Category: Health Insurance

Periodo de inscripción abierta. Preguntas frecuentes.

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¿Cuándo es el Período de Inscripción Abierta para el Mercado de Seguros Médicos?

El Período de Inscripción Abierta para el Mercado de Seguros Médicos (Healthcare.gov) es del 1 de noviembre de 2025 al 15 de enero de 2026.

¿Todavía hay una multa por no tener seguro médico?

Desde el 1 de enero de 2019, ya no existe una multa por no tener seguro médico.

¿Qué compañías de seguros médicos ofrecerán planes en 2025 en los condados de Mecklenburg, Cabarrus y Union?

Las compañías que ofrecerán planes en los condados de Mecklenburg, Cabarrus y Union son: Ambetter, Blue Cross Blue Shield, Cigna, United Healthcare y Oscar.

Ya tengo cobertura. ¿Cómo puedo prepararme para solicitar cobertura del Mercado en 2026?

Si ya tienes una cuenta en Healthcare.gov, asegúrate de poder iniciar sesión. Si el tamaño de tu hogar o tus ingresos han cambiado, reúne documentación de respaldo, como la declaración de impuestos del año pasado o recibos de pago recientes. Es posible que el Mercado te solicite copias de estos documentos. ¡Ten en cuenta que los planes han cambiado! Puedes programar una cita gratuita con un Navegador para analizar tus opciones y asegurarte de estar inscrito en el mejor plan para ti y tu familia.

¿Qué pasa si no me inscribo?

Si eres elegible y puedes pagar un seguro médico, pero aun así decides no comprarlo, podrías enfrentar altos costos de bolsillo si tienes una emergencia médica o necesitas ver a un médico. Usa la herramienta de comparación en Healthcare.gov para ver los planes disponibles en tu área; puede que tú y tu familia califiquen para subsidios. ¡Tu prima mensual podría ser menor de lo que piensas!

Actualizar tu solicitud del Mercado de Seguros Médicos para 2026 es crucial este año debido a cambios en el Mercado, incluyendo la expiración de créditos fiscales, aumentos en las primas y otros posibles cambios en los planes.

Al actualizar activamente tu solicitud en lugar de permitir que tu plan se renueve automáticamente, puedes evitar costos inesperados y asegurarte de recibir los máximos subsidios para los que calificas.

Es importante completar el proceso de solicitud para conocer tus opciones, ya que hay muchos cambios.

También es posible que ya no seas elegible para los créditos fiscales sobre las primas.

¿Qué debo hacer si un agente o corredor me inscribió en un plan del Mercado sin mi permiso?

La inscripción no autorizada en un plan de salud del Mercado por parte de un agente o corredor—sin tu consentimiento o conocimiento—es un problema serio. Puede causar cargos inesperados, interrupciones en tu acceso a atención médica y consecuencias fiscales.

Esto puede afectarte de las siguientes maneras:

  • Facturas inesperadas: Podrías recibir facturas de primas o sanciones fiscales por una cobertura que no autorizaste.
  • Reembolso de los Créditos Fiscales Anticipados para Primas: Si te inscriben en un plan del Mercado mientras eres elegible para Medicaid o Medicare, no calificas para recibir subsidios que cubran el costo de la prima.
  • Confusión con la cobertura: Puede que no tengas acceso a los médicos o medicamentos que necesitas si el plan no se ajusta a tus necesidades.

Pasos que debes tomar de inmediato:

  • Contacta a uno de nuestros Navegadores para ayudarte a escalar el problema y solicitar la cancelación retroactiva.
  • Reporta el problema al Mercado: Llama al Centro de Llamadas del Mercado al 1-800-318-2596 (TTY: 1-855-889-4325) y explica la situación.
  • Solicita la cancelación o corrección: Pide que se cancele o corrija el plan no autorizado.
  • Presenta una queja contra el agente o corredor: Puedes hacerlo a través del Mercado y/o del Departamento de Seguros de tu estado.
  • Monitorea tu cuenta: Revisa tu cuenta del Mercado para detectar cualquier otra actividad no autorizada.

Protege tu información: Cambia la contraseña de tu cuenta y evita compartir datos personales con agentes no verificados.

Si sospechas de fraude, actúa rápidamente. Cuanto antes lo reportes, más fácil será revertir cualquier daño y proteger tus opciones de cobertura.

¿Puedo simplemente esperar y dejar que mi plan actual se renueve automáticamente?

Aunque estés satisfecho con tu plan y no tengas cambios importantes que reportar (como mudarte a otro estado o cambios en tus ingresos o en el tamaño de tu hogar), aún deberías revisar tu solicitud y asegurarte de que toda tu información esté actualizada. Esto garantiza que estés recibiendo toda la asistencia financiera para la que calificas. También puedes revisar los planes de salud disponibles en tu área. Podrías beneficiarte de un cambio, ¡y no lo sabrás hasta que compares! Puedes hacerlo tú mismo iniciando sesión en tu cuenta de Healthcare.gov o llamando directamente al Mercado al 1-800-318-2596. También puedes hacer una cita con un Navegador para revisar tus opciones —¡llama hoy!

Si tus ingresos o la situación de tu hogar han cambiado, no actualizar tu información podría resultar en que recibas demasiado dinero en pagos anticipados del Crédito Fiscal para Primas. Esto podría obligarte a devolver el exceso cuando presentes tus impuestos del año 2026.

¿Cuándo comenzará mi cobertura si me inscribo o actualizo mi solicitud después del 15 de diciembre de 2025?

Si te inscribes en un plan o actualizas tu solicitud después del 15 de diciembre de 2025, tu nueva cobertura comenzará el 1 de febrero de 2026.

Ya no tengo cobertura, o la perdí durante 2025; ¿cuáles son mis opciones?

Aunque hayas perdido tu cobertura este año, aún podrías calificar para asistencia financiera y puedes inscribirte en un plan de salud accesible para el próximo año. Puedes volver a iniciar sesión en tu cuenta del Mercado, llamar al Mercado o reunirte con un Navegador para comenzar una nueva solicitud para 2026.

