In this column for Nature, KFF’s Alina Salganicoff reviews efforts to improve women’s health research during previous U.S. administrations that fell short of their promise and highlights the recommendations of a congressionally mandated National Academy of Sciences, Engineering and Medicine committee, which she co-chaired, aimed at improving women’s health research at the National Institutes of Health.

This brief examines how the budget reconciliation law expanded access to HSA-eligible plans and accounts on the ACA Marketplaces and what these changes means for enrollees. Health Savings Accounts (HSAs) are tax-advantaged savings accounts that enrollees in certain high-deductible health plan (HDHPs) can use to pay for qualified medical expenses.

HSA-compatible plan options have grown substantially since the law took effect, creating both benefits and risks for consumers. For example, Marketplace enrollees could benefit from the tax advantages of contributing to an HSA—but doing so requires enrolling in a high-deductible plan and anticipating future health care costs and income.

The brief is part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Medicaid’s non-emergency medical transportation (NEMT) benefit provides transportation to care for low-income enrollees who otherwise may not have a reliable, affordable means of getting to health care appointments. NEMT also assists people with disabilities who have frequent appointments and people with limited public transit options or long travel times to health care providers, such as those in rural areas. Medicaid covers a range of transportation services under the NEMT benefit, including van rides, public transportation, buses, taxis, and ride shares. In some cases, NEMT may subsidize the costs of travel in personal vehicles by reimbursing enrollees for gas and mileage. Despite representing less than 1% of Medicaid spending, NEMT facilitates access to Medicaid services. Recent policy discussions focus on potential overuse or fraud in NEMT services, but there may also be people who need and are eligible for NEMT but are unaware of the benefit. KFF’s analysis of the 2024 National Health Interview Survey (NHIS) finds that more than 3.8 million adult Medicaid enrollees under age 65 have missed medical appointments, meetings, work, or other things needed for daily living due to lack of reliable transportation (data not shown).

Potential fraud in state Medicaid programs is garnering more attention and creating additional administrative tasks for states and providers of services deemed “high risk.” The Centers for Medicare & Medicaid Services (CMS) has classified NEMT as a high-risk service, flagging NEMT in letters to California, New York, and Minnesota, thus increasing attention on Medicaid’s NEMT benefit. In September 2026, a House Energy and Commerce Committee majority staff report identified NEMT as one of several Medicaid services with “high rates of fraud,” and noted that Colorado, Minnesota, and New York deemed providers of NEMT as “high risk” concerning program integrity. The same month, Committee Republicans introduced a package of Medicaid program integrity bills. One of those bills, the Strengthening Tools for Oversight to Prevent (STOP) Medicaid Fraud Act, would extend electronic visit verification (EVV) requirements to NEMT trips. Current EVV requirements apply to Medicaid personal care and home health, using computer/mobile systems to track and record details about services provided under Medicaid.

While additional scrutiny and oversight could limit fraudulent or inappropriate Medicaid spending, these efforts and new administrative burdens for providers could also result in fewer providers and more limited access for Medicaid enrollees who rely on the benefit. This issue brief describes the NEMT benefit structure and administration, Medicaid spending on NEMT, and the demographic and health characteristics of Medicaid enrollees who use NEMT compared with all Medicaid enrollees. Key takeaways include:

• States are required to provide NEMT but have flexibility in how they deliver and pay for it.
• Medicaid spending and utilization of NEMT have increased nearly every year since 2020, yet NEMT still accounts for less than 1% of total Medicaid spending.
• Medicaid enrollees who use NEMT are more likely to qualify for Medicaid through aged or disabled pathways, to be dually-eligible for Medicare and Medicaid, and to have chronic conditions when compared with all Medicaid enrollees.

What is NEMT and how is it administered?

People who are low income or have significant disabilities may have difficulty with transportation to medical care. As a result, states are required to provide NEMT, but they have choices regarding which services to offer, the way to administer the program, and how to claim reimbursement for the federal share of costs. This section describes federal requirements governing NEMT and the flexibility available to states.

State Medicaid programs are required to provide NEMT for enrollees who otherwise may not be able to access care. Medicaid covers a range of transportation services under the NEMT benefit. The method of transportation covered by Medicaid varies depending on the enrollee’s geographic location, individual needs, and states’ policy choices. For example, enrollees in urban areas are more likely to use public transit, while those in rural areas more often rely on taxis or mileage reimbursement for personal vehicles, and enrollees with mobility limitations may need wheelchair-accessible or stretcher vans. Enrollees can use NEMT to get to any Medicaid-covered medical appointment or service, including transportation to and from pharmacies.

