What’s Changing in 2026: A Consumer’s Guide to Marketplace & State-Based Health Insurance

August 19, 2025

Big changes are coming in 2026 for people who use Healthcare.gov or a state-based health insurance exchange. These updates will impact eligibility, premium assistance, and how you stay enrolled. If you rely on the Marketplace for affordable coverage, here’s what you need to know and how to prepare.

Loss of Enhanced Premium Tax Credits

The extra help many people have been receiving to lower monthly premiums, known as enhanced premium tax credits (ePTCs), is set to end after 2025. These subsidies, expanded under federal relief laws, made more people eligible and capped premium costs at 8.5% of income. Without Congressional action, premiums will rise for millions of Americans, with some seeing increases of 75% or more. The Congressional Budget Office estimates that approximately 4.2 million people could lose coverage as a result.


Stricter Enrollment & Eligibility Rules

New rules beginning in 2026 will make enrollment more difficult for many. Low-income households under 150% of the federal poverty level will no longer have access to year-round enrollment through Special Enrollment Periods (SEPs); instead, they’ll be limited to the standard open enrollment window or qualifying life events. Income verification will also tighten, applicants must now submit proof of income during enrollment or renewal and respond within 90 days, ending the previously available 60-day extension. Auto-renewal will also no longer be available for subsidized enrollees; if you don’t confirm your information, you could lose your financial assistance and be enrolled in a $5/month basic plan by default for members with $0 premium. And if your reported income doesn’t match IRS records, you’ll be required to justify your estimate or risk denial of coverage. These changes are meant to improve program integrity, but they also increase the paperwork and deadlines consumers must manage. Using an agent can be even more important in understanding and navigating the enrollment process.


Changes for DACA Recipients

As of 2026, individuals with Deferred Action for Childhood Arrivals (DACA) status will no longer be considered “lawfully present” for the purpose of enrolling in Marketplace coverage or receiving subsidies. This reverses a 2024 rule that expanded access and will impact roughly 10,000 people nationwide who currently rely on Marketplace insurance.


End of APTC Repayment Caps

Another major shift for 2026 is the removal of the cap on repaying excess Advanced Premium Tax Credits (APTC). In the past, if your income ended up higher than expected, your repayment was limited based on your income level. That protection is going away. Starting in 2026, if you miscalculate and receive more tax credits than you’re entitled to, you’ll have to repay the full amount, no matter your income level. This makes accurate income estimates and midyear updates even more critical.


Revised Open Enrollment Period

The open enrollment window for 2026 will run from November 1, 2025 through January 15, 2026, giving consumers around 10 weeks to select or renew their plans. However, starting in 2027, that window will likely shrink. Federally-facilitated Marketplaces are expected to reduce open enrollment to just six weeks (November 1 to December 15), while most state-based exchanges may adopt slightly longer timelines.


Expanded Access to Health Savings Accounts (HSAs)

There is good news for some consumers, beginning in 2026, many more Marketplace plans will become HSA-eligible. Specifically, bronze and catastrophic plans will now qualify as High-Deductible Health Plans (HDHPs), meaning you can open and contribute to a Health Savings Account. HSAs let you save money tax-free for qualified medical expenses, providing added flexibility and financial benefits.


Updated Cost-Sharing Limits

Out-of-pocket maximums are increasing as well. For 2026, the most you’ll have to pay for covered medical expenses in a year will rise to $10,600 for individuals and $21,200 for families. These limits are adjusted annually to reflect changes in healthcare costs and inflation, and they could impact budgeting for anyone who uses a high-deductible plan.


How These Changes Affect You

Whether you enroll through Healthcare.gov or a state-based exchange like Georgia Access, these federal rules apply across the board. Some states may offer their own subsidies or support programs, but the most significant policy shifts, such as tighter verification, reduced enrollment flexibility, and the loss of financial protections, will be nationwide. State-based exchanges may try to ease the transition with better outreach and resources, but the burden will ultimately fall on consumers to stay informed and meet new requirements.


What You Can Do to Prepare

If you use Marketplace coverage, take these steps to protect yourself. First, estimate your income carefully when applying. Without a repayment cap, underestimating can lead to a large tax bill. Be sure to update your income midyear if your financial situation changes. Second, gather and submit your verification documents on time. You’ll likely need to provide proof of income, immigration status, or other eligibility criteria more quickly than before. Third, don’t rely on automatic renewal, reach out to us to update your information and confirm your plan each year. Fourth, keep track of the enrollment window and plan to take action between November 1, 2025 and January 15, 2026. Lastly, consider opening an HSA if you select a qualifying plan. These accounts can help you manage out-of-pocket expenses while offering valuable tax savings.


