In this article

• Which carriers have announced they’re leaving the Marketplace?
• Will any carriers exit the market before the end of 2026?
• Why are carriers pulling out of the Marketplace?
• Declining Marketplace enrollment drives carrier decisions
• Marketplace participation is ultimately a business decision
• Current withdrawals reflect a familiar cycle
• What should consumers expect next?

At least seven health insurers have announced plans to leave the ACA Marketplace after 2026, affecting more than 650,000 enrollees across multiple states. The exits are raising new questions about the stability of the individual market and whether additional insurers could follow.

Although insurer participation in the ACA Marketplace has fluctuated for years, the latest withdrawals come at a time of growing uncertainty driven by higher premiums, declining enrollment, and federal rule changes that could further reshape the market in 2027.

Declining Marketplace enrollment drives carrier decisions

Marketplace enrollment declined in 2026, after five years of steady growth¹⁷ – and according to a Wakely analysis, effectuated enrollment is projected to be 17% to 26% lower in 2026 than it was in 2025.¹⁸

Although we don’t yet have official nationwide 2026 effectuated enrollment data from Centers for Medicare & Medicaid Services (CMS), NOTUS (News of the United States) has obtained internal CMS documents and reported that 21% of HealthCare.gov enrollees were disenrolled in the early months of 2026 for failure to pay premiums. Across state-run Marketplaces, the drop-off was much smaller, at about 8%, due in part to the supplemental subsidies offered by some state-run Marketplaces.

But nationwide, about 17% of the people who selected a plan during the open enrollment period for 2026 (or whose coverage was automatically renewed) have already lost their coverage for failure to pay premiums.¹⁹

And some state-run Marketplaces are showing significant declines in effectuated enrollment in early 2026. For example, Georgia’s effectuated Marketplace enrollment dropped from nearly 1.5 million in early 2025²⁰ to 950,000 by April 2026.²¹ In Washington state (which does offer state-funded subsidies), effectuated enrollment as of February 2026 was down more than 15% from where it had been a year earlier.²²

Overall, CMS projects that average effectuated Marketplace enrollment will be about 18.9 million people in 2026,²³ although it could potentially drop to as low as 16.5 million. In comparison, average effectuated Marketplace enrollment was 22.3 million people in 2025.²⁴

A major reason for the enrollment decline is the expiration of enhanced federal subsidies at the end of 2025. Many Marketplace consumers saw premiums rise sharply when those subsidy enhancements expired. Even though millions of people switched to plans with higher out-of-pocket costs or dropped their coverage altogether, average net premiums in the Marketplace still rose by 58% in 2026.

That sharp increase in net premiums is the primary reason so many people failed to pay their premiums in the early part of 2026.¹⁹ That matters because healthier consumers are generally more likely to drop coverage when premiums increase, while people with ongoing medical needs are more likely to keep their insurance.²⁵

As healthier people leave the market, insurers are left covering a smaller but less healthy risk pool. That increases average medical costs per enrollee and puts upward pressure on premiums.

The Trump administration’s rule changes for 2027 could intensify those pressures even further. Federal regulators have projected that the new rules could lead to as many as 2 million additional people leaving the Marketplace.¹⁶

CMS has also acknowledged that healthier enrollees may be more likely to lose or discontinue coverage under the new rules, potentially contributing to additional premium increases (although CMS notes that these premium increases may be offset by more eligibility verification for special enrollment periods and lower exchange user fees).¹⁶

Marketplace participation is ultimately a business decision

For insurers, participation in the Marketplace is fundamentally a financial calculation.

Insurers continuously evaluate whether Marketplace coverage is profitable and whether the market appears stable enough to justify continued participation. When enrollment declines, risk pools worsen, and policy uncertainty increases, some insurers decide the business risk is no longer worthwhile.

There can also be state-specific policy factors involved. New Mexico, for example, requires Medicaid managed care insurers to also offer statewide Marketplace coverage.²⁶ But in most states, Marketplace participation decisions are largely driven by insurers’ assessment of profitability and overall market stability.

Current withdrawals reflect a familiar cycle

Insurer participation in the Marketplaces has been cyclical over time, generally increasing when the individual market was healthier and larger, and decreasing when it was sicker and smaller. We can see a clear illustration of this when we look at how Aetna’s Marketplace participation has shifted in response to changing market conditions.

At the end of 2016, Aetna exited the Marketplace in 11 of the 15 states where it offered coverage.²⁷ The company then fully exited the ACA exchanges after 2017.²⁸

But Aetna later returned to the Marketplace in 2022 and expanded into additional states in 2023.²⁹ However, the company once again fully exited the Marketplace after 2025.³⁰

That pattern mirrors broader Marketplace trends over the past decade.

Insurer participation declined significantly in 2017 and 2018 amid repeated congressional repeal efforts and policy uncertainty surrounding the ACA.³¹

Participation later rebounded during the Biden administration, when enhanced subsidies and other policy changes (including a low-income special enrollment period, fixing the “family glitch,” and Marketplace access for DACA recipients) made Marketplace coverage more affordable and accessible, resulting in far more people with Marketplace coverage.³²

But the number of insurers participating in the Marketplace declined again for 2026, after several of the Biden-era changes were eliminated. This was the first overall decline in insurer participation since 2018.³³

Still, today’s Marketplace participation levels remain significantly stronger than they were during the market instability of 2017 and 2018.

In 2018, more than a quarter of Marketplace enrollees only had access to plans from a single insurer.³⁴ By contrast, despite the recent decline in participation, only 1% of HealthCare.gov enrollees in 2026 had access to just one insurer’s plans.³⁵

1. “Cigna Healthcare’s 2026 Footprint” Cigna. Accessed April 30, 2026
2. “Cigna to quit health insurance exchanges” Modern Healthcare. April 30, 2026
3. “Individual & Family Marketplace plans” Baylor Scott & White Health Plan. Accessed April 16, 2026
4. “Baylor Scott & White Health Plan will no longer carry Medicaid and marketplace insurance plans” WFAA, Apr. 15, 2026
5. “Non-Renewal of Health Insurance Marketplace and Off-Exchange Plans” CareSource. May 15, 2026. West Virginia SERFF tracking number CASO-134960434, and Ohio SERFF filing number CASO-134960415
6. “Two Major Insurers Are Leaving Indiana’s Health Marketplace in 2027. What Every Hoosier Needs to Know” Nefouse Benefits Consultants. Accessed May 7, 2026
7. “Ohio SERFF tracking number CASO-134960415” (See withdrawal notification in the SERFF filing). Ohio SERFF. Accessed June 11, 2026
8. ”SERFF tracking number CASO-134960415″ (See Part III Actuarial Memorandum) West Virginia SERFF. Accessed June 11, 2026
9. “Ohio SERFF tracking number CASO-134960415” (See FAQ page in the SERFF filing). Ohio SERFF. Accessed June 11, 2026
10. “PacificSource to exit ACA market, pull out of Montana entirely” Becker’s Payer Issues. May 22, 2026
11. “Providence to end most of its health insurance business” OPB. May 20, 2026
12. “Enrollment Data” Oregon Department of Financial Regulation. Accessed May 25, 2026
13. ”Requested Rate Increases Effective 2027” Connecticut Insurance Department. Accessed June 9, 2026
14. ”Mending Health Notifies Maine Bureau of Insurance that it Will Cease Offering Health Insurance Plans” Maine Bureau of Insurance. June 8, 2026. And “Mending to no longer serve as health insurance carrier amid its national direct primary care push” Becker’s Payer Issues. June 9, 2026. Source for enrollment total in Oklahoma is an email conversation with Jeff Yuan, co-founder of Mending.
15. “A ‘Perfect Storm’ Is Brewing for Health Insurers” Colorado Association of Health Plans. July 15, 2025
16. “Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program” Centers for Medicare & Medicaid Services. May 15, 2026
17. “Open Enrollment Marketplace Plan Selections, 2014-2026” KFF.org. Accessed May 7, 2026
18. “Who Paid, and Who Stayed? Early 2026 Enrollment Trends in the Individual Market” Wakely. Accessed May 7, 2026
19. “One in Five HealthCare.gov Enrollees Dropped Insurance Coverage This Year” NOTUS. May 12, 2026
20. “Effectuated Enrollment: Early 2025 Snapshot and Full Year 2024 Average” Centers for Medicare & Medicaid Services. July 24, 2025
21. “Georgia’s ACA enrollment plunges, raising concerns for rural hospitals” The Current GA. April 20, 2026
22. “Washington: Effectuated ACA enrollment down 11 – 16% so far; over 46,000 have already lost coverage” ACA Signups. May 6, 2026
23. “Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program” Centers for Medicare & Medicaid Services. May 15, 2026
24. “What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles” KFF.org. May 19, 2026
25. “Cigna Reports Q1 Gains, Announces ACA Marketplace Exit” Health Care Un-Covered” May 4, 2026
26. “State of New Mexico Health Care Authority (HCA) Medicaid Managed Care Services Agreement” New Mexico Human Services Department. Accessed May 8, 2026
27. “Why Are Insurers Leaving the ACA Marketplace and what does it mean for Obamacare?” Health Care Recruiters International. Oct. 25, 2016
28. “Aetna fully exits Obamacare exchanges with pull-out in two states” Reuters. May 10, 2017
29. “Aetna expanding to ACA exchanges in four new states” Health Care Finance. Sep. 13, 2022
30. “Aetna Members With ACA Plans Will Need New Coverage in 2026; CVS to Exit ACA Marketplace” OncoVenture. May 1, 2025
31. “Timeline of ACA repeal and replace efforts” BallotPedia. Accessed May 8, 2026
32. “Inflation Reduction Act Health Insurance Subsidies: What is Their Impact and What Would Happen if They Expire?” KFF.org. July 26, 2024
33. “Number of Insurers Participating in the Individual Health Insurance Marketplaces” KFF.org. Accessed May 7, 2026
34. “For 3rd Year in a Row, More Insurers are Entering the ACA Marketplaces, Creating More Options for Consumers” KFF.org. Nov. 23, 2020
35. “Plan Year 2026 Marketplace Plans and Prices Fact Sheet” Centers for Medicare & Medicaid Services. Oct. 30, 2025

In this article

• Key findings at a glance
• Marketplace coverage ‘downgrades’ were widespread as consumers searched for ‘cheap health insurance’
• How much will Marketplace enrollment drop in 2026?
• A spike in searches about going without coverage

As net health insurance premiums in the Marketplace have jumped by an average of nearly 60% nationally¹ due to the expiration of federal subsidy enhancements, many consumers have been reassessing what coverage they can afford – or whether they can afford coverage at all.

One of the clearest signals of that growing anxiety isn’t coming just from enrollment data or policy analysis. It’s showing up in what people are searching for online, particularly when it comes to the cost of health insurance.