Soy elegible para beneficios de salud en el trabajo, pero quiero ver si puedo obtener una mejor oferta en el Mercado. ¿Puedo hacerlo?

Sí, siempre puedes comparar opciones de cobertura en Healthcare.gov, siempre que cumplas con los demás requisitos de elegibilidad. Sin embargo, si tienes acceso a una cobertura médica asequible a través de tu empleador o del empleador de tu cónyuge, es posible que no califiques para subsidios en el Mercado. Es importante tener información sobre la oferta de cobertura de tu empleador cuando completes la solicitud del Mercado. El umbral de asequibilidad para seguros patrocinados por el empleador en 2026 es 9.96% del ingreso anual para el costo de la cobertura familiar.

Tengo COBRA, pero es muy costoso. ¿Puedo cancelarlo durante el Período de Inscripción Abierta e inscribirme en un plan del Mercado en su lugar?

Durante el Período de Inscripción Abierta, puedes inscribirte en un plan del Mercado incluso si ya tienes COBRA. Tendrás que cancelar tu cobertura de COBRA efectiva en la fecha en que comience tu nueva cobertura del Mercado. Sin embargo, después de que finalice el Período de Inscripción Abierta, si cancelas voluntariamente tu cobertura de COBRA o dejas de pagar las primas, no serás elegible para una oportunidad de inscripción especial. Tendrás que esperar hasta el próximo Período de Inscripción Abierta. Solo el agotamiento de tu cobertura COBRA activa una oportunidad de inscripción especial.

¿Cómo puedo saber si mi médico y/o medicamento recetado está dentro de la red de un plan de salud?

Cada plan vendido en Healthcare.gov proporciona un enlace a su directorio de proveedores de salud y a su formulario de medicamentos recetados, para que los consumidores puedan verificar si sus médicos y medicamentos están incluidos.

Actualmente no estoy trabajando. Aunque no tengo ingresos, ¿debería revisar mis opciones de cobertura médica para 2026?

¡SÍ! Aunque no estés trabajando actualmente, la solicitud del Mercado pide información sobre tus ingresos estimados para el próximo año. Por lo tanto, puedes hacer una estimación de tus ingresos potenciales para 2026, incluso si ahora no estás trabajando. Siempre puedes actualizar tus ingresos usando la solicitud del Mercado. Los Navegadores pueden ayudarte a revisar tus opciones. Programa una cita gratuita, en persona o virtual, llamando al 980-256-3782 o visitando ncnavigator.org.

También podrías ser elegible para Medicaid bajo la Expansión de Medicaid en Carolina del Norte. Los Navegadores pueden ayudarte a entender tu elegibilidad y encontrar el mejor plan para ti y tu familia. Haz clic aquí para obtener más información.

¿Qué pasa si necesito ayuda?

Hay Navegadores disponibles en tu área y están aceptando citas, ¡pero anticipamos que se llenarán rápidamente! Como siempre, las citas son gratuitas y están disponibles en horarios convenientes. También hay citas disponibles en ubicaciones accesibles, incluyendo nuestra oficina. Llama al 980-256-3782 o visita ncnavigator.org para programar tu cita hoy.

Cambios importantes en el acceso a la cobertura de salud: Lo que los consumidores deben saber

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Centro de Apoyo legal de Charlotte / Octubre 2025

A partir del presente año, comenzaran cambios importantes en los programas de cobertura de salud del Mercado y Medicaid, mismos que impactaran significativamente a personas de bajos ingresos, comunidades inmigrantes y quienes dependen de programas de asistencia para la cobertura médica en general. Estas reformas son resultado de nuevas regulaciones emitidas por los Centros de Servicios de Medicare y Medicaid (CMS) y de la aprobación de la Ley de Reconciliación Presupuestaria (P.L. 119-21). Los cambios se realizara por fases, comenzando en agosto de 2025 y hasta enero de 2028.

Cambios efectivos a partir del 25 de agosto de 2025

Eliminación del periodo especial de inscripción a las personas de bajos ingresos

Las personas con ingresos inferiores al 150% de la línea de pobreza federal, no serán elegibles para poder inscribirse al mercado de la salud en cualquier momento del año. Este cambio afectara a 1 de cada 2 personas inscritas en 2025.

Prohibición de inscripción al mercado de la salud a las personas beneficiarias del programa DACA

En 2025 las personas beneficiarias del programa DACA pudieron inscribirse en el mercado de la salud. Con los cambios aprobado esta población dejara de ser elegible y los planes activos se cancelarán el 30 de septiembre de 2025.

Menor tiempo para la resolución de inconsistencias en los datos

El periodo de gracia adicional de 60 días para la resolución de la inconsistencia de datos será eliminado por lo que las personas que no resuelvan dichas inconsistencias en los 90 días estipulados originalmente, verán cancelados sus subsidios.

Cambios al Mercado de la salud programados para agosto de 2025 que no entraron en vigor

Cambios al Mercado de la salud programados para agosto de 2025 que no entraron en vigor por estar sujetos a un proceso legal

Autodeclaración de ingresos superiores al 100% del nivel federal de pobreza (FPL)

Se requiere verificación si los ingresos declarados en la solicitud difieren de las fuentes de datos federales.

Primas vencidas

La nueva norma permite a las aseguradoras en todos los estados negar la cobertura para el próximo año a personas con primas no pagadas en cualquier momento en el pasado.

Extensión del monto ‘de minimis’ para los planes

Se modifican los montos “de minimis” que guían la proporción de costos compartidos según el nivel metálico del plan.

Esto permitiría a las aseguradoras ofrecer planes con valores actuariales por debajo del valor estándar.

Cambios al Mercado de la Salud en 2026

Perdida de los créditos fiscales mejorados y regreso del monto total de créditos fiscales mal calculados

A menos que el Congreso actúe, el año 2026 marcará el fin de los subsidios mejorados y el restablecimiento del requisito de reembolso completo por créditos fiscales pagados en exceso. Esto también eliminará el umbral de pago de primas del mercado.