State Medicaid agencies have the flexibility to administer NEMT using one or a combination of three delivery methods. Federal regulations require state Medicaid programs to specify which methods they use to administer NEMT: fee-for-service (FFS), where the state pays providers directly, managed care, where the state pays a managed care organization to provide benefits, or a brokerage model, where the state pays a third party to administer the benefit. Paying providers directly allows the state the most control and may facilitate coordination with non-Medicaid state transportation services, but brokerage models may allow states to benefit from specialized expertise from brokers, and managed care models may allow states to have more predictable spending and coordinate NEMT with health care services for people enrolled in comprehensive managed care organizations (MCOs) (see Appendix). As of 2024, 19 states used the FFS delivery model, 12 states used the managed care delivery model, and 30 states used the brokerage model in some capacity.

States can choose whether to claim NEMT reimbursement as administrative expenses or as medical service expenses. Claiming NEMT as an administrative expense offers states greater flexibility in system design but, in most cases, a lower matching rate from the federal government (see Appendix). States must specify their choice in the Medicaid state plan. In 2024, the year of the most recent available Medicaid expenditure reports (known as the CMS-64), 32 states claimed NEMT as medical expenses, 3 states claimed NEMT as administrative expenses, and 16 states claimed NEMT under both categories.

How much does Medicaid spend on NEMT?

In February 2026, the Department of Health and Human Services (HHS) released a publicly available dataset with provider-level spending data. The data include the national provider identifier (NPI) for the billing and servicing providers, the Healthcare Common Procedure Coding System (HCPCS) code, the month and year, the number of enrollees seen, the count of claims, and the total amount paid for the services (FFS and MCO). An advantage of the HHS data relative to other Medicaid claims is that they include payments from MCOs to health care providers. (Other claims data have more detailed information and can be linked to specific enrollees, but do not include payments from MCOs, which cover most Medicaid enrollees.) The public data include claims and encounter records for noninstitutional services used by Medicaid enrollees. Noninstitutional services include a wide range of services such as professional and clinical services, labs and radiology, outpatient hospital services and home care. They also include professional services billed separately during inpatient stays. NEMT claims and spending were identified using HCPCS codes, which also identified the type of transportation:

• Individual (transportation provided in a personal vehicle),
• Taxi,
• Public transportation,
• Van (transportation in a shared or specialized van),
• Airplane,
• Non-transport ancillary services (costs associated with transportation—parking, tolls, etc.), and
• NEMT other (trips that do not specify vehicle type or other costs—per diem billing, driver wait time, etc.).

Medicaid spending and utilization of NEMT have increased nearly every year since 2020 (Figure 1). In 2020, the COVID-19 pandemic led to major declines in the use of all health care. At the end of 2020, health services spending was down almost 3% and remained suppressed at the beginning of 2021. The pandemic, and subsequently the decrease in overall health care use, likely explains the sharp decrease in Medicaid spending and utilization of NEMT services in 2020. In nearly every year after 2020, Medicaid spending and utilization of NEMT have grown. In 2024, Medicaid spent $4.65 billion on NEMT services. While spending on NEMT has grown, NEMT is still a small share of overall Medicaid spending, accounting for less than 1% of all Medicaid spending.

Two-thirds of Medicaid NEMT spending in the public data pays for van and taxi services (Figure 2). Van and taxi transportation account for about two-thirds of Medicaid NEMT spending (67%) and utilization (63%) in 2024. The “other” NEMT services category makes up the next largest share of Medicaid spending (26%) and utilization (24%). Services in this category include claims for NEMT case workers, patient attendants, escorts, and per diems. Combined, the remaining categories (individual transportation, public transportation, airplane, and non-transport ancillary services) account for less than 10% of Medicaid spending on NEMT and 13% of Medicaid NEMT utilization.

Who uses NEMT?

This analysis uses 2024 Medicaid claims data (the Transformed Medicaid Statistical Information System [T-MSIS] Analytic Files) to understand the characteristics of people who use Medicaid NEMT. People were identified as using NEMT if they had at least one claim with an NEMT-identified HCPCS code in the 2024 Other Services (OT) T-MSIS Research Identifiable File. The OT file captures claims for all noninstitutional services, which includes a wide range of services such as professional services (regardless of where they were provided), labs and radiology, clinical services, outpatient hospital services, and home care. People’s chronic conditions were identified as described in KFF’s earlier work on chronic conditions among adult Medicaid enrollees. The research identifiable file does not include spending from MCO encounter records, so the analysis only includes measures of utilization and omits spending estimates. Data about dual eligibility and chronic conditions exclude Oregon due to data quality issues.

A disproportionate share of Medicaid enrollees who use NEMT qualify for Medicaid because of a disability or because they are age 65 or older compared with all Medicaid enrollees (Figure 3). More than half (58%) of the Medicaid enrollees who use NEMT are eligible for Medicaid because they are age 65 or older or have a long-term disability, compared with about one in five (23%) of all Medicaid enrollees. Conversely, children make up 33% of all Medicaid enrollees, but only 12% of Medicaid enrollees who use NEMT. Medicaid enrollees who are older or qualify for a disability use more health care than other enrollees and also may have greater need for assistance with transportation.