A healthinsurance.org analysis of more than five years of Google Trends data shows a sharp spike in affordability-related searches in 2025, followed by continued growth in early 2026. Searches related to the cost of health insurance, lower-cost coverage options, subsidies, and even the consequences of going without insurance surged as consumers grapple with rising costs.

Taken together, these trends suggest a meaningful shift in how consumers are approaching health coverage in today’s higher-cost environment.

Key findings at a glance

Google Trends data reflects relative search interest over time, offering a real-time view into what consumers are actively Googling. Between 2024 and 2025, search interest for:

• “cost of health insurance” increased about 54%
• “bronze health plan” increased about 75%
• “catastrophic health insurance” increased about 71%
• “cheap health insurance” and “low cost health insurance” surged 48% to multi-year highs
• “Do you get penalized for not having health insurance?” increased 65%.

These queries did not fade when open enrollment ended in January 2026. Between January and March, when many consumers faced their first premium payments of the year, search interest accelerated. Compared to previous winters, for example, search interest in “cheap health insurance” sharply increased over 160%.

See the findings below.

Why consumers’ interest in health insurance costs surged

During the open enrollment period for 2026 Marketplace health coverage, some clear trends emerged in conjunction with the expiration of federal premium subsidy enhancements: Fewer people enrolled, and more people selected Bronze plans, which have lower premiums but higher out-of-pocket costs. And even with those changes, average net (after-subsidy) premiums grew by 58%, going from $113/month in 2025¹ to $178/month in 2026.²

So it’s not surprising that there has also been a significant increase in online search interest around health insurance costs and lower-premium coverage options in 2025 and 2026.

The cost of health insurance is causing consumer anxiety

In early 2026, search interest in “cost of health insurance” was more than double what it had been at the same time in 2025, and search interest in “health care subsidy” had nearly tripled. This makes sense given the expiration of federal premium subsidy enhancements at the end of 2025, and the anxiety this may have caused for consumers.³

If all Marketplace enrollees had renewed their 2025 plans for 2026, average net premiums were projected to increase by 114%.⁴ This caused significant sticker shock when people got their renewal notices last fall. Instead of renewing, many consumers opted to downgrade to a plan with a lower premium or drop their coverage altogether, resulting in net premiums “only” increasing by 58%.

The unfortunate reality is that most 2026 Marketplace enrollees were faced with higher premiums, higher out-of-pocket costs, or both. As a result, a recent KFF survey found that more than half of returning Marketplace enrollees are reducing their spending on food or basic household items so that they can afford their health insurance premiums and out-of-pocket costs.⁵

Marketplace coverage ‘downgrades’ were widespread as consumers searched for ‘cheap health insurance’

There has also been a spike in search interest related to Bronze and Catastrophic health plans, as well as “cheap” and “low-cost” health insurance. This is all indicative of the pressure that consumers are feeling when it comes to the monthly premiums they’re paying, and their efforts to find lower-cost coverage options.

Unfortunately, lower-cost options generally mean higher out-of-pocket costs. And that’s a best-case scenario that assumes a person continues to have ACA-compliant coverage. A person who switches from a Silver Marketplace plan to a Bronze or Catastrophic Marketplace plan will have higher out-of-pocket costs, but they’ll still have the ACA’s consumer protections, including coverage for pre-existing conditions and essential health benefits.

But we know that 1.2 million fewer people enrolled in Marketplace plans for 2026.⁶ Some of those people might have moved to other ACA-compliant coverage, such as an employer’s health plan. But some are likely uninsured altogether in 2026, while others might have opted for non-ACA-compliant insurance or even “coverage” that isn’t actually insurance, such as health care sharing ministry plans or Farm Bureau plans.⁷

Bronze plans became much more popular with Marketplace enrollees in 2026, growing from about 30% of enrollments in 2025 to about 40% of enrollments in 2026.⁸

At the same time, Silver plan selections dropped significantly, going from 56% of enrollments in 2025 to 43% in 2026.⁹

And while Gold plan selections increased slightly, from 13% of enrollments in 2025 to 17% in 2026,¹⁰ it’s worth noting that in many cases this was still a coverage downgrade, if the person previously had a Silver plan with strong cost-sharing reductions.¹¹

This is because for those with income that doesn’t exceed 200% of the federal poverty level, a Silver plan provides much more robust benefits than a Gold plan. But in many states, Gold plans have lower premiums than Silver plans.¹²

This helps to explain why some enrollees switched from Silver plans to Gold plans (or Bronze plans) in an effort to reduce premiums, despite giving up cost-sharing reductions to do so: Across all Marketplace enrollees, 51% were receiving CSR benefits in 2025, and that dropped to 37% in 2026.¹³ CSR benefits are only available on Silver plans, so consumers who are CSR-eligible are forfeiting that benefit if they select a non-Silver plan.¹⁴

Searches for ‘catastrophic health insurance’

Despite the fact that the Trump administration took steps to expand access to Catastrophic plans in the fall of 2025, Catastrophic plans accounted for just 0.3% of all Marketplace plan selections in 2026, up only slightly from about 0.2% in 2025.¹⁵ Catastrophic plans aren’t available at all in 14 states, are only offered by some (but not all) Marketplace insurers in most other states, and can never be purchased with premium tax credits.¹⁶ So while they’re fully ACA-compliant, they still make up just a tiny sliver of Marketplace enrollment.

But it’s also worth pointing out that while “Catastrophic health insurance” has a specific definition under the ACA, consumers were using this term to describe cheap “bare bones” coverage long before the ACA. Search interest in “catastrophic health insurance” grew considerably in 2025 and 2026, and although some people using this search phrase might be looking for ACA-compliant coverage, others might be looking for lower-cost plans that aren’t ACA-compliant.

Increasing interest in high-deductible health plans

Search interest related to high-deductible health plans has been steadily climbing in recent years, reaching new highs in 2025 and early 2026. As is the case with “catastrophic health insurance,” the term “high-deductible health plan” (HDHP) has a specific definition.¹⁷ These plans are regulated by the IRS, and enrollees are allowed to make pre-tax contributions to a health savings account. But consumers who are doing online searches may or may not know that, and might simply be looking for lower-cost coverage.

In 2026, for the first time, all Bronze and Catastrophic Marketplace plans are considered HDHPs, meaning enrollees in these plans can make HSA contributions. For enrollees who are willing and able to do so, this could have significant tax advantages, and could explain why some people opted to switch to these plans, despite the higher out-of-pocket costs.

But having access to an HSA doesn’t necessarily mean that a person will utilize that option. Opening an HSA and making contributions to it are optional. And while the majority of people enrolled in employer-sponsored HDHPs receive HSA contributions from their employer,¹⁸ most people with HDHPs purchased in the individual market have to make their own HSA contributions.

How much will Marketplace enrollment drop in 2026?

Although Marketplace plan selections during open enrollment dropped by about 1.2 million people in 2026 compared with the year before, that doesn’t account for people who might not have paid their initial premiums to effectuate their coverage. Nor does it account for people whose coverage was terminated at the end of a grace period due to non-payment of premiums.

A Wakely analysis that covered about 80% of the individual market found that 86% of the people who selected a plan during the open enrollment period for 2026 (including those whose coverage was auto-renewed) paid their January premium. The other 14% includes some people whose coverage didn’t get effectuated, and others who were in a grace period and may or may not have paid their past-due premiums by the end of that grace period.

But overall, the Wakely analysis projects that “average enrollment in the individual market could shrink 17% to 26% in 2026 compared to 2025 average enrollment.”¹⁹

A KFF analysis of returning Marketplace enrollees found that nearly one in five reported being unsure they’ll be able to continue to pay their monthly premiums throughout 2026.⁵ So it’s not surprising that online search interest in whether there’s a penalty for going without health insurance increased so much in 2025 and early 2026. Some people have already given up their coverage (plan selections during open enrollment dropped by about 1.2 million people compared with 2025), and others are unsure whether they’ll be able to maintain their coverage throughout 2026.⁵

Although the Wakely analysis gives some good clues about early effectuated enrollment, it will likely be at least mid-2026 before we have official nationwide numbers from CMS in terms of how many people had effectuated Marketplace coverage as of February 2026. The effectuated enrollment number is always lower than the number of plan selections made during open enrollment.

But the first effectuated enrollment report won’t reflect the number of policies that lapsed at the end of March when their three-month grace period ended. Nor will it reflect people who were able to make their initial premium payments but weren’t able to continue to make those payments later in the year.²⁰

So as insurers start to prepare rates and plans for next year, it remains to be seen how many people will have individual-market coverage as we head into 2027.

A spike in searches about going without coverage

Consumer search interest in whether there’s a penalty for not having health insurance grew significantly in 2025 and the early part of 2026. This corresponds with a drop in Marketplace enrollment: 24.3 million people selected Marketplace plans for 2025,²¹ and that dropped to 23.1 million for 2026.²² So it makes sense that more people might want to learn more about the ramifications of going without health insurance.

Note: There hasn’t been a federal penalty for being uninsured since 2018, but DC and four states do impose a penalty.

What to do if you’re struggling with health insurance costs

If health insurance feels unaffordable in 2026, you’re certainly not alone. Read more about what to do if you’re feeling premium sticker shock, and what you can do if you can’t afford health insurance and aren’t eligible for Medicaid.

Consumer search trends signal growing cost pressure in health insurance

1. “2025 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column AB) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
2. “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column AG) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
3. “Worried About Health Insurance Costs? There May Be Cheaper Options — But With Trade-Offs” KFF Health News. Dec. 18, 2025
4. “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire” KFF.org. Sep. 30, 2026
5. “Cost Concerns and Coverage Changes: A Follow-Up Survey of ACA Marketplace Enrollees” KFF.org. Mar. 19, 2026
6. “2025 Marketplace Open Enrollment Period Public Use Files” and “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column H) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
7. “Private Health Coverage: Information on Farm Bureau Health Plans, Health Care Sharing Ministries, and Fixed Indemnity Plans” Government Accountability Office. July 26, 2023
8. “2025 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BR) and “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BW) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
9. “2025 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BS) and “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BX) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
10. “2025 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BT) and “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BY) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
11. “Final 2026 Open Enrollment Report: Metal Levels (Part 5B)” ACA Signups. Apr. 6, 2026
12. “ACA marketplace 2026: The silver loading mitigation” Xpostfactoid. Nov. 7, 2025
13. “2025 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column AE) and “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column AJ) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
14. “Cost sharing reduction (CSR)” HealthCare.gov. Accessed Apr. 7, 2026
15. “2025 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BQ) and “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column BV) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
16. “Policy Changes Bring Renewed Focus on High-Deductible Health Plans” KFF.org. Jan. 5, 2026
17. “Publication 969 (2025), Health Savings Accounts and Other Tax-Favored Health Plans” Internal Revenue Service. Accessed Apr. 7, 2026
18. “Employer Health Benefits, 2025 Annual Survey” KFF.org. Oct. 22, 2025
19. “Who Paid, and Who Stayed? Early 2026 Enrollment Trends in the Individual Market” Wakely. Accessed Apr. 15, 2026
20. “ACA Marketplace Enrollment is Down in 2026—But All of the Data Isn’t in Yet” KFF.org. Feb. 5, 2026
21. “2025 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column H) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026
22. “2026 Marketplace Open Enrollment Period Public Use Files” (State level PUFs, Column H) Centers for Medicare & Medicaid Services. Accessed Apr. 7, 2026

As long as you have fewer than 50 full-time equivalent (FTE) employees and don’t also offer a group health plan, you have your choice of either an ICHRA or a QSEHRA. Note that only employers with fewer than 50 FTE employees can select a QSHERA.