Eliminación de créditos fiscales para ciertas categorías de inmigrantes

Aquellos que no son elegibles para Medicaid debido a su estatus, y que ganan menos del 100% del nivel federal de pobreza (FPL), ahora tampoco serán elegibles para recibir Créditos fiscales para primas.

Atención médica de afirmación de género eliminada como beneficio esencial

Los estados ya no podrán incluir la atención médica de afirmación de género como un Beneficio Esencial de Salud. Si desean seguir ofreciendo este tipo de atención, deberán financiarla directamente.

Eliminación del auto enrollamiento a un plan de categoría plata donde estuviera disponible

Los consumidores ya no serán sujetos a una renovación que priorice su elegibilidad a un seguro de mejor costo en donde estuviera disponible

Incremento en las primas, gastos máximos y gastos compartidos por el cliente debido a cambios en la fórmula utilizada para la estimación de la mimas

El gasto máximo de bolsillo incrementará de $10,150 a $10,600. El costo neto de los premium (después de los créditos fiscales) incrementara en 2.7 por ciento.

reducción de los créditos fiscales basado en una contribución de la cliente esperada mayor (esto aunado a la ya disminución en los montos de créditos fiscales otorgados)

Cambios en el Mercado de la salud que no entraran en vigor el 1 de enero de 2026

Cambios al Mercado de la salud programados para enero de 2025 que no entraran en vigor por estar sujetos a un proceso legal

Verificación estricta para el otorgamiento de un periodo especial de inscripción

Los clientes únicamente contarán con 30 días para compartir evidencia de los cambios de vida tales como matrimonio, nacimiento o cambio de domicilio.

Cuota de $5 dólares por inscripción pasiva

Clientes que sean inscritos de manera pasiva a planes de $0-premium deberán pagar una cuata de 5 dólares, o su plan no será activado.

Reconciliación fiscal del año anterior necesaria para la inscripción en el año próximo (únicamente para 2026)

Las personas que busquen inscribirse en un plan del Mercado de la Salud para 2026 deberán haber realizado ya su reconciliación fiscal para los años 2023 y 2024, ya que, de no hacerlo, no serán aprobados para obtener créditos fiscales en 2026.

Cambios permanente al Mercado de la Salud a partir de 2027-2028

Periodo de inscripción abierta de menor duración

El periodo de inscripción abierta será del 1 de noviembre al 15 de diciembre para la mayoría de los Estados.

Restricciones al acceso a créditos fiscales a ciertos grupos poblacionales

La gran mayoría de inmigrantes con estatus migratorio legal ya no serán elegibles para los subsidios. Las excepciones serán los Residentes Permanentes (Green card). Migrantes COFA y cierto tipo de migrantes provenientes de Cuba y Haiti.

Fata de cumplir con el requisito de estar trabajando

Clientes cuyo Medicaid sea cancelado por no cumplir con los requisitos de estar trabajando serán no elegibles para subsidios en el Mercado de la Salud.

Mayores barreras para mantener la cobertura

A partir de 2028, la inscripción automática y la continuación de los subsidios serán cancelados por lo que los usuarios deberán reaplicar y volver a enviar todos sus documentos para verificación.

Reformas al programa Medicaid. Efectivas a partir del 2026

El programa Medicaid también sufrirá cambios significativos en su estructura y procesos de elegibilidad:

A partir de octubre de 2026

  • La definición de migrante calificado se hará más pequeña
    Aunque el proyecto de ley de conciliación HR1 no modifica en sentido estricto la definición de inmigrantes calificados, elimina los fondos federales de correspondencia de Medicaid para todas las categorías distintas de residentes permanentes legales (LPR), ciudadanos estadounidenses (USC) y migrantes del Acuerdo de Libre Asociación (COFA). No cambia la normativa sobre la opción estatal para garantizar cobertura a personas embarazadas y niños menores.        

A partir de enero de 2027

  • Requisito de trabajo para las personas adultas en Medicaid expansión
    Las personas adultas entre las edades de 19 y 64, y con el Medicaid en la categoría de expansión, deberán reportar estar trabajando o realizando actividades elegibles por al menos 80 horas al mes
  • Menor temporalidad para la cobertura retroactiva
    La cobertura retroactiva pasara de 3 meses a un mes para los adultos en expansión, y a dos meses para el resto de las categorías.
  • Recertificación de elegibilidad cada 6 meses
    En vez del requisito de recertificación anual, estas deberán ser de manera semestral.

Comenzado el 1 de octubre de 2028

  • Nuevos requisitos de costos compartidos
    Las personas adultas inscritas en la expansión con ingresos entre el 100% y el 138% de la FPL serán sujetos del pago de hasta $35 por servicio, con algunas excepciones.

¿Qué deben hacer los consumidores?

Para continuar con su seguro y evitar posibles problemas los clientes deben:

  • Leer y responder las notificaciones enviadas por el Mercado de la Salud y por las oficinas de Medicaid
  • Mantener actualizada la información de ingresos y tamaño del hogar
  • Reportar sus impuestos incluyendo las reconciliaciones de los créditos fiscales obtenidos
  • Pagar sus premium en tiempo y forma o buscar asistencia
  • Hacer una cita con un nevegador cercano para enterder los nuevos cambios y requerimientos

2026 Health Insurance Marketplace Open Enrollment FAQ

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When is Open Enrollment for the Health Insurance Marketplace? 

Open Enrollment for the Health Insurance Marketplace (Healthcare.gov) runs from November 1, 2025, to January 15, 2026. 

Is there still a penalty for not having health insurance? 

Effective January 1, 2019, there is no longer a penalty for not having health insurance. 

Which health insurance companies will be offering plans in 2025 in Mecklenburg, Cabarrus, and Union counties? 

The plans offered for Mecklenburg, Cabarrus, and Union Counties are Ambetter, Blue Cross Blue Shield, Cigna, United Healthcare, and Oscar 

I already have coverage. How can I get ready to apply for 2026 Marketplace health coverage? 

