NOTE: The ACA provides new dependent coverage for children up to age 26 for all individual group policies. In addition, insurers are prohibited from denying coverage to children with preexisting conditions.
aMedicaid Eligibility (state-based): low-income and categorically eligible (disabled, pregnant women, children, medically needy); states may seek waivers to cover other groups (such as non-disabled, childless adults); must be a U.S. citizen or a legal resident for at least 5 years. As of 2010, the ACA gave states the option to expand coverage to low-income individuals up to 133 percent of the federal poverty level (FPL), regardless of disability or other status (which some states have done). For current state eligibility requirements and information on which states have moved to expand Medicaid as permitted by the ACA, see, Kaiser Family Foundation, State Health Facts, Medicaid Income Eligibility Limits for Adults as a Percent of Federal Poverty Level, http://statehealthfacts.org/comparereport.jsp?rep=130&cat=4. For more information on Medicaid, see, Kaiser Family Foundation, Medicaid: A Primer, http://www.kff.org/medicaid/7334.cfm.
bMedicare Eligibility (national): ≥65, disabled (SSDI), or end stage renal disease; must be a U.S. citizen or a legal resident for at least 5 years. Medicare beneficiaries are getting discounts on drugs while in the Medicare coverage gap and preventive services are covered without cost sharing. For more information on Medicare, see, Kaiser Family Foundation, Medicare: A Primer, http://www.kff.org/medicare/7615.cfm.
cState High-Risk Insurance Pools: Prior to the ACA, health plans were permitted to deny coverage to individuals with pre-existing conditions or to charge them higher premiums. Because of this, several states operate state high risk pools which provide health insurance to residents who are considered medically uninsurable and are unable to buy coverage in the individual market. See Kaiser Family Foundation, State Health Facts, State High Risk Pool Programs and Enrollment, http://www.statehealthfacts.org/comparetable.jsp?ind=602&cat=7. In addition, the ACA created the temporary PCIP program in 2010 (see below).
dPre-Existing Condition Insurance Plan (PCIP): Created by the ACA, PCIP is a temporary program that runs from 2010-2014 to provide health coverage to individuals with pre-existing medical conditions who have been uninsured for at least six months. The plan will be operated by the states or the federal government. For more information on the current status of PCIPs, see, Kaiser Family Foundation, State Health Facts, Pre-Existing Condition Insurance Plan: Operation Decisions and Preliminary Funding Allocations, http://www.statehealthfacts.org/comparemapreport.jsp?rep=67&cat=17.
eRyan White: The Ryan White HIV/AIDS Program, the single largest federal program designed specifically for people with HIV in the United States, provides care and services for people with HIV who are uninsured or underinsured, serving as payer of last resort. It includes the AIDS Drug Assistance Program (ADAP). Federal funding is provided to states, cities and providers but may not match the number of people who need services or the cost of their care. For more information, see, Kaiser Family Foundation, The Ryan White Program, http://www.kff.org/hivaids/7582.cfm.
SOURCE: Adapted from KFF, 2012b.