Read our overviews of ICHRAs and QSEHRAs.

What are the differences between a QSEHRA and an ICHRA?

Here’s a summary of how these two types of health reimbursement arrangements compare, to help you determine which one will be a better fit for your business:

1. “Health Reimbursement Arrangements (HRAs): 3 things to know” HealthCare.gov. Accessed May 20, 2025
2. “Health Reimbursement Arrangements (HRAs)” and “FAQs on New Health Coverage Options for Employers and Employees” Internal Revenue Service. June 13, 2019. Accessed May 20, 2025
3. “Notice 2017-67, Qualified Small Employer Health Reimbursement Arrangements” Internal Revenue Service. Accessed May 20, 2025
4. “FAQs on New Health Coverage Options for Employers and Employees” Internal Revenue Service. June 13, 2019. Accessed May 20, 2025
5. ”Revenue Procedure 2025-32” Internal Revenue Service. Accessed Apr. 15, 2026
6. “Notice 2017-67, Qualified Small Employer Health Reimbursement Arrangements” Internal Revenue Service. And “Qualified Small Employer HRAs (QSEHRAs)” HealthCare.gov. Accessed May 20, 2025
7. “Notice 2017-67, Qualified Small Employer Health Reimbursement Arrangements” (Appendix A) Internal Revenue Service. Accessed May 20, 2025
8. “Cures Act – QSEHRA Q&A” Washington Healthplanfinder. Accessed May 20, 2025
9. “Guide to the individual coverage HRA (ICHRA)” PeopleKeep. Accessed May 20, 2025
10. “2025 Guide for Qualified Small Employer HRAs (QSEHRA)” Take Command. Accessed May 20, 2025

In this article

• What’s happening with Marketplace health plan enrollments?
• Why might consumers be downgrading to Bronze plans?
• Which states saw a decrease in Bronze plan selections?
• What does a shift to Bronze plans mean for consumers?
• Options for Bronze plan buyers facing higher out-of-pocket costs

As consumers face decreased access to Marketplace health insurance subsidies for 2026 plans – and higher net premiums for consumers who continue to be subsidy-eligible – one clear buying trend has emerged: a migration of buyers to Bronze-level health plans.

During the open enrollment period for 2026 coverage, nearly 40% of all Marketplace enrollees selected a Bronze plan,¹ up from about 30% the year before.²

And while about 43% of enrollees selected Silver plans for 2026,³ that was down from about 56% the year before.⁴ In other words, a significant number of enrollees have downgraded their coverage for 2026, in addition to the people who simply dropped their coverage altogether.

Options for Bronze plan buyers facing higher out-of-pocket costs

If you’re enrolled in a Bronze plan and worried about higher out-of-pocket costs, there are several tips to keep in mind:

• Comparison shop for your care whenever possible. Although your health plan might have a wide range of in-network hospitals, medical offices, and pharmacies, that doesn’t mean your out-of-pocket costs will be the same at all of them. If you need a prescription, you can check with various in-network pharmacies (including mail-order options) to see if there are price differences. The same is true for other medical care, and there are transparency tools that can help you determine what your costs will be.²³
• Discuss your financial situation with your medical providers. You may find that they can offer a payment plan that fits within your budget.
• If at all possible, consider opening and funding an HSA. All Bronze plans are HSA-eligible as of 2026. The money you contribute to an HSA is pre-tax. And if you need to use it to pay your deductible or other medical expenses, it will continue to be tax-free when you make the withdrawal. If you don’t end up needing to use the money in your HSA, it will remain in the account in future years until if and when you need it.
• If your income isn’t more than 200% of the federal poverty level, you might be eligible for reduced out-of-pocket costs if you use a federally qualified health center (FQHC) that’s in your plan’s provider network. Depending on your income, these clinics can reduce the amount that you’d otherwise have to pay out-of-pocket under the terms of your health plan.²⁴
• Consider supplemental coverage, such as a critical illness policy or an accident insurance policy, that could reimburse some of your out-of-pocket costs if you were to face unexpected medical costs for a covered illness or injury.
• Some people with high-deductible health insurance choose to enroll in a local doctor’s direct primary care (DPC) membership program, to have unlimited access to various primary care services. And as of 2026, having a DPC membership no longer prohibits a person from making HSA contributions if they also have an HSA-eligible health plan, as long as the DPC membership meets certain parameters.²⁵

1. “2026 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BW divided by Column H). Centers for Medicare & Medicaid Services. Mar. 27, 2026
2. “2025 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BR divided by Column H). Centers for Medicare & Medicaid Services. May 12, 2025
3. “2026 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BX divided by Column H). Centers for Medicare & Medicaid Services. Mar. 27, 2026
4. “2025 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BS divided by Column H). Centers for Medicare & Medicaid Services. May 12, 2025
5. “ACA Sign-Ups Are Down by Over a Million People, But It’s Still an Incomplete Picture” KFF.org. Jan. 29, 2026
6. “2026 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column H). Centers for Medicare & Medicaid Services. Mar. 27, 2026
7. “Marketplace Enrollment, 2014-2025” KFF.org. Accessed Mar. 3, 2026
8. “2026 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BW divided by Column H). Centers for Medicare & Medicaid Services. Mar. 27, 2026. And ”2025 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BR divided by Column H). Centers for Medicare & Medicaid Services. May 12, 2025
9. “Deductibles in ACA Marketplace Plans, 2014-2026” KFF.org. Nov. 6, 2025
10. “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire” KFF.org. Sep. 30, 2025
11. “2026 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column AG). Centers for Medicare & Medicaid Services. Mar. 27, 2026. And ”2025 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column AB). Centers for Medicare & Medicaid Services. May 12, 2025
12. “2025 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BT divided by Column H). Centers for Medicare & Medicaid Services. May 12, 2025
13. “2026 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BY divided by Column H). Centers for Medicare & Medicaid Services. Mar. 27, 2026.

    This migration to Gold plans (and reduction in Silver and Bronze plan selections) happened because Washington adopted premium alignment for 2026, requiring insurers to add a 43% load to the premiums for Silver plans. This is because most Silver plans actually have benefits that are similar to those of Platinum plans, as a result of cost-sharing reductions (CSR).[efn_note]“Final Cascade Care Savings amounts for plan year 2026” Washington Health Benefit Exchange. Sept. 30, 2025

14. “2026 Open enrollment Preview Report” Washington Health Benefit Exchange. Jan. 16, 2026
15. “New Mexico Open Enrollment 2025 Level of Coverage Summary” BeWellnm. Accessed Mar. 3, 2026
16. “New Mexico Open Enrollment 2026 Level of Coverage Summary” BeWellnm. Accessed Mar. 3, 2026
17. “2026 Marketplace Open Enrollment Period Public Use Files” (state-level public use files, Column BW divided by Column H). Centers for Medicare & Medicaid Services. Mar. 27, 2026.
18. “Health Insurance Marketplace Affordability Program” New Mexico Health Care Authority. Accessed Mar. 3, 2026
19. “New Mexico HB4, Fiscal Impact Report” New Mexico Legislature. Feb. 5, 2026
20. “More Americans are picking higher-deductible Obamacare plans, possibly risking their health” Politico. Feb. 4, 2026
21. “Patient Protection and Affordable Care Act; Marketplace Integrity and Affordability” Centers for Medicare & Medicaid Services; Department of Health and Human Services. June 25, 2025
22. “Out-of-pocket maximum/limit” HealthCare.gov. Accessed Mar. 6, 2026
23. “Hospital Price Transparency” and “Health Plan Price Transparency” Centers for Medicare & Medicaid Services. Accessed Mar. 3, 2026
24. “Chapter 9: Sliding Fee Discount Program” HRSA Health Center Program. Accessed Mar. 3, 2026
25. “H.R.1” (Section 71308(a)) Congress.gov. Enacted July 4, 2025

In this article

• What is managed care? And why do health plans have managed care designations?
• Four types of managed care
• What’s the difference between an HMO and a PPO (and other types of managed care)?
• What might you consider when buying an HMO, EPO, PPO or POS plan.
• Confusion over what is and isn’t managed care

Among the many factors to consider when you’re shopping for individual health insurance coverage is the type of managed care plan. HMO vs PPO vs EPO vs POS: To decide which works best for your situation, you need to understand the differences between the options and how they can affect your budget and access to medical providers.

Four types of managed care

As you’re selecting a health plan, you may notice that the plan is labeled as an HMO, PPO, EPO, or POS. These are categories of managed care, which is how virtually all modern health insurance is organized. Here’s what those acronyms stand for:

• HMO – Health Maintenance Organization
• PPO – Preferred Provider Organization
• EPO – Exclusive Provider Organization
• POS – Point of Service

2. Narrowness of networks varies

All four types of managed care plans can have broad, narrow, or mid-size provider networks. Don’t assume anything. Instead, you’ll want to actively compare the provider networks of each plan you’re considering, to see whether your specific providers are in-network.

If you don’t currently have any providers, it’s a good idea to see whether each plan you’re considering has in-network hospitals and medical offices that would be convenient if you end up needing medical care. It’s also a good idea to utilize the preventive care benefits that are provided with zero cost-sharing on all ACA-compliant plans.¹⁸ This will generally require finding a primary care provider who can help you obtain preventive services.

3. Managed care is different in the individual market

Individual/family plans aren’t the same as employer-sponsored plans, and that includes the provider networks and managed care rules. You may have had an employer-sponsored plan offered or administered by a particular insurer, but don’t assume that individual/family plans from that insurer will have the same provider network or managed care rules. (For example, whether or not a referral is required.)

4. Referral requirements vary

Although you may have heard that HMOs and POS plans require a referral from a primary care physician in order to see a specialist, that’s not necessarily true. Again, you’ll need to check the specifics of the plans you’re considering.

