Vol 23, 2014 Annals of Health Law 36
THE ACA AND PEOPLE LIVING WITH HIV/AIDS
these requirements, states retain significant power in crafting coverage and
eligibility provisions, which vary significantly from state to state. 55 Most
states determine eligibility criteria for Medicaid based in part on the
applicant’s income in relation to the federal poverty level (FPL) 56 and on
other factors such as disability or age. 57 Until the passage of PPACA, many
of the United States’s poorest citizens were not eligible for Medicaid
because they did not meet the additional requirements that they be disabled,
elderly, a parent, or a child. 58
PPACA addresses the problems surrounding access to Medicaid and its
cost by eliminating all non-income based eligibility requirements. 59
Beginning in 2014, states will receive federal funding for Medicaid benefits
paid to individuals earning less than 138% of the FPL. 60 Before National
Federation, PPACA authorized HHS to rescind Medicaid funds entirely
from states that refused to expand Medicaid eligibility to this group of
people. 61 In other words, HHS could force states to pay for their Medicaid
program without the benefit of any federal funding if they maintained any
non-income based eligibility requirements or refused to raise the income
55. See SOC. SEC. ADMIN., ANNUAL STATISTICAL SUPPLEMENT TO THE SOCIAL SECURITY
BULLETIN, 2011 56 (2012), available at http://www.socialsecurity.gov/policy/docs/
statcomps/supplement/2011/supplement11.pdf; Timothy Jost, Implementing Health Reform:
State Innovation and Medicaid Waivers, HEALTH AFFAIRS BLOG (Feb. 23, 2012),
medicaid-waivers/ (commenting that even though federal requirements do exist, states have
often received waivers to depart from those minimum standards which result in either an
expansion or contraction of eligibility criteria, often quite dramatically).
56. The Department of Health and Human Services annually sets the FPL by issuing
“poverty guidelines,” which administrative agencies use to determine who is eligible for
public assistance. Dep’t Health & Human Servs., 2013 Poverty Guidelines,
http://aspe.hhs.gov/poverty/13poverty.cfm (last visited Nov. 20, 2013). The District of
Columbia and every state but Alaska and Hawaii share the same FPL. Id.
57. Ctrs. for Medicare & Medicaid Servs., Eligibility, http://www.medicaid.gov/
Medicaid-CHIP-Program-Information/By-Topics/Eligibility/ Eligibility.html (last visited
Nov. 20, 2013); see also Ctrs. for Medicare & Medicaid Servs., 2013 Poverty Guidelines,
Downloads/2013-Federal-Poverty-level-charts.pdf (last visited Nov. 20, 2013). The 2013
FPL for a family of four was $23,550. Id.
58. See SOC. SEC. ADMIN., supra note 55, at 56-57.
59. 42 U.S. C. A. § 1396a(a)( 10)( A)( i)(VIII) (West, WestlawNext through P.L. 112-283).
60. See id.; State Health Access Data Assistance Ctr., ACA Note: When 133 Equals 138
– FPL Calculations in the Affordable Care Act (Jan. 13, 2011), http://www.shadac.org/
blog/aca-note-when-133-equals-138-fpl-calculations-in-affordable-care-act (noting that the
language of PPACA states that childless adults with a “Modified Adjusted Gross Income”
below 133% are eligible for Medicaid and that the eligibility threshold for Medicaid is
effectively 138% because of how PPACA and the Internal Revenue Service calculate
adjusted gross income).
61. Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2607 (2012).