Patient Protection and Affordable Care Act (ACA): Resources for Frequently Asked Questions

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) had numerous provisions affecting private health insurance and public health coverage programs. This report provides resources to help congressional staff respond to constituents’ frequently asked questions (FAQs) about the ACA. It lists selected resources regarding consumers, employers, and other stakeholders, with a focus on federal sources. It also lists Congressional Research Service (CRS) reports that summarize the ACA’s provisions.

The Coronavirus Disease 2019 (COVID-19) pandemic has raised questions among some constituents about how to obtain and use health coverage. The ACA had several provisions to expand health coverage for certain eligible individuals. For example, the ACA established exchanges (sometimes called marketplaces) to provide eligible individuals with access to private health plans; it provides many exchange enrollees with subsidies to help pay for premiums, cost-sharing, or both. In addition, under the ACA, some states have expanded Medicaid eligibility. This report begins with contacts for constituents’ specific questions on obtaining and using health coverage (such as contact information for exchanges, state Medicaid agencies, organizations providing enrollment assistance, state insurance departments, and the U.S. Department of Labor’s consumer hotline for questions on employer-based coverage). These contacts can help constituents determine their health coverage options. The report also provides contacts for questions about health issues, and sources for congressional staff to contact federal agencies with ACA questions.

The report then provides basic consumer sources, including a glossary of health coverage terms and sources for obtaining the law’s full text. The next sections focus on private health insurance, exchanges, and employer-sponsored coverage. These are followed by information on public health care programs, such as Medicaid, the State Children’s Health Insurance Program (CHIP), and Medicare. The report also provides sources on the ACA’s provisions on specific populations: women’s health care, Indian health care, veterans’ and military health care, and the treatment of noncitizens under the ACA. These are followed by sources on behavioral health (mental health and substance use disorders); public health, workforce, and quality; and state innovation waivers. Finally, the report lists sources on taxes, congressional efforts to repeal or amend the ACA, ACA agency audits and investigations, cost estimates and spending, insurance coverage statistics, and legal and regulatory issues.

This list is not a comprehensive directory of all resources on the ACA but rather is intended to address some questions that may arise frequently.

Patient Protection and Affordable Care Act (ACA): Resources for Frequently Asked Questions

Updated May 5, 2020 (R43215)
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Contents

Summary

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) had numerous provisions affecting private health insurance and public health coverage programs. This report provides resources to help congressional staff respond to constituents' frequently asked questions (FAQs) about the ACA. It lists selected resources regarding consumers, employers, and other stakeholders, with a focus on federal sources. It also lists Congressional Research Service (CRS) reports that summarize the ACA's provisions.

The Coronavirus Disease 2019 (COVID-19) pandemic has raised questions among some constituents about how to obtain and use health coverage. The ACA had several provisions to expand health coverage for certain eligible individuals. For example, the ACA established exchanges (sometimes called marketplaces) to provide eligible individuals with access to private health plans; it provides many exchange enrollees with subsidies to help pay for premiums, cost-sharing, or both. In addition, under the ACA, some states have expanded Medicaid eligibility. This report begins with contacts for constituents' specific questions on obtaining and using health coverage (such as contact information for exchanges, state Medicaid agencies, organizations providing enrollment assistance, state insurance departments, and the U.S. Department of Labor's consumer hotline for questions on employer-based coverage). These contacts can help constituents determine their health coverage options. The report also provides contacts for questions about health issues, and sources for congressional staff to contact federal agencies with ACA questions.

The report then provides basic consumer sources, including a glossary of health coverage terms and sources for obtaining the law's full text. The next sections focus on private health insurance, exchanges, and employer-sponsored coverage. These are followed by information on public health care programs, such as Medicaid, the State Children's Health Insurance Program (CHIP), and Medicare. The report also provides sources on the ACA's provisions on specific populations: women's health care, Indian health care, veterans' and military health care, and the treatment of noncitizens under the ACA. These are followed by sources on behavioral health (mental health and substance use disorders); public health, workforce, and quality; and state innovation waivers. Finally, the report lists sources on taxes, congressional efforts to repeal or amend the ACA, ACA agency audits and investigations, cost estimates and spending, insurance coverage statistics, and legal and regulatory issues.

This list is not a comprehensive directory of all resources on the ACA but rather is intended to address some questions that may arise frequently.


This report provides resources to help congressional staff respond to constituents' frequently asked questions (FAQs) about the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). The report lists selected resources regarding consumers, employers, and other stakeholders, with a focus on federal sources. It also lists Congressional Research Service (CRS) reports that summarize the ACA's provisions. The resources are arranged by topic.

This list is not a comprehensive directory of all resources on the ACA but rather is intended to address some questions that may arise frequently.

Contacts for ACA Assistance

Help with Obtaining and Using Health Coverage

Contact Us (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/contact-us/

HealthCare.gov is the official federal portal for ACA consumer information. It has questions and answers on options for obtaining coverage and other health insurance questions. The website offers a 24/7 consumer hotline, 1-800-318-2596 (TTY: 1-855-889-4325).1 For translation assistance in other languages, constituents may call the HealthCare.gov hotline or visit the website at https://www.healthcare.gov/language-resource.

Find Local Help (U.S. Department of Health and Human Services, HealthCare.gov)
https://localhelp.healthcare.gov

A directory of state and local organizations trained to provide enrollment assistance and help constituents understand their health coverage options. The directory also includes insurance agents and brokers.

Consumer Assistance Program (The Center for Consumer Information and Insurance Oversight)
https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/

A clickable map directory of consumer assistance programs and other state agencies that can answer constituent questions on ACA and health insurance, including options for obtaining coverage.

Contact Your State With Questions (Centers for Medicare & Medicaid Services)
https://www.medicaid.gov/about-us/contact-us/contact-your-state-questions/index.html

A directory of state Medicaid contacts. Individuals can apply for Medicaid coverage any time of the year.

InsureKidsNow.gov (Centers for Medicare & Medicaid Services)
https://www.insurekidsnow.gov/

Families interested in Medicaid or State Children's Health Insurance Program (CHIP) coverage may call 1-877-KIDS-NOW (1-877-543-7669).

Map of NAIC States & Jurisdictions (National Association of Insurance Commissioners)
http://www.naic.org/state_web_map.htm

States are the primary regulators of health insurance. Constituents with health insurance questions and problems may contact state insurance departments for assistance. The map links to each insurance department's website.

Ask EBSA (U.S. Department of Labor, Employee Benefits Security Administration)
https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa

Constituents with questions about job-based health coverage can speak with benefits advisors at 1-866-444-3272. Benefits advisors can also answer questions about COBRA continuation coverage, which "gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events." See https://www.dol.gov/general/topic/health-plans/cobra.

State Health Insurance Assistance Programs (SHIPs) (Centers for Medicare & Medicaid Services)
https://www.medicare.gov/contacts/#resources/ships

SHIPs offer personalized health insurance counseling for Medicare beneficiaries

Health plan enrollees may contact insurers directly to verify enrollment or to ask about coverage of particular drugs, medical services, and health care providers. Enrollees can find their health plan's customer service phone number on their insurance card, on the insurer's website, or by calling the HealthCare.gov hotline, 1-800-318-2596 (TTY: 1-855-889-4325).

Help with Health and Health Care Questions

Federal Health Information Centers and Clearinghouses (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion)
https://health.gov/our-work/health-literacy/resources/national-health-information-center/clearinghouses/topic

A directory of federal hotlines and information clearinghouses related to health and health care.

Health Info Lines (National Institutes of Health)
https://www.nih.gov/health-information/health-info-lines

A directory of hotlines for health information.

The resources above do not provide medical advice. Constituents should contact their own health care providers for medical advice.

Find Doctors and Medical Facilities (USA.gov)
https://www.usa.gov/doctors

A compilation of tools for finding providers (such as physicians) and health care facilities (such as hospitals). Some of the listed directories incorporate quality measures. Health plan enrollees should also check their health plan's website for a provider directory.

Help with Taxes

Telephone Assistance (Internal Revenue Service)
https://www.irs.gov/help/telephone-assistance

The IRS is implementing many of the ACA's tax provisions, including premium tax credits and employer shared responsibility penalties. The Internal Revenue Service (IRS) has a Healthcare Hotline for ACA questions (1-800-919-0452) and other telephone hotlines to answer questions from individuals and employers.

Assistance for Congressional Staff

Congressional Marketplace Hotline (U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services)

A dedicated hotline exclusively for Members of Congress and congressional staff with questions about ACA implementation and exchanges: 202-690-8004, [email address scrubbed].

CRS Report 98-446, Congressional Liaison Offices of Selected Federal Agencies

The CRS report lists congressional liaison offices at federal agencies, including those that work on ACA issues, such as the Department of Health and Human Services (HHS); HHS's Centers for Medicare & Medicaid Services, which administers the ACA's private health insurance, Medicare, and Medicaid provisions; the IRS, which administers the ACA's revenue (tax) provisions; the Department of Labor, which administers ACA provisions related to employer-sponsored coverage; and the Congressional Budget Office. Congressional liaison offices answer questions from Members of Congress and congressional staff; they usually do not assist constituents directly.

Assistant Secretary for Legislation (ASL) Offices (U.S. Department of Health and Human Services)
https://www.hhs.gov/about/agencies/asl/about-asl/asl-offices/index.html

Lists contact information and subject area portfolios for HHS congressional liaison staff.

CRS reports on ACA and other health policy issues are at CRS.gov: Issue Area: Health Care
http://www.crs.gov/iap/health-care

Click "All Subissues" for reports on "Health Care Reform," "Private Health Insurance," and "Medicaid & CHIP," among other health-related topics. Each report has author contact information. CRS authors are available to answer questions from Members of Congress and congressional staff. CRS provides research and analysis exclusively to Congress. CRS authors are unable to assist constituents directly.

Basic Consumer Sources

HealthCare.gov (U.S. Department of Health and Human Services)
http://www.healthcare.gov

The official federal portal for ACA consumer information. Click "Get Answers" for frequently asked questions and answers, including options for obtaining coverage. Click "See Topics": "Browse all topics" for sources tailored to specific populations, such as unemployed people, self-employed people, people under 30, people with disabilities, veterans, American Indians and Alaska Natives, immigrants, pregnant women, same-sex married couples, transgender people, retirees, and incarcerated people. Marketplace coverage & Coronavirus covers topics such as "If I lost my job or experienced a reduction in hours due to COVID-19" https://www.healthcare.gov/coronavirus/. A Spanish-language version of HealthCare.gov is at http://www.CuidadoDeSalud.gov.

Affordable Care Act Tax Provisions for Individuals and Families (Internal Revenue Service)
https://www.irs.gov/affordable-care-act/individuals-and-families

Explains ACA tax provisions for consumers, including provisions on premium tax credits. FAQs are at https://www.irs.gov/affordable-care-act/affordable-care-act-tax-provisions-questions-and-answers.

Glossary (U.S. Department of Health and Human Services, HealthCare.gov)
http://www.healthcare.gov/glossary/index.html

Plain-language definitions of health care and health insurance terms.