(And there are pros and cons to referral requirements. On one hand, they mean an additional office visit, which adds to your costs. But on the other hand, your PCP can help to ensure that you’re seeing the correct specialist, and can coordinate the care you receive from multiple specialists.)

Referrals are sometimes confused with prior authorizations (pre-authorizations), but those are two different concepts. A referral comes from a primary care physician, whereas prior authorization has to be obtained from the health plan itself. Health plans can set their own rules in terms of which services require prior authorization. All four types of managed care plans – HMOs, PPOs, EPOs, and POS plans – can and do require prior authorization for various services. But there’s a lot of variation from one plan to another in terms of what services need prior authorization.

So it’s important to understand your plan’s rules, and to ensure that your doctor has your health plan information so that they can submit prior authorization requests on your behalf. And if in doubt, it’s best to contact your health plan before any non-emergency service is scheduled, to make sure you know whether prior authorization is necessary, and if so, whether it has been granted.

Confusion over what is and isn’t managed care

If you’ve read this far, you may be wondering why a health savings account (HSA) and a high-deductible health plan (HDHP) aren’t listed here. It’s common to see these acronyms in articles that compare PPO, EPO, HMO, and POS plans – and that leads many consumers to assume that an HSA or HDHP is a form of managed care plan. But neither is.

HSA-qualified high-deductible health plans (HDHPs) allow enrollees to contribute pre-tax money to an HSA. (You cannot contribute to an HSA unless you have active coverage under an HDHP.) And HDHPs must conform to specific IRS rules (or be Bronze or Catastrophic plans obtained in the individual market, starting with the 2026 plan year).¹⁹

The IRS sets minimum deductibles and maximum out-of-pocket limits (which are lower than what the Department of Health and Human Services sets for other plans), and limits the services that the plan can pay for before the deductible is met (the regular IRS rules for HDHPs do not apply to Bronze or Catastrophic plans, as those are now HDHPs regardless of plan design).

However, an HDHP will also be either a PPO, an EPO, an HMO, or a POS plan. The HDHP designation means that the plan conforms to the IRS rules for HSA-qualified plans. And the HMO, PPO, EPO, or POS designation describes the plan’s approach to managed care.

Learn more about HSA-qualified high-deductible health plans (HDHPs).

1. “Care Management Program: How Your Healthcare System Can Improve Patient Outcomes” WelkinHealth.com, Accessed 2023
2. ”Health Insurance Coverage of the Total Population” KFF.org. Accessed Mar. 24, 2026
3. “Employer Health Benefits 2025 Annual Survey” p. 10, KFF.org, October 22, 2025
4. “The individual health insurance market in 2023” McKinsey.com, Apr. 11, 2023
5. ”Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program” Centers for Medicare & Medicaid Services. Feb. 11, 2026
6. “Managed Care Enrollment Summary” Medicaid.gov. Oct. 16, 2024
7. “Medicare Monthly Enrollment, December 2025” CMS.gov. Accessed Mar. 24, 2026
8. “Medicare Advantage in 2025: Enrollment Update and Key Trends” KFF.org, Jul. 28, 2025
9. “Managed Care” Centers for Disease Control and Prevention. National Center for Health Statistics. Accessed Mar. 24, 2026
10. Examples: “Pathway Essentials –  Quick Reference Guide Anthem’s New Network” Anthem. And “Health Maintenance Organization (HMO) Plans” Cigna. Accessed Mar. 24, 2026
11. “Ending Surprise Medical Bills” Centers for Medicare and Medicaid Services. Accessed Mar. 24, 2026
12. “What happens if I need care from a doctor who isn’t in my plan’s network?” KFF.org, Accessed October 2023
13. “Out-of-Pocket Maximum/Limit” HealthCare.gov Glossary. Accessed Feb. 17, 2025
14. ”Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program” Centers for Medicare & Medicaid Services. Feb. 11, 2026
15. ”Deductibles in ACA Marketplace Plans, 2014-2026” KFF.org. Nov. 6, 2025
16. “Patient Protection and Affordable Care Act; Actuarial Value Calculator Methodology” U.S. Department of Health and Human Services. Accessed Oct. 18, 2023.
17. ”QHP Landscape PY2025 Individual Medical” HHS.gov. Accessed Feb. 17, 2025
18. “Health Benefits and Coverage, Preventive Health Services” HealthCare.gov, Accessed Mar. 24, 2026
19. ”Notice 2026-5, Expanded Availability of Health Savings Accounts under the One, Big, Beautiful Bill Act (OBBBA)” Internal Revenue Service. Accessed Mar. 24, 2026

In this article

1. Your kids might be eligible for Medicaid even if you’re not.
2. Your children can enroll in Medicaid at any time.
3. Medicaid might help pay for employer-sponsored coverage for your children.
4. A child’s disability may make them eligible for Medicaid.
5. In most states, you’ll need to renew your kids’ coverage each year.
6. If your baby’s birth is covered by Medicaid, they will remain covered for at least a full year.

Medicaid for children plays a vital role in covering kids in the United States. As of late 2024, more than 37 million children – almost half the nation’s children¹ – were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).² And children account for nearly half of everyone enrolled in Medicaid/CHIP.³

But many families may not be aware of the state and federal guidelines that make their children eligible for coverage. Here are six facts about eligibility that might help if you need Medicaid for your children.

1. Your kids might be eligible for Medicaid even if you’re not.

When parents are looking for affordable children’s health insurance, they may be pleasantly surprised to learn that Medicaid income limits for children can be much higher than the limits that apply to adults.⁴

Depending on the state, the coverage might be provided by Medicaid, a separate CHIP, or a combination of the two.⁵ And in all states except Idaho, Medicaid or CHIP is available to kids in households with income up to at least 200% of the federal poverty level (FPL), and in many states the income limits are much higher than that⁶(in Idaho, the limit is 195% of FPL, including the 5% income disregard).⁷

In almost all cases, Medicaid eligibility for children is based on modified adjusted gross income alone, without considering their household’s asset levels.⁸ And there’s a 5% income disregard, meaning that the actual income limit is often five percentage points higher than the stated income limit.⁹

The income eligibility limits for adults – especially those who are not pregnant – tend to be quite a bit lower than the limits to determine a child’s eligibility for Medicaid.⁴ So even if the adults in a household are not eligible for Medicaid, the children might be. In that scenario, the kids can be enrolled in Medicaid and the parents will need to enroll in other coverage – possibly through an employer’s plan or a policy obtained in the health insurance Marketplace.

In nine states, there’s a “coverage gap” for some low-income adults who aren’t eligible for Medicaid and whose income is too low to be eligible for Marketplace subsidies. (Income generally must be at least 100% of the federal poverty level to qualify for Marketplace subsidies).¹⁰ But there is no coverage gap for children, because Medicaid income limits for kids extend well above the federal poverty level in all states.

Are my children eligible for Medicaid? You can use our federal poverty level calculator to get an idea of whether your kids might be eligible for Medicaid or CHIP.

2. Your children can enroll in Medicaid at any time.

Unlike private health insurance through the Marketplace, off-exchange from an insurer, or from an employer, there is no annual enrollment window for Medicaid.¹¹ An eligible person can enroll anytime. So if your kids are uninsured and you think they might be eligible for Medicaid or CHIP, you can apply for coverage on their behalf right away. You can select your state on this page to see details about eligibility and the enrollment process.

And Medicaid can be retroactive by up to three months in most states, meaning that medical expenses your kids incurred recently might be covered after they enroll.¹² Starting in 2027, however, retroactive coverage will be available for a maximum of two months, due to the “One Big Beautiful Bill” that was enacted in 2025.¹³

3. Medicaid might help pay for employer-sponsored coverage for your children.

If your employer offers family health benefits but you can’t afford the premiums, you might find that you can get help with the cost. The majority of the states have programs that use Medicaid or CHIP funds to help Medicaid-eligible and CHIP-eligible families pay for employer-sponsored health insurance (in addition to Medicaid or CHIP) if it’s available to them.¹⁴

The specifics of these programs – including whether they’re voluntary or mandatory¹⁵ – vary from one state to another, so you’ll need to contact your state Medicaid office for details.

If your child has Medicaid in addition to other coverage, Medicaid is always the secondary payer. This means the other insurance will be primary, and Medicaid will only start to pay benefits after the claim has been processed by the primary insurance.¹⁶

With limited exceptions, CHIP is not available to children who are eligible for coverage under a state health benefits plan. So if a parent works for the state and has access to family coverage under the state health benefits program, their children will generally not be eligible for CHIP.¹⁷

And states can impose more restrictive limits on CHIP. For example, Utah does not allow a child to enroll in CHIP if the child could enroll in an employer-sponsored plan for less than 5% of the household’s income.¹⁸

4. A child’s disability may make them eligible for Medicaid.

If your child is disabled¹⁹ or has certain special healthcare needs, they may qualify for Medicaid – even if your household’s income isn’t within the standard eligibility limits. And depending on the state and the child’s medical needs, they may qualify for Medicaid coverage for in-home care as an alternative to institutional care, without being disqualified due to their parents’ income and assets.²⁰

In other words, these kids can potentially be in households that would not otherwise qualify for income-based Medicaid, or for disability-based Medicaid — which uses both income and assets to determine eligibility.²¹

As is always the case with Medicaid and CHIP, the details vary by state. But if your child is disabled or has costly ongoing medical needs, you may find that they can qualify for Medicaid even if your household wouldn’t otherwise qualify based on income alone. You can reach out to the Medicaid office in your state to get more information.

5. In most states, you’ll need to renew your kids’ coverage each year.

If your kids are enrolled in Medicaid or CHIP, it’s important to pay attention to any paperwork you get from the state regarding their coverage. Most state Medicaid programs recheck enrollees’ eligibility each year.²² This will continue to be the case in 2027 and future years, even though adults enrolled in Medicaid expansion will start to have their eligibility rechecked twice per year.²³

Your state may be able to confirm your child’s ongoing eligibility automatically.²⁴ But if not, they will send you a request for updated information, and your children can be disenrolled if you don’t respond.

Some states have changed their rules to ensure continuous Medicaid and CHIP coverage for kids up to a certain age. This means that a child’s coverage will continue regardless of changes to the family’s circumstances, and without the need for annual eligibility redeterminations. Continuous coverage extends through different ages, depending on the state. But as described below, these programs, which were approved by the Biden administration, are temporary:

• Hawai’i: Until the child turns 6. After that, eligibility is redetermined every 24 months until age 19.²⁵
• Minnesota: Until the child turns 6.²⁶
• New Mexico: Until the child turns 6.²⁷
• New York: Until the child turns 6.²⁸
• North Carolina: Until the child turns 6.²⁹
• Oregon: Until the child turns 6. (Eligibility for most other enrollees is only redetermined every two years.)³⁰
• Washington: Until the child turns 6.³¹

Pennsylvania and Colorado received CMS approval to implement continuous Medicaid for young children (until age 3 in Colorado, and until age 6 in Pennsylvania),³² but neither state implemented the multi-year continuous eligibility program.³³

And in mid-2025, the Trump administration notified states that CMS “does not anticipate approving new state proposals” for continuous coverage that doesn’t require annual eligibility redeterminations.³⁴ Already-approved waivers can continue, but won’t be renewed when they reach their expiration date (unless that happens under a future administration that takes a different approach).

