Affordable, quality health care. For everyone.

What Is Your State Doing to Affect Access to Adequate Health Insurance?


Select a state on the map and an action above to learn what the individual insurance market stabilization strategies states may be pursuing.

Notes: Section 1332 of the ACA authorizes states to apply to waive specified provisions of the health law to facilitate state-specific programs for improving coverage. If a state's "innovation waiver" program is forecast to reduce federal spending, the state is entitled to have these savings passed through to it for purposes of implementing the program. The states identified in this table have secured, or are seeking, approval for innovation waivers that use these federal "pass-through" funds to partially finance the state's reinsurance program.

*Program funding and projected premium effects data are estimates and come from the states' Section 1332 waiver applications.

**For states with an approved waiver for which pass-through funding levels have been announced by the federal government, the federal share of program funding equals the federal pass-through funding for the year identified, as calculated by the federal government, divided by the total program funding, as estimated in the state's waiver application. For these states, the state share of funding equals the difference of total program funding and federal funding. For states with a pending waiver application, or with an approved application for which pass-through funding levels have not yet been announced, the respective funding shares are derived from information provided in the state's waiver application.

***State reinsurance programs typically are designed following one of two broad models. A "condition-specific" reinsurance program covers some or all of an insurer's claims costs that have been incurred by enrollees diagnosed with one more specified high-cost health conditions. An "attachment point" reinsurance program covers some or all of an insurer's claims costs that exceed a specified threshold, or attachment point, regardless of the type of claim.

Note: The ACA requires most individuals to maintain "minimum essential" health coverage or pay a tax penalty (the individual mandate). Recent changes in federal law, effective in 2019, reduce this tax penalty to $0, but do not repeal the underlying requirement to maintain coverage. This graphic identifies states that require residents to maintain adequate health coverage -- whether or not the state imposes a penalty on individuals who fail to do so -- notwithstanding the elimination of the federal tax penalty.

Note: The ACA provides federal subsidies to reduce the cost of individual market health insurance for eligible individuals. Premium tax credits are available to otherwise eligible individuals with household income between 100% and 400% of the federal poverty level (FPL) who enroll in coverage through an ACA marketplace, and cost-sharing subsidies are available to such individuals with incomes between 100% and 250% FPL who enroll in a silver tier plan. This graphic identifies states that make available separate, state-funded subsidies to defray the cost of ACA-compliant individual market health coverage: for example, an additional premium subsidy for individuals receiving federal premium tax credits, or a subsidy for individual market consumers whose incomes render them ineligible for federal coverage assistance.

Notes: Short-term policies are not subject to the federal consumer protections of the ACA. Under federal regulations finalized in August 2018, short-term policies may provide coverage for a period of 364 days and may be renewed, at the discretion of the insurance company, for up to 36 months. This table identifies states that, by limiting the maximum duration of short-term coverage to less than 364 days, or by applying state law consumer protections to such coverage, impose limitations on the sale of short-term plans than are more strict than those mandated under the default federal approach.

*The states identified entirely prohibit short-term coverage or bar short-term insurers from discriminating on the basis of an applicant's health status.

**A state is identified as having limited the initial contract duration of underwritten short-term coverage to less than 364 days if a short-term plan lasting longer than the specified duration would become subject to one or more of the following state consumer protections: guaranteed issue, guaranteed renewability, or required coverage of essential health benefits. Such states typically impose limitations on the renewal of short-term policies, but, in most cases, do not prohibit insurers from issuing multiple new short-term policies consecutively.

***A state is identified as having limited the total length of time a consumer may be enrolled in underwritten short-term coverage to less than 364 days if it prohibits the issuance of multiple short-term policies consecutively, closing a loophole that otherwise may permit continuous enrollment in such plans.

†Connecticut makes consecutive short-term policies subject to certain preexisting condition coverage requirements.

††Hawaii also prohibits the issuance of a short-term policy to an individual who was eligible to purchase coverage through the ACA marketplace during an open or special enrollment period in the previous calendar year.

†††California prohibits the issuance of any health insurance policy with a duration of less than 12 months.