If you already have a Healthcare.gov account, make sure you can log in. If your household size or income has changed, gather supporting documentation, such as last year’s tax returns or recent pay stubs. You may be required to provide copies of these documents to the Marketplace. Please note plans have changed! You can schedule a free appointment with a Navigator to discuss your options and make sure you are enrolled in the best plan for you and your family. 

What happens if I don’t sign up? 

If you can afford health insurance but choose not to buy it, you may face high out-of-pocket costs if you have a medical emergency or need to visit a doctor. Use the window-shopping tool on Healthcare.gov to see the plans available in your area; financial assistance may be available to you and your family. Your premium may be less than you think! 

Updating your Health Insurance Marketplace application for 2026 is crucial this year due to changes with the Marketplace, including the expiration of tax credits, premium increases, and other potential changes to plans.   

  • By actively updating your application instead of having your plan auto-renewed, you can avoid unexpected costs and ensure you receive the maximum financial assistance you qualify for.   
  • It is important to go through the application process to learn your options because there are so many changes 
  • You may no longer be eligible for premium tax credits 

What should I do if an agent or broker enrolled me in a Marketplace plan without my permission? 

Unauthorized enrollment in a Marketplace health plan by an agent or broker—without your consent or knowledge—is a serious issue. It can lead to unexpected premium charges, disruption of your healthcare access, and Tax implications. 

Here’s how it can affect you: 

  • Unexpected bills: You might receive premium invoices or tax penalties for coverage you didn’t authorize. 
  • Repayment of the Advance Premium Tax Credits: Being enrolled in a Marketplace plan while you are eligible for Medicaid or Medicare will not make you eligible to receive subsidies to cover your premium amount for a health insurance plan.  
  • Coverage confusion: You may not be able to access the doctors or prescriptions you need if the plan doesn’t match your needs. 

Steps to take immediately: 

  1. Contact one of our Navigators to help you navigate your escalation and retroactive cancellation.  
  1. Report the issue to the Marketplace: Call the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) and explain the situation. 
  1. Request a termination or correction: Ask to have the unauthorized plan canceled or corrected. 
  1. File a complaint against the agent or broker: You can do this through the Marketplace and/or your state’s Department of Insurance. 
  1. Monitor your account: Check your Marketplace account for any other unauthorized activity. 
  1. Protect your information: Change your account password and avoid sharing personal details with unverified agents. 

If you suspect fraud, act quickly. The sooner you report it, the easier it is to reverse any damage and protect your coverage options. 

Can I just wait and have my current plan automatically renewed? 

Even if you’re happy with your plan and you don’t have any life changes to report (like moving to a new state or changes in your income or household), you should still go back through the application and make sure all your information is up to date to ensure that you are receiving all the financial assistance you are eligible for. You can also check the health plans available in your area. You might benefit from a change, and you never know until you compare. You can do this yourself by logging into your Healthcare.gov account or by calling the Marketplace directly at 1-800-318-2596. You can also make an appointment with a navigator to go over your options —call today! 

If your income or household situation has changed, failing to update your information could result in receiving too much in Advance Premium Tax Credit payments. This could force you to pay back the excess amount when you file your 2026 taxes.  

When will my coverage start if I enroll or update my application after December 15, 2025? 

If you enroll in a plan or update your application after December 15, 2025, your new coverage will start on February 1, 2026. 

I no longer have coverage, or I lost coverage during 2025; what are my options? 

Even if you lost coverage this year, you may still qualify for financial assistance and can enroll in an affordable health plan for next year. You can log back into your Marketplace account, call the Marketplace, or meet with a navigator to start a new 2026 application. 

I am eligible for health benefits at work, but I want to see if I can get a better deal on the Marketplace. Can I do that?  

Yes, you can always shop for coverage on  Healthcare.gov, assuming you meet other eligibility requirements. However, if you have access to affordable job-based coverage through your employer or your spouse’s employer, you may not qualify for financial assistance in the Marketplace. It is important to have information about your employer coverage offer when you complete a Marketplace application. The Employer-Sponsored Insurance Affordability threshold for 2026 is 9.96% of annual income for the Cost of Family coverage. 

I have COBRA, but it’s too expensive. Can I drop it during Open Enrollment and enroll in a Marketplace plan instead? 

During Open Enrollment, you can sign up for a Marketplace plan even if you already have COBRA. You will have to drop your COBRA coverage effectively on the date your new Marketplace plan coverage begins. After Open Enrollment ends, however, if you voluntarily drop your COBRA coverage or stop paying premiums, you will not be eligible for a special enrollment opportunity. You will have to wait until the next Open Enrollment period. Only exhaustion of your COBRA coverage triggers a special enrollment opportunity. 

How can I find out if my doctor and/or prescription medication is in a health plan’s network?  

Each plan sold on Healthcare.gov provides a link to its health provider directory and prescription drug formulary so consumers can find out if their health providers and medications are included. 

I am not currently working. Although I do not have income, should I still review my healthcare options for 2026? 

YES! Although you are not currently working, the Marketplace application asks for information about your anticipated income for the following year. Therefore, you can estimate your potential income for 2026 even if you are not working right now. You can always update your income using the Marketplace application. Navigators can walk you through your options. Schedule a free appointment, in person or virtually, by calling 980-256-3782 or going online to ncnavigator.org 

You may also be now eligible for Medicaid under Medicaid Expansion in North Carolina. The Navigators will be able to assist you in understanding your eligibility and finding the best plan to fit your needs and protect you and your family. Click here to learn more. 

What if I need help? 

Navigators are available in your area and taking appointments, but we anticipate that appointments will fill up quickly! As always, appointments are free and available at convenient times. Appointments are available at convenient locations, including our office. Walk-in times for self-help and the computer lab are also available at our office on Saturdays, 9:30 am-2:00 pm. Call 980-256-3782 or visit ncnavigator.org to schedule an appointment today. 

