Health Issues

The federal government has proposed a wide range of health insurance rule changes for 2025 and – if approved – they’re likely to affect Marketplace enrollment deadlines and plan benefits as well as enrollees’ transition from Marketplace coverage to Medicare.

Two agencies – the Centers for Medicare & Medicaid Services (CMS), and Department of the Treasury – proposed the rule changes in November 2023 and have already accepted public comments on the proposals. The final rule, including potential modifications to the initial proposals, will be published in early 2024.

The proposed rule addresses a wide range of issues. Let’s take a look at six that are most likely to have a direct effect on Marketplace consumers in 2025 and future years:

The proposed rule would require state-run exchanges to more closely align their open enrollment periods with the federal exchange, HealthCare.gov, beginning open enrollment on November 1, and ending it no earlier than January 15. This rule could help reduce confusion for consumers in some states.

Under current rules, the open enrollment period for the federally run Marketplace, HealthCare.gov, (used in 32 states) runs from November 1 to January 15, and most state-run exchanges follow the same schedule.

But state-run exchanges can have different start dates (Idaho’s starts in mid-October and New York’s starts in mid-November) and different end dates, as long as the end date isn’t before December 15. Idaho currently ends open enrollment on December 15, and is the only state where open enrollment ends before January 15.

If finalized, this rule change would require Idaho to change both the start and end dates of its open enrollment period, and New York would have to change its start date. And state-run exchanges created after these rules go into effect would also have to follow the standardized schedule of November 1 through at least January 15.

This proposal is supported by various entities, including the National Association of Community Health Centers, but opposed by other entities, including the National Association of Insurance Commissioners, the state of Idaho, and the state of Georgia (Georgia plans to have a fully state-run Marketplace by the fall of 2024).

The proposed rule would require state-run exchanges to have first-of-the-following-month effective dates for applications submitted at any time during a calendar month during special enrollment periods.

Starting in 2022, HealthCare.gov switched to this approach. Before that, HealthCare.gov and most of the state-run exchanges required an application to be submitted by the 15th of the month for the coverage to be effective the first of the following month. (Some qualifying life events, including marriage, loss of other coverage, and birth/adoption, had more flexible enrollment deadlines.) This meant that an application submitted on June 20 would have an August 1 effective date. But under the protocol that HealthCare.gov and some state-run exchanges adopted in 2022, that application now gets a July 1 effective date.

When HealthCare.gov switched to the new rules under which coverage is effective at the start of the next month – regardless of the day of the month the application was submitted during a special enrollment period – it was optional for state-run-exchanges to also make the change. Some have since adopted the same approach, but others have not.

If the proposed rule is adopted, consumers in every state will be able to get coverage effective as of the first of the month following their application during a special enrollment period, regardless of the date they apply. The goal? Minimizing gaps in coverage by reducing the amount of time that people in some states currently have to wait for their SEP enrollments to take effect.

This proposed rule did not generate much feedback in the public comments, but there were some comments on either side of the issue. For example, it’s opposed by the state of Georgia, which plans to be running its own exchange by the fall of 2024. It’s supported, however, by the Massachusetts Health Connector (Massachusetts Marketplace), which currently requires SEP applications to be submitted by the 23rd of the month to have coverage effective the first of the following month.

3. It would be easier for states to add to their essential health benefit requirements

The proposed rule would make it easier for states to update their essential health benefits (EHB) benchmark plan requirements, and would allow states to add mandated benefits via the regulatory or legislative process without having to cover the cost of the new benefit. (Current rules require the state to pay the cost of adding the new benefits by sending money directly to the health plan or its enrollees.)

Under current rules, states can use the benchmarking process (directly updating the EHB benchmark plan, as opposed to a legislative or regulatory benefit mandate) to add benefits without defraying the cost. But states have reported that updating the benchmark plan is burdensome, and only nine states have updated their benchmark plans since this became available in 2020. ^{If a state adds required benefits via regulatory or legislative state mandates (as opposed to the benchmarking process) after 2011, they have to defray the cost, even if they subsequently add it via the benchmarking process.}

The proposed rule would ensure that if a particular benefit is covered by a state’s EHB benchmark plan, the cost doesn’t have to be borne by the state, even if the state mandated the benefit via regulation or legislation. And separately, the proposed rule calls for a more simplified process for states to update their EHB Benchmark plan, making it easier to add new benefits over time. (States have reported that the current process can be burdensome and onerous.)

To clarify, a state would not be required to make any change to its EHB Benchmark plan or add any new benefits. But for states that wish to do so, the proposed rules are designed to make the process easier and less costly.

There are a variety of services that a state could choose to add to its EHB benchmark plan, including some services that have only become available in recent years, after the original EHB benchmark plans were established (weight loss medication, for example). Other examples are gender-affirming care, vasectomies, infertility treatment, and substance use disorder treatments that have been developed since EHB Benchmark plans were first created.

Among the public comments received, the National Association of Insurance Commissioners strongly supports this proposed rule change, while Elevance Health (formerly Anthem) opposes it.

Self-insured and large-group plans are not required to cover EHBs (and most covered workers are in self-insured or large group plans). But to the extent that they do, they cannot impose annual or lifetime limits on how much the plan will pay for those services.

The proposed rule clarifies that if a state chooses to add adult dental coverage to its EHB benchmark plan and an employer purchases that plan for its workers in the large group market (51 or more employees in most states) ^{the carrier would have to provide dental benefits without annual or lifetime benefit caps. But if a large employer uses a stand-alone dental plan in addition to a medical plan, the dental plan could continue to have benefit caps.}

(For clarification, small-group health plans are sold to employers with up to 50 employees in most states, and up to 100 employees in four states. ^{If the employer has more employees than the small-group threshold and is purchasing commercial insurance — as opposed to self-insuring — they are buying coverage in the large-group market, which is regulated under different rules than the small-group market.)}

States are responsible for determining the specific services that must be covered as essential health benefits, but the Affordable Care Act prohibits states from including adult dental in their EHB package. This is because the EHB package was meant to be representative of a typical employer-sponsored health plan, and employer-sponsored health plans generally do not include dental coverage.

In the proposed rule, the government notes that they’re now looking at this from the perspective of an overall employer benefit package, which often includes separate dental coverage in addition to the medical plan. So while it continues to be the case that employer-sponsored medical plans typically do not include dental coverage, the proposed rule change would allow states to bring their EHB-Benchmark plan more in line with a typical employer benefits package, which often includes both medical and dental coverage.

Quite a few public comments were submitted in response to the proposal to allow states to add adult dental to EHB.

The proposal is supported by the American Association of Endodontists, the National Rural Health Association, the National Association of Insurance Commissioners, the National Association of Community Health Centers, and the Tribal Technical Advisory Group.

But it’s opposed by Sanford and Priority Health (both insurers), and the Academy of General Dentistry.

The agencies clarified in the proposed rule that they are not proposing a change to allow states to add adult vision or custodial long-term care coverage to EHB (both of which are also not allowed to be added to EHB at this point), but they are seeking feedback from stakeholders and the public regarding whether they should consider that in future rulemaking.