Roadmap to Better Care (Centers for Medicare & Medicaid Services)
https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/c2c/consumerresources/roadmap-to-better-care.html

Consumer booklets on how to read an insurance card, how to choose a provider, how to set up and prepare for a health care appointment, and more. Some resources have been translated to other languages.

CRS Report R45244, Legislative Actions to Modify the Affordable Care Act in the 111th-115th Congresses

Includes "A Brief Overview of the ACA."

Find Doctors and Medical Facilities (USA.gov)
https://www.usa.gov/doctors

A compilation of tools for finding providers (such as physicians) and health care facilities (such as hospitals). Some of the listed directories incorporate quality measures. Health plan enrollees should also check their health plan's website for a provider directory.

MedlinePlus (U.S. National Library of Medicine, National Institutes of Health)
https://medlineplus.gov/

Plain-language information on numerous health topics, drugs, and supplements. Some materials are in Spanish at https://medlineplus.gov/spanish/.

ACA Text

The following resources can help with constituent requests for the text of the ACA.

Compilation of the Patient Protection and Affordable Care Act (U.S. House of Representatives, Office of the Legislative Counsel)
https://www.govinfo.gov/app/collection/comps/

The ACA compilation is listed under "P" on this website. The House Office of the Legislative Counsel compiled the text of the ACA, consolidated with amendments made by subsequent laws. The compilation is unofficial. It is updated periodically.

P.L. 111-148, Patient Protection and Affordable Care Act (Government Publishing Office, March 23, 2010, 124 Stat. 119)
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

Unlike the unofficial compilation above, this is the official publication of the ACA as enacted on March 23, 2010. However, this does not reflect current law, as the ACA has since been amended by several subsequent laws, including P.L. 111-152, Health Care and Education Reconciliation Act of 2010, http://www.gpo.gov/fdsys/pkg/PLAW-111publ152/pdf/PLAW-111publ152.pdf.

The Individual Mandate

See also "Tax Statistics"

CRS Report R44438, The Individual Mandate for Health Insurance Coverage: In Brief

Basic background and state-level statistics on the individual mandate, the requirement that most individuals have minimum essential health coverage or else pay a tax penalty. The report also discusses how the Tax Cuts and Jobs Act (P.L. 115-97) effectively eliminated the individual mandate penalty beginning in 2019.

The fee for not having health insurance (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/fees/

Details on the federal individual mandate penalty, which no longer applies beginning with plan year 2019. Although the federal penalty has been eliminated, some states have enacted their own individual mandate laws.

Private Health Insurance

See also "Exchanges" and "Employer-Sponsored Coverage."

Overviews

CRS Report R45146, Federal Requirements on Private Health Insurance Plans

Table 1 shows which federal requirements apply to which health plans, depending on whether they are sold in the large group, small group, or individual market; and whether plans are fully insured or self-insured. Table A-1 compares requirements pre-ACA and under current law.

CRS Report RL32237, Health Insurance: A Primer

A basic overview of health insurance: key definitions and principles, the regulation of health insurance, and sources of health insurance.

CRS Insight IN10969, Consumer Protections in Private Health Insurance for Individuals with Preexisting Health Conditions

A brief overview of preexisting condition protections, pre-ACA and under current law.

Health coverage rights and protections (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/health-care-law-protections/

Summarizes consumer protections under ACA, such as coverage for preexisting conditions, the requirement that insurers provide a plain-language Summary of Benefits and Coverage, and restrictions on lifetime and annual limits.

Fact Sheets and Frequently Asked Questions (FAQs) (The Center for Consumer Information and Insurance Oversight)
http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index.html

The federal Center for Consumer Information and Insurance Oversight is charged with implementing the ACA's private health insurance reforms. The page provides information for stakeholders, including state officials, health insurance companies, and consumers. Private health insurance resources include, for example, Coronavirus Disease 2019 (COVID-19) Guidance, https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index#COVID-19 and FAQs About Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation (April 11, 2020), https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf.

CRS In Focus IF11359, Applicability of Federal Requirements to Selected Health Coverage Arrangements: An Overview

In general, private health insurance plans must comply with certain federal health insurance requirements, including some requirements enacted by ACA as amended. However, some health coverage arrangements, including certain exempted health coverage arrangements and noncompliant health coverage arrangements (as termed for purposes of this report), do not comply with federal health insurance requirements. This report gives a brief overview of these arrangements. More details are in CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements.

CRS In Focus IF11523, Health Insurance Options Following Loss of Employment

Two-page overview of potential health coverage options following job loss, including private health insurance options such as exchange coverage. Due to the COVID-19 pandemic's economic impact, many Americans may lose jobs through which they receive health insurance.

Dependent Coverage

Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Businesses and Families FAQs (Employee Benefits Security Administration)
https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/young-adult-and-aca

Questions and answers on the ACA's dependent coverage provision. Under the ACA, if a health plan provides for dependent coverage of children, the plan must make such coverage available for adult children under the age of 26.

Essential Health Benefits

CRS In Focus IF10287, The Essential Health Benefits (EHB)

Two-pager gives brief background and infographics on EHB.

CRS Report R44163, The Patient Protection and Affordable Care Act's Essential Health Benefits (EHB)

Describes EHB, interstate and intrastate variations in EHB coverage, the applicability of EHB requirements to health plans, and how other ACA provisions apply to EHB.

Information on Essential Health Benefits (EHB) Benchmark Plans (The Center for Consumer Information and Insurance Oversight)
https://www.cms.gov/cciio/resources/data-resources/ehb.html

Describes current requirements and options for states to select their EHB benchmark plans; summarizes other requirements related to the EHB; and links to all states' benchmark plan documents and lists of any additionally mandated benefits. The page includes "FAQs on Essential Health Benefits Coverage and the Coronavirus (COVID-19)."

Risk Mitigation

CRS In Focus IF10994, Risk Adjustment in the Private Health Insurance Market

Two-page overview of the concept of risk mitigation and the ACA's risk adjustment program.

CRS Report R45334, The Patient Protection and Affordable Care Act's (ACA's) Risk Adjustment Program: Frequently Asked Questions

Summarizes the concepts of risk and risk mitigation in health insurance. Describes the mechanics of the ACA's risk adjustment program and how the risk adjustment program works in practice.

CRS In Focus IF10707, Reinsurance in Health Insurance

Reinsurance is also known as insurance for insurers. Two-page overview of insurance risk, reinsurance funding and payment structures, federal reinsurance programs, and reinsurance funds' potential impact on premiums.

CRS Report R44690, The Patient Protection and Affordable Care Act's (ACA's) Transitional Reinsurance Program

The ACA's temporary (2014-2016) transitional reinsurance program was designed to pay individual market health plans that enrolled high-cost enrollees. This report also summarizes the ACA's other risk mitigation programs: the permanent risk adjustment program and the temporary (2014-2016) risk corridors program.

CRS Legal Sidebar LSB10360, Using the Power of the Purse to Change Policy: SCOTUS Case on ACA Risk Corridors Asks Important Appropriations Law Question

CRS analysis of the lawsuits consolidated under Maine Community Health Options v. United States, pertaining to ACA's risk corridor provision. The Supreme Court heard oral arguments on December 10, 2019 and issued a decision on April 27, 2020, https://www.supremecourt.gov/opinions/19pdf/18-1023_m64o.pdf.

Statistics

See also "Statistics on Insurance Coverage" and "Exchange Statistics"

Trends in Subsidized and Unsubsidized Enrollment (Centers for Medicare & Medicaid Services, August 12, 2019)
https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/Trends-Subsidized-Unsubsidized-Enrollment-BY17-18.pdf

Includes state-level data on enrollment in the individual (nongroup) market. An earlier version of this report was Trends in Subsidized and Unsubsidized Individual Health Insurance Market Enrollment (Centers for Medicare & Medicaid Services, July 2, 2018), https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/2018-07-02-Trends-Report-2.pdf.

CRS In Focus IF10558, Coverage in the Private Health Insurance Market

Brief descriptions of and summary statistics for private health insurance coverage: group (employer) insurance coverage and nongroup (individual) insurance coverage, including statistics on ACA exchange coverage. It also lists selected data sources for private health insurance coverage estimates.

Private Health Insurance: Enrollment Remains Concentrated among Few Issuers, including in Exchanges (Government Accountability Office (GAO), March 21, 2019)
https://www.gao.gov/products/GAO-19-306

State-level data include Appendix V, Number and Market Share of Largest Issuers Participating in Each State's Overall Individual Market; Appendix VII, Number and Market Share of Largest Issuers Participating in Overall Small Group Health Insurance Market; and Appendix VIII, Number and Market Share of Largest Issuers Participating in Each State's Overall Large Group Health Insurance Market. The report also includes state-level data on exchanges.

Compilation of State Data on the Affordable Care Act (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, December 2016)
https://aspe.hhs.gov/compilation-state-data-affordable-care-act

Excel spreadsheet of state data on the effects of selected ACA provisions, including several provisions related to private health insurance (employer coverage and individual market coverage).

The Center for Consumer Information & Insurance Oversight: Data Resources (Centers for Medicare & Medicaid Services)
https://www.cms.gov/CCIIO/Resources/Data-Resources/index.html

This collection of federal private health insurance data sources includes:

Exchanges

Getting Exchange Coverage

HealthCare.gov (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/

Under the ACA, exchanges (sometimes called marketplaces) have been established to provide eligible individuals with access to private health plans. The website has plain-language information about the exchanges.

  • For a briefer overview, see "A quick guide to the Health Insurance Marketplace," https://www.healthcare.gov/quick-guide/.
  • To find a specific state's exchange, use the pull-down menu at https://www.healthcare.gov/get-coverage/. Open Enrollment periods differ by state.
  • Getting health coverage outside Open Enrollment (U.S. Department of Health and Human Services, HealthCare.gov)
    https://www.healthcare.gov/coverage-outside-open-enrollment/
  • Describes how certain individuals could qualify for "special enrollment periods" outside of open enrollment periods. (Examples of qualifying events include losing other health coverage, a change in income, marriage, death, birth, adoption, experiencing spousal abandonment or domestic violence, and moving to a new county.) Open Enrollment periods differ by state. The Open Enrollment period for 2020 coverage was November 1, 2019 to December 15, 2019 in most states using HealthCare.gov as their exchange platform. Some states have opened special enrollment periods in response to the COVID-19 pandemic, allowing uninsured persons to enroll in exchange coverage.2 Marketplace coverage & Coronavirus also describes special enrollment periods in "If I lost my job or experienced a reduction in hours due to COVID-19" https://www.healthcare.gov/coronavirus/. Individuals can apply for Medicaid or State Children's Health Insurance Program (CHIP) coverage any time.

See plans & prices (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/see-plans/

In states using HealthCare.gov as their exchange platform, this website lets consumers view plan information and premium estimates without opening a HealthCare.gov account.

How to pick a health insurance plan (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/choose-a-plan/

Tips and considerations for consumers choosing a health plan.