Looking Ahead

The 2026 health insurance landscape will bring significant changes. With the possible end of enhanced subsidies, tougher enrollment rules, and greater financial risks for reporting errors, consumers must stay engaged to maintain affordable coverage. While state exchanges may provide support, the main rules apply nationwide, and the stakes are higher than ever. Staying organized, watching deadlines, and updating your information will be key to protecting your health coverage in the years ahead. Please reach out to our office via phone at 706-257-5073 or email at info@michellecrawfordbenefits.com so we can assist you in navigating your coverage with ease!

How Life Events Can Qualify You for Special Enrollment

January 23, 2026
Health insurance enrollment is not always limited to a single time of year. While Open Enrollment is the most widely known opportunity to sign up for or change health coverage, many people are surprised to learn that certain life changes can allow them to enroll outside of that window. These opportunities are called Special Enrollment Periods, often referred to as SEPs. If you experience a qualifying life event, you may be able to enroll in a new health insurance plan or make changes to your existing coverage without waiting for Open Enrollment. Understanding how Special Enrollment works can help you avoid gaps in coverage, unexpected medical bills, and unnecessary stress during major life transitions. What Is a Special Enrollment Period? A Special Enrollment Period is a limited timeframe that allows you to enroll in or modify your health insurance coverage after experiencing a qualifying life event. For individual health insurance, this window lasts 60 days from the date of the event, although most group (employer) plans allow a shorter period of 30 days. During a Special Enrollment Period, you may be able to apply for a new health plan, switch plans, add or remove dependents, or adjust your coverage to better match your new circumstances. If you miss this window, you may have to wait until the next Open Enrollment period to make changes, which could leave you uninsured or underinsured for months. Acting promptly is key. Common Life Events That Qualify for Special Enrollment Several major life changes can make you eligible for a Special Enrollment Period. One of the most common qualifying events is loss of credible health coverage. This can include losing employer-sponsored insurance, aging off a parent’s plan at age 26, or losing eligibility for Medicaid or CHIP. When coverage ends unexpectedly, a Special Enrollment Period allows you to replace it without waiting until Open Enrollment. Changes in household status are another common qualifying category. Events such as getting married, getting divorced, having a baby, adopting a child, or having a child placed in foster care can all trigger Special Enrollment. These life events often significantly change healthcare needs and costs, making it important to update your coverage as soon as possible. A change in residence can also qualify you for Special Enrollment, especially if the move gives you access to new health insurance plans. Moving to a new state or county, relocating for work or school, or returning to the U.S. after living abroad may all make you eligible. However, simply moving within the same area without access to new plans may not qualify, so it’s important to understand the details. Income Changes and Special Enrollment Income changes can also play a role in Special Enrollment eligibility, particularly for those who purchase coverage through the Health Insurance Marketplace. If your income decreases, you may become eligible for premium tax credits or cost-sharing reductions that make coverage more affordable. In some cases, a significant income change can open a Special Enrollment Period. On the other hand, an increase in income may affect your current financial assistance and require plan updates to avoid owing money back at tax time. Reporting income changes promptly helps ensure you are enrolled in the correct plan and receiving the appropriate level of financial support. What Does Not Qualify as a Life Event? Not every change in your life qualifies for a Special Enrollment Period. Simply deciding whether you want a different health insurance plan or missing the Open Enrollment deadline does not trigger eligibility. Voluntarily canceling your coverage without another qualifying reason may also leave you uninsured until the next Open Enrollment period. Because Special Enrollment eligibility depends on specific criteria, understanding which events qualify and providing proper documentation is essential. Assuming eligibility without confirmation can lead to delays or denied applications. How to Use Your Special Enrollment Period If you experience a qualifying life event, the first step is to gather any required documentation. This may include proof of loss of coverage, a marriage certificate, birth or adoption records, or proof of a change in address. These documents are often required to verify your eligibility. Working with a licensed health insurance professional can simplify the process. An experienced advisor can help you understand your options, ensure deadlines are met, and guide you toward a plan that fits both your healthcare needs and your budget. Don’t Wait to Protect Your Coverage Life changes can happen quickly and unexpectedly but losing health insurance does not have to add to the stress. Knowing how Special Enrollment works gives you the confidence to take action when it matters most. If you believe you have experienced a qualifying life event, it is best to explore your options as soon as possible to avoid coverage gaps. Having the right health insurance at the right time provides peace of mind, financial protection, and access to the care you need. That peace of mind is something everyone deserves.