The proposed rule would make the low-income special enrollment period (SEP) permanent, instead of ending it if and when the American Rescue Plan’s (ARP) subsidy enhancements expire.

The rationale behind the low-income SEP is that subsidy-eligible enrollees with income up to 150% of the federal poverty level (FPL) are currently eligible for $0 premium coverage, so the adverse selection risk is low. (That means it’s unlikely that a person would let their coverage lapse when they’re healthy if they’re not having to pay for it. Adverse selection refers to situations in which healthy people do not maintain coverage, and the overall risk pool becomes less healthy and more expensive to treat.)

Under current rules, subsidy-eligible applicants with household income up to 150% of FPL will continue to be able to enroll year-round as long as the ARP subsidy enhancements remain in effect. They’re currently in place through 2025, and an extension would require Congressional action. If the proposed rule is finalized, the low-income SEP will remain in place even if the subsidy enhancements end.

The National Association of Community Health Centers supports this proposal, while Elevance Health (formerly Anthem) opposes it. Another insurer, Priority Health, expressed general opposition to the expansion of special enrollment opportunities and wants CMS to “reduce the total number of SEPs,” noting that “ongoing enrollment contributes to adverse selection and encourages healthy persons to delay enrollment until they need care.”

Conversely, CMS and the IRS note in the proposed rules that because most consumers with income up to 150% FPL would continue to be eligible for some zero-cost plans in the Marketplace even without the ARP subsidy enhancements, they “would be unlikely to use the proposed 150 FPL SEP in a way that caused adverse selection.”

Under current rules, the option to retroactively terminate Marketplace coverage is extremely limited. The proposed rule would allow a retroactive coverage termination date if a person becomes eligible for backdated Medicare coverage. .

Once a Marketplace enrollee becomes eligible for premium-free Medicare Part A, they are no longer eligible for premium subsidies. And even if they aren’t receiving subsidies, Medicare doesn’t coordinate with individual/family coverage. The advice from CMS is that “In most cases, you’ll want to end your Marketplace coverage” when your Medicare coverage begins. And consumers are responsible for canceling their Marketplace coverage when they transition to Medicare.

In most cases, Marketplace plans can only be canceled prospectively (or at the earliest, on the day the cancellation request is made). This works well in situations where a person knows that their Medicare will take effect on a particular day in the future and can schedule the termination of their Marketplace plan for the same time. But it becomes much more complicated when a person learns that they’ve been enrolled in Medicare with a backdated effective date.

This can happen when a person is approved for Social Security Disability Insurance (SSDI) benefits with a retroactive effective date more than 25 months in the past. (Medicare becomes available in the 25th month of SSDI benefits.) It can also happen when a person enrolls in Medicare after they’re initially eligible and their Medicare Part A coverage is backdated up to six months.

In those scenarios, the person doesn’t have an opportunity to cancel their Marketplace plan prospectively, since they’re finding out after the fact that their Medicare coverage has already begun. The proposed rule would allow them to request that their Marketplace coverage be canceled back to the day before their Medicare took effect. This could result in premium savings for the individual, and also reduce the likelihood that they’ll have to repay excess premium tax credits to the IRS when they file their taxes.

The proposed rule does not allow retroactive terminations in a situation where an individual enrolled prospectively didn’t understand that they needed to cancel their Marketplace plan once they’ve got Medicare coverage and later tries to retroactively terminate enrollment in a QHP. But it could address some of the challenges Marketplace enrollees currently face when they are retroactively enrolled in Medicare.

If the proposed rule is finalized, retroactive termination would become available via HealthCare.gov, but would be optional for the state-run Marketplaces.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

On January 8, Olympic gymnast Mary Lou Retton attracted national attention and an outpouring of support when she appeared on the Today Show, explaining the health scare she faced in the fall of 2023. Retton recounted how she fell gravely ill with a rare form of pneumonia and – because she couldn’t afford health insurance – faced thousands of dollars in hospital bills.

The story fortunately has a happy ending: Retton was discharged from the hospital after about a month, and is recovering at home. And her daughters had organized a fundraiser that raised more than $459,000 in contributions. The family has confirmed that any funds beyond what’s needed for medical bills will be donated to charity. And Retton reports that she now has health insurance.

But to me, Retton’s story also included some important lessons for consumers, many of whom may assume that the celebrity’s health scare is a sign of barriers to affordable health coverage. Here’s what consumers can learn from Retton’s experience:

1. Having health coverage is critical.

Retton reported that her unexpected illness resulted in a month of hospital treatment, much of which was in the intensive care unit. With the per-day cost of a hospital stay in Texas averaging $2,913 in 2021, ^{it’s easy to see how expenses can rack up quickly — and ICU costs are higher than regular inpatient care. Retton lives in Texas and was hospitalized there, but the national average cost is similar to the Texas average, at $2,883 per day for regular inpatient care.}

2. Pre-existing conditions are no longer a barrier to coverage.

On the Today Show, Retton pointed to previous health issues as a reason why she didn’t have coverage.

“When COVID hit and after my divorce and all my pre-existing (conditions), I mean, I’ve had over 30 operations of orthopedic stuff, I couldn’t afford it… But who would even know that this was going to happen to me?”

Unfortunately, that may leave some viewers with the impression that coverage might be unaffordable due to pre-existing medical conditions. In fact, medical underwriting hasn’t been used for individual/family health insurance policies since 2013.

For individual/family major medical policies with effective dates of 2014 or later, the insurer cannot take the applicant’s medical history into consideration. So pre-existing conditions will not affect the premium or the person’s eligibility for coverage. That was not true before 2014 in most states, but it has been true nationwide since 2014.

3. Enrollment windows are limited.

One possible reason that Retton didn’t have coverage is that she may have tried to enroll in comprehensive health coverage outside of open enrollment, and if she wasn’t eligible for a special enrollment period, she would have had to wait until open enrollment (with coverage effective in January).

Although coverage is guaranteed-issue regardless of medical history, enrollment in individual/family major medical plans is only available during open enrollment or a special enrollment period. This is the same as the employer-sponsored health coverage rules that have been used for decades.

4. Consumers in some states still face a coverage gap.

Retton, like many people in Texas, could be in the coverage gap, which exists because Texas has not yet elected to expand Medicaid under the Affordable Care Act (ACA). Texas is one of nine states where there’s a coverage gap, and an estimated 772,000 low-income Texas residents are in the coverage gap.

If a Texas resident’s household income is less than the federal poverty level, they’d be in the coverage gap, meaning they would not be eligible for Texas Medicaid or Marketplace premium subsidies.

It’s important to note that Marketplace premium subsidy eligibility is based on income, and assets are not taken into consideration. (Here’s how income is calculated under the ACA). So a person with considerable assets could still fall into the coverage gap in Texas, if their income is below the poverty level.

A person in the coverage gap can still enroll in Marketplace coverage, but will not qualify for any subsidies. Their decision to enroll in coverage will depend on whether they can afford to pay full price premiums.

