The Center for Healthcare Research & Transformation (CHRT) illuminates best practices and opportunities for improving health policy and practice. Based at the University of Michigan, CHRT is a non-profit partnership between U-M and Blue Cross Blue Shield of Michigan designed to promote evidence-based care delivery, improve population health, and expand access to care.

© Center for Healthcare Research & Transformation, December 2011 www.chrt.org/ACAflowchart Page 1 of 2

This flow chart provides a high-level picture of the ways that people will obtain health coverage in 2014, assuming the Patient Protection and Affordable Care Act (ACA) is implemented as it exists today. It 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, assuming the ACA is implemented under current law.

Exemptions from Individual Mandate1

• Exempt from filing income tax• Incarcerated• Member of an Indian tribe• Those with short coverage gaps and hardships• Member of religious sect exempted from paying Social

Security, Medicare, payroll, and self-employment taxes• Lack access to affordable coverage (as defined in ACA

Sect. 1302)• Undocumented immigrants

Guide to AcronymsCHIP — Children’s Health Insurance ProgramFPL — Federal poverty levelSSDI — Social Security Disability Income

1 Option to buy catastrophic-only coverage is available for individuals who are exempt from the individual mandate due to hardship or lack of access to affordable coverage.

2 Child-only plans are available for those under age 213 Employers with over 200 full-time employees must auto-enroll employees

in coverage. Employees may opt out to obtain coverage elsewhere or remain uninsured (with possible penalty).

4 Legal immigrants in U.S. <5 years with incomes <139% of FPL are not eligible for Medicaid but qualify for tax credits for buying coverage through Exchange.

5 Eligible individuals can buy catastrophic-only insurance through the Exchange, but premium tax credits cannot be used to buy this coverage.

6 Premium tax credits can be used to buy single or family plans on the individual market of the Exchange.

Eligible for Medicaid4

Buy catastrophic-only insurance

Buy coverage on Exchange and receive premium tax credits

(and cost-sharing subsidies if income

equal to or less than 250% FPL)6

Buy coverage on Exchange

or individual market without

premium tax credits

Covered under parent’s policy

NO

YESYES

Income less than139% FPL?

NO

NO

YES

YES

YES

YES YES

YES

YES

YES

YES YES

YES

YES

YES

YES

NONO NO

NO

NO

NO

NO

NO

NO NO NONO

NO

CHILDREN 0 – 182

Are you age 65 or older? (Or otherwise entitled

to Medicare, e.g. receive SSDI.)

Eligible for Medicare

Uninsured (Penalty)

Uninsured (No Penalty)

Buy catastrophic-only insurance

Eligible forMedicaid4

Eligible for CHIPDo you choose to remain uninsured?

Is available premium >8% of income, or are you

otherwise exempt from individual mandate?

Are you less than 26 years old?

Choose option to be on parent’s

policy?

Coverage available through parents?

Family income less than139% FPL?

Ineligible for Medicaid but meet CHIP standard (in Michigan, equal to or less than 200% of FPL)?

Are you less than 30 years old?

Choose option to buy catastrophic-only

insurance?5

Is health coverage available to you through

an employer?3

Income equal to or less than 400% of FPL?

Is available premium on the individual market more than 8% of your

income?

Choose option to buy catastrophic-only

insurance?5

START

Are you age 19 – 64?

The Path to Health Care Coverage Under the Affordable Care Act, in 2014

© Center for Healthcare Research & Transformation, December 2011 www.chrt.org/ACAflowchart Page 2 of 2

Income equal to or less than 400% FPL?

Income equal to or less than 400% FPL?

Income equal to or less than 400% FPL?

Does employer plan cover 60% or more of your share of health

expenses (on average)?

Does employer plan cover 60% or more of your share of health

expenses (on average)?

YES

NOIs available premium between 8% and 9.5% of

your income?

Is available premium more than 9.5% of your

income?

NO

NO NO

NO

NO

YES YES YES

YESYES

YES

YES

YES

NO

NO

Income less than 139% FPL?

Is available premium equal to or less than 8%

of your income?

YES

Option to accept employer

coverage (and receive premium

assistance subsidies if state offers) OR

enroll in Medicaid4

Option to accept employer coverage OR buy coverage

on Exchange or individual market without premium

tax credits

Option to accept employer coverage OR buy coverage on Exchange and receive premium tax credits (and

cost-sharing subsidies if income

equal to or less than 250% FPL)6

Option to accept employer coverage OR buy coverage

on Exchange or individual market without premium

tax credits OR buy catastrophic-only insurance5 OR opt

out of coverage without penalty

Option to accept employer coverage OR buy coverage on Exchange and receive premium tax credits (and

cost-sharing subsidies if

income equal to or less than 250%

FPL)6 OR buy catastrophic-only insurance5 OR opt

out of coverage without penalty