Health Insurance Marketplace (Centers for Medicare & Medicaid Services)
http://marketplace.cms.gov/

For professionals assisting consumers with enrollment, this site has technical assistance resources, applications and forms, and federal education and outreach materials. Some of the resources are available in Spanish and selected other languages.

Using Exchange Coverage

Using Your Health Insurance Coverage (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/using-marketplace-coverage/

Consumer tips for getting prescription drugs, finding a doctor, getting emergency care, and appealing insurance-company decisions.

What Marketplace Health Insurance Plans Cover (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/coverage/

Lists the "essential health benefits" that exchange plans are required to cover. Specific benefit details differ by state and by plan.

Your total costs for health care: Premium, deductible & out-of-pocket costs (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/choose-a-plan/your-total-costs/

Tips about out-of-pocket costs and deductibles that affect consumers' total spending on health care.

CRS Report R44065, Overview of Health Insurance Exchanges

Summarizes individual and Small Business Health Options Program (SHOP) exchanges. Discusses eligibility, enrollment, enrollment assistance, financial assistance, the plans offered through exchanges, and exchange funding.

Exchange Subsidies

CRS Report R44425, Health Insurance Premium Tax Credits and Cost-Sharing Subsidies

Describes premium tax credits: who is eligible to receive them, how amounts are calculated, and data on recipients and payments. The report also describes cost-sharing subsidies (also known as cost-sharing reductions or CSRs) and the termination of CSR payments starting October 2017.

Saving money on health insurance (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/lower-costs/

This screener helps consumers check if they may be eligible for health coverage subsidies, including premium tax credits and cost-sharing subsidies.

The Premium Tax Credit – The Basics (Internal Revenue Service)
https://www.irs.gov/affordable-care-act/individuals-and-families/the-premium-tax-credit-the-basics

Basic background on premium credits. FAQs are at Questions and Answers on the Premium Tax Credit https://www.irs.gov/affordable-care-act/individuals-and-families/questions-and-answers-on-the-premium-tax-credit.

Premium Tax Credit Change Estimator (Internal Revenue Service, Taxpayer Advocate Service)
http://www.taxpayeradvocate.irs.gov/estimator/premiumtaxcreditchange/

The tool can help individuals estimate how their premium tax credit could change if their income or family size changes during the year.

How to make updates when your income or household change (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/reporting-changes/

For persons with exchange coverage, this site provides instructions for reporting changes in income, health coverage eligibility (for example, an offer of job-based coverage), and household members (for example, marriage, birth, adoption). These changes could affect subsidy amounts and eligibility for coverage.

Exchange Statistics and Research

Statistics and research on health insurance exchanges are available from several governmental sources. Overviews of those sources are listed here, and specific reports are detailed in relevant sections below.

Most states use the federal HealthCare.gov platform to administer their exchanges; some states use their own state-based exchange platforms. Note that sources vary in whether they have data on all states or on a subset (e.g., only those states using the Healthcare.gov platform).

U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE)

ACA-related research, including exchange statistics, as published under the current and previous administrations. Reports vary with respect to states covered. (For example, some ASPE reports have data only on states that use the Healthcare.gov platform.)

Health Coverage Research: Reports published under the current administration (since January 20, 2017, https://aspe.hhs.gov/health-coverage-research

Historical Research: Reports published before January 20, 2017, https://aspe.hhs.gov/historical-research

Centers for Medicare & Medicaid Services (CMS)

The Center for Consumer Information & Insurance Oversight: Data Resources
https://www.cms.gov/CCIIO/Resources/Data-Resources/index.html

Includes several exchange data sources, such as:

Government Accountability Office (GAO)

GAO's mission is "[w]e support Congress in meeting its constitutional responsibilities, and help improve the performance and ensure the accountability of the federal government. We provide Congress with timely information that is objective, fact-based, nonpartisan, nonideological, and balanced." GAO has published several analyses of the ACA exchanges, including analyses of data on premiums, market concentration, plan availability, and enrollee experiences. See the search of GAO's website for examples of exchange-related reports at https://go.usa.gov/xv82a.

Enrollment Statistics

This section lists CMS and ASPE reports and data files on exchange enrollment by plan year (which is generally the calendar year). Some resources also include data on premiums, advanced premium tax credits (APTC), enrollees with cost-sharing reductions (CSR), or other topics. Unless otherwise noted, these resources focus on the individual (not small business) exchanges.

The resources below include both pre-effectuated and effectuated data on enrollment in coverage through the individual exchanges:

  • Pre-effectuated enrollment data reflect individuals who have selected a plan, but might not necessarily have paid their first premium.
  • Effectuated enrollment data reflect individuals who have selected a plan and have submitted the first premium payment for a plan.

When comparing exchange statistics from one year to another, it is generally best to compare estimates of the same type (e.g., only comparing pre-effectuated estimates to each other, or comparing one point-in-time effectuated enrollment estimate as of February to another year's point-in-time effectuated enrollment estimate as of February). Thus, enrollment data sources are grouped below by type. See Table 1 in CRS Report R44065, Overview of Health Insurance Exchanges for a high-level comparison of enrollment data by year. Some trend data are also in Additional Exchange Statistics.

Pre-effectuated Enrollment Data

Pre-effectuated enrollment data reflect individuals who have selected a plan, but might not necessarily have paid their first premium. For HealthCare.gov states,3 pre-effectuated enrollment estimates were released weekly during the Open Enrollment Period through the CMS Newsroom.

CMS Newsroom: Enrollment Snapshots during Open Enrollment Period

Newsroom: This search brings up Newsroom articles that have been assigned the topic heading "Affordable Care Act." During the Open Enrollment Period, CMS publishes weekly pre-effectuated enrollment snapshots for states using the HealthCare.gov platform at https://www.cms.gov/newsroom/search?search_api_language=en&sort_by=field_date&sort_order=DESC&items_per_page=10&f%5B0%5D=topic%3A111.

CMS also issues annual reports and spreadsheets that summarize pre-effectuated enrollment through an open enrollment period. They typically include national and state data on premiums, plan selections, APTC, enrollees with CSR, and enrollee demographics.4 The annual reports are typically released in the spring after the open enrollment period. For Healthcare.gov states, selected county and zip code level data are available for plan years since 2015. Table 1 provides links to fact sheets or issue briefs as well as public use data files.

Table 1. Pre-effectuated Enrollment Data Sources

(include selected data on premiums, plan selections, APTC, enrollees with CSR, and enrollee demographics)

Plan Year

Sources

Date Released

 

 

 

2020

Fact sheet: Health Insurance Exchanges 2020 Open Enrollment Report, https://www.cms.gov/files/document/4120-health-insurance-exchanges-2020-open-enrollment-report-final.pdf

Public use data files: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2020-Marketplace-Open-Enrollment-Period-Public-Use-Files

April 2020

2019

Fact sheet: Health Insurance Exchanges 2019 Open Enrollment Report, https://www.cms.gov/newsroom/fact-sheets/health-insurance-exchanges-2019-open-enrollment-report

Public use data files: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2019_Open_Enrollment.html

March 2019

2018

Fact sheet: Health Insurance Exchanges 2018 Open Enrollment Final Report, https://www.cms.gov/newsroom/fact-sheets/health-insurance-exchanges-2018-open-enrollment-period-final-report

Public use data files: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2018_Open_Enrollment

April 2018

2017a

Fact sheet: Health Insurance Marketplaces 2017 Open Enrollment Period Final Enrollment Report: November 1, 2016 – January 31, 2017, https://www.cms.gov/newsroom/fact-sheets/health-insurance-marketplaces-2017-open-enrollment-period-final-enrollment-report-november-1-2016

Public use data files: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2019_Open_Enrollment

March 2017

2016b

Issue brief, addendum, and state level tables: Health Insurance Marketplaces 2016 Open Enrollment Period: Final Enrollment Report, https://aspe.hhs.gov/health-insurance-marketplaces-2016-open-enrollment-period-final-enrollment-report

Public use data files: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2016_Open_Enrollment

March 2016

2015

Issue brief: Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report, https://aspe.hhs.gov/system/files/pdf/83656/ib_2015mar_enrollment.pdf

Public use files: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2015_Open_Enrollment

March 2015

2014c

Summary report: Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period, https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-summary-enrollment-report-initial-annual-open-enrollment-period

Addendum with detailed state and demographic data: https://aspe.hhs.gov/pdf-report/addendum-health-insurance-marketplace-summary-enrollment-report

State profiles: https://aspe.hhs.gov/profiles-affordable-care-act-coverage-expansion-enrollment-medicaid-chip-and-health-insurance-marketplace-10-1-2013-3-31-2014

May 2014

Source: Compiled by the Congressional Research Service (CRS).

Notes: The abbreviation APTC refers to advanced premium tax credits. CSR refers to cost-sharing reductions. CMS refers to the Centers for Medicare & Medicaid Services.

a. CMS also issued a companion report for 2017: Race, Ethnicity, and Language Preference in the Health Insurance Marketplaces 2017 Open Enrollment Period (Centers for Medicare & Medicaid Services, April 2017). This report had national and state data on adult HealthCare.gov enrollees by race, ethnicity, and preferred spoken and written language. Includes subgroup data for Hispanics/Latinos, Asians, and Native Hawaiians or Other Pacific Islanders (NHOPI). https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Data-Highlight-Race-Ethnicity-and-Language-Preference-Marketplace.pdf

b. CMS also released related CSR data for 2016: Health Insurance Marketplace Cost Sharing Reduction Subsidies by Zip Code and County 2016 (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation). For HealthCare.gov states, this spreadsheet had county and zip code (but not state) data on the number of consumers with CSR subsidies, and the average advanced CSR payment by CSR actuarial value ("AV"). Actuarial value is a measure of a plan's generosity, the estimated insurer's share of medical expenses for a standard population and a set of allowed charges. For example, consumers with CSR AV 94% would expect to pay, on average, an estimated 6% of their medical expenses out-of-pocket. Consumers may qualify for particular CSR AV levels depending on their income. Some spreadsheet data were suppressed for privacy. https://aspe.hhs.gov/health-insurance-marketplace-cost-sharing-reduction-subsidies-zip-code-and-county-2016

c. The reports for the 2014 plan year did not have premium or CSR data. CMS did not release county or zip code data for the 2014 plan year.

Point-in-Time Effectuated Enrollment Data
  • Effectuated enrollment data reflect individuals who have selected a plan and have submitted the first premium payment for a plan. Point-in-time enrollment data provide a snapshot of enrollment as of a specified month.

Release dates vary for point-in-time effectuated enrollment estimates. Reports summarized in Table 2 include point-in-time data on effectuated enrollment nationwide and for all states. They typically include data on enrollment, APTC, and enrollees with CSR. Since 2018, they also include data on premiums.