5. Income affects subsidy eligibility.

On the other end of the spectrum, Retton’s income might have been too high to qualify for any Marketplace subsidies. Using HealthCare.gov’s 2023 plan comparison tool for a 55-year-old in her area, we can see that subsidies would have phased out at an income of roughly $98,000. (Subsidies phase out at the point where the price of the second-lowest-cost Silver plan becomes no more than 8.5% of the person’s household income, which is what the American Rescue Plan and Inflation Reduction Act consider affordable at that income level.)

If her income had been above that, she would have been paying full price for a plan, with 2023 premiums somewhere in the range of $501 to $1,075/month, depending on the plan. (These premiums are specific to Retton’s age and location; they will vary for other applicants).

6. But the income range for subsidy eligibility is wide.

But if an individual Retton’s age and living in her area had a 2023 household income between $13,590 (the 2022 poverty level) and about $98,000 (the level at which subsidies in that case would have phased out altogether), they would have been eligible for Marketplace premium subsidies that covered some or all of the cost of the coverage, depending on where in that income range they were, and the plan they selected.

Although the ACA prohibits insurers from considering an applicant’s medical history, a person might not know about that if they haven’t had experience with purchasing coverage in the individual market in recent years.

And if a person hasn’t applied for coverage or used a subsidy calculator, they may not be aware of how substantial the premium subsidies can be in the Marketplace.

Ultimately, even an unsubsidized premium of several hundred dollars a month is a bargain compared with having to pay for a month-long stay in the ICU. But fortunately, most Marketplace enrollees do not pay anything close to the full amount of their premiums.

In 2023, the average full-price Marketplace premium in Texas was $578/month. But thanks to premium subsidies, the average enrollee paid just $65/month. And out of the 2.4 million Texas residents who enrolled in Marketplace coverage in 2023, more than 1.4 million were paying less than $10/month for their coverage.

I’m glad that Retton recovered and has secured health insurance going forward. These circumstances remind us that ACA-compliant health insurance can be obtained – regardless of our medical history, and with substantial subsidies available to most applicants.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

Medicaid disenrollments resumed several months ago (in April, May, June, or July, depending on the state), and the process is proceeding mostly as expected, with millions already disenrolled. But it’s also had some unexpected problems.

Here’s a look at disenrollments thus far – and a look at who’s been losing Medicaid coverage, and how some who’ve been disenrolled are taking steps to replace their lost coverage.

States had the option to prioritize eligibility redeterminations for enrollees they believed were most likely to no longer be eligible, ^{so it’s not surprising that there was a fairly high rate of disenrollments in some states in the early months of the unwinding process. For example, by September (last month), Idaho had already completed eligibility redeterminations for everyone whose eligibility had been pending during the pandemic, and is now back to their normal annual eligibility redeterminations.}

CMS had previously directed some states to pause procedural disenrollments while problems with their eligibility redetermination processes were addressed. As of June 2023, some or all procedural disenrollments had been paused in DC and 16 states.

A pause on procedural disenrollments does not prevent a state from continuing to process renewals and disenroll people who no longer meet the eligibility guidelines. It just prevents states from disenrolling people when they don’t have enough information to determine whether the person is still eligible.

And states can adjust their approach to processing Medicaid redeterminations based on state-specific circumstances. For example, Hawaii opted to pause all Medicaid disenrollments through the end of 2023 ^{due to the wildfires in Maui, and will wait until June 2024 to resume eligibility redeterminations for West Maui residents.}

• More than 291,000 former Medicaid enrollees had selected Marketplace qualified health plans (QHPs) through HealthCare.gov.
• More than 63,000 people had selected QHPs through state-run exchanges.
• In addition, nearly 56,000 people had transitioned to Basic Health Program (BHP) coverage in New York and Minnesota.

So, based on CMS’ recent reports, more than 410,000 former Medicaid enrollees had transitioned to Marketplace coverage – QHP or BHP coverage – by June 2023.

In the state-run exchanges, enrollment included nearly 7,600 people for whom a QHP had been automatically selected. ^{Only four states (California, Maryland, Massachusetts, and Rhode Island) have implemented auto-enrollment protocols for at least some people whose Medicaid is terminated during the unwinding process. In the rest of the country, a person’s data may be transferred to the Marketplace, but they must actively select a plan in order to enroll in a QHP.}

Last year, CMS had estimated that 2.7 million people losing Medicaid during the unwinding period would be eligible for advance premium tax credits (APTC) to offset the cost of Marketplace coverage. ^{As of June 2023, a total of about 583,000 former Medicaid enrollees had been deemed eligible for APTC (337,230 in states that use HealthCare.gov and} 245,879 in states that run their own exchanges.⁾

APTC eligibility depends on income but also on whether the person has an offer of affordable coverage from an employer. People who lose Medicaid but are eligible to enroll in an employer’s plan are generally not eligible for financial assistance in the Marketplace.

It’s important to note that HealthCare.gov has an ongoing special enrollment period, through July 2024, for people who lose Medicaid during the unwinding process. So a person who lost Medicaid early in the unwinding process still has a lengthy window to enroll in a Marketplace plan if that’s their preference.

States that run their own exchanges can choose to offer extended special enrollment periods for people who lose Medicaid, or they can use the normal special enrollment period rules that allow a person up to 60 days to select a new plan after losing Medicaid.

Read our overview of Medicaid redetermination to learn more about coverage replacement options for people who are disenrolled from Medicaid. The overview also links to pages devoted to each state’s Medicaid program, with details about how the unwinding process is being handled.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Footnotes

The Affordable Care Act (ACA) has faced numerous legal challenges, but has been upheld three times by the Supreme Court. Over the years, the headlines surrounding the possibility of the ACA (aka Obamacare) being overturned have often focused on people with pre-existing conditions who buy their own health insurance. (This is certainly a valid concern, as those individuals would undoubtedly be worse off without the ACA.)

But the impact of the ACA goes well beyond securing access to healthcare for people with pre-existing conditions. Who are these Americans, whose lives are better off, thanks to the ACA? See if you can find yourself – or your loved ones – in this list:

1. More than 14 million Americans (91% of all Marketplace/exchange enrollees) who are receiving premium subsidies in the exchanges that make their coverage affordable. The average full-price premium is $605/month in 2023, but the average subsidy amount ($527/month) covers the majority of the average premium.
2. More than 7.5 million people who are receiving cost-sharing reductions that make medical care more affordable and accessible.
3. People who are (or want to be) self-employed and wouldn’t have been able to qualify for and/or afford a privately purchased health insurance plan without the ACA’s guaranteed-issue provisions and premium subsidies.
4. People with pre-existing conditions who gain access to an employer-sponsored plan after being uninsured for 63+ days. HIPAA guaranteed that they could enroll in the employer-sponsored plan, but there were waiting periods for pre-existing conditions. The ACA eliminated those waiting periods.
5. People who lose access to an employer’s plan and no longer have to rely on COBRA (or mini-COBRA/state continuation) for health coverage.
6. People who gain access to an employer’s plan and have a waiting period of no more than 90 days before their coverage takes effect. Pre-ACA, employers could determine their own waiting periods, which were sometimes longer than three months.
7. Full-time (30+ hours/week) workers at large businesses who are offered real health insurance instead of “mini-med” plans, thanks to the employer mandate. (Employers can choose not to comply, but they face a penalty in that case.)
8. 