California³⁵ and Ohio³⁶ had been working to gain federal approval for continuous Medicaid coverage for children (until they turn five in California, and until they turn four in Ohio), but it appears unlikely that either state will receive federal approval under the Trump administration, given the 2025 message from CMS. Pending legislation in Alaska calls for continuous Medicaid until age six,³⁷ but the bill has not advanced and federal approval is unlikely even if the state enacts the legislation.

6. If your baby’s birth is covered by Medicaid, they will remain covered for at least a full year.

Medicaid covers more than 40% of births in the U.S.³⁸ Those infants are automatically covered by Medicaid or CHIP as soon as they’re born, and will remain eligible at least until their first birthday.³⁹ As noted above, children’s Medicaid eligibility is redetermined annually in most states, so ongoing eligibility will depend on the household’s financial circumstances.

1. “AAP analysis: 49% of children insured by Medicaid or CHIP” American Academy of Pediatrics. Feb. 27, 2025
2. “November 2024 Medicaid & CHIP Enrollment Data Highlights” Medicaid.gov. Accessed Apr. 8, 2025
3. ”November 2025 Medicaid & CHIP Enrollment Data Highlights” Medicaid.gov. Accessed Mar. 25, 2026
4. “Medicaid, Children’s Health Insurance Program, & Basic Health Program Eligibility Levels” Medicaid.gov. Accessed Mar. 25, 2026
5. “Children’s Health Insurance Program (CHIP) State Program Information” Medicaid.gov. Accessed Mar. 25, 2026
6. “Medicaid, Children’s Health Insurance Program, & Basic Health Program Eligibility Levels” Medicaid.gov. And “North Dakota Medicaid State Plan Amendment” Accessed Mar. 25, 2026
7. ”About Medicaid for Children” Idaho Department of Health & Welfare. Accessed Mar. 25, 2026
8. “Eligibility Policy” Medicaid.gov. Accessed Apr. 10, 2025
9. ”With respect to MAGI conversion, how will the 5% disregard be applied?” Medicaid.gov. Accessed Mar. 25, 2026
10. “Form 8962 Instructions, Who can take the PTC?” Internal Revenue Service. Accessed Mar. 25, 2026
11. “Frequently Asked Questions” InsureKidsNow.gov. Accessed Mar. 25, 2026
12. “States that Have Eliminated 90-day Retroactive Medicaid Coverage” Triage Cancer. Accessed Mar. 25, 2026
13. ”OBBBA Slashes Retroactive Coverage for Medicaid Beneficiaries” National Health Law Program. July 25, 2025
14. “Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)” DOL.gov. Accessed Mar. 25, 2026
15. “Federal Requirements and State Options: Premium Assistance” MACPAC. Sep. 2018
16. “Coordination of Benefits & Third Party Liability” Medicaid.gov. Accessed Mar. 25, 2026
17. “CHIP Eligibility & Enrollment, Targeted low-income children” Medicaid.gov. Accessed Mar. 25, 2026
18. “220-4 Access to Employer-Sponsored Health Insurance” Utah DHHS, CHIP Policy Manual. Accessed Mar. 25, 2026
19. ”Title 20 § 416.906 Basic definition of disability for children” and “Title 20 § 416.907 Disability under a State plan” Code of Federal Regulations. Accessed Apr. 21, 2025
20. “Welcome to Kids’ Waivers! Your source for information on children’s Medicaid Waivers, Katie Beckett programs, and other Medicaid programs” Kids’ Waivers. And ”The Case of One Little Girl Leads to Big Medicaid Changes for Millions” Centers for Medicare & Medicaid Services. Accessed Apr. 10, 2025
21. ”Medicaid Eligibility and Enrollment Policies for Seniors and People with Disabilities (Non-MAGI) During the Unwinding” KFF.org. June 20, 2024
22. “Title 42 § 435.916 Regularly scheduled renewals of Medicaid eligibility” Code of Federal Regulations. Accessed Apr. 10, 2025
23. ”Implementation of “Eligibility Redeterminations,” Section 71107 of the “Working Families Tax Cut” Legislation (Public Law 119-21)” Centers for Medicare & Medicaid Services. Mar. 6, 2026
24. “Understanding Medicaid Ex Parte Renewals During the Unwinding” KFF.org. Oct. 2, 2023
25. “Hawai‘i Expands Medicaid Coverage to Provide Stable Health Care for Keiki” Hawai’i Department of Human Services. Dec. 31, 2024
26. “Minnesota stabilizes Medicaid for children up to age 6” Minnesota Department of Human Services. Dec. 30, 2024
27. “New Mexico saves thousands of children from losing Medicaid coverage” New Mexico Health Care Authority. Accessed Apr. 10, 2025
28. “New York expands Medicaid for kids under six” Insurance Business. Dec. 2, 2024
29. ”Continuous Eligibility for Children” North Carolina Department of Health & Human Services. Mar. 31, 2025
30. “Oregon Health Plan (OHP) Continuous Eligibility” Oregon Health Authority. Accessed Apr. 10, 2025
31. “Children” Washington State Health Care Authority. Accessed Mar. 25, 2026
32. “Biden-Harris Administration Announces Approvals in Five States that will Keep Eligible Children and Adults Enrolled in Medicaid and CHIP” Centers for Medicare & Medicaid Services. Nov. 14, 2024
33. ”Multi-Year Continuous Eligibility for Children” Georgetown University, Center for Children and Families. Accessed Mar. 25, 2026
34. ”Section 1115 Demonstration Authority for Continuous Eligibility Initiatives” Centers for Medicare & Medicaid Services. July 17, 2025
35. “CalAIM 1115 Demonstration & 1915(b) Waiver” California DHCS. Accessed Apr. 10, 2025
36. “Multi-Year Continuous Eligibility 1115 Waiver” Ohio Department of Medicaid. Accessed Apr. 10, 2025
37. “Alaska HB151” BillTrack50. In committee Mar. 24, 2025
38. “Births financed by Medicaid” KFF.org. Accessed Apr. 10, 2025
39. “Implementation Guide: Medicaid State Plan Eligibility, Deemed Newborns” Medicaid.gov. Accessed Apr. 10, 2025

In this article

• Why you might not qualify for Medicaid
• Scenario 1: You earn too much to qualify for a subsidy
• Scenario 2: You qualify for subsidies, but coverage still seems unaffordable
• Scenario 3: You’re in the coverage gap
• Scenario 4: You cannot afford ACA-compliant health insurance
• How to get help finding coverage

For people who buy their own health insurance, premiums rose significantly in 2026 after Congress failed to extend federal subsidy enhancements that expired at the end of 2025. Stories of consumers facing unaffordable health insurance premiums are widespread.¹ You’re not alone if you feel like you can’t afford health insurance.

Why you might not qualify for Medicaid

We’ll discuss private health insurance in a moment, but if health coverage feels unaffordable and you’re also not eligible for Medicaid, you might have wondered why you can’t enroll in Medicaid. There are a few reasons this might be the case:

• You might be in a state that hasn’t expanded Medicaid under the ACA (more about that below).
• Your income might be above the eligibility cut off for Medicaid.
• You might be a recent (within the last five years) immigrant.²
• Your kids might be Medicaid/CHIP-eligible but you might not be, because the income limits are higher for kids. ³

Now let’s take a look at a few scenarios to explain why you might be facing unaffordable health insurance premiums, and what you might be able to do about it.

Scenario 1: You earn too much to qualify for a subsidy

The “subsidy cliff” returned in 2026, due to the expiration of the federal subsidy enhancements. This means that federal premium subsidies (premium tax credits) are no longer available to Marketplace enrollees with household income above 400% of the federal poverty level (FPL), regardless of how expensive their coverage options are. (Note that state-funded subsidies do extend above 400% of FPL in Connecticut, New Jersey, and New Mexico.)

What can you do to qualify for subsidies?

If you lost your subsidy altogether at the end of 2025, it’s likely because your household ACA-specific Modified Adjusted Gross Income (MAGI) is over 400% of FPL. (For 2026 coverage in the continental United States, that means you earn more than $62,600 for a single person, or more than $128,600 for a family of four).⁴

Eligibility for a federal Marketplace premium tax credit requires that a household’s Modified Adjusted Gross Income (MAGI) be at or below 400% of the Federal Poverty Level (FPL). Depending on how far above this threshold your projected income is, it may be possible to bring your MAGI within the required range. This is generally done in one of two ways:

• Adjusting projected income if you are working fewer hours, taking on fewer clients, or otherwise earning less.
• Reducing MAGI through allowable tax deductions, including contributions to pre‑tax retirement accounts or health savings accounts.

If your income is too high to qualify for subsidies, you’ll pay full price for whatever plan you select. Here are some tips for choosing the plan that best fits your needs and budget.

If you’re not subsidy-eligible and you prefer a Silver plan, you might consider an off-exchange plan. These are ACA-compliant individual-market policies, but in most states, full-price Silver plans are less expensive off-exchange than on-exchange.⁵ This is because the cost of cost-sharing reductions is added to the premiums for on-exchange Silver plans in most states.

Premium subsidies are not available for off-exchange plans. But if you’re not eligible for subsidies due to your income, you won’t be giving up anything by opting for an off-exchange plan. (“Off-exchange” refers to fully ACA-compliant individual-market plans, and does not include non-ACA-compliant plans. Those are addressed in more detail below.)

If you prefer a Bronze or Gold plan, the full-price premiums for those plans are generally the same on-exchange or off-exchange because there are no CSRs impacting the price on or off exchange. But depending on where you live, there may be insurers that offer coverage only on-exchange or only off-exchange. So if you’re not subsidy-eligible, a comprehensive comparison of both on-exchange and off-exchange plans will give you a full picture of what’s available in your area.

(Regardless of whether you’re shopping on-exchange or off-exchange, you can complete the process yourself or do it with help from a broker, which won’t cost you anything.)

Scenario 2: You qualify for subsidies, but coverage still seems unaffordable

You’re certainly not alone if you’re in this category. Most Marketplace enrollees are still eligible for subsidies in 2026,⁶ but after-subsidy premiums were projected to more than double in 2026, due to the expiration of the subsidy enhancements at the end of 2025.⁷

As noted above, enrollees with household income above 400% of FPL lost their subsidies altogether at the end of 2025, resulting in substantial premium increases. But even for those who still qualify for subsidies, the subsidies now cover a smaller share of enrollees’ total premiums. To continue to have Marketplace coverage in 2026, these enrollees must either pay higher premiums, downgrade their coverage, or both.