More than one in three (39%) NEMT users are dually eligible for Medicare and Medicaid, compared with 14% of overall Medicaid enrollees. Traditional Medicare does not typically cover NEMT benefits. Some Medicare Advantage (MA) plans offer supplemental NEMT benefits, but coverage varies by plan. For dual-eligible individuals, Medicare is the primary payer and covers medical and post-acute care, while Medicaid wraps around Medicare coverage by paying Medicare premiums and, in most cases, cost sharing. For medical appointments where Medicare is the primary payer, Medicaid can still pay for transportation to get to the appointment.

Nearly nine in ten (85%) Medicaid enrollees using NEMT have at least one chronic condition, compared with fewer than four in ten Medicaid enrollees overall (36%, Figure 4). Medicaid enrollees who use NEMT are most likely to have a physical health condition (61%), compared with 24% of all Medicaid enrollees. Rates of behavioral health conditions (56% vs. 17%) and cognitive health conditions (17% vs. 5%) are also higher among individuals using NEMT compared with all Medicaid enrollees. NEMT may provide disproportionate benefits for enrollees with certain conditions, like chronic kidney disease or intellectual and developmental disabilities. Such enrollees need regular access to care but may face additional transportation-related obstacles to accessing their ongoing services (Box 1).

Appendix: States’ Options for Providing NEMT and Claiming Federal Reimbursement

A 2021 report to Congress by the Medicaid and CHIP Payment and Access Commission (MACPAC) summarizes each delivery model and its benefits and drawbacks:

• Fee-for-service (FFS): Under an FFS (or in-house) model, states contract with independent transportation providers and reimburse providers for services based on payment rates set by the state. This model provides states with more control over NEMT policies and operations and can facilitate coordination with other state programs that subsidize transportation costs for low-income people (such as those offered through state departments of transportation). However, FFS NEMT delivery also carries a large administrative burden for states, including the burden of ensuring program integrity and identifying fraud and abuse.
• Managed care: Some MCOs “carve in” NEMT as part of their coverage, alongside other Medicaid benefits. The individual managed care plans that include NEMT coverage can choose to directly manage NEMT themselves or contract with a broker. Using managed care to administer NEMT removes some administrative burden from states, provides greater predictability in spending, and can allow for better coordination with other benefits also provided under the managed care plan. However, this delivery model can increase the administrative burden for NEMT providers who must contract with multiple managed care plans rather than only with the state.
• Brokerage: Under a brokerage model, states contract with a third party that manages their NEMT benefit. States can pay the broker on an FFS basis or using another approach such as paying a flat amount for each enrollee each month (i.e., a capitated approach). Brokerage models allow states to leverage brokers’ expertise in transportation administration and their capacity to administer the benefit. One risk of using capitated payments with brokers is that it creates an incentive for the brokers to decline trips, potentially making it harder for enrollees to access NEMT.

A Medicaid Transportation Coverage Guide from the Centers for Medicare and Medicaid Services (CMS) describes the two reimbursement methods as well as their benefits and drawbacks.

• Administrative expenses: When states claim spending as an administrative expense, the federal government pays 50% of the total cost, which is the administrative expense federal matching rate. When states claim NEMT as an administrative expense, they are exempt from Medicaid’s requirement to provide enrollees with free choice of providers, allowing for contracts with a single provider and alternative payment models, like vouchers. Additionally, electing to claim NEMT as an administrative expense allows states to limit the amount, duration, and scope of NEMT benefits.
• Medical service expenses: When states claim spending as a medical expense, the federal government pays the state’s regular federal matching rate (ranging from 50% to 77.32% in fiscal year 2027). Claiming NEMT as a medical service expense generally makes NEMT services subject to additional guidelines, including the free choice of provider, comparability, and statewideness requirements. The Deficit Reduction Act (DRA) of 2005 added an option for states to include NEMT brokerage programs in their Medicaid state plans where cost-effective, and to waive some of the additional guidelines, such as limiting enrollees’ free choice of provider. However, states must provide NEMT using a brokerage if they want additional flexibility, so some states may prefer to continue claiming NEMT as administrative expenses.

Introduction

The 2025 reconciliation law includes new eligibility restrictions for many lawfully present immigrants for federally funded health programs, including subsidized Affordable Care Act (ACA) Marketplace, Medicaid and the Children’s Health Insurance Program (CHIP), and Medicare coverage. Undocumented immigrants are already ineligible for federally funded health coverage under longstanding policy.

Beginning January 1, 2027, the 2025 reconciliation law will limit eligibility for Marketplace subsidies, including for all premium tax credits (PTCs) and cost-sharing reductions (CSRs), to lawfully present immigrants who are lawful permanent residents (LPRs or “green card” holders), Cuban and Haitian entrants, and people residing in the U.S. under Compacts of Free Association (COFA). These restrictions will eliminate eligibility for Marketplace coverage subsidies for many groups of lawfully present immigrants, including refugees and asylees without a green card and individuals on work visas, among others. The Congressional Budget Office (CBO) estimates that this provision will reduce federal spending by $91.4 billion and lead to an additional one million individuals becoming uninsured by 2035, with most of the coverage losses occurring in 2027, the year the provision takes effect. The law also eliminated access to subsidized Marketplace coverage for all lawfully present immigrants earning less than 100% of the federal poverty level (FPL) who were not eligible for Medicaid due to immigration status, including those in the five-year waiting period for coverage, beginning January 1, 2026. The CBO estimates that this provision will lead to an additional 200,000 individuals becoming uninsured and reduce federal spending by $27.3 billion over the 2026 to 2035 time period.