   People with serious conditions often exhausted their coverage under pre-ACA plan because of annual or lifetime benefits caps.

   People with serious medical conditions who would otherwise have exhausted their coverage in the private market, including employer-sponsored plans. Pre-ACA, annual and lifetime benefit caps were the norm. And it could be shockingly easy to hit those maximums if you had a premature baby or a serious medical condition.

9. Coal miners with black lung disease, and their survivors. The ACA made benefits under the Black Lung Benefits Act of 1972 available to more people.
10. Medicare beneficiaries who use Part D prescription coverage and who would have ended up in the donut hole.  before. (The ACA closed the donut hole as of 2020.)
11. Medicare beneficiaries who receive free preventive care.
12. American taxpayers and Medicare beneficiaries who benefit from ACA cost controls that have extended the solvency of the Medicare Hospital Insurance trust fund and improved Medicare’s long-term financial outlook.
13. Seniors who are able to remain in their homes as they age, thanks to the ACA’s expansion of Medicaid funding for in-home long-term care services and supports.
14. Nursing home residents – and people with loved ones living in nursing homes – who benefit from federal funding for background checks on employees who interact with patients.
15. The 12 million low-income Americans who are elderly and/or disabled, covered simultaneously by both Medicare and Medicaid, and who benefit from the improvements the ACA made for the dual-eligible population.
16. College students who are no longer offered skimpy health plans.
17. Women (and their partners) who have access to contraception at no cost – including birth control methods such as IUDs, implants, and tubal ligations that are highly effective but would have prohibitively high up-front costs if they weren’t covered by insurance.
18. Pregnant women who have access to free routine prenatal care.
19. Expectant parents – male and female – who can enroll in a health plan in the individual market. (Pre-ACA, expectant parents’ applications were rejected in nearly every state.)
20. People who buy their own health insurance and would like to have a child. Pre-ACA, individual health insurance rarely covered maternity care.
21. Breastfeeding mothers who have access to breast pumps and breastfeeding counseling as part of their insurance benefits. The ACA also guarantees that breastfeeding mothers who work for large employers have access to adequate breaks and a private, non-bathroom area for pumping milk.
22. Anyone who is better off in a world where people in need of mental health care can access it – because their health insurance covers it and they aren’t rejected altogether when they apply for a new health plan.
23. People with substance abuse disorders who can obtain treatment that would be unaffordable without health insurance coverage.
24. The 21 million people who have gained access to Medicaid thanks to the ACA’s expansion of coverage to low-income adults.
25. Low-income families and individuals who no longer have to meet asset tests in order to qualify for Medicaid or CHIP, with eligibility now based on the ACA’s modified adjusted gross income instead (some populations, including the elderly and disabled, are still subject to asset tests for Medicaid eligibility).
26. People in some rural areas of the country where hospitals have been able to remain open thanks to Medicaid expansion.
27. Young adults who are able to remain on their parents’ health insurance as they work to start their careers.
28. Young adults who were in foster care until age 18, and who are allowed to continue their Medicaid coverage until age 26, regardless of income.
29. Early retirees who can enroll in self-purchased health insurance for the pre-Medicare years, without worrying about pre-existing conditions.
30. 

    ACA’s marketplace plans must cover a list of vaccinations for children from birth to age 18.

    Children who have access to free vaccines and well-child care.

31. Adults who have access to a wide range of preventive health services at no cost.
32. Families whose health plan covers their kids’ dental care.
33. People in New York and Minnesota who earn a little too much for Medicaid but are eligible for coverage under Basic Health Programs (Oregon plans to debut a Basic Health Program in mid-2024).
34. People who find themselves needing to appeal their health plan’s decision on a prior authorization request or claim.
35. Medicare Advantage enrollees whose health plan is required to spend at least 85% of revenue on members’ medical claims and quality improvements.
36. Individuals and employers whose insurers are required to spend at least 80% or 85% of premiums on members’ medical claims and quality improvements.
37. People age 65 and older, including recent immigrants, who are able to enroll in ACA-compliant health plans if they’re not eligible for premium-free Medicare (pre-ACA, individual market insurers generally would not enroll people over age 64).
38. Women, who no longer pay more for health insurance than men.
39. Older people (including those age 65+ who aren’t eligible for premium-free Medicare), whose premiums are no more than three times as much as the premiums for a 21-year-old.
40. People who buy their own health insurance and no longer have to worry that the policy could get rescinded because they forgot to mention something on the application. (This was usually due to an omission in the medical history section, and those questions are no longer asked – thanks, also, to the ACA.)
41. Everyone who benefits from the more robust premium review processes that states have as a result of the ACA.
42. Everyone who benefits from the ACA’s risk adjustment program, which levels the playing field and helps to prevent plan designs that would be unappealing to individuals and groups with high-cost medical conditions.
43. People with individual and small-group coverage that includes all of the essential health benefits.
44. People who pay full price for individual health insurance in Alaska, Colorado, Delaware, Georgia, Idaho, Maine, Maryland, Minnesota, Montana, New Hampshire, New Jersey, North Dakota, Oregon, Pennsylvania, Rhode Island, Virginia, and Wisconsin, who are paying lower premiums thanks to reinsurance programs that were implemented under Section 1332 of the ACA.
45. Native Americans and Alaska Natives, who can enroll year-round in plans sold through the exchanges, and who are eligible for plans with zero cost-sharing if their income doesn’t exceed 300% of the poverty level. (That’s $90,000 for a family of four enrolling in 2024 coverage.)
46. Native Americans and Alaska Natives who receive care via Indian Health Services – as the ACA permanently reauthorized the Indian Health Care Improvement Act.
47. People who are protected from discrimination in healthcare based on race, national origin, sex, age, or disability, thanks to Section 1557 of the ACA. (The details of how these protections work are determined by HHS, so there have been some changes over time. HHS initially issued rulemaking in 2016, but it was rolled back in 2020. However, HHS proposed new rules in 2022 that would largely revert to the stronger anti-discrimination protections that were implemented in 2016.)
48. People who are able to make more informed food choices thanks to nutritional and calorie information on restaurant menus. This stems from Section 4205 of the ACA, and was implemented in 2018.
49. People who shop for coverage in the health insurance exchange and find the new star rating system for health plans to be helpful during the plan selection process.
50. People who could benefit from new biosimilar drugs becoming available. Section 7002 of the ACA created the pathway under which biosimilar drugs are approved by the FDA.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Since 2018, federal rules have made it possible for consumers in many states to buy short-term, limited-duration insurance (STLDI) and keep that coverage for as long as three years, including renewals and extensions. (States can set their own more stringent rules, which is why these rules don’t apply nationwide.) But a rule proposed by the Biden administration in July 2023 would significantly limit the length of STLDI plans.

If finalized, the rule would limit the initial term of STLDI policies to no longer than three months. Though the rule would allow renewal of a policy, the total duration of a plan would be limited to four months, and a buyer would not be allowed to purchase another short-term plan from the same insurer within 12 months of their initial policy effective date.

The agencies publishing the rule noted that these changes are designed to ensure that short-term coverage is used to fill a temporary gap between two comprehensive policies, rather than serving as a long-term coverage solution. The rule is also intended to reduce the number of people who inadvertently purchase short-term coverage when trying to buy comprehensive coverage.