Major Changes Coming to Health Coverage Access: What Consumers Need to Know

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Major Changes Coming to Health Coverage Access: What Consumers Need to Know 

Charlotte Center for Legal Advocacy | October 2025 

Important changes to both Marketplace and Medicaid health coverage programs are scheduled to begin this year, significantly impacting low-income individuals, immigrant communities, and those who rely on coverage assistance programs. These reforms are the result of recent regulations from the Centers for Medicare & Medicaid Services (CMS) and the passing of the Budget Reconciliation Bill (P.L. 119-21). The changes will take effect from August 2025 through 2028. 

Key Marketplace Changes – Effective August 25, 2025 

  1. Elimination of Low-Income Special Enrollment Period (SEP) 
    Consumers earning under 150% of the Federal Poverty Level (FPL) will no longer be able to enroll year-round. This change affects nearly 47% of 2025 enrollees. 
  1. Marketplace Ban on DACA Recipients 
    DACA recipients newly eligible for coverage in 2025 will be barred from coverage and have their plans terminated as of September 30th, 2025. 
  1. Less Time for Data Matching 
    The additional 60-day grace period for resolving income inconsistencies is eliminated. Failure to resolve within 90 days will result in the end of subsidies. 

Marketplace Changes – Did not take effect on August 25, 2025 

Changes enacted on August 25, 2025, that have been stayed by the litigation in the court system 

  1. Self-Attestation to income above 100% FPL 

Verification required if attested income on the application differs from federal data sources 

  1. Past-due premiums 

The new rule allows insurers in all states to deny coverage for an upcoming year to individuals with unpaid premiums at any point in the past. 

  1. Extending the ‘de minimis’ amount for plans 

Changes “de minimis” amounts guiding the plan’s metal level out-of-pocket cost share. 

Would allow insurers to offer plans with actuarial values below the standard value.  

Marketplace Changes Coming in 2026 

  • Loss of Enhanced PTCs & Return of Full Repayment Rules: 
    Unless Congress acts, 2026 marks the end of enhanced subsidies and the reinstatement of full repayment requirements for overpaid tax credits. This will eliminate the marketplace premium payment threshold as well. 
  • Eliminates APTCs’ repayment caps 

Starting in tax year 2026, households with incomes higher than their projected income or those who are otherwise ineligible for the premium tax credit will have to repay all excess PTCs they received.  

  • Elimination of PTCs for Certain Immigrants: 
    Those not eligible for Medicaid due to status, and earning below 100% FPL, will now be denied Premium Tax Credits. 
  • Gender-Affirming Care Removed as Essential Benefit: 
    States will no longer be able to include gender-affirming care as an Essential Health Benefit. States must fund this care directly if they wish to continue offering it. 
  • Eliminates automatic re-enrollment in a Silver plan where available: 
    Consumers won’t be automatically moved to lower-cost plans even if one is available. 
  • Increase in plan premiums, Out-of-Pocket Maximums, and consumer cost sharing (due to changes in formula): 

MOOP for 2026 plans will increase from $10,150 to $10,600.  Net premiums (after APTC) will increase by 2.7 percent. 

Reduced PTCs based on higher expected consumer contribution % (this is on top of the end of enhanced PTCs).  

Marketplace Changes – Will not take effect on January 1, 2026 

Changes are suspended due to litigation in the court system, and we are expecting a final ruling 

  • Stricter Special Enrollment Verification: 
    Consumers will have just 30 days to submit proof of life changes like marriage, birth, or moving. 
  • $5 Passive Enrollment Fee: 
    Consumers re-enrolled passively into a $0-premium plan must pay a fee or their plan won’t activate. 
  • Re-instates one-year failure to reconcile PTCs (for plan year 2026 only) 

This means that those enrolling in the Marketplace plan for 2026 must reconcile their PTCs for both 2023 and 2024 tax years; otherwise, they will not be approved for 2026 PTCs. 

Permanent Marketplace Changes in 2027–2028 

  • Shortened Open Enrollment Period: 
    Open enrollment will now run only from Nov. 1 – Dec. 15 in most states. 
  • Immigration-Based PTC Restrictions: 
    Most lawfully present immigrants lose eligibility for subsidies, with exceptions for Legal Permanent Residents, COFA migrants, and Cuban-Haitian Entrants. 
  • Work Requirement Impact: 
    Consumers disenrolled from Medicaid for not meeting work requirements will also be ineligible for Marketplace subsidies. 
  • Higher Burdens to Maintain Coverage: 
    From 2028, auto-reenrollment and subsidy continuation will require active reapplication and complete documentation verification. 

Medicaid Program Reforms – Effective 2026 Onward 

The Medicaid program will also undergo significant structural and eligibility changes: 

Starting October 1, 2026: 

  • Narrowed Definition of “Qualified Immigrant”: 
    While the HR1 reconciliation bill does not change the definition of qualified immigrants, it ends federal Medicaid matching funds for all categories other than LPRs, USC, and COFA migrants. Does not change the rule around the state option to ensure pregnant people and minor children.  

Starting January 1, 2027: 

  • Work Requirements for Expansion Adults: 
    Adults ages 19–64 in the expansion category must report at least 80 hours/month of work or qualifying activity. 
  • Shortened Retroactive Coverage Window: 
    Retroactive eligibility was reduced to 1 month for expansion adults and 2 months for others. 
  • Eligibility Redeterminations Every 6 Months 
    Replacing the current annual review. 

Starting October 1, 2028: 

  • New Cost Sharing Requirements: 
    Expansion adults with incomes between 100–138% FPL will be subject to up to $35 per service, with some key exemptions. 

What Should Consumers Do? 

To stay covered and minimize disruptions, individuals should: 

  • Read and respond to notices from the Marketplace and Medicaid offices. 
  • Actively update income and household information. 
  • File taxes and reconcile Premium Tax Credits. 
  • Pay premiums on time or seek assistance. 

Get help from Navigators to understand changes and requirements. 
 

Our Health Insurance Navigators Are Leading the Way in Healthcare Access, and Now They’re Award-Winning

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At Charlotte Center for Legal Advocacy, we know that access to healthcare changes lives—and so does the dedication of the people who help make that access possible.