The Centers for Medicare and Medicaid Services (CMS) released guidance on how the federally facilitated exchange (FFE) will verify immigrant eligibility for subsidies during the 2027 plan year Marketplace Open Enrollment Period, which starts November 1, 2026. State-based exchanges (SBEs) are also required to implement the immigrant eligibility restrictions for subsidies, but outreach and immigration status verification procedures may vary from the FFE. Lawfully present immigrants who are no longer eligible for subsidies under the new restrictions can purchase Marketplace coverage at full cost. However, unsubsidized coverage will likely be unaffordable for many amid rising ACA Marketplace premiums due in part to the expiration of enhanced premium tax credits and other federal policy changes. Beyond those losing coverage due to ineligibility and cost, there may also be coverage losses among individuals who remain eligible for subsidies but have challenges understanding or responding to notices requesting information and documentation to verify their eligibility. This brief provides an overview of implementation of the immigrant eligibility changes for Marketplace subsidies and issues to consider for affected individuals and states.

Marketplace Subsidy Immigrant Eligibility Changes

Starting January 1, 2027, the 2025 reconciliation law will restrict eligibility for PTCs and income-based CSRs to LPRs or “green card” holders, Cuban and Haitian entrants, and people residing in the U.S. under COFA (Table 1). The guidance refers to these groups as “eligible noncitizens.” The law eliminates eligibility for Marketplace subsidies for many other groups of lawfully present immigrants, including refugees and asylees without a green card and individuals on work visas, among others. The law also eliminated access to Marketplace subsidies for lawfully present immigrants earning less than 100% FPL who were not eligible for Medicaid due to immigration status, including those in the five-year waiting period for Medicaid coverage, beginning January 1, 2026. Lawfully present immigrants who do not have an “eligible noncitizen” status still may purchase a qualified health plan (QHP) through the Marketplace at full cost without subsidies if otherwise eligible. However, the coverage will likely be unaffordable for many without subsidies. Prior to the 2025 reconciliation law, undocumented immigrants were already ineligible for federally funded health coverage. Deferred Action for Childhood Arrivals (DACA) recipients are also ineligible to purchase ACA Marketplace coverage under recent federal regulation changes and the 2025 reconciliation law. 

Implementation of Immigrant Eligibility Changes in the FFE

Starting with plan year 2027, the FFE will conduct eligibility determinations for current noncitizen enrollees and new applicants consistent with the new rules for Marketplace subsidies. In the 29 states that use the FFE or a state-based marketplace on the federal platform, the Open Enrollment Period for the 2027 plan year begins November 1, 2026. CMS encourages current noncitizen Marketplace enrollees to ensure their applications are updated with their most recent immigration status by the last day to enroll in or change plans. New noncitizen applicants applying for coverage through the FFE will be asked to attest to whether they have eligible noncitizen status when applying for subsidies or if they have a different lawfully present status that is not eligible for subsidies. Enrollees and applicants may need to provide updated documents or document information, such as their passport number, Permanent Resident Card, Employment Authorization Document (EAD), among others to help the FFE verify their immigration status.

The FFE will use immigration-document information and automated data matching to verify whether current noncitizen enrollees and new applicants meet the new subsidy eligibility requirements. The FFE will automatically verify immigration status through the Department of Homeland Security (DHS) Systematic Alien Verification for Entitlements (SAVE) system using existing information. Current noncitizen enrollees will continue to receive subsidies if the FFE can verify eligible noncitizen status using the information available in their enrollee profile or through a new SAVE verification, provided the enrollee remains otherwise eligible. New applicants determined to have an eligible noncitizen status will also be able to enroll in a plan with subsidies if they meet all other eligibility requirements. While CMS did not discuss potential issues with the SAVE system in this guidance, in previous guidance to states regarding immigrant eligibility restrictions in Medicaid, it noted that SAVE provides “point in time” verification and does not update prior verification responses when there is a change in immigration status or category. As such, potentially affected enrollees may have applied for and been granted adjustment to LPR status or may have another eligible status that is not reflected in SAVE.

Noncitizen enrollees and applicants who attest to having an eligible noncitizen status, but whose status cannot be automatically verified by the FFE, will receive a 95-day period to submit documentation from when the notice of the verification is sent by the FFE. Individuals may be eligible to enroll in subsidized Marketplace coverage during this time. Eligible documentation may include a Permanent Resident Card (also known as a "green card"), an EAD, or an arrival/departure record (I-94/I-94A). In addition to requesting documentation to resolve issues verifying eligible noncitizen status for subsidies, the FFE may also request additional documentation if it cannot verify that an individual is lawfully present. Enrollees will be required to repay any PTC received during the 95-day period in future tax filings if they are found to be ineligible for subsidies. Other proposed changes from the Internal Revenue Service (IRS) to implement provisions of the 2025 reconciliation law would eliminate income-based caps on such repayment amounts.