KFF surveyed Marketplace enrollees in November 2025, asking what they would do when confronted with net premiums that were more than doubling. More than half indicated that they would either select a plan with lower premiums but higher deductibles and co-pays, or drop their coverage altogether.⁸

If your coverage feels unaffordable even with subsidies, there are a couple of options to make it more affordable:

• Reduce MAGI. As long as your MAGI stays above the Medicaid eligibility threshold in your state (and doesn’t drop below 100% of FPL), a lower MAGI will result in a larger subsidy. You can use a subsidy calculator to see how changes in your MAGI will affect the size of your subsidy.
• Downgrade to a plan with a lower premium. Several state-run Marketplaces have published data on 2026 plan selections, and there was a clear trend towards higher enrollment in Bronze plans (which have higher out-of-pocket costs but lower premiums than Silver or Gold plans).⁹ But at this point, most current enrollees won’t have an opportunity to change their coverage for the rest of the year, as open enrollment for 2026 has ended and most special enrollment periods limit current enrollees to a different plan at the same metal level as their current plan.¹⁰

Scenario 3: You’re in the coverage gap

The coverage gap is not new in 2026. It has always existed in nine states that haven’t expanded Medicaid as called for in the ACA: Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming. Because those states have chosen not to expand Medicaid, many adult residents with income below the federal poverty level are not eligible for any financial assistance with their health coverage and are not eligible for Medicaid.

Learn more about the coverage gap.

What can you do to qualify for financial assistance?

If you’re an adult in one of those nine states and your income is below the federal poverty level, you’re not eligible for Marketplace subsidies.¹¹ You may find that you’re not eligible for Medicaid either (unless you’re pregnant or the parent of a minor child, although Medicaid income rules for this vary by state).¹²

To become eligible for Marketplace subsidies, you would need an ACA-specific modified adjusted gross income (MAGI) of at least 100% of the prior year’s FPL.

For 2026 coverage, that’s $15,650 for a single adult, or $21,150 for a household of two.⁴

Note: If you’re in a coverage gap state and you enter an income below the FPL on the Marketplace plan comparison tool, it will tell you that you aren’t subsidy eligible, but it won’t tell you why. The reason is that your income is below the FPL.

Here’s how MAGI is calculated under the ACA. Note that it’s gross income, rather than take-home pay, and it’s different than the MAGI used for other purposes.

Be sure to include all income, and remember it’s household income, not just your own income.¹³

If you’re in the coverage gap and your income increases to at least the FPL, you’ll qualify for a special enrollment period to enroll in a Marketplace plan.

Medicaid eligibility varies by state, with the states that expanded Medicaid eligibility under the Affordable Care Act covering a much greater portion of the low-income adult population. If you’re affected by the coverage gap, you may find that you’d actually be eligible for Medicaid if you lived in one of your neighboring states.

Starting in 2027, Medicaid recipients in expansion states will face a work requirement (nationwide), which will require at least 80 hours per month of work or other community engagement.¹⁴

Scenario 4: You cannot afford ACA-compliant health insurance

If you’ve tried all of the above strategies and can’t make an ACA-compliant health plan work with your budget, you may have already dropped your coverage or be planning to do so soon.

There are some additional coverage options you may consider, which might be better than going without any coverage at all. None of these alternatives is regulated by the ACA. Some aren’t considered insurance at all, and thus aren’t subject to a state’s insurance laws. Because these plans aren’t ACA-compliant, they don’t have to cover the essential health benefits, typically exclude pre-existing conditions, and generally have annual and lifetime benefit caps. But depending on your circumstances and budget, they may pay for some health care costs that you would otherwise pay entirely out-of-pocket if you had no coverage at all. It’s important to review the plan details thoroughly before making a decision.

Non-ACA-compliant insurance options

These include short-term health insurance, fixed-indemnity plans, and various types of supplemental coverage such as accident insurance and critical illness insurance. Short-term health insurance availability varies by state: In some states there are no plans available, while in others there are plans available with total durations of up to three years, including renewals. None of these plans are considered comprehensive coverage under the ACA.

Non-ACA-compliant options that aren’t considered insurance

There are a variety of “coverage options” that aren’t actually insurance, although consumers aren’t always aware of that. These include, for example, direct primary care memberships, Farm Bureau plans available in certain states, and health care sharing ministry plans.

The specific benefits vary from one plan to another. But since these types of coverage are not considered insurance, consumers who have problems with them cannot turn to the state insurance department for assistance.

Free and low-cost health care

Depending on your financial situation, you may qualify for free or low-cost care at a federally qualified health center.¹⁵ (Here’s a tool that can help you find one near you.)

Almost all hospital emergency departments are required to assess and stabilize patients regardless of their ability to pay.¹⁶ But the hospital can still bill you for the care you receive in the emergency department.¹⁷

How to get help finding coverage

There are people online, on the phone, and in your community who can help you with the process of getting health coverage. You don’t have to pay anything for their assistance, as premiums are the same whether you have assistance or take a DIY approach. Here’s an overview of the help that’s available to you:

• Agents and brokers can help with on-exchange or off-exchange plans. They receive a commission from the insurance carrier if they enroll you in a plan, but it doesn’t affect the price you pay.
• Navigators and Certified Application Counselors (CACs) can help with on-exchange plans as well as Medicaid
• The Marketplace call center can answer questions and help with enrollment. If you’re in a state that uses HealthCare.gov, the number is 1-800-318-2596. If you’re in a state that runs its own exchange (20 states plus DC), there will be a state-run call center.
• The “find local help” tool on HealthCare.gov will let you see agents, brokers, Navigators, and CACs in your area. State-run Marketplaces have similar tools.
• An Enhanced Direct Enrollment (EDE) entity can walk you through the enrollment process for an on-exchange or off-exchange plan. See a current list of approved EDE entities.
• Dial 211. If you aren’t sure where to turn, calling 211 will get you to a local or regional call center that can connect you to helpful health coverage resources.¹⁸

1. “Stories to cover as Americans seek affordable health insurance” Association of Health Care Journalists. Jan. 28, 2026
2. “Coverage for lawfully present immigrants” HealthCare.gov. Accessed Feb. 25, 2026
3. “Medicaid, Children’s Health Insurance Program, & Basic Health Program Eligibility Levels” Centers for Medicare & Medicaid Services. December 2023.
4. “2025 Poverty Guidelines” U.S. Department of Health & Human Services. Accessed Feb. 18, 2026
5. “Explaining Cost-Sharing Reductions and Silver Loading in ACA Marketplaces” KFF.org. June 26, 2025
6. “Plan Year 2026 Marketplace Plans and Prices Fact Sheet” CMS Newsroom. Oct. 30, 2025
7. “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire” KFF.org. Sep. 30, 2025
8. “2025 KFF Marketplace Enrollees Survey” KFF.org. Dec. 4, 2025
9. “The other shoe to drop: How many enrollees were forced to “buy down” to a worse plan with higher out of pocket costs?” ACA Signups. Feb. 5, 2026
10. “Special Enrollment Period Reference Chart” Center on Budget and Policy Priorities. And “Title 45 § 155.420 Special enrollment periods” Code of Federal Regulations. Accessed Feb. 20, 2026
11. “Subsidized coverage” HealthCare.gov. Accessed Feb. 18, 2026
12. “Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level” KFF.org. Accessed Feb. 18, 2026
13. “Count income & household size” HealthCare.gov. Accessed Feb. 18, 2026
14. “A Summary of Federal Medicaid Work Requirements” Center for Health Care Strategies. Accessed Feb. 18, 2026
15. “Federally Qualified Health Center (FQHC)” HealthCare.gov. Accessed Feb. 19, 2026
16. “You have rights in an emergency room under EMTALA” Centers for Medicare & Medicaid Services. Accessed Feb. 19, 2026
17. “Overview of the Emergency Medical Treatment and Active Labor Act (EMTALA) and Emergency Abortion Services” Congress.gov. Accessed Feb. 19, 2026
18. “Dial 211 for Essential Community Services” Federal Communications Commission. Accessed Feb. 25, 2026

In this article

• Can early retirees get health insurance through the ACA Marketplace?
• How can early retirees find out if they’re eligible for Marketplace subsidies?
• Can early retirees get Medicaid if they’re in an expansion state?
• Is COBRA or state continuation a good option for early retirees?
• Early retirement health insurance through a spouse’s coverage

If you’re retiring before age 65 and your employer doesn’t offer retiree health benefits, you’ll need a plan for your health coverage until you become eligible for Medicare at 65. Let’s take a look at your early retirement health insurance options and what you need to know about each one.

Early retirement health insurance through a spouse’s coverage

If you’re retiring early but your spouse is still working, you may both have access to your spouse’s employer-sponsored health plan. There is no federal law requiring group health plans to offer coverage to spouses, but almost all of them do.¹⁷

If your spouse is enrolled in their employer’s plan and you’re enrolled in your own employer’s plan, your loss of coverage will trigger a special enrollment period that will allow you to be added to your spouse’s plan (assuming the plan is offered to employees’ spouses).

If you and your spouse are both covered under your plan, the loss of coverage when you retire will trigger a special enrollment period that will allow both of you to enroll in your spouse’s plan (assuming your spouse is an eligible employee and the plan allows employees’ spouses to enroll).¹⁸

1. “Guidance Regarding Age Curves and State Reporting” Centers for Medicare & Medicaid Services. Dec. 16, 2016
2. “Premium Tax Credit (PTC) Overview” Internal Revenue Service. Accessed Feb. 11, 2026
3. “APTC and CSR Basics” Centers for Medicare & Medicaid Services. Oct. 2025
4. “2025 Poverty Guidelines“ U.S. Department of Health & Human Services. Accessed Feb. 11, 2026
5. “Count income & household size” HealthCare.gov. Accessed Feb. 11, 2026
6. “Starting Your Retirement Benefits Early” Social Security Administration. Accessed Feb. 11, 2026
7. “See Plans & Prices” (zip code 36525) HealthCare.gov. Accessed Feb. 11, 2026
8. “Topic no. 451, Individual retirement arrangements (IRAs)” Internal Revenue Service. Accessed Feb. 11, 2026
9. ”Status of State Medicaid Expansion Decisions” KFF.org. Feb. 9, 2026
10. “Eligibility Policy” Medicaid.gov. Accessed Feb. 11, 2026
11. “Seniors & Medicare and Medicaid Enrollees” Medicaid.gov. Accessed Feb. 11, 2026
12. “Income Definitions for Marketplace and Medicaid Coverage” Center on Budget and Policy Priorities. Aug. 2025
13. “H.R. 1” (Section 71119) Congress.gov. Enacted July 4, 2025
14. “Estate Recovery” Medicaid.gov. Accessed Feb. 11, 2026
15. “FAQs on COBRA Continuation Health Coverage for Workers” U.S. Department of Labor. Accessed Feb. 11, 2026
16. “What are the COBRA Laws State-by-State?” COBRA Help. Accessed Feb. 11, 2026
17. “Employer Health Benefits, 2025 Annual Survey” (Page 52) KFF.org. Oct. 22, 2025
18. “Title 29 § 2590.701-6 Special enrollment periods” Code of Federal Regulations. Accessed Feb. 11, 2026

In this article

• Many older Marketplace buyers face drastic premium hikes
• ‘Subsidy cliff’ affects households with incomes above 400% of federal poverty level
• American Rescue Plan & Inflation Reduction Act temporarily eliminated ‘subsidy cliff’
• Why it’s called a ‘cliff’
• Areas with higher average premiums will be hit hardest by the ‘cliff’

It’s happened. Congress has not extended enhanced Marketplace subsidies that have made coverage more affordable since 2021¹ – and hundreds of thousands of Marketplace enrollees with household incomes over 400% of the federal poverty level are now experiencing the return of the so-called “subsidy cliff,”² due to the loss of their premium subsidies.