As a part of the North Carolina Navigator Consortium, our federally certified Health Insurance Navigators provide free, unbiased assistance to individuals and families who need help navigating health insurance options under the Affordable Care Act (ACA), along with Medicaid and other federal and state programs.

Advocacy Center Navigators Honored with Statewide Award for Impact on Healthcare Enrollment

In March, our Health Insurance Navigators received the Consortium Member Impact Award from the NC Navigator Consortium. This recognition celebrates the Navigators’ exceptional contributions to public health through their work supporting Affordable Care Act (ACA) and Medicaid enrollment efforts across North Carolina.

The award was presented during a special gathering in Raleigh that marked two major milestones: the 15th anniversary of the ACA and the enrollment of more than 640,000 North Carolinians in Medicaid expansion. Navigators from across the state joined community partners and fellow advocates to celebrate these achievements.

Advocacy Center Navigators Recognized at Assister Appreciation Event

In April, two Advocacy Center Health Insurance Navigators received top honors at the North Carolina Annual Assister Appreciation Event in Greensboro.

Tanja Pauler was named Navigator of the Year. This award goes to a Navigator who has shown exceptional dedication and outstanding service throughout the year, continuously going above and beyond to help our communities navigate the healthcare system and access health coverage. 

Natalie Marles, Health Insurance Navigator Project Manager, shared:

Since joining the CCLA team in 2022, Tanja has been an incredible addition to our team in the constantly changing world of access to healthcare. Her dedication, expertise, and strong integrity have raised the bar for what it means to advocate for those trying to navigate the often-tricky world of health coverage. Tanja has tackled some of the toughest challenges in our field, especially those involving agent and broker fraud and the complexities of Medicaid eligibility during the expansion. These are not easy topics to navigate; they demand a deep knowledge of policy, attention to detail, and a heartfelt commitment to clients’ well-being. Tanja brings all of this—and so much more—every single day. Her clients see her as not just a Navigator, but as a trusted friend and advocate. Her colleagues think of her as a go-to resource, a collaborative partner, and a caring presence. We all know her work has made a real impact on the lives of many people. Tanja, your professionalism, compassion, and tireless commitment to helping your clients embody the spirit of this award.

Natalie Marles was honored as the Health Access Champion, a recognition reserved for those who go above and beyond in their efforts to ensure North Carolinians can access vital healthcare services and coverage. Natalie’s leadership has been critical in supporting our team and driving impact across the region.

Julieanne Taylor, Interim Director of the Family Support & Health Care Program, said:

Since becoming the Navigator Program Manager at the Advocacy Center, Natalie has worked tirelessly with her team to reach as many North Carolinians as possible to ensure they have access to healthcare. Natalie’s passion for helping others is evident in her fearlessness to fight for immigrant families and those who are underserved in our community. Natalie is a trusted community leader and has cultivated relationships with countless partner organizations across North Carolina to expand her impact in the healthcare arena. Natalie has hosted Health & Human Services Secretary Xavier Becerra, Vice President Kamala Harris, and has been recognized by Former NC Governor Roy Cooper for her Medicaid Expansion efforts. Natalie is beyond deserving of this honor and we are so proud of the incredible work she does everyday. Congratulations, Natalie!!

We are so proud of both Tanja and Natalie and grateful for the dedication they bring to this work. Their commitment makes a difference every single day.

If you or someone you know needs help understanding their health coverage options, our team is here to help.

Call 980-256-3782 or visit www.ncnavigator.org to schedule a free appointment.

Norma’s Story

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Norma is a passionate entrepreneur who poured her heart into starting her own business, Pan Dulce/Conchas, bringing the warmth of traditional Mexican bread to her community. But turning her dream into reality came at a cost—she had to leave her full-time job, losing the health insurance that came with it.

For two long years, Norma faced an agonizing choice: prioritize her health or keep her business afloat. Every doctor’s visit, every prescription, and every follow-up appointment with specialists came straight out of her pocket. She often delayed care, hoping minor issues wouldn’t turn into something worse.

Then, in 2024, everything changed. Norma learned that as a Deferred Action for Childhood Arrivals (DACA) recipient, she was finally eligible for health insurance. While some states cruelly blocked this new opportunity, North Carolina did not.

Health Insurance Navigator Rodrigo Medinilla Corzo helped Norma with the sign-up process. He states: “Our job as navigators is to help you invest your time in the projects you are passionate about and reduce the risks of a financial collapse due to illness or accident.”

For the first time in years, Norma could breathe easier—knowing she wouldn’t have to choose between her health and her livelihood.

“Knowing that I have health insurance gives me the confidence to keep working to grow my business,” Norma shares.

Now, with the security of health coverage, Norma can focus on what she does best: growing her business, serving her community, and creating a better future for herself and others.

Advocacy Center Health Insurance Navigators Recognized With Consortium Member Impact Award

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This week, we had the privilege of joining the NC Navigator Consortium, alongside community partners and advocates, to celebrate two incredible milestones: 15 years of the Affordable Care Act (ACA) and more than 640,000 North Carolinians enrolling in Medicaid Expansion. These achievements mark significant progress in expanding access to quality, affordable health coverage across our state.

At the event, we were honored to receive the Consortium Member Impact Award from the NC Navigator Consortium. This award recognizes our Health Insurance Navigator‘s outstanding achievements in promoting public health by advancing Affordable Care Act and Medicaid enrollment across North Carolina.

Need Health Insurance? We Can Help!

If you have questions about Medicaid eligibility or Marketplace enrollment, our Health Insurance Navigators are here to guide you through the process—for free!

Schedule an appointment with a local Navigator:
📞 980-256-3782
🌐 ncnavigator.org

Medicaid in NC: What You Need to Know

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Ver información en Español 

Medicaid is a federal and state-funded health insurance program that provides full coverage for some vulnerable low-income North Carolinians. It improves access to healthcare and health outcomes for North Carolinians by increasing access to primary care providers, regular checkups, preventative care, and care for chronic conditions.

