Health coverage plays a major role in enabling people to access health care and protecting families from high medical costs. There have been longstanding racial and ethnic disparities in health coverage that contribute to disparities in health. Due to Medicaid and Affordable Care Act (ACA) cuts in the 2025 reconciliation law and the expiration of the ACA’s enhanced premium tax credits, the number of uninsured is expected to increase by more than 14 million by 2034, potentially exacerbating racial disparities in coverage. This brief examines trends in health coverage by race and ethnicity from 2010 through 2024 and discusses the implications for health disparities. It is based on KFF analysis of American Community Survey (ACS) data for people under age 65. All noted differences between groups and years described in the text are statistically significant at the p<0.05 level. Key takeaways include:

Since 2010, there have been large gains in health coverage across racial and ethnic groups but racial and ethnic disparities in coverage persisted. The largest gains occurred after implementation of the ACA coverage expansions in 2014, with increases continuing until 2016. Hispanic people under age 65 had the largest percentage point increase in coverage, with their uninsured rate falling from 32.6% in 2014 to 19.1% as of 2016. Black, Asian, and American Indian or Alaska Native (AIAN) people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, Hispanic, Black, AIAN, and Native Hawaiian or Pacific Islander (NHPI) people under age 65 remained more likely than their White counterparts to be uninsured as of 2016. Beginning in 2017, coverage gains began reversing, and the overall number of uninsured increased for three consecutive years, coinciding with the first Trump administration. Pandemic-era policies drove broad coverage gains and reduced uninsured rates across most racial and ethnic groups between 2019 and 2023.

In 2024, the overall uninsured rate increased for the first time since 2019 as pandemic-era continuous enrollment in Medicaid came to an end, with significant increases among Hispanic, Black, and White people under age 65. Asian, AIAN and NHPI people did not have statistically significant changes in coverage over this period. As of 2024,AIAN and Hispanic people under age 65 had the highest uninsured rates at 18.9% and 18.4%, respectively. Uninsured rates for NHPI (12.3%) and Black people (10.1%) under age 65 also were higher than the rate for their White counterparts (6.8%). Asian people had the lowest uninsured rate at 5.7%.

Coverage disparities have persisted over time and, in some cases, widened despite earlier gains under the ACA. For example, between 2010 and 2024, the uninsured rate for AIAN people grew from 2.4 to 2.8 times higher than the uninsured rate for White people, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people, and Black people remained 1.5 times more likely to be uninsured than White people.

Recent policy changes are projected to lead to increased coverage losses in coming years, which will likely widen racial and ethnic coverage disparities. The 2025 reconciliation law makes significant changes to Medicaid and the ACA Marketplaces, which are projected to lead to large coverage losses. It also further restricts access to health coverage for lawfully present immigrants across public health insurance programs. Additionally, the expiration of enhanced premium tax credits for ACA Marketplace enrollees has led to substantial out-of-pocket premium increases and further growth in the uninsured population. The Congressional Budget Office estimates that the combined impact of the reconciliation law with the expiration of the ACA’s enhanced premium tax credits will increase the number of uninsured by more than 14 million in 2034. Medicaid and ACA Marketplace coverage losses will likely widen racial disparities in coverage given that disproportionately large shares of Hispanic, Black, AIAN, and NHPI people are covered through these sources. Coverage losses, in turn, would likely contribute to widening disparities in health.

Prior to the enactment of the ACA in 2010, Hispanic, Black, Asian, AIAN, and NHPI people under age 65 were more likely to be uninsured compared to their White counterparts, with Hispanic and AIAN people at the highest risk of lacking coverage (Figure 1). Their higher uninsured rates reflected more limited access to affordable health coverage options. Although the majority of individuals have at least one full-time worker in the family across racial and ethnic groups, there are ongoing racial disparities in employment and income that result in some groups having more limited access to coverage offered by an employer or having greater difficulty affording private coverage when it is available. While Medicaid helps fill some of these gaps in private coverage, prior to the ACA, Medicaid eligibility for parents in most states was limited to those with very low incomes (often below 50% of the poverty level), and adults without dependent children—regardless of how poor—were ineligible under federal rules.