In introducing the proposed rule, President Biden said his administration is “cracking down” on limited-duration insurance being sold to individuals who often don’t understand the coverage and then are surprised when they get hit with large medical bills.

The proposed change would roll back a 2018 rule that expanded the availability of short-term, limited-duration plans, allowing them to last for up to three years if the coverage is renewable.

According to the National Association of Insurance Commissioners, 235,775 people were covered under short-term policies as of 2022. However, the actual number of enrollees is uncertain because insurance carriers are not required to report enrollment data.

What happens next?

The Centers for Medicare & Medicaid Services is accepting public comments on the proposed rule until September 11, 2023. Rulemaking is a multi-month process, so any rule change likely won’t be finalized until late 2023.

If approved, the rules would not apply to new short-term policies until 75 days after the rule is finalized. Policies issued before that date would not have to comply with the new rules.

For now, consumers in many states can continue enrolling in longer-duration short-term plans. We say “many states” because although the 2018 rule permits states to allow the sale of longer-duration plans, nearly half of the states have adopted stricter limits on STLDI duration. (See details below for each state.)

Some states have banned the sale of short-term plans outright while other states have adopted regulations that have caused insurers to stop selling the plans.

The proposed rule published in July 2023, would change all three of the rules that the Trump administration put in place. Those 2018 rules:

• Limit short-term plans to initial terms of up to 364 days.
• Allow short-term plans to be renewed as long as the total duration of the plan doesn’t exceed 36 months.
• Require short-term plan information to include a disclosure to help people understand how short-term plans differ from individual health insurance.

Under the Biden administration’s proposed rule:

• New short-term policies would be limited to initial terms of no more than three months.
• Carriers would be able to offer renewable policies, but the total duration – including renewals – could not exceed four months. The proposed rule notes that the three-month window is designed to align with the maximum waiting period that a new employee can be subject to before being eligible for an employer-sponsored health plan.
• A consumer would not be allowed to purchase an additional short-term policy from the same insurer within 12 months of the effective date of the first policy.

The required disclosure notice would be updated to clarify that federal financial assistance is not available with short-term policies, and that surprise balance billing protections do not apply to these policies.

In a few states – New York, New Jersey, Massachusetts, Rhode Island, and Vermont – short-term plans weren’t sold at all as of 2018. And by 2020, five additional states – California, Colorado, New Mexico, Maine, and Hawaii – and Washington, DC also had no insurers offering short-term plans.

In Washington, the sale of short-term health plans was discontinued in mid-2022 and no insurers offer short-term health plans in Washington as of 2023. New Hampshire and Minnesota also had no insurers offering short-term health plans by mid-2023.

In addition, several states had already capped the duration of short-term plans at three or six months, even before the Obama administration took action to limit short-term plans. Other states have subsequently implemented three- or six-month caps on short-term plans.

Ultimately, there are more states with their own restrictions on short-term plans than there are states that are defaulting to the federal rules. Use this map to see how states restrict short-term plans.

If the Biden administration’s proposed rules are finalized, states will no longer have the option to allow short-term policies to have initial terms of more than three months, or total durations of more than four months. Policies with longer terms would not be considered short-term plans and would have to comply with the ACA’s rules for individual-market coverage.

• Colorado – Six-month initial durations are allowed, but insurers stopped offering short-term plans as of 2019.
• Connecticut
• Illinois limits initial plan duration to six months with no renewals.
• Michigan limits initial plan durations to 185 days with no renewals.
• Minnesota limits initial plan durations 185 days, but no insurers offer plans as of August 2023.
• Nevada limits initial plan durations to 185 days with no renewals.
• New Hampshire limits initial plan durations to six months and 18 months total within a two-year period, but no insurers offer plans as of 2023.

States (and the District of Columbia) allowing short-term plans to have duration up to three months

A handful of states allow short-term plans to have initial terms in line with the new federal rules (364 days), but place more restrictive limits on renewals and total plan duration:

• Idaho – “Enhanced” short-term plans are guaranteed renewable for total duration of three years. State limits initial duration of non-enhanced short-term plans to six months with no renewals.
• Kansas – (Only one renewal permitted.)
• Ohio – (Renewals not permitted.)
• South Carolina – (11-month maximum initial term, and 33-month maximum duration.)
• Wisconsin – (Total duration limited to 18 months.)

In 14 states and the District of Columbia, no short-term plans are available for purchase. In some cases, state regulations ban sale of the plans outright. In others, state regulations make it unappealing for insurers to offer short-term plans.

• California – State law prohibits the sale of short-term plans.
• Colorado – As noted, plans are technically allowed with six-month initial durations, but insurers have stopped offering short-term plans.
• Connecticut
• District of Columbia – Plans are allowed for up to three months with no renewals, but no insurers offer them.
• Hawaii – As noted, no insurers offer plans under the rules the state implemented.
• Maine – New rules took effect in 2020, and no insurers offer plans.
• Minnesota – No insurers offer plans as of August 2023.
• New Hampshire — No insurers offer plans as of 2023.
• New York
• New Jersey
• Massachusetts – Health plans are required to be guaranteed-issue, so short-term policies are not available in the state
• New Mexico – State regulations limit the plans to three months and prohibit renewals, but no insurers were offering plans as of mid-2019.
• Rhode Island – STLDI is not banned, but state rules are strict enough that no insurers offer these policies
• Vermont – There are no short-term plans available in Vermont, but legislation was also enacted in 2018 to limit short-term plans to three months and prohibit renewals, in case any plans are approved in the future.
• Washington – Plans are allowed for up to three months, but no insurers offer them.

You can use the map on this page to see more details about short-term health insurance rules and availability in each state.

Under regulation changes that HHS finalized in 2018 – and in effect since October of 2018 – the initial duration of short-term plans was lengthened to 364 days with an option to renew a plan for coverage up to a total of three years. This 2018 rule reversed regulations – put in place by the Obama administration – that had limited short-term plan durations to 90 days and did not allow renewal of policies.

The 2018 rule also established that a plan is considered “short-term” as long as it has an initial term of less than a year (no more than 364 days).

But the 2018 rule also allows short-term plans to offer enrollees the option to renew their plans without additional medical underwriting and use renewal to keep the same plan in force for up to 36 months.

Under the Trump administration, HHS justified this by noting that the coverage has long been called “short-term limited duration” health coverage, and pointing out that “short-term” and “limited duration” must mean different things, otherwise the phrases would be redundant.

So HHS said that “short-term” refers to the initial term, which must be under 12 months. But they allowed the “limited duration” part to mean up to 36 months in total, under the same plan.

It’s important to note that HHS may have expected this to be challenged in court, as they included a severability clause for the part about 36-month total duration: If a court were to strike down that provision, the rest of the rule would remain in place. (A lawsuit was filed over the legality of the new short-term insurance rule in September 2018, but that case ended with a ruling in favor of the Trump administration.)

In the 2018 rule, HHS noted that there is nothing in federal statute that would prevent a person from enrolling in a new short-term plan after the 36 months (or purchasing an option from the initial insurer that will allow them to buy a new plan at a later date, with the new plan allowed to start after the full 36-month duration of the prior plan).