Table 2. Point-in-Time Effectuated Enrollment Reports

(include selected data on APTC and enrollees with CSR)

Point-in-Time Date

Reports

Date released

February 2019

Fact sheet: Early 2019 Effectuated Enrollment Snapshot, https://www.cms.gov/newsroom/fact-sheets/early-2019-effectuated-enrollment-snapshot

Report: Early 2019 Effectuated Enrollment Snapshot, https://www.cms.gov/sites/default/files/2019-08/08-12-2019%20TABLE%20Early-2019-2018-Average-Effectuated-Enrollment.pdf

August 2019

February 2018

News release: Centers for Medicare and Medicaid Services Releases Reports on the Performance of the Exchanges and Individual Health Insurance Market, https://www.cms.gov/newsroom/press-releases/centers-medicare-and-medicaid-services-releases-reports-performance-exchanges-and-individual-health

Report: Early 2018 Effectuated Enrollment Snapshot https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/2018-07-02-Trends-Report-1.pdf

July 2018

February 2017

News release: High Costs, Lack of Affordability Most Common Factors that Lead Consumers to Cancel Health Insurance Coverage, https://www.cms.gov/newsroom/press-releases/high-costs-lack-affordability-most-common-factors-lead-consumers-cancel-health-insurance-coverage

Report: 2017 Effectuated Enrollment Snapshot, https://downloads.cms.gov/files/effectuated-enrollment-snapshot-report-06-12-17.pdf

June 2017

March 2016

Fact sheet: March 31, 2016 Effectuated Enrollment Snapshot, https://www.cms.gov/newsroom/fact-sheets/march-31-2016-effectuated-enrollment-snapshot

Public use file (see March 2016 file): https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_Quarterly_Snapshots

June 2016

December 2015

Fact sheet: December 31, 2015 Effectuated Enrollment Snapshot, https://www.cms.gov/newsroom/fact-sheets/december-31-2015-effectuated-enrollment-snapshot

Public use file (see December 2015 file): https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_Quarterly_Snapshots

March 2016

September 2015

Fact sheet: September 30, 2015 Effectuated Enrollment Snapshot, https://www.cms.gov/newsroom/fact-sheets/september-30-2015-effectuated-enrollment-snapshot

Public use file (see September 2015 file): https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_Quarterly_Snapshots

December 2015

June 2015

Fact sheet: June 30, 2015 Effectuated Enrollment Snapshot, https://www.cms.gov/newsroom/fact-sheets/june-30-2015-effectuated-enrollment-snapshot

Public use file (see June 2015 file): https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_Quarterly_Snapshots

September 2015

March 2015

Fact sheet: March 31, 2015 Effectuated Enrollment Snapshot, https://www.cms.gov/newsroom/fact-sheets/march-31-2015-effectuated-enrollment-snapshot

Public use file (see March 2015 file): https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_Quarterly_Snapshots

June 2015

December 2014

Fact sheet: March 31, 2015 Effectuated Enrollment Snapshot (scroll down to "December 2014 Total Effectuated Enrollment and Financial Assistance"), https://www.cms.gov/newsroom/fact-sheets/march-31-2015-effectuated-enrollment-snapshot

Public use file (see December 2014 file): https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/Effectuated_Quarterly_Snapshots

June 2015

October 2014a

Report includes a point-in-time nationwide effectuated enrollment estimate of 6.7 million individuals as of October 2014 (footnote 3): How Many Individuals Might Have Marketplace Coverage After the 2015 Open Enrollment Period? https://aspe.hhs.gov/pdf-report/how-many-individuals-might-have-marketplace-coverage-after-2015-open-enrollment-period

November 2014

Source: Compiled by the Congressional Research Service (CRS).

Notes: The abbreviation APTC refers to advanced premium tax credits; CSR refers to cost-sharing reductions.

a. National effectuated enrollment estimate only; did not include state-level data. Did not include premium, APTC, or CSR data. Earlier in Plan Year 2014, ASPE released Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period. Effectuated Enrollment (May 2014), which had examples of insurance issuers' public statements that 80 to 90 percent of the people who selected a Marketplace plan effectuated their coverage: https://aspe.hhs.gov/report/health-insurance-marketplace-summary-enrollment-report-initial-annual-open-enrollment-period/effectuated-enrollment.

Average Monthly Effectuated Enrollment Data

Average enrollment data reflect an average over a specified time period. Effectuated enrollment data reflect individuals who have selected a plan and have submitted the first premium payment for a plan.

Reports summarized in Table 3 provide average monthly effectuated enrollment data, nationwide and for all states. A member month reflects one health plan member enrolled for one month. The reports state that "The average monthly effectuated enrollment number was calculated by adding total member months for the year and dividing by 12."

Since 2018, these reports have been released in the summer following the year covered by the data.

Table 3. Average Monthly Effectuated Enrollment Reports

(include selected data on premiums, APTC and enrollees with CSR)

Data Time Frame

Reports

Date Released

2018

Report; see "2018 Average Monthly Effectuated Enrollment" (starts p. 5): https://www.cms.gov/sites/default/files/2019-08/08-12-2019%20TABLE%20Early-2019-2018-Average-Effectuated-Enrollment.pdf#page=5

August 2019

2017

Report; see "2017 Average Monthly Effectuated Enrollment" (starts p. 6): https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/2018-07-02-Trends-Report-1.pdf#page=6

July 2018

Source: Compiled by the Congressional Research Service (CRS).

Note: The abbreviation APTC refers to advanced premium tax credits. CSR refers to cost-sharing reductions.

Average Effectuated Enrollment Data for the First Half of the Year

Average enrollment data reflect an average over a specified time period. Effectuated enrollment data reflect individuals who have selected a plan and have submitted the first premium payment for a plan.

Reports summarized in Table 4 provide average effectuated enrollment for the first six months of the year, as well as selected data on APTC and enrollees with CSR, nationwide and for all states.

These reports have typically been released annually late in the year.

Table 4. Average Effectuated Enrollment for First Half of the Year Reports

(includes selected data on APTC and enrollees with CSR)

Data Time Frame

Reports

Date Released

First half of 2019a

Fact sheet: Effectuated Enrollment for the First Half of 2019: "Effectuated enrollment is the average number of individuals who had an active policy at any point from January through June of 2019, and who paid their premium (thus effectuating their coverage) as of September 15, 2019," https://www.cms.gov/newsroom/fact-sheets/effectuated-enrollment-first-half-2019

Report: https://www.cms.gov/files/document/effectuated-enrollment-first-half-2019

December 2019

First half of 2018a

Fact sheet: Effectuated Enrollment for the First Half of 2018: "Effectuated enrollment is the average number of individuals who had an active policy from January through June of 2018, and who paid their premium (thus effectuating their coverage) as of September 15, 2018," https://www.cms.gov/newsroom/fact-sheets/effectuated-enrollment-first-half-2018

Report: https://www.cms.gov/sites/default/files/2018-11/11-28-2018%20Effectuated%20Enrollment%20Table.pdf

November 2018

First half of 2017

Fact sheet: First Half of 2017 Average Effectuated Enrollment Report: "Effectuated enrollment is the average number of individuals who had an active policy from January through June of 2017, and who paid their premium (thus effectuating their coverage) as of September 15, 2017," https://www.cms.gov/newsroom/fact-sheets/first-half-2017-average-effectuated-enrollment-report

Report: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/2017-12-13-2017-Effected-Enrollment-Data.pdf

December 2017

First half of 2016b

Fact sheet: First Half of 2016 Effectuated Enrollment Snapshot: The fact sheet is "based on the average number of effectuated enrollments and disenrollments over the relevant time period. Average effectuated enrollment provides a more meaningful metric of Marketplace participation, since it captures all enrollments over the time period and is less subject to monthly variation that is not meaningful," https://www.cms.gov/newsroom/fact-sheets/first-half-2016-effectuated-enrollment-snapshot

October 2016

Source: Compiled by the Congressional Research Service (CRS).

Notes: The abbreviation APTC refers to advanced premium tax credits. CSR refers to cost-sharing reductions.

a. Includes data on average premiums by state.

b. Provides national data only; did not have state-level data.

Additional Exchange Statistics

Trends in Subsidized and Unsubsidized Enrollment (CMS, August 12, 2019)

Includes state-level data on enrollment and APTC subsidies for persons who purchase on- and off-Exchange individual (nongroup) market health insurance plans.

Private Health Insurance: Enrollment Remains Concentrated among Few Issuers, including in Exchanges (GAO, March 21, 2019)

State-level data include Appendix I, Individual Market Health Insurance Exchange Enrollment as a Proportion of the Overall Market, 2016; Appendix II, Number and Market Share of Issuers in Each State's Individual Market Health Insurance Exchange, 2015-2017; Appendix III: Small Group Health Insurance Exchange Enrollment as a Proportion of the Overall Market, 2016; Appendix IV, Number and Market Share of Issuers in Each State's Small Group Health Insurance Exchange, 2015-2017; and Appendix VI, Market Share for Consumer Operated and Oriented Plans That Participated in the Exchanges.

Health Insurance Exchanges: Claims Costs and Federal and State Policies Drove Issuer Participation, Premiums, and Plan Design (GAO, January 28, 2019)

Discusses research and trends in claims costs for selected issuers in five states' exchanges.

Data on 2019 Individual Health Insurance Market Conditions (Centers for Medicare & Medicaid Services, October 11, 2018)

Summarizes data on premium trends and insurer participation. For HealthCare.gov states, a table shows 2016-2019 average monthly premiums for the second-lowest cost silver plan and lowest cost plan. The premiums are for a 27-year-old single nonsmoker.

The Exchanges Trends Report (CMS, July 2, 2018)5

Data on HealthCare.gov call center satisfaction, reasons why uninsured consumers decided not to purchase a health plan, agent and broker participation, and use of Special Enrollment Periods.

The Health Insurance Exchanges Trends Report: High Premiums and Disruptions in Coverage Lead to Decreased Enrollment in the Health Insurance Exchanges (CMS, June 12, 2017)6

Analyzes survey data from consumers who terminated or cancelled exchange coverage. In this report, exchange consumers who selected a plan but did not pay their first month's premium are considered to have cancelled their coverage.

Compares premiums in individual market plans purchased in 2013 to premiums in ACA exchange plans purchased in 2017. The data do not take into account premium subsidies in the exchanges. Many of ACA's private health insurance provisions took effect in 2014 (for example, inclusion of the essential health benefits), which makes comparing premiums before and after the ACA difficult given the products offered in the two time frames are vastly different.

Qualified Health Plan Choice and Premiums in HealthCare.gov States (CMS)
https://www.cms.gov/CCIIO/Resources/Data-Resources/QHP-Choice-Premiums.html

Appendix tables have state and county trend data since plan year 2014 on the number of insurers participating in ACA exchanges in HealthCare.gov states. Also includes selected state and county data on cost-sharing and on premiums, including average lowest cost plan (LCP) premiums and second lowest cost silver plan (SLCSP) premiums.

Similar reports for previous years were released by U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). Reports varied with respect to methodology and states covered:

Details About Baseline Projections for Selected Programs: Federal Subsidies for Health Insurance (Includes Effects of the Affordable Care Act) (Congressional Budget Office)
https://www.cbo.gov/about/products/baseline-projections-selected-programs#6

The Congressional Budget Office (CBO) periodically produces 10-year baseline projections, which "reflect CBO's best judgment about how the economy and the budget will evolve under existing laws." These projections include estimates of subsidized and unsubsidized enrollment in individual (nongroup) exchanges (marketplaces), and estimates of federal outlays for premium tax credits.