The impact of this “subsidy cliff” is causing dramatic increases in health insurance premium expenditures. Particularly hard hit are enrollees in their 50s and 60s, who – without subsidies – could well face premiums that consume half or more of their income.

(Premiums are age-based; without subsidies, a person who is 52 will pay about twice as much as a person who is 21, and a person who is 64 will pay three times as much as a person who is 21).³

Here’s what Marketplace buyers are facing in 2026 with the return of the “subsidy cliff”:

Many older Marketplace buyers face drastic premium hikes

With the “subsidy cliff” returning to the health insurance Marketplace in 2026, a 63-year-old couple in Charleston, West Virginia, earning $85,000/year, will pay more than 15 times as much for the lowest-cost Gold plan, compared with what they paid in 2025.

In 2025, they would have paid about $300/month for the lowest-cost Gold plan, and they even had access to a zero-premium Bronze plan.⁴

But because Congress didn’t extend the subsidy enhancements that had been keeping coverage more affordable since 2021, this hypothetical couple has lost their subsidy altogether.

• To buy the lowest-cost Gold plan in 2025, they would have paid $300/month. But in 2026, their premium is $4,562/month for the lowest-cost Gold plan.
• The lowest-cost Bronze plan in 2025 had no premium at all for this couple’s demographics, as their subsidy covered the full cost. But in 2026, the lowest-cost Gold plan has a premium of $3,648/month.⁵

If they decided keep the Gold plan, they’ll be spending two-thirds of their household income on health insurance.

And even the lowest premium Bronze plan – which they could get with no premium at all in 2025 – will cost more than half of their household income in 2026.

‘Subsidy cliff’ affects households with incomes above 400% of federal poverty level

That’s because $85,000 for a household of two is 402% of the 2025 federal poverty level (FPL).⁶ And the ACA has a so-called “cliff” where Marketplace subsidy eligibility ends abruptly if an enrollee’s household income is more than 400% of the previous year’s FPL. That’s how it worked from 2014 through 2020, when subsidies weren’t available to these enrollees, regardless of how expensive their coverage was.⁷

The subsidy eligibility income limit was temporarily lifted from 2021 through 2025, due to the American Rescue Plan (ARP) and Inflation Reduction Act (IRA). But it returned  in 2026 because the ARP/IRA subsidy enhancements were not extended by Congress.¹

To illustrate the “subsidy cliff” in more detail, let’s look at the ten states where average full-price Marketplace premiums were projected to be highest for plan year 2026.⁸ The following table illustrates the effect of lost or decreased subsidies, including their effect on three different buyer age bands:

American Rescue Plan and Inflation Reduction Act temporarily eliminated ‘subsidy cliff’

Section 9661 of the ARP capped Marketplace health insurance premiums (for the benchmark Silver plan) at no more than 8.5% of household income.⁹ The 8.5% cap applied to people with household incomes of 400% of the federal poverty level or higher. For people with lower incomes, the percentage of income that had to be paid for the benchmark premium was reduced across the board. These subsidy enhancements were initially applicable for 2021 and 2022, but the Inflation Reduction Act extended them through 2025.

If your household income was more than 400% of FPL and the benchmark plan’s premium was no more than 8.5% of your income, you wouldn’t qualify for a premium subsidy (meaning, the ARP/IRA didn’t change anything about your situation). This was more likely to be the case for younger enrollees in areas of the country where health insurance is less costly than average.

But if the full-price cost of the benchmark plan was more than 8.5% of your income, you were eligible for a premium subsidy between 2021 and 2025.  (This assumes you met the rest of the eligibility requirements, meaning that you were lawfully present in the U.S. and not eligible for Medicaid, premium-free Medicare Part A, or employer-sponsored coverage that was considered affordable and provided minimum value).

So for some people, especially older enrollees in areas of the country where health insurance is particularly costly, even those with income well above 400% of FPL were receiving a premium subsidy between 2021 and 2025. But people who earn more than 400% of FPL no longer qualify for a subsidy in 2026 – no matter how expensive their health insurance is.

Why it’s called a ‘cliff’

Due to the “subsidy cliff,” a few hundred dollars in extra annual income could translate to the loss of thousands of dollars per month in subsidies, if it pushes you over the 400% FPL threshold. And as we illustrated above, some enrollees will find that even the most inexpensive health plan now has premiums that amount to more than half their annual income. For most households, that’s simply unaffordable.

It’s called a cliff because there’s a sharp and sudden spike in health insurance premiums when subsidies end abruptly at 400% of FPL. From 2021 through 2025, subsidies were instead phased out slowly as income increased. But that is no longer the case in 2026 as subsidies are once again only available to enrollees with household income up to 400% of FPL.

Let’s take another look at the 63-year-old West Virginia couple described above, but let’s assume their income in 2026 is $84,500, instead of $85,000. That puts them just over 399% of the 2025 FPL, meaning they will still qualify for a premium subsidy in 2026.

In that case, their after-subsidy premiums for the benchmark Silver plan will be capped at a little less than 10% of their household income. That means the benchmark plan will cost them a little more than $700/month in 2026. They’ll be able to apply their subsidy to any metal-level plan, meaning they’ll be able to get the lowest-cost Bronze or Gold plan for even lower premiums.

But if their income goes above $84,600 (400% of the 2025 FPL),⁶ they will lose their subsidy altogether.

Areas with higher average premiums are hit hardest by the ‘cliff’

We used West Virginia as the example here because individual/family health insurance premiums in West Virginia are much higher than the national average.¹⁰

So let’s also consider Idaho, where 2025 premiums were much lower than the national average.¹⁰ We’ll assume we have the same 63-year-old couple, earning $85,000, but now they live in Boise instead of Charleston, WV.¹¹

• In 2025, the lowest-cost Bronze plan cost them less than $2/month after subsidies. In 2026, that plan will cost them $1,527/month as the “subsidy cliff” returns.
• In 2025, the lowest-cost Gold plan cost $712/month. That jumped to $2,354/month in 2026, with the return of the “subsidy cliff.”

While these amounts aren’t as extreme as the West Virginia example (because full-price health insurance premiums are lower in Idaho), this couple will still have to pay more than a fifth of their household income for the lowest-cost plan, now that the “subsidy cliff” has returned.

1. “ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire” KFF.org. Sep. 30, 2025
2. “2025 Marketplace Open Enrollment Period Public Use Files” Centers for Medicare & Medicaid Services. Accessed Oct. 8, 2025
3. “State Specific Age Curve Variations” Centers for Medicare & Medicaid Services. Accessed Oct. 17, 2025
4. “See Plans & Prices” (zip code 25301) HealthCare.gov. Accessed Oct. 7, 2025
5. “See Plans & Prices” (zip code 25301) HealthCare.gov. Accessed Jan. 27, 2026
6. “2025 Poverty Guidelines” U.S. Department of Health & Human Services. Accessed Oct. 6, 2025
7. “Questions and answers on the Premium Tax Credit” Internal Revenue Service. Accessed Oct. 7, 2025
8. “2026 Rate Change Project” ACA Signups. Oct. 3, 2025
9. “Text of the American Rescue Plan” (Section 6991). Congress.gov. Accessed Oct. 7, 2025
10. ”Effectuated Enrollment: Early 2025 Snapshot and Full Year 2024 Average” CMS.gov, July 24, 2025
11. “Estimate Your Premiums For 2026 (and 2025)” Your Health Idaho. Accessed Oct. 7, 2025

In this article

• What has happened to Marketplace health insurance subsidies in 2026?
• How did ARP’s subsidy enhancements affect eligibility for Marketplace premiums?
• How were the subsidies enhanced – and what has happened when those enhancements expired?
• Who is feeling the change the most?
• ACA subsidy rules have reverted
• Temporary subsidy enhancements under the ARP and IRA
• Subsidies disappeared for people with household incomes over 400% FPL
• For everyone else, subsidies are smaller than they would have been if the enhancements had been extended

ACA subsidy rules have reverted

With the subsidy enhancements expired, the rules have reverted to the subsidy rules set by the ACA. Here’s how the reinstated ACA premium subsidy rules work: ⁹

• Subsidies are available if household income is at least 100% of the federal poverty level (FPL), or more than 138% FPL in states that had expanded Medicaid eligibility under the ACA. However,
• Subsidies are not available if household income is more than 400% FPL, regardless of the percentage of income a household would have to spend to buy coverage. This results in a “subsidy cliff” at 400% FPL.

For subsidy-eligible enrollees, the subsidy amount was designed so that an the enrollee would have to pay a certain percentage of their household income for the benchmark plan (second-lowest-cost Silver plan). That percentage varied with household income and ranged between roughly 2% and 9.5% of household income. (This is called the “applicable percentage” and the range was indexed each year by the IRS.)¹⁰

Temporary subsidy enhancements under the ARP and IRA

Now let’s take a look at how the ARP temporarily changed these rules, and how the IRA extended those changes through 2025:

• Elimination of the subsidy cliff. The 400% FPL cap on subsidy eligibility was temporarily eliminated, so we haven’t had a subsidy cliff for the last five years. Instead, people with household income over 400% FPL were eligible for subsidies if the cost of the benchmark plan was more than 8.5% of their household income. (This assumes they met other subsidy eligibility requirements, including not having access to Medicaid, premium-free Medicare Part A, or an employer’s plan that’s considered affordable and provides minimum value.) Because subsidy eligibility is based on keeping the cost of the benchmark plan at no more than 8.5% of household income, the subsidy amounts phase out as income increases. 8.5% of $500,000 is a much larger amount than 8.5% of $100,000. So the higher a person’s income gets, the more they’re expected to pay on their own, and the smaller their subsidy gets. Eventually, if income is high enough, the subsidy drops to $0. But this is a gradual phasing out, rather than a sharp cliff where subsidy amounts suddenly drop to $0
• Bigger subsidies for everyone who’s subsidy-eligible. For subsidy-eligible enrollees, the percentage of household income that the enrollee had to pay for the benchmark Silver plan was reduced across the board. Instead of ranging from roughly 2% to 9.5% of household income, it ranged from 0% to 8.5% of household income.¹¹ And again, that applied to households with income above 400% FPL.
• No change to lower-income eligibility. The bottom income threshold for premium subsidy eligibility did not change.