Between 2010 and 2016, there were large gains in coverage across racial and ethnic groups under the ACA, but racial and ethnic disparities in coverage persisted. The ACA created new coverage options for low- and moderate-income individuals. These included provisions to extend dependent coverage in the private market up to age 26 and prevent insurers from denying people coverage or charging them more due to health status. Further, beginning in 2014, the ACA expanded Medicaid coverage to nearly all adults with incomes at or below 138% of poverty in states that adopted the expansion and made tax credits available to people with incomes up to 400% of poverty to purchase coverage through a health insurance Marketplace. Following the ACA’s enactment in 2010 through 2016, coverage increased across all racial and ethnic groups, with the largest increases occurring after implementation of the Medicaid and Marketplace coverage expansions in 2014. Hispanic people under age 65 had the largest percentage point increase in coverage, with their uninsured rate falling from 24.8% to 19.1% between 2014 and 2016. Black, Asian, and AIAN people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, Hispanic, Black, AIAN, and NHPI people under age 65 remained more likely than their White counterparts to be uninsured as of 2016.

Beginning in 2017, coverage gains began reversing, and the number of uninsured increased for three consecutive years. The uninsured rate for the total population under age 65 increased from 10.0% in 2016 to 10.9% in 2019. Hispanic people had the largest statistically significant increase in their uninsured rate over this period (from 19.1% to 20.0%) although the absolute change was small. There were also small but statistically significant increases in the uninsured rates among White and Black people under age 65, which rose from 7.1% to 7.8% and 10.7% to 11.4%, respectively, between 2016 and 2019. Rates for AIAN, NHPI, and Asian people under age 65 did not have a significant change. These coverage losses likely reflected policy changes made by the first Trump administration after taking office in 2017. These changes included decreased funds for outreach and enrollment assistance, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage as well as to increase the frequency of eligibility verifications, and changes to public charge immigration policy that made some immigrant families more reluctant to participate in Medicaid and the Children’s Health Insurance Program (CHIP) (which were later reversed by the Biden administration).

Pandemic-era policies drove broad coverage gains and reduced uninsured rates across most racial and ethnic groups between 2019 and 2023. After rising in the years before the pandemic, uninsured rates declined between 2019 and 2023, with 3.6 million more people under age 65 gaining coverage as the uninsured rate fell from 10.9% to 9.5%. Declines occurred across most racial and ethnic groups, with the largest drop among AIAN people (21.7% to 18.7%), alongside smaller but significant declines among Hispanic (20.0% to 17.9%), Black (11.4% to 9.7%), Asian (7.2% to 5.8%), and White people (7.8% to 6.5%), while changes for NHPI people were not statistically significant. These gains were driven largely by increased Medicaid coverage, which offset declines in employer-sponsored insurance, and reflected pandemic-era policies that stabilized and expanded coverage. These policies included the Families First Coronavirus Response Act’s continuous enrollment provision for Medicaid, which required states to pause disenrollments from Medicaid during the COVID pandemic in exchange for increased federal funding to states, enhanced ACA Marketplace subsidies under the American Rescue Plan Act and Inflation Reduction Act, increased outreach and enrollment efforts, and low Marketplace attrition.

After years of decline, the overall uninsured rate among people under age 65 increased in 2024, with significant increases among Hispanic, Black, and White people. The total number of people under age 65 without health coverage increased by more than 1.3 million to 26.7 million in 2024, and the uninsured rate for the population under age 65 increased from 9.5% to 9.8%.Hispanic people experienced the largest increase in uninsured rates between 2023 and 2024 (17.9% to 18.4%), followed by Black (9.7% to 10.1%) and White people (6.5% to 6.8%).Asian, AIAN andNHPI people did not have statistically significant changes in coverage over this period.