Coverage of Abortion Services by Exchange Plans

CRS Report RL33467, Abortion: Judicial History and Legislative Response

Describes ACA's provisions on the coverage of abortion services by health plans that are available through exchanges.

CMS Announces Enhanced Program Integrity Efforts for the Exchange (Centers for Medicare & Medicaid Services, December 20, 2019)
https://www.cms.gov/newsroom/press-releases/cms-announces-enhanced-program-integrity-efforts-exchange

This press release links to a final rule on exchange plans' billing and collection of premium payments for certain abortion services. Lawsuits challenging the rule have been filed. The rule's effective dates have also been modified (https://www.federalregister.gov/d/2020-09608).

Employer-Sponsored Coverage

Sources for Employees and Their Families

Overviews

People with job-based coverage (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/have-job-based-coverage/

FAQs for consumers with employer-sponsored coverage and those who are losing their employer-sponsored coverage.

Affordable Care ActInformation for Workers and Families (U.S. Department of Labor, Employee Benefits Security Administration)
https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-workers-and-families

For employees who receive health coverage through their jobs, this page lists consumer protections under the ACA, such as coverage of preexisting conditions and preventive services; and the requirement that employees receive a plain-language Summary of Benefits and Coverage.

Ask EBSA (U.S. Department of Labor, Employee Benefits Security Administration)
https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa

Constituents with questions about employer-based health coverage can speak with benefits advisors at 1-866-444-3272. Benefits advisors can also answer questions about COBRA continuation coverage, which "gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events." https://www.dol.gov/general/topic/health-plans/cobra

Federal Employee Health Benefits Program

CRS Report R43922, Federal Employees Health Benefits (FEHB) Program: An Overview

Includes a section on "Impact of the Affordable Care Act."

The Affordable Care Act and OPM (U.S. Office of Personnel Management)
http://www.opm.gov/healthcare-insurance/affordable-care-act/

ACA resources and FAQs for FEHBP beneficiaries.

Tribal Employers: Indian Tribes FAQs (U.S. Office of Personnel Management)
http://www.opm.gov/healthcare-insurance/tribal-employers/faqs/

Under the ACA, certain tribal employers may purchase FEHBP coverage for their tribal employees. FAQs on how the ACA expands FEHBP eligibility for tribal employees.

Changes to Federal Benefits Eligibility Due to Health Reform: Frequently Asked Questions (FAQs) (U.S. Office of Personnel Management)
http://www.opm.gov/healthcare-insurance/special-initiatives/health-care-reform/

FAQs for federal employees on the ACA dependent coverage provision, which became effective for plan years beginning on or after September 23, 2010.

Healthcare: Carriers: Carrier Letters (U.S. Office of Personnel Management)
https://www.opm.gov/healthcare-insurance/healthcare/carriers/#url=Carrier-Letters

Guidance for FEHB program carriers. Includes, for example, Information for Carriers on Coronavirus (March 11, 2020) https://www.opm.gov/healthcare-insurance/healthcare/carriers/2020/2020-02.pdf and Coverage of Diagnostic Testing, Preventive Services, and Telehealth for COVID-19 (April 23, 2020) https://www.opm.gov/healthcare-insurance/healthcare/carriers/2020/2020-08.pdf

Members of Congress and Congressional Staff

CRS Report R43194, Health Benefits for Members of Congress and Designated Congressional Staff: In Brief

A provision in the ACA specifically affects Members of Congress and certain congressional staff and their employer-sponsored health benefits. The report explains the implementation of that provision.

The Affordable Care Act and OPM (U.S. Office of Personnel Management)
http://www.opm.gov/healthcare-insurance/affordable-care-act/

Includes ACA resources for Members of Congress and congressional staff. FAQs are at Insurance: Members of Congress & Staff, https://www.opm.gov/faqs/topic/insure/?cid=6bf9dd32-d3b9-4fc[phone number scrubbed]-431e535f933a

Who can use DC Health Link? (DC Health Link)
https://dchealthlink.com/node/1660

Members of Congress and designated congressional staff can purchase health insurance from the District of Columbia SHOP exchange, called DC Health Link (855-532-5465). Questions can also be answered by the U.S. Senate Disbursing Office (202-224-1093) and the House of Representatives Office of Payroll and Benefits (202-225-1435).

Sources for Employers

See also "Excise Tax on High-Cost Employer-Sponsored Health Coverage" under "Taxes."

Overviews

Affordable Care Act (U.S. Department of Labor, Employee Benefits Security Administration)
https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers

Information on ACA implementation for employers. The page has information on grandfathered plans, waiting periods, and other topics for employer-sponsored health coverage.

Affordable Care Act Tax Provisions for Employers (Internal Revenue Service)
https://www.irs.gov/affordable-care-act/employers

Explanations of ACA tax provisions for employers, such as W-2 reporting requirements, the Small Business Health Care Tax Credit, and potential employer penalties for certain large employers.

Employer Penalties

CRS Report R45455, The Affordable Care Act's (ACA's) Employer Shared Responsibility Provisions (ESRP)

ACA's employer shared responsibility provisions (ESRP) are also known as the "employer mandate." Certain "applicable large employers" (ALEs) are subject to penalties if they do not offer affordable and adequate health coverage to employees and at least one of their full-time employees obtains a premium tax credit or cost-sharing subsidy through the exchanges. This report summarizes how employers determine whether they are ALEs and how ESRP penalties are calculated. It also describes ESRP implementation and defines terms used in ESRP law and regulations.

Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act (Internal Revenue Service)
https://www.irs.gov/affordable-care-act/employers/questions-and-answers-on-employer-shared-responsibility-provisions-under-the-affordable-care-act

FAQs on the employer shared responsibility provisions under the ACA. The document describes which employers are subject to the penalty and how the penalty amount is calculated, and it provides important dates.

Employer Shared Responsibility Provision Estimator (Internal Revenue Service, Taxpayer Advocate Service)
https://taxpayeradvocate.irs.gov/estimator/esrp/

Employers can use this estimator to determine whether they may be an applicable large employer, and to estimate their maximum potential liability for the employer shared responsibility payment.

CRS In Focus IF10039, Proposals to Change the ACA's Definition of "Full Time"

Two-pager analyzes proposals to change ACA's definition of "full-time" from 30 hours to 40 hours a week.

Employer Wellness Programs and Genetic Information

CRS Report R44311, Employer Wellness Programs and Genetic Information: Frequently Asked Questions

Describes requirements for when an employer may request genetic information from an employee as part of a wellness program.

Small Businesses

Exploring coverage options for small businesses (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/small-businesses/learn-more/how-aca-affects-businesses/

Information on how the ACA affects small employers.

CRS Report R44065, Overview of Health Insurance Exchanges

Describes Small Business Health Options Program (SHOP) exchanges.

Health insurance for your business and employees (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/small-businesses

Resources about the SHOP exchange. For further questions, the federal health insurance call center for small employers is 1-800-706-7893.

CRS Report R43181, The Affordable Care Act and Small Business: Economic Issues

Analysis of ACA employer penalties, the small business health insurance tax credit, and SHOP exchanges.

Small Business Health Care Tax Credit and the SHOP Marketplace (Internal Revenue Service)
https://www.irs.gov/affordable-care-act/employers/small-business-health-care-tax-credit-and-the-shop-marketplace

Certain small employers participating in the SHOP exchange may be eligible for the small business health insurance tax credit. This page describes eligibility and how to claim the credit.

Medicaid and the State Children's Health Insurance Program

Individuals can enroll in Medicaid and the State Children's Health Insurance Program (CHIP) any time of the year. There is no limited enrollment period for these programs. Eligibility criteria vary by state.

Each state operates its own Medicaid and CHIP programs within federal guidelines.

Medicaid and CHIP coverage (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/medicaid-chip/

FAQs and tips for Medicaid and CHIP potential applicants and new enrollees.

CRS In Focus IF10399, Overview of the ACA Medicaid Expansion

As of January 1, 2014, states have the option to extend Medicaid coverage to most nonelderly, low-income individuals. Two-pager includes a map of states' Medicaid expansion decisions, and a brief overview of the expansion's rules, financing, and projections of enrollment and spending.

CRS Report R41210, Medicaid and the State Children's Health Insurance Program (CHIP) Provisions in ACA: Summary and Timeline

Detailed section-by-section summary of ACA's Medicaid and CHIP provisions. This CRS report, which may be of historical interest, contains some ACA provisions that may have been amended since the report was published.

The Affordable Care Act and Medicaid (Medicaid and CHIP Payment and Access Commission, MACPAC)
https://www.macpac.gov/topics/aca-medicaid/

MACPAC analysis of Medicaid policy and data. MACPAC is a nonpartisan legislative branch agency that makes recommendations to Congress and the U.S. Department of Health and Human Services.

2018 Actuarial Report on the Financial Outlook for Medicaid (CMS Office of the Actuary, 2020)
https://www.cms.gov/files/document/2018-report.pdf

Includes national estimates of ACA Medicaid expansion enrollment and per-person expenditures. See the "Expansion adults" column in "Table 16—Past and Projected Numbers of Medicaid Enrollees, by Category, Fiscal Years 2000–2027" and "Table 22—Past and Projected Medicaid Expenditures on Medical Assistance Payments Per Enrollee, by Enrollment Category, Fiscal Years 2000–2027" (pp. 53 and 68); and "Impacts of the Medicaid Eligibility Expansion" (p. 19). Note that these figures for the expansion adults do not include ACA expansion adults who were "not newly eligible." Some states had expanded their Medicaid eligibility to certain expansion adults prior to 2014; in those cases, some of the expansion adults are considered "not newly eligible."

Medicaid Enrollment Data Collected through MBES (Centers for Medicare & Medicaid Services, Medicaid.gov)
https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/enrollment-mbes/index.html

These Medicaid Budget and Expenditure System (MBES) reports have state data on total Medicaid enrollees and, in Medicaid expansion states, "Total VIII Group" enrollees. The VIII Group, also known as the "New Adult Group," consists of adults enrolled in Medicaid through the ACA Medicaid expansion. (Most of these adults are considered "newly eligible." However, some states had expanded their Medicaid eligibility to certain adults prior to 2014; in those cases, some of the VIII Group members are considered "not newly eligible.") Note that data may be missing for some Medicaid expansion states.

Expenditure Reports from MBES/CBES (Centers for Medicare & Medicaid Services, Medicaid.gov)
https://www.medicaid.gov/medicaid/financing-and-reimbursement/state-expenditure-reporting/expenditure-reports/index.html

ACA Medicaid expansion spending data are in expenditure reports from the Medicaid Budget and Expenditure System (MBES). Nationally in FY2016, expenditures for individuals in the ACA Medicaid expansion (the "VIII Group") totaled $82.262 billion, including $77.999 billion in federal dollars and $4.263 billion in state dollars. For FY2016 annual data by state, click "FY 2016 Medicaid Financial Management Data – By State." Within that spreadsheet, for each state, the service category "Total VIII Group" shows expenditures for individuals in the ACA Medicaid expansion. On the right of the spreadsheet, in the "Find in this Dataset" search box, type VIII. Total expenditures are in the "Total Computable" column. Federal expenditures are in the "Federal Share" column. State expenditures are in the "State Share" column.