So technically, federal rules allow people to string together multiple “short-term” plans indefinitely. But as noted above, there are quite a few states with much stronger short-term plan regulations, and some states implemented restrictions on short-term plans specifically in response to the new federal rules.

The disclosure notice required in the 2018 rule was intended to inform consumers of several aspects of short-term coverage: That the plans are not required to comply with the ACA, may not cover certain medical costs, and may impose annual/lifetime benefit limits. The disclosure also notes that the termination of a short-term plan does not trigger a special enrollment period in the individual market (although it does for group health plans).

Enrollees who develop health conditions while covered under a short-term plan – and may be subject to pre-existing condition exclusions under a new short-term plan – might find themselves without short-term coverage and having to wait until the next open enrollment period to sign up for Marketplace coverage.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

South Dakota is the 39th state to expand Medicaid eligibility to cover low-income adults, with coverage that could take effect as early as July 1. Applications were accepted starting June 1, and enrollment continues year-round.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org since 2013. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Friday Health Plans, which offers coverage in five states, is winding down its business operations. And in at least three of those states, thousands of enrollees need to select new plans in the coming weeks to avoid becoming uninsured.

Friday Health Plans of Georgia has been placed into receivership, and its health policies will terminate on July 31, 2023. Friday Health Plans of Oklahoma and Friday Health Plans of North Carolina have also been placed into receivership, with coverage ending on August 31, 2023. Enrollees will need to continue paying their Friday Health Plans premiums through those dates to maintain coverage until the plans terminate at the end of July or August, depending on the state.

Policyholders in these states will need to select new health insurance plans if they want to avoid coverage gaps for the remainder of 2023.

Learn more about what to do when your insurer stops offering coverage.

Louise Norris is an independent individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org since 2013. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

If you’ve received notification that you’re losing Medicaid eligibility, you’re certainly not alone. Millions of Americans will get similar notices in 2023 and 2024, now that states are once again disenrolling people from Medicaid after not doing so between March 2020 and March 2023.

(If you need help to understand why you lost Medicaid, how to avoid loss of coverage or appeal lost coverage, please visit our article explaining Medicaid redeterminations.)

But that doesn’t make it any easier to find out your health coverage is ending. You’re still left with a big question: What to do now that you’ve been declared ineligible for Medicaid and dropped from the program? Let’s take a look.

Louise Norris is an independent individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Enrollment in ACA marketplace plans has surged, thanks to expanded eligibility for ACA marketplace subsidies. Leading that surge: buyers with higher incomes.

After the American Rescue Plan (ARP) expanded eligibility for premium subsidies in the ACA marketplace in 2021, enrollment in 2022 plans increased by 21%. Enrollment in 2023 plans is on pace to grow by another 13%, to about 16.4 million by the time the open enrollment period ends in all states. Plainly, Americans who lack access to affordable employer-sponsored health plans, Medicaid, or Medicare are recognizing that the ARP made health plans in the ACA marketplace far more affordable.

The ARP increased premium subsidies in the ACA marketplace at every income level and removed the income cap on subsidy eligibility, which had been 400% of the Federal Poverty Level (FPL) since the ACA marketplace launched in 2014. In 2023, 400% FPL is $54,360 for an individual and $111,000 for a family of four. Enrollees with income above that level used to pay the full premium without subsidy. Now they receive premium subsidies if the unsubsidized benchmark Silver plan premium would cost them more than 8.5% of annual family income.

The table below shows the enrollment increase at each income level for 2022 plans in the 33 states that use HealthCare.gov, the federally run exchange. While enrollment in 2022 coverage rose by double-digit margins at all reported income levels, the growth rate increased with income and was highest at incomes over 400% FPL – i.e. among those formerly ineligible for subsidies. (Information about 2023 enrollees’ income is not yet available.)

A note on one data limitation: the chart combines enrollment by those with incomes below 100% FPL and above 400% FPL because that’s the way CMS reported income in 2021, when enrollees with incomes over 400% FPL were not eligible for subsidies. In 2022, 146,297 enrollees in HealthCare.gov states had income below 100% FPL, while 655,944 reported income above 400% FPL – so likely almost all of the increase in that combined category is attributable to enrollees with incomes above 400% FPL.

An obvious surge in enrollment at income levels over 400% FPL

In 2022, the first year in which there was no income cap on subsidies, enrollment at incomes above 400% FPL more than doubled. When you look at premiums with and without subsidies for enrollees of different ages, as shown below, it’s not hard to see why.

Coverage is much more affordable at incomes above 400% FPL than it was prior to 2022 – far more so than many people who looked at marketplace offerings before they became subsidy eligible probably recognize.  Note also that the number of enrollees who did not report income plummeted. That’s doubtless because the ARP dramatically reduced the number of enrollees who earn too much to obtain a subsidy.

Source: 2022 Marketplace Open Enrollment Public Use Files / CMS.gov

The enrollment surge, illustrated

Let’s take a closer look at one of the ACA’s hottest markets: Houston, Texas. Enrollment in 2022 coverage in Texas increased by 42%, and enrollment in 2023 plans is on pace to increase another 32%. The chart below shows what premiums now look like for couples of different ages with an annual income of $74,000 – slightly above the 400% FPL threshold – compared to what those couples would pay if they were ineligible for subsidies, as they would have been in years before 2022.

The source for all premiums quoted below is the “See plans and prices” tool on HealthCare.gov.

Impact of the American Rescue Plan on ACA premium subsidies

Monthly premiums paid with and without ARP subsidy increases: Houston, TX in 2023

Notice that the premiums that the older couple will pay (after subsidy) for Bronze and Gold plans are much lower than those paid by the 40-year-olds. That’s because premiums before subsidies are credited rise with age: At age 64, they are three times the premium for a 21-year-old and more than twice the premium for a 40-year-old.

But subsidies are structured so that everyone with the same income pays the same amount for the benchmark Silver plan: An enrollee with income at >400% of FPL receives a subsidy in a fixed amount that enables the enrollee to pay not more than 8.5% of their income for the benchmark, regardless of age. So the subsidy for the older couple is bigger than for the younger couple.

When the subsidy gets bigger, it covers a larger share of the premium for plans that cost less than the benchmark plan. Since the “spread” between the benchmark plan’s premium and the premiums for cheaper plans (one Silver and many Bronze plans) increases in proportion to the age of enrollees, older enrollees get bigger savings on cheaper plans.

Louise Norris has more on how the ARP has decreased premiums for older enrollees. For eligible higher income and older enrollees, the ARP subsidy boosts are not just an “8.5% solution.” Coverage, including sometimes Gold coverage, is often available for much less.

What do the lowest-cost Bronze, Silver and Gold plans shown above look like? Below are some key features. Note that in ACA marketplace plans, select features may not be subject to the deductible, meaning you don’t have to pay full price before you meet your deductible (i.e. a service may be free or you may pay only a co-pay).