Current noncitizen Marketplace enrollees who do not take any action to update their applications by the plan selection deadline for coverage and whose eligible noncitizen status cannot be verified by the FFE will lose subsidies effective January 1, 2027. Re-enrolling consumers whom the FFE determines as no longer lawfully present will lose eligibility for Marketplace coverage entirely effective January 1, 2027. CMS does not provide any information as to whether determinations of individuals as no longer lawfully present will be used for immigration enforcement purposes.

The FFE will automatically re-enroll current enrollees who are determined lawfully present but ineligible for subsidies into a Marketplace plan without subsidies, and they will be responsible for paying the unsubsidized monthly premiums unless they cancel coverage. Enrollees can cancel their coverage through their online Marketplace account or by contacting the Marketplace Call Center. If enrollees do not cancel their plan, they will be responsible for paying the unsubsidized monthly premiums if they are auto-enrolled into a QHP without subsidies. If the enrollee does not pay the unsubsidized monthly premium, the enrollee would be subject to the grace period policy set by the plan issuer or applicable state laws, in contrast to the three-month grace period provided to those receiving subsidized coverage. Individuals who lose coverage due to nonpayment of premiums would have to wait until the next Open Enrollment Period to re-enroll in Marketplace coverage unless they qualify for a Special Enrollment Period. Individuals may also be able to appeal coverage cancellation decisions by plan issuers due to nonpayment of premiums.

The FFE updated Marketplace websites and platforms and is sending targeted notices about immigrant eligibility changes. Prior to the start of the 2027 plan year Open Enrollment Period, applications on HealthCare.gov and Enhanced Direct Enrollment partner platforms were updated to highlight that only U.S. citizens and certain lawfully present noncitizen statuses qualify for financial assistance. The FFE is sending several targeted notices to affected enrollees, including the following:

• Current enrollees whose eligible noncitizen status cannot be verified through DHS SAVE will receive tailored Marketplace Open Enrollment Notices (MOEN) explaining that they will lose PTCs and CSRs unless they update their application and submit documentation to confirm their eligible noncitizen status.
• Enrollees whom the FFE determines as no longer eligible for Marketplace subsidies will receive a Marketplace Eligibility Determination Notice explaining that they are ineligible for PTCs and CSRs due to their immigration status and their appeal rights.
• Enrollees whom the FFE determines as no longer eligible for Marketplace coverage due to immigration status will receive a notice explaining that their Marketplace enrollment will end, their appeal rights, and additional options available to them. If an enrollee in a multi-member household is found no longer eligible for Marketplace coverage, the FFE will designate another eligible household member as the primary plan subscriber.

SBEs used by 22 states, including DC, may use different outreach and verification procedures compared with the FFE. CMS notes that the guidance is specific to the FFE and that noncitizen enrollees and applicants in states that operate their own exchange should follow guidance issued by their SBE. States with SBEs are required to verify eligible noncitizen status for subsidies for all noncitizen enrollees and applicants during the 2027 plan year Open Enrollment Period, though states have varying Open Enrollment timelines. CMS indicates that SBEs will have access to the same immigration status verification system (Federal Data Services Hub Verify Lawful Presence service) used by the FFE and have a direct connection to DHS SAVE, in addition to technical assistance from CMS.

Issues to Consider

Lawfully present immigrants without an eligible noncitizen status would still be eligible to purchase Marketplace coverage at full cost, but it would likely be unaffordable. Premiums have increased due in part to the expiration of enhanced PTCs and other policy changes, which have coincided with Marketplace enrollment declines, and premiums are expected to keep rising in 2027. If an enrollee loses coverage due to nonpayment of premiums, they may be responsible for any medical bills incurred during the period of nonpayment. Providers may also request that individuals pay the full cost of care out of pocket, or they may not provide care until the premiums are paid.

Some individuals who remain eligible for subsidized Marketplace coverage may still lose coverage due to challenges verifying eligibility or fear and confusion. CMS noted in previous guidance to states regarding immigrant eligibility restrictions in Medicaid that SAVE may not be accurate as it provides “point in time” verification and may not reflect that potentially affected enrollees have since applied for and been granted adjustment to an eligible noncitizen status. As such, some individuals may have an eligible noncitizen status even if it is not verified through a data match through SAVE. However, they would need to submit documentation to verify that eligibility. Individuals may have difficulty understanding new eligibility rules and whether they remain eligible for subsidies. Eligible enrollees may also face challenges submitting required documentation to verify eligible noncitizen status. Confusion and fears about enrolling in coverage may be amplified by other immigration policies like public charge and other increased federal immigration enforcement actions.