CRS Report R45412, Medicaid Alternative Benefit Plan Coverage: Frequently Asked Questions

States implementing the ACA Medicaid expansion are required to cover the expansion population using alternative benefit plans (ABP). The ACA also made other changes to ABP requirements. This report explains ABP and answers frequently asked questions.

Compilation of State Data on the Affordable Care Act (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, December 2016)
https://aspe.hhs.gov/compilation-state-data-affordable-care-act

Excel spreadsheet of state data on the effects of selected ACA provisions, including several Medicaid provisions.

CRS In Focus IF10422, Medicaid Disproportionate Share Hospital (DSH) Reductions

Federal Medicaid statute requires states to make disproportionate share hospital (DSH) payments to hospitals with a disproportionate share of low-income patients. ACA has a provision to reduce Medicaid DSH allotments. The two-page report describes the ACA provision and how it has since been amended.

Frequently Asked Questions (Centers for Medicare & Medicaid Services, Medicaid.gov)
https://www.medicaid.gov/faq/index.html#/

For state officials and stakeholders, these sources address questions on the ACA, Medicaid, and CHIP. On the right, choose "Affordable Care Act" under "Filter by Topic."

CRS In Focus IF11010, Medicaid Coverage for Former Foster Youth Up to Age 26

Two-page overview of the ACA requirement that states provide Medicaid coverage to certain former foster youth until their 26th birthday.

Coronavirus Disease 2019 (COVID-19) (Centers for Medicare & Medicaid Services, Medicaid.gov)
https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/coronavirus-disease-2019-covid-19/index.html

Information on Medicaid coverage and benefits related to COVID-19.

CRS In Focus IF11523, Health Insurance Options Following Loss of Employment

Two-page overview of potential health coverage options following job loss, including the ACA Medicaid expansion. Due to the COVID-19 pandemic's economic impact, many Americans may lose jobs through which they receive health insurance.

Medicare

Medicare.gov (Centers for Medicare & Medicaid Services)
https://www.medicare.gov/

The official federal portal for consumer information on Medicare.

Medicare and the Marketplace (Centers for Medicare & Medicaid Services)
http://www.cms.gov/Medicare/Eligibility-and-Enrollment/Medicare-and-the-Marketplace/Overview1.html

Detailed FAQs about the relationship between Medicare and the ACA exchanges (marketplaces), including questions on enrollment, coordination of benefits, and end-stage renal disease.

Medicare and the Marketplace (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/medicare/medicare-and-the-marketplace/

Information on how to switch from exchange coverage to Medicare.

CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline

Detailed section-by-section summary of the ACA's Medicare provisions. This CRS report, which may be of historical interest, contains some ACA provisions that may have been amended since the report was published.

CRS Report R44075, The Independent Payment Advisory Board (IPAB): Frequently Asked Questions

The CRS report, which may be of historical interest, has FAQs on the Independent Payment Advisory Board, which ACA established to develop proposals to "reduce the per capita rate of growth in Medicare spending." P.L. 115-123, the Bipartisan Budget Act of 2018, repealed the Independent Payment Advisory Board.

Compilation of State Data on the Affordable Care Act (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, December 2016)
https://aspe.hhs.gov/compilation-state-data-affordable-care-act

Excel spreadsheet of selected state data on the effects of selected ACA provisions, including several Medicare provisions.

Specific Populations

Women's Health Care

See also "Coverage of Abortion Services by Exchange Plans"

CRS Report R45426, The Pregnancy Assistance Fund: An Overview

The Pregnancy Assistance Fund was established by the ACA.

Preventive Services

Women's Preventive Services Guidelines (U.S. Department of Health and Human Services, Health Resources and Services Administration)
https://www.hrsa.gov/womens-guidelines-2019

Lists the women's preventive services that nongrandfathered health plans generally are required to cover without cost sharing, when furnished in-network.

Fact Sheets and Frequently Asked Questions (FAQs) (The Center for Consumer Information and Insurance Oversight)
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index.html

The section "Affordable Care Act" includes FAQs on women's preventive services.

Contraceptive Coverage7

CRS Report R45928, The Federal Contraceptive Coverage Requirement: Past and Pending Legal Challenges

The federal contraceptive coverage requirement stems from the ACA, which requires health insurance issuers and employment-based health plans to cover preventive care for women "as provided for" in certain agency-supported guidelines. 42 U.S.C. § 300gg-13(a)(4). Those guidelines include FDA-approved contraceptives among the covered services. See Health Resources and Services Administration, Women's Preventive Services Guidelines, https://www.hrsa.gov/womens-guidelines-2019 (last updated Dec. 2019).

This report provides background on the federal contraceptive coverage requirement, the regulations exempting certain entities from that requirement, and related legal challenges.

Little Sisters of the Poor Saints Peter & Paul Home v. Pennsylvania, No. 19-431
https://www.supremecourt.gov/search.aspx?filename=/docket/docketfiles/html/public/19-431.html

In 2018, the Department of Health and Human Services, along with the Departments of Labor and the Treasury, issued final rules expanding upon existing regulatory exemptions for certain entities with religious objections to providing contraceptive coverage. See Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 83 Fed. Reg. 57,536 (2018) https://www.federalregister.gov/d/2018-24512; Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 83 Fed. Reg. 57,592 (2018) https://www.federalregister.gov/d/2018-24514; see also Press Release, Trump Administration Issues Final Rules Protecting Conscience Rights in Health Insurance, HHS.gov (Nov. 7, 2018), https://www.hhs.gov/about/news/2018/11/07/trump-administration-issues-final-rules-protecting-conscience-rights-in-health-insurance.html.

Implementation of the 2018 final rules is currently enjoined as a result of a preliminary nationwide injunction upheld by the U.S. Court of Appeals for the Third Circuit. Pennsylvania v. President United States, 930 F.3d 543, 575-76 (3d Cir. 2019). The U.S. Government and an intervening party have challenged the Third Circuit's decision, and the consolidated cases are pending before the Supreme Court in Little Sisters of the Poor v. Pennsylvania.

Indian Health Care

CRS Report R41152, Indian Health Care: Impact of the Affordable Care Act (ACA)

The ACA reauthorized the Indian Health Care Improvement Act (IHCIA), which authorizes many Indian Health Service programs and services. The report summarizes major IHCIA changes and other ACA provisions that may affect American Indian and Alaska Native health care.

Americans Indians & Alaska Natives (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/american-indians-alaska-natives/coverage/

An overview of coverage options for American Indians and Alaska Natives.

CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the ACA: Detailed Summary and Timeline

Detailed section-by-section summary of IHCIA provisions in the ACA.

Affordable Care Act (Indian Health Service)
https://www.ihs.gov/aca/

Includes FAQs on the ACA for Indian Health Service-eligible persons.

Veterans and Military Health Care

The Affordable Care Act and Your VA Health Coverage (U.S. Department of Veterans Affairs)
https://www.va.gov/health-care/about-affordable-care-act/

Answers to veterans' questions about the ACA individual mandate, whether the ACA changes VA health benefits, and how to obtain health coverage.

TRICARE and the Affordable Care Act (Defense Health Agency)
http://tricare.mil/aca

Explains that the military's TRICARE health program is considered minimum essential coverage for the purpose of ACA's individual mandate.

CRS Report R45399, Military Medical Care: Frequently Asked Questions

See "How does the Patient Protection and Affordable Care Act affect TRICARE?"

Noncitizens

Health coverage for immigrants (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/immigrants/

Describes the eligibility of immigrants for exchange coverage and subsidies, Medicaid, and CHIP.

CRS Report R43561, Treatment of Noncitizens Under the Affordable Care Act

The CRS report, which may be of historical interest, summarizes how the ACA's individual mandate, exchanges, exchange subsidies, and Medicaid provisions apply to noncitizens. It also describes the verification of alien status for exchange coverage.

CRS Legal Sidebar LSB10341, DHS Final Rule on Public Charge: Overview and Considerations for Congress

Describes the "public charge" rule and how Medicaid and private health insurance are considered in making public charge determinations.

Behavioral Health

Health Insurance and Mental Health Services (U.S. Department of Health and Human Services, MentalHealth.gov)
https://www.mentalhealth.gov/get-help/health-insurance

FAQs about private health insurance, Medicare, and Medicaid coverage of mental health benefits.

Health benefits & coverage: Mental health & substance abuse coverage (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/

Brief overview of requirements for behavioral health services coverage in exchange plans.

Affordable Care Act Implementation FAQsSet 17 (The Center for Consumer Information and Insurance Oversight, November 8, 2013)
http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs17.html

FAQs about the implementation of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as amended by the ACA.

Affordable Care Act Implementation FAQsSet 29 (The Center for Consumer Information and Insurance Oversight, October 23, 2015)
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-Part-XXIX.pdf

Additional FAQs about MHPAEA and disclosure, and anorexia treatment coverage.

FAQs About Affordable Care Act Implementation Part 31 (The Center for Consumer Information and Insurance Oversight, April 20, 2016)
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-31_Final-4-20-16.pdf

Additional FAQs about MHPAEA implementation and Medication Assisted Therapy (MAT) for opioid use disorder.

FAQs About Affordable Care Act Implementation Part 34 and Mental Health and Substance Abuse Disorder Parity Implementation (The Center for Consumer Information and Insurance Oversight, October 27, 2016)
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQ-part-34_10-26-16_FINAL.PDF

Additional FAQs about MHPAEA implementation and disclosure, financial requirements and quantitative treatment limitations, nonquantitative treatment limitations. MAT for opioid use disorder, and court-ordered treatment.

FAQs About Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act Part 38 (The Center for Consumer Information and Insurance Oversight, June 16, 2017)
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQ-Part-38.pdf

Additional FAQs about implementation and disclosure under the MHPAEA, as amended by ACA and the 21st Century Cures Act.

FAQs About Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act Part 39 (The Center for Consumer Information and Insurance Oversight, September 5, 2019)
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-Part-39.pdf

Additional FAQs about implementation and disclosure under the MHPAEA, as amended by ACA and the 21st Century Cures Act.


Public Health, Workforce, Quality, and Related Provisions

CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in ACA: Summary and Timeline

Detailed section-by-section summary of the ACA's provisions on public health, the health workforce, quality improvement, health centers, prevention and wellness, maternal and child health, nursing homes and other long-term care providers, comparative effectiveness research, health information technology, emergency care, elder justice, biomedical research, FDA and medical products, 340B drug pricing, and malpractice reform. Some of the provisions in this report may have been amended since the report was first published.

CRS Report R44796, The ACA Prevention and Public Health Fund: In Brief

Overview of the Prevention and Public Health Fund, which was established by ACA. It describes authority, appropriations, funding distributions, and funded activities.

