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
- 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.
- 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.
- 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
- Self-Attestation to income above 100% FPL
Verification required if attested income on the application differs from federal data sources
- 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.
- 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.