• The lowest-cost Bronze plan in this market from Blue Cross Blue Shield of Texas, has a deductible of $7,400, and an annual out-of-pocket maximum of $9,100 (the highest allowable by law). Primary care doctor visits are free regardless of whether the plan’s deductible has been met, and generic drug prescriptions are $5, also before the deductible.
• The lowest-cost Silver plan, from Ambetter, has a $5,800 deductible and an $8,900 out-of-pocket max. Primary care visits are $40 and generic drug prescriptions are $20, both before the deductible, and other services (urgent care, specialist visits) are also not subject to the deductible.
• The lowest-cost Gold plan, from Blue Cross Blue Shield, has a deductible of $1,100, an out-of-pocket max of $9,100. Primary care doctor visits are free and generic drug prescriptions of $5, neither subject to the deductible.

Bargains are Gold-plated in Texas and a handful of other states

The tables also show an extra benefit in the Texas marketplace. In 2022, the Texas legislature unanimously passed a law, signed by Gov. Greg Abbott, instructing the Department of Insurance to issue regulations that would ensure that insurers price Gold plans lower than Silver plans. How can that be?

Well, most marketplace enrollees have incomes below 200% FPL, and below that threshold, Cost Sharing Reduction (CSR) subsidies give Silver plans lower out-of-pocket costs than Gold plans. In Texas in 2022, 88% of Silver plan enrollees had income below 200% FPL. So, setting Gold plan premiums below Silver premiums is a major benefit to enrollees with incomes above 200% FPL, for whom Gold plans have lower out-of-pocket costs than Silver.

At least six states have taken measures to have Gold plans consistently priced below or on a rough par with Silver, and in other states and regions, insurers have done so on their own. This post by Charles Gaba spotlights states and counties in which the economic upsides for Gold plans are most extreme.

Pricing CSR directly into Silver plan premiums is a practice known as “silver loading,” which began in 2018 after the federal government stopped paying insurers separately for the value of CSR. Silver loading creates discounts in Bronze as well as Gold plans – often wiping out the Bronze premium entirely, as the chart above illustrates in the case of the 63-year-olds. Insurers in all states except Mississippi and Indiana practice Silver loading to some degree.

When premiums go high, so does subsidy eligibility

At an income of $150,000 per year for a couple of 40-year-olds – more than 800% FPL for a two-person household –  the unsubsidized benchmark Silver plan in Houston costs less than 8.5% of income. The premium would be the same if the ARP were not in effect.

For two 60-somethings, however, the benchmark premium rises so high that it’s more than 8.5% of income even for a couple earning $150,000.  Subsidies therefore kick in even at this high income.

Those prohibitively high unsubsidized premiums may seem like an extreme case, but they’re not unusual for older enrollees. Providing affordable insurance to people who retire or are laid off before they’re eligible for Medicare is a major function of the ACA marketplace. In 2022, 28% of all enrollees were aged 55-64.

The ARP of course made plans significantly more affordable at every income bracket below 400% FPL as well.  Examples of how the subsidy increases affect enrollees at various income levels are laid out in this post.

The American Rescue Plan was originally designed as COVID-19 relief, and the subsidy increases in the ACA marketplace were only granted through 2022. The Inflation Reduction Act, enacted in August 2022, extended the increased subsidies through 2025. Beyond that point, their future is uncertain, though they have plainly helped to reduce the uninsured population nationwide.

At least through 2025, if you need to find insurance in the individual market and have not yet examined your options, you’re likely to be pleasantly surprised – particularly if you were jolted by unsubsidized premiums in the past and now find yourself eligible for subsidized coverage.

Andrew Sprung is a freelance writer who blogs about health care policy and ACA implementation at xpostfactoid and at healthinsurance.org. His articles have appeared in publications including Health Affairs, The American Prospect, USA Today, The New York Times, The Incidental Economist, Mother Jones, The Atlantic and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Health Care Digital Media Award and holds a Ph.D. in English literature from the University of Rochester.

In case you missed it during a frenzied election season, the annual open enrollment period for ACA marketplace plans (which are  ACA-compliant health coverage) in 2023 kicked off on November 1. You may also have missed that last year, the American Rescue Plan Act made coverage in private plans sold in the ACA marketplace far more affordable than it used to be, and that the improved premium subsidies will continue at least through 2025, thanks to the Inflation Reduction Act passed in August 2022.

If you’re a citizen or legally present noncitizen, are under 65, can’t get health coverage through your employer or your spouse’s employer, and are not on disability Medicare, you really should check out what’s available to you in the ACA exchanges. HealthCare.gov, the federal exchange that serves 33 states, reports that four out of five people who enroll can find a plan for $10 per month or less (though many will choose a plan that costs more).

While you may be pleasantly surprised by what the ACA exchanges have to offer, it’s best not to be too surprised. That is, it’s important to go in with some awareness of what you’re likely to get at different income levels.

The most basic rule is, the higher your income, the more you’ll pay for coverage, ranging from zero in the lowest income brackets (for Medicaid or free private-plan coverage) to 8.5% of household income for a benchmark Silver plan if your income is well above average.

Before you shop, it’s good to absorb two rules of the road:

1. Small differences in projected income can have a large impact on available benefits.
2. The income you report is an estimate for the coming year – and so for many people, there’s some built-in wiggle room.

The poet Robert Frost said that writing poetry without rhyming was like playing tennis without a net. Applying for ACA coverage without knowing the income levels at which benefits change is like playing tennis without any lines. And when you don’t see the lines, it’s easy to hit the ball out.

In the ACA application, your estimate of your gross (before-tax) household income for the coming year will place you in one of several income brackets, defined as a percentage of the federal poverty level (FPL). (The ACA application slightly modifies the “Adjusted Gross Income” you see on your annual tax form.) How much you’ll pay – and in some cases, the kind of coverage available to you – depends on what bracket you’re in. Let’s look at some key “break points” where benefits shift.

100% FPL – the minimum income required to qualify for private plan coverage in 11 states

• $13,590 per year for a single person
• $18,310 for a two-person household,
• $23,030 for a family of three
• $27,750 for a family of four

It’s a cruel reality that in 11 states* – Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, and Wyoming – most adults who estimate household income below the 100% FPL threshold get no help from the government in obtaining health coverage.

As first drafted, the ACA made Medicaid available to most adults with an income below 138% FPL. In 2012, however, the Supreme Court ruled that the federal government couldn’t force states to expand Medicaid eligibility in that way. The states listed above have refused to date to go along, and in those states, most adults with incomes below 100% FPL get no help paying for any kind of coverage. (In the November election, South Dakota voted by referendum to adopt the expansion, and Medicaid enrollment under the ACA eligibility rules will begin there in July 2024.)

In a drafting inconsistency that turned out to be lucky, the ACA pegged the minimum income for subsidy eligibility in the marketplace at 100% FPL rather than 138% FPL. So, in states that have not expanded Medicaid, having an income of at least 100% FPL moves you out of the “no help” territory.

As discussed in more detail below, a low income is often an uncertain income, and applicants in the “nonexpansion” states with income likely to be anywhere near the 100% FPL threshold should leave no stone unturned to get a good-faith estimate of next year’s income over the eligibility threshold. Knowing the threshold is the key first step – especially since marketplace coverage with low out-of-pocket costs is available for free to applicants with income in the 100-150% FPL range.