CRS Report R43911, The Community Health Center Fund: In Brief

Overview of the Community Health Center Fund, established by ACA. Includes a table of awarded funds by state. The fund supports the federal Health Center Program and the National Health Service Corps.

CRS Report R44620, Biologics and Biosimilars: Background and Key Issues

Discusses the Biologics Price Competition and Innovation Act (BPCIA), enacted as Title VII of the ACA.

CRS Insight IN10728, The Teaching Health Center Graduate Medical Education (THCGME) Program: Increased Funding and Policy Changes in BBA 2018

Brief summary of the THCGME program, which was established by ACA. This CRS Insight may be of historical interest.

CRS Insight IN10185, Congress May Consider Options to Extend Expiring Funds for Primary Care

Summary of ACA mandatory funding to support the Health Centers program, the National Health Service Corps, and the Teaching Health Center Graduate Medical Education program. Discusses legislation to extend this funding.

CRS Report R44282, The Ryan White HIV/AIDS Program: Overview and Impact of the Affordable Care Act

Describes the Ryan White Program and notes that "The long-range impact of ACA on the Ryan White Program—in which health and treatment services provided under Ryan White are replaced by access to such services through health insurance coverage via ACA—remains to be determined."

CRS Report R44272, Nutrition Labeling of Restaurant Menu and Vending Machine Items

The report provides background information and summarizes selected aspects of implementing regulations.

CRS Report R43930, Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program: Background and Funding

Describes the ACA-established MIECHV Program to support home visits to certain families with young children. The visits are conducted by nurses, mental health clinicians, social workers, or paraprofessionals with specialized training.

CRS Report R45183, Teen Pregnancy: Federal Prevention Programs

Describes the Personal Responsibility Education Program (PREP), which was established by ACA.

CRS Insight IN11010, Funding for ACA-Established Patient-Centered Outcomes Research Trust Fund (PCORTF) Extended Through FY2029

Describes the Patient-Centered Outcomes Research Institute (PCORI), a private, nonprofit, tax-exempt corporation established by ACA. Also describes funding for the Patient-Centered Outcomes Research Trust Fund (PCORTF), which supports PCORI.

State Innovation Waivers

CRS Report R44760, State Innovation Waivers: Frequently Asked Questions

Describes the waiver program, including which ACA provisions may be waived, the application process, and waiver requirements.

Section 1332: State Innovation Waivers (The Center for Consumer Information and Insurance Oversight)
https://www.cms.gov/cciio/programs-and-initiatives/state-innovation-waivers/section_1332_state_innovation_waivers-.html

Federal guidance and correspondence on state innovation waivers and state waiver applications.

Taxes

See also "The Individual Mandate" and "Exchange Subsidies."

Tax Filing Resources

Health coverage & your federal taxes (U.S. Department of Health and Human Services, HealthCare.gov)
https://www.healthcare.gov/taxes/

For consumers, links to forms, tips, and tools for completing federal income tax returns.

Affordable Care Act (ACA) Tax Provisions (Internal Revenue Service)
https://www.irs.gov/Affordable-Care-Act/

Links to common "Questions and Answers" and "Health Care Tax Tips."

ACA Information Center for Tax Professionals (Internal Revenue Service)
https://www.irs.gov/tax-professionals/aca-information-center-for-tax-professionals

Guidance for tax professionals.

Contacts for Tax Filing Assistance

Telephone Assistance (Internal Revenue Service)
https://www.irs.gov/help-resources/telephone-assistance

The IRS is implementing many of the ACA's tax provisions, including the individual mandate, premium tax credits, and employer shared responsibility penalties. The IRS has a Healthcare Hotline for ACA questions (1-800-919-0452) and other telephone hotlines to answer questions from individuals and employers.

Contact Your Local IRS Office (Internal Revenue Service)
https://www.irs.gov/help-resources/contact-your-local-irs-office

Directory of IRS Taxpayer Assistance Centers for in-person help with tax questions and problems. In a directory listing, click the "Services Provided" link; many locations provide "assistance with Affordable Care Act tax provision questions for individuals."

Free Tax Return Preparation for Qualifying Taxpayers (Internal Revenue Service)
https://www.irs.gov/individuals/free-tax-return-preparation-for-you-by-volunteers

Describes tax return preparation programs for persons who make $56,000 or less, persons with disabilities, limited English speaking taxpayers, and persons aged 60 and older.

Need someone to prepare your tax return? (Internal Revenue Service)
https://www.irs.gov/tax-professionals/choosing-a-tax-professional

Tips for choosing a tax preparer, a Directory of Federal Tax Return Preparers with Credentials and Select Qualifications, and how to make a complaint about a tax preparer.

Tax Provisions

Overviews

CRS In Focus IF10591, Taxes and Fees Enacted as Part of the Affordable Care Act

Two-page overview of ACA's revenue provisions.

Affordable Care Act (ACA) Tax Provisions (Internal Revenue Service)
https://www.irs.gov/affordable-care-act

Briefly summarizes the ACA's tax provisions. For a more comprehensive list, click "List of Tax Provisions" in the left navigation bar; for many provisions, there are links to "Questions and Answers."

Present Law And Background Relating To The Tax-Related Provisions In The Affordable Care Act (Joint Committee on Taxation, JCX-6-13, March 4, 2013)
https://www.jct.gov/publications.html?func=startdown&id=4511

Summarizes the ACA's revenue (tax) provisions. Note that this publication has not been updated since 2013. Some ACA provisions may have been amended since then (for example, effective dates may have changed or certain provisions may have been repealed).

Tax Statistics

Results of the 2019 Filing Season (Treasury Inspector General for Tax Administration, January 22, 2020)
https://www.treasury.gov/tigta/auditreports/2020reports/202044007fr.pdf

The section "Administration of Affordable Care Act Provisions" has statistics on tax returns regarding premium tax credits (PTC) and advance premium tax credits (APTC).

SOI [Statistics of Income] Tax Stats – Affordable Care Act (ACA) Statistics (Internal Revenue Service)
https://www.irs.gov/uac/soi-tax-stats-affordable-care-act-aca-statistics

Statistics on ACA tax provisions, including the individual mandate (also called the "Health Care Individual Responsibility Payment"), premium tax credits, excise taxes, and the Small Employer Health Care Tax Credit.

SOI [Statistics of Income] Tax Stats—Historic Table 2 (Internal Revenue Service)
https://www.irs.gov/statistics/soi-tax-stats-historic-table-2

Links to state-by-state spreadsheets with data on the ACA individual mandate (see "Health care individual responsibility payment" rows).

Medical Device Tax

CRS Report R43342, The Medical Device Excise Tax: Economic Analysis

The report gives an overview of the tax: its legislative origins, its revenue effects, arguments for and against the tax, and its economic effects. Note that the Further Consolidated Appropriations Act, 2020 (P.L. 116-94, December 20, 2019) repealed the tax; the tax does not apply to sales after December 31, 2019. Previously, the Consolidated Appropriations Act, 2016 (P.L. 114-113, December 18, 2015) included a two-year moratorium on the tax for 2016 and 2017. P.L. 115-120 (January 22, 2018) extended the moratorium for an additional two years, for 2018 and 2019, https://www.irs.gov/newsroom/medical-device-excise-tax.

Excise Tax on High-Cost Employer-Sponsored Health Coverage

CRS Report R44147, Excise Tax on High-Cost Employer-Sponsored Health Coverage: In Brief

The ACA included a 40% tax on employer-sponsored health coverage. The tax would have applied to the aggregate cost of applicable coverage that exceeded a specified dollar limit. The tax was sometimes called the "Cadillac tax." Note that the Further Consolidated Appropriations Act, 2020 (P.L. 116-94, December 20, 2019) repealed the tax, effective for taxable years beginning after December 31, 2019. Previously, the Consolidated Appropriations Act, 2016 (P.L. 114-113, December 18, 2015) delayed the tax's effective date by two years, to 2020. P.L. 115-120 (January 22, 2018) delayed the tax's effective date for an additional two years, to 2022.

CRS Report R44160, The Excise Tax on High-Cost Employer-Sponsored Health Coverage: Background and Economic Analysis

The report analyzed Medical Expenditure Panel Survey data to estimate the share of employer plans with premiums that could exceed the Cadillac tax threshold in future years.

CRS Report R44159, The Excise Tax on High-Cost Employer-Sponsored Health Insurance: Estimated Economic and Market Effects

The report "examines several issues. It evaluates the potential of the Cadillac tax to affect health insurance coverage and the health care market. It also examines the expected incidence (burden) of the tax—that is, which group's income will be reduced by the tax. Finally, the report discusses implications for economic efficiency in the context of tax administration."

Congressional Efforts to Repeal or Amend ACA

CRS Report R45244, Legislative Actions to Modify the Affordable Care Act in the 111th-115th Congresses

The report summarizes laws enacted during the 111th-115th Congresses that repealed or modified ACA provisions. It also summarizes bills passed in the House or Senate during the 111th-115th Congresses that would have repealed or modified ACA provisions, had they been enacted.

CRS Report R44883, Comparison of the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA)

Side-by-side comparison of: (1) current law, (2) the AHCA as passed by the House on May 4, 2017, and (3) the Senate's BCRA discussion draft as updated July 20, 2017.

CRS Report R44903, Provisions of Obamacare Repeal Reconciliation Act of 2017 (ORRA)

Section-by-section summary of ORRA as posted on the Senate Budget Committee website on July 19, 2017. ORRA was largely based on H.R. 3762, Restoring Americans' Healthcare Freedom Reconciliation Act of 2015, which President Obama vetoed on January 8, 2016.

CRS Report R44785, H.R. 1628: The American Health Care Act (AHCA)

Summarizes the AHCA as passed by the House on May 4, 2017.

H.R. 3762To provide for reconciliation pursuant to section 2002 of the concurrent resolution on the budget for fiscal year 2016 (Congress.gov)
https://www.congress.gov/bill/114th-congress/house-bill/3762

H.R. 3762 in the 114th Congress would have amended or repealed several ACA provisions. Congress.gov links to bill and amendment texts, legislative actions, and floor votes. President Obama vetoed the bill on January 8, 2016.

CRS Report R44300, Provisions of the Senate Amendment to H.R. 3762

The report, which may be of historical interest, summarizes the version of H.R. 3762 that President Obama vetoed on January 8, 2016.

CRS Report R44238, Potential Policy Implications of the House Reconciliation Bill (H.R. 3762)

The report, which may be of historical interest, summarizes the version of H.R. 3762, the Restoring Americans' Healthcare Freedom Reconciliation Act of 2015, that passed the House on October 23, 2015.

CRS Report R44100, Use of the Annual Appropriations Process to Block Implementation of the Affordable Care Act (FY2011-FY2017)

Describes ACA's impact on federal spending and ACA provisions in enacted appropriations acts.

Affordable Care Act (Congressional Budget Office)
https://www.cbo.gov/topics/health-care/affordable-care-act

A collection of Congressional Budget Office (CBO) analyses and cost estimates on the ACA and proposals to amend or repeal the ACA.

