Affordable Care Act (Kaiser Family Foundation)
Summary of Health Reform Law (Kaiser Family Foundation)
Health Insurance Exchanges: Key Issues for State Implementation (Robert Wood Johnson Foundation)
The federal poverty threshold is a different measure, used mainly for statistical purposes such as Census Bureau estimates of the number of Americans in poverty each year.
Children’s Health Insurance Program
Consumers Guide to Health Reform—Q&A (Kaiser Health News, March 2010)