Individuals who become uninsured will be left with limited options for comprehensive coverage and care. Individuals who become uninsured may visit community health centers for free or sliding fee scale health care services, but they may have access to a limited scope of services. Some states offer fully state-funded coverage programs for immigrants regardless of status, which may be a coverage option for those losing eligibility for subsidized Marketplace coverage. However, several states have recently scaled back state-funded coverage programs for immigrants or have reached enrollment caps due to budget pressures and higher than expected demand. New Mexico is using state funds to provide coverage with premium subsidies through a state-based exchange to lawfully present noncitizens losing subsidized ACA Marketplace coverage, as well as DACA recipients.

Broader changes to Marketplace coverage may also impact immigrant families. As noted, the elimination of caps on repayment amounts means that all enrollees, including immigrant enrollees, who received excess PTCs will need to repay excess amounts without any limit. Additionally, beginning in the 2028 tax year, all individuals who are eligible for PTCs will not be able to receive them until the Exchange verifies their eligibility, including household income, health coverage status or eligibility for coverage, place of residence, family size, and immigration status. As such, individuals will no longer be able to receive PTCs while this information is being verified and can choose to pay full price for their premium while the verification is in process or pending their plan selection. This could have a disproportionate effect on immigrants and may leave families with mixed immigration status to make a difficult decision between covering some family members but not others.

States operating SBEs may face increased administrative burden to conduct outreach, reverify enrollees, and update systems and other materials to reflect new immigrant eligibility rules. State pressures may be compounded since they are implementing these changes at the same time they are implementing Medicaid immigrant eligibility restrictions as well as work requirements and more frequent eligibility redeterminations for ACA expansion adults.

The Affordable Care Act (ACA) Marketplace 2027 Open Enrollment period starts November 1, 2026, in most states. In 2026, the enhanced premium tax credits expired, provisions of the 2025 budget reconciliation law (the “One Big Beautiful Bill Act”) began to take effect, and Trump administration regulations began to change Marketplace coverage, with effects expected to carry into 2027 enrollment. Further changes in the ACA Marketplaces are again expected in 2027.

Here are the nine things to know for the 2027 Open Enrollment period:

1. Premiums are going up by double-digits, but most people get a subsidy.

While insurers proposed a median premium increase of 15%, the average increase in finalized benchmark silver premiums for 2027 is 13%, marking a second consecutive year of double-digit proposed increases (these premiums rose by 26% from 2025 to 2026). In states that use the Healthcare.gov platform, benchmark silver premiums are increasing 11%, whereas states that run their own enrollment platforms are seeing premium increases of 16%. From 2025 to 2026, HealthCare.gov states saw a 30% increase, whereas state-based Marketplaces saw a roughly 17% increase in benchmark premiums.

In their rate filings, insurers point to a higher-than-usual increase in the underlying cost of care, which is not unique to the ACA Marketplaces; some employer plans have also seen steep cost increases.

ACA Marketplace insurers also cite the expiration of the enhanced premium tax credits and the resulting changes in the risk pool as factors contributing to higher premiums. KFF’s analysis of insurer filings found that insurers estimated risk pool changes added about four percentage points on average to premiums in 2026 and expect a similar, additional effect in 2027.

Most enrollees get a subsidy that will cushion the impact of these increases in 2027. However, people with incomes above 400% of the federal poverty level (FPL) will be particularly hard hit because they no longer qualify for premium tax credits and must pay the full cost of coverage. Sharp premium increases in 2027 follow even steeper increases going into 2026. These higher costs may lead additional healthier enrollees to drop coverage, further worsening the risk pool and putting additional upward pressure on premiums.

2. Marketplace enrollment is declining following the expiration of enhanced premium tax credits, and may continue to fall for other reasons.

Enrollment in the ACA Marketplaces declined following the expiration of the enhanced premium tax credits. During the 2026 Open Enrollment Period, Marketplace plan selections fell by 1.2 million from 2025. By February 2026, effectuated Marketplace enrollment (i.e., people who pay their premiums and remain enrolled) was down 12% (or 2.6 million people) from the previous year to 19.2 million people. More recent Marketplace-specific enrollment data are not yet available, but enrollment data for the individual market suggest the decline may have continued through the first half of 2026. Data for the broader individual market, which includes both Marketplace coverage and plans purchased directly from insurers or brokers, show a continued decline. Individual market enrollment fell 18% by June 2026, from 25.2 million to 20.5 million people—a loss of more than 4.6 million.

Looking ahead to 2027, several insurers have said they expect the market to continue to deteriorate in 2027 as a continued result of the enhanced premium tax credits ending. Some enrollees who were able to keep coverage in 2026 may no longer be able to make ends meet.

As discussed more below, anti-fraud efforts and changes to eligibility for tax credits affecting certain immigrants will also have a downward effect on Marketplace enrollment. In its latest projections, the Congressional Budget Office (CBO) estimated ACA Marketplace enrollment would fall from a peak of 22.4 million in 2025 to 13.1 million in 2027.

