Affordable Care Act Provides New Insurance Eligibility

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The New Year has begun with many insurance eligibility changes due to the Affordable Care Act. Programs such as Medicaid and CHIP (Children’s Health Insurance Program) were established in 1965 and 1997, respectively, in order to provide health coverage for low-income families. Under the ACA, Americans under the age of 65 and with an income below 133% of the federal poverty level qualify for Medicaid coverage, beginning January 1st 2014.

This will allow both children and adults with a low income to receive Medicaid benefits across the country and the changes can make a significant difference. Children under the age of 19 will no longer be denied coverage based only on a pre-existing condition. It’s also possible for coverage to start up to 3 months retroactively. This requires that, had the individual applied during that period, he or she would have been eligible. However, requirements such as immigration status, proof of citizenship, or residency must also be met for Medicaid eligibility.

States are required by federal law to cover mandatory eligibility groups:

  • Low-income families
  • Deemed newborns (born to women receiving Medicaid)
  • Disabled adult children
  • Essential spouses (those of aged, blind, or disabled individuals)

Optional eligibility groups are the ones that states can choose to cover. These include the following:

  • Independent foster care adolescents
  • Presumptively eligible children and pregnant women
  • Individuals receiving hospice care
  • Qualified disabled children under 19

The complete list of both mandatory and optional eligibility groups can be found at

The changes have created some difficulties for healthcare practices as well. Though many individuals have recently applied for insurance coverage, there are several who haven’t yet received insurance identification cards, but are still making appointments and seeking healthcare. Practices could be put into a difficult position here and will need to focus their efforts on confirming a patient’s insurance. They may need to rely on cash reserves until the situation is resolved. This could take a few months as it can depend on whether they’re covered by a state plan or federal plan.

Author: Apoorva Anupindi

One thought on “Affordable Care Act Provides New Insurance Eligibility

  1. These changes will provide healthcare for a significant number of people. It will be interesting to see what an effect this has on the healthcare system as a whole.

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