‡Virginia prohibits the issuance of a short-term policy during the annual open enrollment period; Washington also prohibits the issuance of a short-term policy during the annual open enrollment period, for coverage beginning in the upcoming year.

‡‡Delaware prohibits insurers from (1) issuing the same short-term policy to an enrollee for successive back-to-back terms; and (2) from issuing a different short-term policy to the same individual more than once in any given year.

Notes: In 2017, federal regulations reduced the open enrollment period for ACA marketplace coverage from 90 to 45 days. Starting with the annual open enrollment period for 2018 coverage, eligible individuals could enroll in a health plan during the window beginning on November 1 and ending on December 15. However, the states that operate their own ACA marketplaces and use their own enrollment platforms (11 states and the District of Columbia in 2018-19; 12 states and DC in 2020; 14 states and DC in 2021) have authority to modify the federally-specified enrollment dates, including by lengthening the duration of the sign-up period. The states that use for enrollment do not have such authority. The table identifies those states that extended the length of the 2018, 2019, 2020 or 2021 open enrollment periods beyond the 45-day federal default. While, as a formal matter, some of these states have provided for an extension by establishing a broadly available special enrollment period beginning on the day following the end of the federal default open enrollment window, the table identifies those states that, as a matter of practice, offer a continuous, broadly available enrollment period for next-year coverage than is longer than 45 days.

Note: This graphic identifies states that have adopted certain specific actions intended to promote a competitive ACA marketplace. In particular, only those states that: (1) have merged their individual and small-group markets; (2) require that all individual market coverage be sold through the ACA marketplace; or (3) leverage insurers’ participation in state public health insurance programs, such as Medicaid, or state insurance markets to encourage or require participation in the ACA marketplace. Other factors and state actions not identified here also may affect the competitiveness of a state's ACA marketplace.

Note: States may adopt a program, such as a "public option" or "Medicaid buy-in," which offers individual market consumers the option of enrolling in coverage that is sponsored and/or administered by the state. Under Section 1331 of the ACA, states may also establish a Basic Health Program (BHP) for individuals with incomes up to 200% of the federal poverty level who would otherwise be eligible for individual market coverage. The BHP, which is funded by a combination of state and federal dollars, must provide coverage that is at least as comprehensive and affordable as subsidized ACA marketplace coverage. This table identifies states that have established a public option, Medicaid buy-in, or other similar program, or that operate a BHP. The table does not include state actions related to the ACA's Medicaid expansion.

Note: The ACA requires all individual market health plans to cover broadly similar benefits, adhere to overall limits on cost-sharing, and fall within standard actuarial value tiers. This table identifies states that also require participating individual market insurers to offer plans that incorporate standardized cost-sharing parameters, such as uniform deductibles and co-payments for certain services.

Note: Transitional policies are those that were issued following the ACA’s enactment in 2010 but before 2014. These policies, also known as “grandmothered plans,” are required to meet some, but not all, of the ACA’s individual market consumer protections. In states where transitional policies are allowed, insurers may choose whether to continue to offer such policies. In some states, transitional policies may no longer exist in the individual market, even though permitted under state law.

*Table reflects state decisions as of December 31, 2018; such decisions govern transitional policies renewed on or before October 1, 2019. State decisions regarding transitional policies renewed after October 1, 2019 are not reflected in this table.

* The table identifies states that have established rules exempting certain health coverage products from federal and state insurance regulation. These rules tend to encourage market segmentation and a deterioration of the ACA-compliant risk pool, thereby making comprehensive individual market coverage less affordable and accessible. States may have taken other actions that are likely to decrease access to affordable and adequate individual market coverage that are not identified in this table. For example, this table does not include state actions that may encourage the sale of, or broaden access to the following forms of coverage, which are not fully compliant with federal rules governing the individual market: short-term, limited duration insurance; association health plans that meet the definition of a large-group plan under federal law; transitional, or "grandmothered" health plans; or coverage arrangements offered by a health care sharing ministry.

Source: J. Giovannelli, K. Lucia, and S. Corlette, "To Understand How Consumers Are Faring in the Individual Health Insurance Markets, Watch the States," To the Point (blog), Commonwealth Fund, July 18, 2018.

Publication Details

Publication Date: October 1, 2020