3. Insurer exits outnumber new entrants.

The number of insurers participating in the ACA Marketplaces is expected to decrease again in 2027, with more insurers announcing plans to exit the Marketplace than to enter. As of October 29, 2026, 11 carriers had announced plans to exit at least one state for 2027, while seven carriers had announced plans to enter a new state. Shrinking Marketplace enrollment after the expiration of the enhanced premium tax credits has reduced the potential market for insurers and raised concerns about the future of the risk pool. The changes will vary across states, but in some areas, consumers will have fewer insurers to choose from in 2027. Cigna, for example, is leaving the individual market in all 11 states where it currently participates.

Insurer exits can reduce competition and leave consumers with fewer choices of plans and provider networks and disrupt coverage for some enrollees.

4. Some state-based Exchanges have backfilled lost enhanced federal tax credits.

Some states that operate their own Exchanges are using state-funded subsidies to help offset the expiration of the enhanced premium tax credits, with several continuing or expanding assistance in 2027. New Mexico went furthest in 2026, fully backfilling the lost federal assistance for Marketplace enrollees. While enrollment declined nationally, New Mexico saw Marketplace enrollment grow during the 2026 Open Enrollment Period. The state is continuing its assistance in 2027.

Other states provided more limited assistance in 2026 and may expand eligibility in 2027. California, for example, is continuing state-funded premium subsidies but is expanding its program to partially backfill lost enhanced tax credits for households with incomes between 165% and 200% FPL. Previously, only households with incomes between 138% and 165% FPL were eligible for state assistance to replace any portion of the expired enhanced tax credits. Several other states have also maintained subsidy programs such as New Jersey, while Rhode Island and Virginia moved to create new state-specific subsidies for the 2027 plan year. These state efforts may help some consumers afford coverage despite the loss of federal assistance, but the amount of support available varies by state and income.

5. Recent federal actions to address fraud may affect enrollment counts and make it more difficult for enrollees needing brokers' services in 2027.

Recent initiatives to combat Marketplace broker fraud could impact counts of the number of enrollees this Open Enrollment cycle, the availability of enrollment assistance, and certain agent and broker practices in 2027. Some provisions that attempt to address fraud by placing new requirements on consumers have been temporarily paused due to court action (discussed more below).

In September 2026, HHS reported they cancelled coverage for approximately 760,000 individuals who CMS says were "phantom” enrollees, meaning a broker or agent may have signed them up without their knowledge. HHS sent a list of about 1.2 million people to insurers to review. These individuals had been signed up by an agent or broker, had no premium payment and were missing a Social Security number or immigration document that could be verified in real time. If insurers were unable to make contact with these individuals or verify they had incurred claims, CMS cancelled the coverage. There are reports that some enrollees have had their coverage reinstated suggesting that the criteria CMS used to identify potential fraud may have also flagged legitimate enrollees. Others who lost coverage through these efforts may not have their coverage restored.

Additionally, HHS is implementing new safeguards on certain agents, brokers, and web-broker practices that put consumers at risk of inappropriate or fraudulent enrollments. This follows investigations of brokers and other related entities moving enrollees to different plans or enrolling them in Marketplace coverage without their knowledge. For instance, the HHS Notice of Benefit and Payment Parameters for 2027 updates standards of conduct for agents, brokers, and web-brokers regarding prohibited marketing tactics, including but not limited to providing cash, monetary rebates, or cash equivalents to persuade consumers to enroll in coverage; falsely claiming that consumers will always qualify for zero-dollar insurance or zero-dollar premiums; and providing false information on enrollment timelines and deadlines. Agents, brokers, and web-brokers must submit marketing materials to HHS upon request in response to monitoring, auditing, or enforcement activities. Agents, brokers, and web-brokers that contract with a third party or other entity to produce marketing materials must ensure that those entities follow the requirements that apply to agents, brokers, and web-brokers.

In September 2026, HHS announced an even more stringent restriction that temporarily pauses the registration of new agents and brokers in the federally facilitated Marketplace and for Marketplaces that operate on the federal platform until February 2027. CMS estimates that approximately 19,000 new agents and brokers would have registered absent the temporary restriction. Combined with the reductions in Navigator funding for 2026 announced in February 2025, consumers may have less access to enrollment assistance in 2027.

6. Some lawfully present immigrants will no longer qualify for subsidized Marketplace coverage in 2027.

Currently, subsidized ACA Marketplace coverage is available to lawfully present immigrants. Lawfully present immigrants include lawful permanent residents (LPRs or green card holders), people on work visas, and humanitarian immigrants such as refugees, victims of human trafficking, asylees, among others. Undocumented immigrants are not eligible to purchase ACA Marketplace coverage, even at full cost. While immigration statuses eligible to purchase ACA Marketplace coverage have not changed for 2027, the 2025 budget reconciliation law limits eligibility for tax credits in the Marketplace to only certain groups of lawfully present immigrants including:

• Lawful permanent residents
• Cuban and Haitian entrants, as defined in section 501(e) of the Refugee Education Assistance Act of 1980
• Any lawful residents living in the U.S. under the Compact of Free Association

Other lawfully present immigrants such as refugees, victims of human trafficking, and asylees, can still purchase Marketplace coverage but will no longer be eligible for premium tax credits. Without subsidies, many may be unable to afford their premiums and could drop coverage. CBO estimates that one million more individuals will be uninsured as a result of this provision by 2035.