138% FPL – the upper income threshold for Medicaid in most states

• $1,563 per month for a single person
• $2,106 for a two-person household
• $2,648 for a family of three
• $3,191 for a family of four

In the 38 states** that have enacted the ACA’s Medicaid expansion, most citizens and legally present noncitizens*** with income below 138% FPL qualify for Medicaid. That makes them ineligible for marketplace coverage.

Medicaid eligibility is determined on a monthly basis, which means (in expansion states) that if your income drops suddenly – after a job loss, for example – and isn’t likely to recover soon, you become eligible.

For most people near this income level, Medicaid is a good option, as there’s almost never a premium (a few states charge a small one at the top of the income bracket) and out-of-pocket costs range from zero to minimal.

Some people with income near the Medicaid eligibility threshold may prefer marketplace coverage, however – which, in some markets at least, allows for a wider choice of doctors and hospitals. While out-of-pocket costs are higher in the marketplace’s private plans than in Medicaid, they are comparatively low in Silver plans at low incomes, thanks to a secondary subsidy called cost sharing reduction (CSR) that attaches to Silver plans for lower income enrollees (more on CSR below). And the two cheapest Silver plans in each region are free to enrollees with income up to 150% FPL.

Since marketplace eligibility and subsidy level is calculated on an annual income basis, an applicant who’s suffered a sudden loss of income may qualify for Medicaid by citing current monthly income – or for marketplace coverage by estimating annual income. The HealthCare.gov application enables the latter when current monthly income is low (or high), providing a section in which you can estimate total annual income and/or a total for the coming year that may be different from income in the current year.

There is one particular case in which an applicant might want to stay out of Medicaid. In more than 20 expansion states, any Medicaid enrollee who is over age 55 is potentially subject to Medicaid Estate Recovery upon their death. If the deceased enrollee owns any significant assets, the state may seek to recover from their estate the value of the services that Medicaid covered, or, if the state contracted with a Medicaid managed care organization, all of the money that the state paid to that organization to administer the person’s coverage.

Once again, knowledge of a key income threshold may in some cases give cause to steer toward one side or the other of it.

200% FPL – the maximum income at which strong Cost Sharing Reduction (CSR) enriches benefits.

• $27,180 per year for a single person
• $36,620 for a family of two
• $46,060 for a family of three
• $55,500 for a family of four

(Note that these income limits are applicable for 2023 coverage; they rise annually.) At incomes up to 200% FPL, cost sharing reduction – which attaches only to Silver plans – raises the value of a Silver plan to a roughly Platinum level (a bit above Platinum at income up to 150% FPL, a bit below at 150-200% FPL). Above the 200% FPL threshold, the value of CSR drops off sharply, and it’s not available at all at incomes above 250% FPL.

At incomes below 200% FPL, CSR makes a big difference in the out-of-pocket costs you’re exposed to. In 2022, deductibles in CSR-enhanced plans average just $146 for people with income up to 150% FPL, and $756 for those with incomes in the 150-200% FPL range. That’s well below the average deductible for Gold plans ($1,600) and in a different universe from Bronze plans ($7,051).

Perhaps more to the point for our “know your thresholds” mantra, Silver plan deductibles take a major jump at the 200% FPL threshold, to an average of $3,215 for enrollees with income in the 200-250% FPL range.

Equally important is the annual cap on maximum out-of-pocket (MOOP) costs that attaches to plans at different metal levels – and, for Silver plans, at different income levels. Up to 200% FPL, the highest allowable MOOP for Silver plans in 2023 is $3,000. In 2022, MOOP in Silver plans averages $1,208 at incomes up to 150% FPL and $2,591 in the 150-200% FPL range. Again, there’s a big jump at the 200% FPL threshold, to an average of $6,436 at the weakest CSR level.

The median MOOP in 2022 for Gold plans is $7,500, according to the Commonwealth Fund, and $8,500 for Silver with no CSR (close to this year’s maximum allowable, $8,700). Bronze MOOP is comparable to Silver.

Bottom line: Affordable marketplace coverage is far more comprehensive for a single person estimating an income of $27,000 per year – a little under 200% FPL – than for the same person estimating an income of $28,000. The strong CSR available at incomes up to 200% FPL is really valuable.

During the ACA’s annual open enrollment period (Nov. 1 – Jan. 15 in HealthCare.gov states), benefits for the coming year are based on an estimate of future gross (pre-tax) income, modified in some cases by deductions. Those who qualify for a special enrollment period outside of open enrollment also estimate their income for the year in progress.

The estimate may be straightforward adults with one stable job and a fixed salary. For others, including most low-income people, the estimate may involve considerable uncertainty – and therefore allow for wiggle room. That’s the case if you’re paid by the hour, and/or rely in large part on tips, or work more than one job, or are partly or wholly self-employed.

If you underestimate your income and take your full subsidy, in the form of an advance premium tax credit (APTC) used to pay your premiums as they are billed (you can opt to take only a portion of it in advance for this purpose), you will owe the difference between the APTC you received and the APTC to which you prove to have been entitled at tax time in the year following (early 2024 for 2023 coverage). CSR will not be clawed back after the fact. The exchange may reduce your APTC and CSR going forward, however, if outside data sources – such as a regular paycheck – indicate that your income is higher than estimated.

What if you’re hovering near the 100% FPL threshold in a nonexpansion state, or near the 138% FPL threshold in an expansion state and you don’t want Medicaid? There is no downside to a good-faith estimate that errs on the optimistic side. If you live alone and estimate your 2023 gross income at $14,000 (a little over 100% FPL), and eventually, your tax return shows it to have been, say, $12,000, your subsidies will not be clawed back (unless the estimate is made with “intentional or reckless disregard for the facts”).

And while you may be asked as part of the application process to document your income, your estimate will not be disallowed if outside data sources indicate that your real income is lower than estimated. See this post for more tips on making sure that you’re fully accounting for all allowable income sources.

Your income estimate must be made in good faith. But if you have good cause to be genuinely uncertain how much you earn, you are fully within your rights to use your knowledge of the ACA’s income break points to your advantage.

* * *

* One nonexpansion state – Wisconsin – offers Medicaid to adults with income up to 100% FPL, as opposed to the 138% FPL threshold in expansion states. Wisconsin therefore has no “coverage gap” – those who lack affordable access to other insurance are eligible either for Medicaid (up to 100% FPL) or subsidized marketplace coverage (over 100% FPL).

** Alaska and Hawaii have different FPLs, viewable on pages 3-6 here.

*** Washington, D.C. extends Medicaid eligibility to 215% FPL. New York and Minnesota run Basic Health Programs – Medicaid-like low-cost programs – for residents with income in the 138-200% FPL range, as well as for legally present noncitizens who are time-barred from Medicaid eligibility. Connecticut extends Medicaid eligibility to parents with incomes up to 160% FPL.

**** Legally present noncitizens who have been in the U.S. for less than five years are ineligible for Medicaid, but eligible for free Silver marketplace coverage if their income is in the 0-150% FPL range.

Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Digital Media Award. He holds a Ph.D. in English literature from the University of Rochester.