There are many different types or categories of Medicaid, each with its own income limits compared to the federal poverty line (FPL). Medicaid expansion is the newly implemented program in the state of North Carolina, covering adults aged 19-64 who meet the income requirements. This expands coverage to college students, working parents, childless adults, and more.

Have questions or think you may be eligible? Make a free appointment with a Health Insurance Navigator at Charlotte Center for Legal Advocacy Call 980-256-3782 or visit the website ncnavigator.org to schedule your free phone appointment today!

  • On March 27, 2023, Governor Cooper signed the Medicaid Expansion into law.
  • NC is the 41st state to expand Medicaid (Including the District of Columbia)
  • As March 2025, more than 630,000 people have enrolled in Medicaid Expansion

Who will be able to get health coverage through NC Medicaid?

Most people can get health care coverage through NC Medicaid if they meet the criteria below. If you were eligible before, you still are. Eligibility criteria:

  • You live in North Carolina
  • Age 19 through 64
  • You are a citizen (some non-U.S. citizens can get health coverage through NC Medicaid)
  • If your household income fits within the following chart:

Click here for a Medicaid PDF with more information.

What should I do?

To apply contact your local DSS office or schedule a free appointment with a Health Insurance Navigator by calling 980-256-3782 or visiting www.ncnavigator.org.

  • Contact your local DSS office to make sure they have your current mailing address, phone number, email, and other contact information.
    • Local DSS Offices:
      • Mecklenburg County
        • 704-336-3000
        • Wallace H. Kuralt Centre, 301 Billingsley Road, Charlotte, NC 28211
        • Community Resource Center, 3205 Freedom Drive, Charlotte, NC 28208
      • Union County
        • 704-296-4300
        • 2330 Concord Avenue Monroe, NC 28110
      • Cabarrus County
        • 704-920-1400
        • 1303 S. Cannon Blvd. Kannapolis, NC 28083
  • Watch for mail, texts, or phone calls from DSS and respond promptly. 
  • Create an enhanced E-Pass account (https://epass.nc.gov):
    • View your benefits,
    • Upload documents supporting any changes, like income or household size,
    • Update your information online

If you are denied and think it is wrong, we may be able to help. Call 704-376-1600 (select public benefits option) or make an appointment online.

You have the right to:

You have the right to appeal.

If you believe there has been an error, you can appeal that decision. You have 60 days (about 2 months) from the date of the notice to ask for an appeal. If you do so within 10 business days, you can request that your Medicaid be continued while the appeal is reviewed. Call 704-376-1600 and press 2 (public benefits) for more information or make an appointment online.

Special Enrollment Periods (SEP) are available for Medicare and Marketplace coverage. 

Individuals who are no longer eligible for Medicaid may be eligible to enroll in Medicare or Marketplace coverage with a special enrollment period.

Health Insurance Navigators

NC Seniors’ Health Insurance Information Program (SHIIP)

  • SHIIP counselors offer free and unbiased information regarding Medicare health care products and eligibility
  • 1-855-408-1212

Free legal assistance may be available.

If you think your Medicaid was wrongfully reduced or terminated, call 704-376-1600 and press 2 (public benefits) or make an appointment online.

For more helpful resources, visit NCMedHelp.org.

U.S. Court Ruling Blocks Marketplace Access for DACA Recipients in Some States – No Impact in North Carolina

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Charlotte, N.C. – A Dec. 9, 2024, federal court decision blocked access to the Health Insurance Marketplace® for DACA recipients living in states that challenged a Biden administration ruling earlier this year making them eligible; the Dec. 9 court decision does not apply to N.C. This means that DACA recipients and other lawfully present immigrants who reside in N.C. can still access affordable health insurance via the HealthCare.gov Marketplace. The Charlotte Center for Legal Advocacy (Advocacy Center) is part of the NC Navigator Consortium; their health insurance navigators are standing by to help residents of Cabarrus, Mecklenburg and Union Counties get covered via HealthCare.gov or N.C. Medicaid.

“To reiterate, this ruling does not impact any eligible North Carolina resident who wants to use the Marketplace to find a high-quality health plan that is affordable,” said Natalie Marles, the health insurance navigator project manager for the Advocacy Center. She added that DACA recipients and eligible immigrant groups are also eligible for financial assistance and subsidies.

As for the future of the Affordable Care Act, Marles added, “Even though this recent ruling has national implications for the future, it will not affect North Carolina residents for this Open Enrollment period or the coverage that they have enrolled in or will secure for 2025.”

These groups are also eligible for a special enrollment period (SEP) that enables them to secure coverage quicker. According to the Centers for Medicare & Medicaid Services (CMS):

“Newly eligible individuals, including DACA recipients, will qualify for a special enrollment period to enroll in a QHP through the Marketplace during the 60 days following November 1, 2024 … Consumers who apply for coverage through a SEP during December 2024 can have their Marketplace coverage begin as early as January 1, 2025, if they meet all other eligibility requirements.” This means those who enroll by Dec. 31, 2024, can get coverage that starts Jan. 1, 2025, or Jan. 15, 2025, to start coverage in February 2025 or even beyond.

For those not included in the SEP, the current HealthCare.gov Open Enrollment period will run through Jan. 15, 2025. Those looking to start coverage on Jan. 1, 2025, will need to enroll before this Sunday, Dec. 15, 2024. 

During Open Enrollment, health insurance navigators at the Advocacy Center work directly with everyone eligible in Cabarrus, Mecklenburg and Union Counties to help them save money on high quality, affordable health insurance plans on the HealthCare.gov Health Insurance Marketplace. (Navigators also help those eligible enroll in NC Medicaid.) HealthCare.gov Open Enrollment will run Nov. 1, 2024, through Jan. 15, 2025. More information is available at charlottelegaladvocacy.org/getcovered.

As a member of the NC Navigator Consortium, Charlotte Center for Legal Advocacy navigators are available to provide free, unbiased advice to residents of Cabarrus, Mecklenburg and Union Counties. Navigators are federally certified and extensively trained in the insurance plan options offered by the Marketplace, in addition to cost-sharing reductions and premium tax credits eligibility. Additional assistance is provided to consumers who are disabled, do not speak English or are unfamiliar with health insurance.

