Guide to state requirements and policy choices in the Affordable Care Act

April 28, 2011

People in a hospital.The Patient Protection and Affordable Care Act of 2010 (ACA) requires the establishment of significant new state-level structures by the year 2014. This document summarizes major ACA requirements and policy choices for states between now and 2014.*

The two most significant ACA requirements for state implementation between now and 2014 are:

  1. To establish health insurance exchanges for individuals and small businesses
  2. To expand Medicaid coverage to cover all those up to 133 percent of the federal poverty level (138 percent with the five percent income disregard), regardless of categorical eligibility.

The ACA outlines major elements of implementation for health insurance exchanges and the Medicaid expansion but also gives states flexibility in many key areas. If states decline to implement some key initiatives, however, it does not mean implementation won’t occur—rather, it means decisions will be made at the federal rather than state level.

The ACA also includes significant provisions relating to long term care (noted in bold in table 4). These provisions include a new long term care insurance program as well as new opportunities within the Medicaid program to promote home and community-based services for long term care.

This document provides a list of actions, implementation dates, funding, and policy issues for:

  • State requirements and policy choices in the ACA (tables 1–4)
  • ACA provisions with potential budgetary impact but no state action required (table 5)

The ACA also includes many grant and demonstration project opportunities involving wellness programs, patient centered medical home demonstrations, expansion of federally qualified health centers, and Medicaid physician reimbursement enhancement. A list of these opportunities may be found in CHRT’s June 2010 policy brief, The Patient Protection and Affordable Care Act at the State and Local Level.


Suggested citation: Ogundimu, Tomi; Eller, Patrice; Udow-Phillips, Marianne. Guide to State Requirements and Policy Choices in the Affordable Care Act. April 2011. Center for Healthcare Research & Transformation. Ann Arbor, MI.

*This assessment was completed under the assumption that the ACA will be implemented based on the statute as it exists December 2010. If court challenges or the political process results in some substantive change to the ACA, revisions to this analysis would be required.