Agency Audits and Investigations

Oversight.gov (Council of the Inspectors General on Integrity and Efficiency)
https://oversight.gov/

A database of recent public reports from federal Inspectors General (IGs). IGs investigate waste, fraud, and abuse in their agencies' programs and operations. One may search the database for terms such as "Affordable Care Act": https://www.oversight.gov/reports?field_address_country=All&keywords_exact=affordable%20care%20act&items_per_page=60

Affordable Care Act Reviews (U.S. Department of Health & Human Services, Office of Inspector General)
http://oig.hhs.gov/reports-and-publications/aca/

A compilation of HHS Office of Inspector General (OIG) reports on the ACA. It includes audits, evaluations, and investigations of exchanges and HHS's other ACA-related programs. The HHS OIG's mission is to protect the integrity of HHS programs and the health and welfare of program beneficiaries.

Explore Key Issues by Topic (U.S. Government Accountability Office)
https://www.gao.gov/key_issues/overview#t=1

Choose "Health care" for a compilation of U.S. Government Accountability Office (GAO) reports on its health-care related investigations. Also search GAO's website for ACA-related reports, https://www.gao.gov/search?q=%22affordable+care+act%22. GAO's mission is "We support Congress in meeting its constitutional responsibilities, and help improve the performance and ensure the accountability of the federal government. We provide Congress with timely information that is objective, fact-based, nonpartisan, nonideological, and balanced."

Cost Estimates and Spending

Affordable Care Act (Congressional Budget Office)
http://www.cbo.gov/topics/health-care/affordable-care-act

A collection of CBO analyses and cost estimates on the ACA and proposals to amend or repeal the ACA, including analyses of the ACA's effects on the federal budget, labor markets, and health insurance coverage. ACA's original cost estimates are in Selected CBO Publications Related to Health Care Legislation, 2009-2010, https://www.cbo.gov/publication/21993

CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA)

Summarizes the ACA's effects on discretionary spending.

CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Summarizes the ACA's mandatory appropriations.

CRS Report R45244, Legislative Actions to Modify the Affordable Care Act in the 111th-115th Congresses

Discusses ACA's impact on federal spending.

CRS Report R44100, Use of the Annual Appropriations Process to Block Implementation of the Affordable Care Act (FY2011-FY2017)

Describes ACA's impact on federal spending and ACA provisions in enacted appropriations acts.

CRS In Focus IF10830, U.S. Health Care Coverage and Spending

Two-page overview of national health expenditures and health coverage.

National Health Expenditure Data: Historical (Centers for Medicare & Medicaid Services, Office of the Actuary)
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

Estimates of total health care spending in the United States, with breakdowns by service type and source of funds.

Health Care Spending Growth and Federal Policy (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, March 22, 2016)
https://aspe.hhs.gov/sites/default/files/pdf/190471/SpendingGrowth.pdf

Analysis of post-ACA trends in national health care spending, Medicare spending, and private health insurance spending.

Deregulating Health Insurance Markets: Value to Market Participants (Council of Economic Advisers, February 2019)
https://www.whitehouse.gov/wp-content/uploads/2019/02/Deregulating-Health-Insurance-Markets-FINAL.pdf

Analyzes the effects of ACA and other health insurance regulations, and more recent deregulatory health insurance reforms. Members of the Council of Economic Advisers are appointed by the President with the advice and consent of the Senate.

"Recent Trends in Health Care Costs," in The Economic Record of the Obama Administration: Reforming the Health Care System (Council of Economic Advisers, December 2016).
https://obamawhitehouse.archives.gov/sites/default/files/page/files/20161213_cea_record_healh_care_reform.pdf#page=58

Analysis of trends in health care costs: prices, per enrollee spending, and aggregate spending. Members of the Council of Economic Advisers are appointed by the President with the advice and consent of the Senate.

CRS Report R44832, Frequently Asked Questions About Prescription Drug Pricing and Policy

Discusses ACA's impact on drug coverage and spending.

Statistics on Insurance Coverage

See also "Exchange Statistics" and "Statistics."

Census Bureau Statistics

Health Insurance (U.S. Census Bureau)
https://www.census.gov/topics/health/health-insurance.html

Census Bureau reports and tables on health coverage.

Health Insurance Coverage in the United States: 2018 (U.S. Census Bureau, September 10, 2019)
https://www.census.gov/library/publications/2019/demo/p60-267.html

National and state health insurance coverage statistics for 2018. Scroll down for detailed tables, including state tables.

My Congressional District (U.S. Census Bureau)
http://www.census.gov/mycd/

After selecting a congressional district, click "$ Socio-Economic" to get health insurance data from the American Community Survey.

Explore Census Data: Advanced Search (U.S. Census Bureau)
https://data.census.gov/cedsci/advanced

Contains detailed health insurance coverage tables for recent years. Under "Filters," choose Topics > Health > Health Insurance. One can also filter by Year. Once one has a table, click Customize Table to modify it by Geographies, including by Congressional District. When using Census tables, note the margins of error.8

Selected Characteristics of Health Insurance Coverage in the United States, Table ID S2701, American Community Survey (U.S. Census Bureau)
https://data.census.gov/cedsci/table?tid=S2701

This table shows the estimated percent of the population that was uninsured at the time of the survey. It also has estimates of the percent uninsured for selected demographic groups. For congressional district data, click "Customize Table" to modify by Geographies, then choose Congressional District. A map is available at Uninsured Rate by Congressional District: 2018, https://www.census.gov/content/dam/Census/library/visualizations/2019/demo/p60-267/Map_Uninsured_Rate_by_CD_2018.pdf.

When using Census tables, note the margins of error.9 The above table and map show one-year estimates (2018). One-year estimates might not be available for geographies with small populations.

Five-year estimates (2014-2018) are available at https://data.census.gov/cedsci/table?tid=ACSST5Y2018.S2701.  Five-year estimates are based on five years of survey data and often have smaller margins of error than one-year estimates. For geographies with small populations, five-year estimates are also more likely to be available than one-year estimates.

Small Area Health Insurance Estimates (SAHIE) Program: Health Insurance Interactive Data Tool (U.S. Census Bureau)
https://www.census.gov/data-tools/demo/sahie/#/

SAHIE produces model-based estimates of health insurance coverage for counties and states. This is an interactive tool for showing uninsured rate trends. On the left, one can filter by state, county, age group, race, sex, and income.

U.S. Department of Health and Human Services Statistics

National Health Interview Survey (Centers for Disease Control and Prevention, National Center for Health Statistics)
http://www.cdc.gov/nchs/nhis/new_nhis.htm

Includes survey data on lack of insurance, public health plan coverage, and private health insurance coverage, by region and state. Most of the tables show the percentage of the population that was uninsured at the time of the survey, although some of the national tables also show estimates of those uninsured for at least part of the year prior to the survey, and those uninsured for more than a year at the time of the survey. See the following:

Health Coverage Research (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation)
https://aspe.hhs.gov/health-coverage-research

Health coverage research published during President Trump's Administration (that is, since January 20, 2017).

Historical Research (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation)
https://aspe.hhs.gov/historical-research

Research on ACA's impacts, including on insurance coverage, published during President Obama's Administration (that is, before January 20, 2017). For example, see Health Insurance Coverage and the Affordable Care Act, 2010-2016 (March 2016), https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf.

Medical Expenditure Panel Survey (Agency for Healthcare Research and Quality)
http://meps.ahrq.gov/

Includes private-sector employer survey data on employer-sponsored insurance; for example,

Legal and Regulatory Issues

See also "Women's Health Care."

CRS Legal Sidebar LSB10389, Fifth Circuit Holds the Individual Mandate Unconstitutional: Implications for Congress

CRS analysis of the lawsuit Texas v. United States. Discusses the December 18, 2019 decision of the U.S. Court of Appeals for the Fifth Circuit, and identifies legislative options for Congress. On March 2, 2020, the Supreme Court granted review in the Texas litigation.

CRS Legal Sidebar LSB10360, Using the Power of the Purse to Change Policy: SCOTUS Case on ACA Risk Corridors Asks Important Appropriations Law Question

CRS analysis of the lawsuits consolidated under Maine Community Health Options v. United States, pertaining to ACA's risk corridor provision. The Supreme Court heard oral arguments on December 10, 2019 and issued a decision on April 27, 2020, https://www.supremecourt.gov/opinions/19pdf/18-1023_m64o.pdf.

Federal Register (National Archives and Records Administration)
https://www.federalregister.gov/documents/search?conditions%5Bterm%5D=%22affordable+care+act%22+%7C+%22111-148%22++%7C+ppaca&order=newest

  • This link searches the Federal Register for proposed rules, final rules, notices, and presidential documents mentioning the ACA.

CRS Report R43474, Implementing the Affordable Care Act: Delays, Extensions, and Other Administrative Actions Taken by the Obama Administration

The report, which may be of historical interest, summarizes selected administrative actions to address ACA implementation and discusses the congressional lawsuit U.S. House of Representatives v. Burwell.

Author Contact Information

Angela Napili, Senior Research Librarian ([email address scrubbed], [phone number scrubbed])

Footnotes

1.

A teletypewriter (TTY) is a communication device used by persons who are deaf, hard-of-hearing, or have severe speech impairments, according to "TTY," Glossary (U.S. Department of Health and Human Services, HealthCare.gov), at https://www.healthcare.gov/glossary/tty/.

2.

See "States open special enrollment periods to enroll uninsured," in Louise Norris, "State and federal efforts to improve access to COVID-19 testing, treatment," https://www.healthinsurance.org/obamacare/state-and-federal-efforts-to-improve-access-to-covid-19-testing-treatment/#sep.

3.

HealthCare.gov states are states that use the HealthCare.gov information technology platform for their exchanges. To determine whether a state currently uses HealthCare.gov or its own exchange platform, check CMS, HealthCare.gov, "Need health insurance?" https://www.healthcare.gov/get-coverage/. See also the Appendix to CRS Report R44065, Overview of Health Insurance Exchanges.

4.

States vary in which data are reported. For example, some data elements are reported only for HealthCare.gov states.

5.

Two other reports were released the same day and are listed above: Early 2018 Effectuated Enrollment Snapshot (CMS, July 2, 2018), https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/2018-07-02-Trends-Report-1.pdf; and The Exchanges Trends Report (CMS, July 2, 2018), https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/2018-07-02-Trends-Report-3.pdf.

6.

Another report was released the same day and is listed above: 2017 Effectuated Enrollment Snapshot (CMS, June 12, 2017), https://downloads.cms.gov/files/effectuated-enrollment-snapshot-report-06-12-17.pdf.

7.

This section was written by CRS Legislative Attorney Victoria Killion.

8.

"Margin of error" is defined at the U.S. Census Bureau's Glossary, https://www.census.gov/glossary/#term_MarginofErrorMOE.

9.

"Margin of error" is defined at the U.S. Census Bureau's Glossary, https://www.census.gov/glossary/#term_MarginofErrorMOE.