What’s Changing in 2026: Key Updates

October 10, 2025
Individual / ACA Marketplace Plans 1. Premiums Are Rising Sharply Insurers in many states are proposing increases in ACA marketplace premiums of 10–27% for 2026. Some preliminary data show a median premium increase around 18% nationwide. 2. Out-of-Pocket Maximums & Deductibles Increasing With healthcare costs and inflation, government rules are pushing up the limits: what you pay in deductibles, copays, and the most you’ll ever pay in a year is going up. For many ACA-compliant plans, the maximum out-of-pocket is moving significantly higher in 2026. 3. Subsidies (Premium Tax Credits) Might Shrink Enhanced premium tax credits that have helped many people afford marketplace plans are set to expire at the end of 2025 unless extended by Congress. When they expire, many people will see their net premiums (what you pay after subsidies) increase—possibly by a large margin. 4. Eligibility Rules and Participation Changes There may also be changes in who qualifies for what levels of help, and how much. Household income, size, and even your recent medical needs could affect the cost and availability of plans more than before. Medicare 1. Part B & Part D Premiums and Cost Sharing Are Increasing Medicare Part B monthly premiums and Part D premiums are projected to go up in 2026. For example, the base beneficiary premium for Part D is expected to increase about 6%, while Part B premium increases are more significant. 2. Out-of-Pocket Drug Caps Go Up The maximum out-of-pocket cost for prescription drugs under Medicare Part D will increase: from $2,000 in 2025 to $2,100 in 2026. 3. Medicare Prescription Payment Plan (MPPP) Changes The MPPP, which helps you spread prescription drug costs across the year rather than paying full cost at the counter every time, will auto-renew unless you opt out. Also, plan sponsors must process opt-outs within three days. 4. Updates to Medicare Advantage (MA), Part D, Dual-Eligible Plans (D-SNPs), and Star Ratings CMS’s 2026 final rule introduces nuanced changes in how plans are rated, how prescription drug benefits are structured, and enhancements/modifications for Dual Eligible Special Needs Plans. Why These Changes Matter for You These are not just abstract policy shifts — they can affect your wallet, your coverage, your access to care, and how much protection you really have. Here’s why reviewing your coverage matters: • Costs Could Go Up Significantly With premiums, out-of-pocket maximums, and deductibles rising, what seemed affordable last year may look very different in 2026. If you rely on subsidies for ACA plans, those shrinking could be a big hit. • Your Health Situation May Have Changed If your health needs have changed (new medications, more frequent doctor visits, upcoming surgeries, etc.), the plan you had before may no longer serve you well. A plan that seemed adequate might now expose you to large costs. • Benefit Designs Differ Widely Even within Medicare Advantage, Part D, and ACA plans, plan features vary: prescription drug formularies, preferred providers, prior-authorization rules, network coverage, and perks are not uniform. A review helps you match plan features to your actual needs (doctors you use, medications, specialists, etc.). • Avoid Gaps, Surprises, & Administrative Issues Auto-renewals or changes might happen that you miss. For instance, with MPPP auto-renewing, you might stay in a plan whose new cost structure works less well for you. Provider directories may change. If you don’t check, you could discover after the fact that your usual doctor isn’t in-network. • Opportunity to Optimize With change comes opportunity. You may find a cheaper plan, more subsidy, or better coverage that suits your situation. You might re-evaluate whether a high-deductible plan with HSA works, or perhaps a more robust Part D plan is worth the premium. A consult helps you see those trade-offs and make an informed decision. What to Ask / Look at During Your Consult or Review When you sit down to review, whether with a licensed agent, broker, or counselor, here are items you’ll want to cover: Projected total costs: premiums + deductibles + drug costs + copays + out-of-pocket maximums Changes to subsidies / tax-credits for ACA plans Plan networks: are your doctors / hospitals included? Drug formularies: are your prescription drugs covered? Are there shifts in prior authorization? Extra benefits (vision, dental, hearing, wellness perks) and trade-offs for those extras Whether your Medicare Advantage plan or Original Medicare plus a supplement better serves you, given new MA changes Timing: open enrollment periods, deadlines, required paperwork for subsidies, verification of income, etc. Conclusion: Why You Should Act Now Given all the changes ahead in 2026, waiting to review can leave you exposed: to cost increases you didn’t anticipate, to being “locked in” to a plan that no longer fits, or missing out on new benefits. Booking a consult / review now gives you lead time to: Understand what changes will hit you Adjust your budget or savings to cover increases Shop smartly and compare alternatives before open enrollment ends Make sure paperwork is in order so you don’t lose subsidies or coverage Give us a call at 706-257-5073 to schedule your 2026 consult now!