So the ARP subsidy enhancements, extended by the IRA, had two major effects:

• They allowed Marketplace enrollees with household income above 400% FPL to potentially qualify for premium subsidies.
• They reduced the percentage of income that people receiving the premium tax credit pay for the benchmark plan at all income levels.

For example, under the original ACA rules, a person earning 150% FPL would pay 4% of their income for the benchmark plan,¹⁰ and their subsidy would cover the rest. But under ARP rules, a person earning 150% FPL paid0% of their income for the benchmark plan. Their subsidy covered the entire cost of the premium.¹²

For 2026 coverage, the 2025 FPL numbers will be compared with Marketplace applicants’ projected 2026 household income.

Since the ARP subsidy enhancements were not extended, the applicable percentages for 2026 range from 2.1% to 9.96%¹³ (up from 0% to 8.5% in 2025). And subsidies are not  available at all for those with household income above 400% of FPL.

Subsidies disappeared for people with household incomes over 400% FPL

The return of the subsidy cliff is particularly significant for older enrollees, since ACA-compliant individual and small-group premiums are based on age. (In almost all states, unsubsidized premiums for a 53-year-old are roughly twice as much as those for a 21-year-old, and a 64-year-old’s unsubsidized premium will be three times as much as a 21-year-old.)¹⁴, ¹⁵, ¹⁶ Subsidies are larger for older people, because they have to offset the larger age-based premiums. But with subsidies disappearing altogether for those with income above 400% FPL, the full-price premiums will be particularly expensive for older enrollees.

It will also be particularly significant in areas where health insurance is more expensive than average since the full premium will have to be paid by enrollees if their household income is over 400% FPL. The national average pre-subsidy Marketplace premium in 2025 was about $619/month,¹⁷ but as we’ll discuss in a moment, some states have much higher averages. And pre-subsidy premiums are increasingly significantly for 2026.¹⁸

To illustrate this, let’s look ten of the states where average full-price Marketplace premiums were projected to be highest for plan year 2026.¹⁹ (Note that although New Mexico was projected to have the eighth-highest full-price premiums in 2026,¹⁹ we’re not including them in our analysis because the state allocated funding to offset the decline in federal subsidies, even for enrollees above 400% of FPL.)²⁰

We’ll consider  three applicants in each state, ages 45, 55, and 64,- earning about 403% of the 2025 FPL, which is used to determine subsidy eligibility for 2026. This amounts to roughly $63,000 in annual income in the continental U.S., and just under $79,000 in Alaska.²¹ But because they’ve lost their subsidies altogether in 2026, their net premiums have increased substantially, as shown in the table below:

Because the ARP subsidy enhancements were allowed to sunset at the end of 2025, these individuals are not  eligible for any premium subsidies in 2026 (assuming their 2026 household income is more than 400% of the 2025 FPL). As a result, the amount they have to pay in premiums for the lowest-cost Marketplace plan has increased by hundreds of dollars per month – in some cases, by more than a thousand dollars per month.

Although this is just an illustration, these enrollees are not hypothetical. Across all Marketplace enrollees nationwide, the 55-64 age group has the highest total enrollment, with nearly 5.5 million enrollees in 2025.²²

And out of the 24.3 million people who selected Marketplace plans during the open enrollment period for 2025 coverage, more than 1.6 million reported incomes above 400% FPL.²³ The chart above illustrates the percentage of enrollees in each state whose income is over 400% FPL. In eight of the ten states we looked at, enrollees with income above 400% FPL account for at least 10% of Marketplace enrollment.

For everyone else, subsidies cover as much of the premium as they did in 2025

In addition to the return of the subsidy cliff for households earning more than 400% FPL, it’s important to understand that a return to the pre-ARP ACA subsidy rules has also resulted in subsidies being smaller than they would otherwise have been, for everyone who continues to be subsidy-eligible. This is because at all income levels, people have to pay a larger percentage of their income to purchase coverage.

In 2025, under the ARP subsidy rules, people paid between 0% and 8.5% of their household income for the benchmark (second-lowest-cost Silver) plan. With the subsidy enhancements expiring  at the end of 2025, this range is instead 2.1% to 9.96% of household income in 2026 (but with no assistance available if household income is above 400% of FPL).²⁴

So for example, consider a single person in the continental U.S. who earns 250% of FPL:

• In 2025, their income was $37,650, which is 250% of the 2024 FPL.²⁵ And in 2025, they had to pay 4% of that income for the benchmark silver plan.²⁶ That means their after-subsidy premium for the benchmark plan was $1,506 for the whole year, or about $126/month.
• In 2026, their income is $39,125, which is 250% of the 2025 FPL.²⁷ But because everyone has to pay a higher percentage of household income for the benchmark plan due to the expiration of the subsidy enhancements, they’ll have to pay 8.44% of their income for the benchmark plan.²⁴ That’s about $3,302 for the whole year, or about $275/month.

So this person went from paying $126/month for the benchmark plan in 2025 to paying $275/month for the benchmark plan in 2026, even though their income stayed at the same percentage of FPL.

Obviously, a person can use their premium subsidy to buy any metal-level plan that’s available to them, so they don’t have to buy the benchmark plan. Their actual after-subsidy cost will depend on the plan they select, and the available options differ greatly from one area to another.

But the reason subsidies won’t stretch to cover as much of the premium in 2026 is because Marketplace enrollees will be expected to pay a larger percentage of their household income to buy the benchmark plan. That means subsidies will be smaller than they would otherwise have been, and after-subsidy premiums will be higher than they would otherwise have been.

The Biden-Harris administration noted that the subsidy enhancements have resulted in not only record-high enrollment, but also an increase in the number of people who upgraded their Marketplace coverage from Bronze to a higher metal level.²⁸ This makes sense, since the larger subsidies allowed people to buy more expensive coverage without increasing their net premiums.

Without the ARP subsidy enhancements, the Congressional Budget Office projects that Marketplace enrollment will drop by about 4 million people.²⁹ And while millions of people will continue to have Marketplace coverage, it stands to reason the plan upgrades in response to the subsidy enhancements could reverse, with people opting to downgrade their coverage to keep the premiums affordable.²⁸

1. “2025 Marketplace Open Enrollment Period Public Use Files” Centers for Medicare & Medicaid Services. Accessed Oct. 7, 2025
2. “Another Year of Record ACA Marketplace Signups, Driven in Part by Medicaid Unwinding and Enhanced Subsidies” KFF.org. Jan. 24, 2024
3. “Historic 21.3 Million People Choose ACA Marketplace Coverage” Centers for Medicare & Medicaid Services. Jan. 24, 2024
4. “Effectuated Enrollment: Early 2025 Snapshot and Full Year 2024 Average” CMS.gov, July 24, 2025
5. “Marketplace 2025 Open Enrollment Fact Sheet” Centers for Medicare & Medicaid Services. Oct. 25, 2024
6. “American Rescue Plan Act of 2021” NCSL.org. Mar. 9, 2021; “American Rescue Plan and the Marketplace” Centers for Medicare & Medicaid Services. Mar. 12, 2021; “Summary: The Inflation Reduction Act of 2022” Senate Democrats. Accessed Oct. 22, 2025
7. “American Rescue Plan and the Marketplace” Centers for Medicare & Medicaid Services. Mar. 12, 2021
8. “2026 Rate Change Project” ACA Signups. Accessed Oct. 3, 2025
9. “Questions and Answers on the Premium Tax Credit” Internal Revenue Service. Accessed Dec. 5, 2024
10. “Text of the Affordable Care Act” (page 111). House.gov. Accessed Nov. 14, 2024
11. “Inflation Reduction Act Health Insurance Subsidies: What is Their Impact and What Would Happen if They Expire?” KFF.org. July 26, 2024
12. “Explaining Health Care Reform: Questions About Health Insurance Subsidies” KFF.org. Oct. 25, 2024
13. “Revenue Procedure 2025-25” Internal Revenue Service. Accessed July 30, 2025
14. “Title 45 § 147.102 Fair health insurance premiums” Code of Federal Regulations. Accessed Oct. 8, 2025
15. “Guidance Regarding Age Curves and State Reporting” (applicable 2018 or later).
16. “Market Rating Reforms” Centers for Medicare & Medicaid Services. Accessed Oct. 8, 2025
17. “Effectuated Enrollment: Early 2025 Snapshot and Full Year 2024 Average” Centers for Medicare & Medicaid Services. July 24, 2025
18. ”How much and why ACA Marketplace premiums are going up in 2026” KFF.org. Aug. 6, 2025
19. “2026 Rate Change Project” ACA Signups. Oct. 3, 2025
20. ”New Mexico Special Session HB2” New Mexico Legislature. Enacted Oct. 7, 2025
21. “HHS Poverty Guidelines for 2025” U.S. Department of Health & Human Services. Accessed Oct. 8, 2025. These enrollees were eligible for significant premium subsidies in 2025.[efn_note]Plan comparison tools for HealthCare.gov, Vermont Health Connect, Access Health CT, and CoverME (used zip code with the largest population in each state) Accessed Oct. 8, 2025
22. “2025 Marketplace Open Enrollment Period Public Use Files” (Demographics tab, Column J) CMS.gov, Accessed Oct. 9, 2025
23. “2024 Marketplace Open Enrollment Period Public Use Files” (FPL Tab, Columns L and M) CMS.gov, Accessed Oct. 9, 20254
24. “Revenue Procedure 2025-25” Internal Revenue Service. Accessed Oct. 9, 2025
25. “2024 Poverty Guidelines” U.S. Department of Health & Human Services. Accessed Oct. 9, 2025
26. “Revenue Procedure 2024-35” Internal Revenue Service. Accessed Oct. 9, 2025
27. “2025 Poverty Guidelines” U.S. Department of Health & Human Services. Accessed Oct. 9, 2025
28. “Expanded Financial Assistance Allows Families to Save Money and Upgrade Health Insurance” The White House. Nov. 8, 2024
29. “The Premium Tax Credit and Related Spending” Congressional Budget Office. July 2024