7. Enrollees will face the elimination of repayment limits.

Beginning in the 2026 tax year, limits that previously capped how much some Marketplace enrollees had to repay in excess premium tax credits were eliminated as enacted through the budget reconciliation law (“The One Big Beautiful Bill Act”). Because the first tax filings under the new rules will not happen until early 2027, enrollees will choose 2027 plans without having seen how uncapped repayment works in practice. Those whose incomes end up higher than projected may face larger tax bills than they expect, and accurately estimating income and updating it when circumstances change will be especially important for people near income thresholds for premium tax credits or cost-sharing reductions.

Some enrollees may be able to lower their modified adjusted gross income (MAGI) through contributions to accounts such as health savings accounts (HSAs) or traditional individual retirement accounts (IRAs). These contributions could increase premium tax credits or help people near 250% FPL qualify for cost-sharing reductions (CSRs). However, HSA contributions are available only to people enrolled in HSA-eligible plans, and not everyone has the funds to contribute. Because Marketplace assistance is based on projected annual income, enrollees considering this approach may also need to update their income estimates during the year.

8. Consumers who are denied or removed from Medicaid coverage for not meeting work requirements will also be ineligible for premium tax credits.

Starting in 2027, in states required to implement Medicaid work requirements, consumers who lose or are denied Medicaid coverage solely for not meeting work requirements will also be ineligible for subsidized Marketplace plans in these states. Prior to the budget reconciliation law, a consumer who was denied Medicaid coverage or disenrolled from Medicaid could sign up for Marketplace coverage as long as they met Marketplace eligibility requirements. Because income eligibility for Medicaid references a monthly income whereas Marketplace premium tax credits are based on an estimated annual income, consumers may be concurrently eligible for both, especially in Medicaid expansion states. While this is likely a small group of people, it may include individuals who recently lost a job and who would likely not meet the Medicaid work requirements.

When the budget reconciliation law was signed, only Georgia had Medicaid work requirements in place; the law now requires 43 states and the District of Columbia to implement work requirements by the start of 2027. Exclusion from ACA tax credits based on failing Medicaid work requirements will apply to adults in Medicaid expansion states and those that are covered under Medicaid Section 1115 waiver programs to expand coverage. People who lose Medicaid coverage as a result of these requirements, including those who are working or qualify for an exemption but fail to navigate reporting rules, may face challenges finding affordable coverage because they will remain ineligible for premium tax credits until they are no longer eligible for Medicaid for reasons other than not meeting work requirements (such as a change in income).

9. Litigation has halted implementation of some Marketplace requirements for 2027.

Litigation challenging two final regulations that make substantial changes to Marketplace requirements – the 2025 program integrity rule and the HHS Notice of Benefit and Payment Parameters for 2027 – have halted implementation of many new rules for the time being. Four key cases are working their way through the courts: The 2025 program integrity rule was challenged in City of Columbus et al. v. Kennedy (Columbus I) and California et al. v. Kennedy (California I). Litigation over the 2027 Payment Notice is also ongoing in City of Columbus et al. v. Kennedy (Columbus II) and California et al. v. Kennedy (California II), with some provisions of the 2027 Payment Notice stayed as the litigation continues.

The state of play after several court decisions over the past year include the following:

• Failure to reconcile requirement: For plan year 2027, consumers will not be disqualified from receiving premium tax credits if they fail to file and reconcile prior years' premium tax credits. So, for example, an enrollee who failed to file their tax return and reconcile for the 2025 tax year in 2026, will not lose subsidies for 2027 coverage.
• Expansion of eligibility for catastrophic plans: A 2025 announcement expanded who can enroll in catastrophic plans, allowing individuals who were not eligible for premium tax credits or other cost-sharing help because their projected income was below the federal poverty level or above 250% FPL to sign up for catastrophic coverage. This expanded eligibility has been temporarily paused due to a June decision in Columbus II. This means only a narrow group of people including individuals under age 30, those whose Marketplace or employer coverage would cost more than 8.5% of their income, and those who qualify for a hardship exemption can enroll in these plans during open enrollment.
• Other requirements are not in place for now or have been vacated. Due to litigation, CMS has stated that it will not implement a long list of final requirements. This includes certain income verification requirements, network adequacy requirements, and the elimination of standardized health plans. In addition, other requirements, including an Administration rule that would prohibit states from including gender-affirming care as an essential health benefit and a rule that would have shortened the Open Enrollment Period to nine weeks, have been vacated.