Free appointments with a local navigator can be made using the statewide appointment hotline at 1-855-733-3711 or local at 980-256-3782 or online at charlottelegaladvocacy.org/getcovered. 

Charlotte Center for Legal Advocacy can provide those in need with information, advice and advocacy in consumer protection, home preservation, health care access and public benefits, immigration, tax assistance and more. Our mission is to pursue justice for those in need. Our vision is to build a just community, where all people are treated fairly and have access to legal representation to meet their basic human needs of safety, economic security and stability. Learn more: charlottelegaladvocacy.org. 

Started in 2014, the NC Navigator Consortium is the only federally funded Navigator entity in the state that serves all 100 counties across North Carolina. Learn more at ncnavigator.org, and follow us on Facebook, Twitter and Instagram. Members of the Consortium are Access East, Care Ring, CareReach, Charlotte Center for Legal Advocacy, Council on Aging of Buncombe County, Cumberland HealthNET, HealthNet Gaston, Kintegra Health, Mountain Projects, NC Field and Pisgah Legal Services. The Consortium is led by Legal Aid of North Carolina. 

Legal Aid of North Carolina is a statewide, nonprofit law firm that provides free legal services in civil matters to low-income people in order to ensure equal access to justice and to remove legal barriers to economic opportunity. Learn more at legalaidnc.org. Follow us on Facebook, Twitter, Instagram, LinkedIn and YouTube. 

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HealthCare.gov Open Enrollment 2025 Kickoff Press Conference Highlights New Insurance Marketplace Ruling for Daca Recipients

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Charlotte, N.C. – HealthCare.gov Open Enrollment 2025 kicked off today with a press conference in Charlotte hosted by Charlotte Center for Legal Advocacy (Advocacy Center) and the NC Navigator Consortium with experts who explained the final rule that allows DACA recipients and other immigrant groups to purchase health insurance through HealthCare.gov. The event also included guest speaker Endy Mendez who is a DACA recipient and health insurance navigator working for the NC Navigator Consortium in Winston-Salem, N.C. After the press conference, navigators helped consumers enroll in and update their HealthCare.gov plans.

During Open Enrollment, health insurance navigators at the Advocacy Center work directly with everyone eligible in Cabarrus, Mecklenburg and Union Counties to help them save money on high quality, affordable health insurance plans on the HealthCare.gov Health Insurance Marketplace®. (Navigators also help those eligible enroll in NC Medicaid.) HealthCare.gov Open Enrollment will run Nov. 1, 2024, through Jan. 15, 2025. More information is available at charlottelegaladvocacy.org/getcovered.

“November 1 marks an important milestone for DACA recipients and many more people who are called ‘lawfully present immigrants’,” said Natalie Marles, the health insurance navigator project manager for the Advocacy Center. “Not only will they have access to healthcare, they may qualify for premium tax credits and other savings on Marketplace plans.”

According to HealthCare.gov: “The term ‘lawfully present’ includes immigrants who have:

  • ‘Qualified non-citizen’ immigration status.
  • Humanitarian statuses or circumstances (including Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, and victims of trafficking).
  • Valid non-immigrant visas.
  • Legal status conferred by other laws (temporary resident status, LIFE Act, Family Unity individuals).”

“More than 20,000 DACA recipients reside in North Carolina according to U.S. Citizenship and Immigration Services, and because of the new rule, they are now eligible for Marketplace plans,” said Marles. “These North Carolinians are your friends, neighbors and coworkers.”

“I am a DACA recipient myself and am currently struggling with renal failure,” said Mendez, a dedicated advocate for the immigrant community in Forsyth and Guilford Counties, N.C. “The lack of access to (the Affordable Care Act) had a huge impact in my life last year.” Mendez has been a health insurance navigator since July 2024, helping others gain access to affordable health coverage. 

“There are still many subsidies and tax credits available through HealthCare.gov, and four out of five families can get coverage for less than $10 a month,” said Nicholas Riggs, director of the NC Navigator Consortium. “It’s important to remember that those who are eligible for NC Medicaid can also use our health insurance navigators to learn more and enroll.”

As a member of the North Carolina Navigator Consortium, Charlotte Center for Legal Advocacy navigators are available to provide free, unbiased advice to residents of Cabarrus, Mecklenburg and Union Counties. Navigators are federally certified and extensively trained in the insurance plan options offered by the Marketplace, in addition to cost-sharing reductions and premium tax credits eligibility. Additional assistance is provided to consumers who are disabled, do not speak English or are unfamiliar with health insurance.

Free appointments with a local navigator can be made using the statewide appointment hotline at 1-855-733-3711 or local at 980-256-3782 or online at charlottelegaladvocacy.org/getcovered. 

Charlotte Center for Legal Advocacy can provide those in need with information, advice and advocacy in consumer protection, home preservation, health care access and public benefits, immigration, tax assistance and more. Our mission is to pursue justice for those in need. Our vision is to build a just community, where all people are treated fairly and have access to legal representation to meet their basic human needs of safety, economic security and stability. Learn more: charlottelegaladvocacy.org.

Started in 2014, the NC Navigator Consortium is the only federally funded Navigator entity in the state that serves all 100 counties across North Carolina. Learn more at ncnavigator.org, and follow us on Facebook, Twitter and Instagram. Members of the Consortium are Access East, Care Ring, CareReach, Charlotte Center for Legal Advocacy, Council on Aging of Buncombe County, Cumberland HealthNET, HealthNet Gaston, Kintegra Health, Mountain Projects, NC Field and Pisgah Legal Services. The Consortium is led by Legal Aid of North Carolina. 

Legal Aid of North Carolina is a statewide, nonprofit law firm that provides free legal services in civil matters to low-income people in order to ensure equal access to justice and to remove legal barriers to economic opportunity. Learn more at legalaidnc.org. Follow us on Facebook, Twitter, Instagram, LinkedIn and YouTube. 

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