Coverage disparities have persisted, and in some cases widened, over time even with recent gains and the large earlier gains in coverage under the ACA. For example, in 2010, the uninsured rate for AIAN people was 2.4 times higher than the uninsured rate for White people; however, in 2024, the gap had increased to 2.9 times higher than the rate for White people. Similarly, the Hispanic uninsured rate grew from 2.5 to 2.8 times higher than the rate for White people from 2010 to 2024, while Black people remained 1.5 times more likely to be uninsured than White people.

Hispanic, Black, AIAN, and NHPI people under age 65 were more likely than their White counterparts to be uninsured as of 2024(Figure 2). AIAN and Hispanic people had the highest uninsured rates at 18.9% and 18.4%, respectively, as of 2024. Uninsured rates for NHPI (12.3%) and Black people (10.1%) also were higher than the rate for their White counterparts (6.8%). Asian people had the lowest uninsured rate at 5.7%, although uninsured rates vary among subgroups of the Asian population. The higher uninsured rates among some groups are driven by lower rates of private coverage. Medicaid coverage helps to narrow these differences but does not fully offset them.

Medicaid and CHIP coverage help fill gaps in private coverage and reduce coverage disparities for children, but some disparities in children’s coverage remain (Figure 2). Medicaid and CHIP cover larger shares of children than adults, reflecting more expansive eligibility levels for children. This coverage helps fill gaps in private coverage, with over half of Hispanic, Black, AIAN, and NHPI children covered by Medicaid and CHIP. However, there remain some disparities in children’s coverage. For example, AIAN children are about three times as likely as their White counterparts to lack coverage (13.6% vs. 4.4%). Moreover, Hispanic children are more than twice as likely as White children to be uninsured (9.8% vs. 4.4%).

Among people under age 65, uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2024 (Figure 3). While uninsured rates for children are lower than for adults across groups, these differences between expansion and non-expansion states persist among children. For example, 16.0% of Hispanic children in non-expansion states are uninsured compared to 6.7% of Hispanic children in expansion states. The differences in coverage rates between Black and Hispanic people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black, Hispanic, Asian and NHPI people compared with White people is similar in expansion and non-expansion states. For example, Hispanic people under the age of 65 years old are roughly 2.6 times as likely as their White counterparts to lack coverage in both expansion and non-expansion states. Uninsured rates for AIAN people are similar in expansion and non-expansion states.

Overall, about half of uninsured people are eligible for Medicaid or Marketplace coverage, but eligibility varies across racial and ethnic groups, with smaller shares of Hispanic and Asian uninsured people eligible for assistance due to these groups having larger shares of ineligible noncitizen immigrants. Overall, over half (52.2%) of people who were uninsured in 2024 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage, while the remaining half (47.8%) were not eligible because they fell in the Medicaid coverage gap in states that have not expanded Medicaid, had income too high to qualify for Marketplace premium tax credits, , were eligible for employer coverage, or had an ineligible immigration status. However, the share of the remaining uninsured eligible for assistance varied by race and ethnicity. For example, uninsured Black people under age 65 were more likely than their uninsured White counterparts to fall in the Medicaid coverage gap, reflecting that most of the 10 states that have not expanded Medicaid, are in the South where a higher share of the Black population resides. Uninsured Hispanic and Asian people under age 65 were also less likely than White people to be eligible for coverage options, in part, due to higher shares of noncitizens who face immigrant eligibility restrictions including eligibility restrictions for lawfully present immigrants and ineligibility for undocumented immigrants. (Figure 4).

• Gavi, the Vaccine Alliance (Gavi) is an independent public-private partnership and multilateral funding mechanism that aims to expand global access to and use of vaccines, particularly among vulnerable children.
• Since its launch in 2000, Gavi has provided approximately $29 billion to support immunization efforts in low- and middle-income countries, not including funding for COVAX.
• The U.S. government (U.S.) has supported Gavi since its creation through direct financial contributions, participation in Gavi’s governance as a member of the Board, and technical assistance; it had been its third largest contributor in recent years, providing 13% of its funding since its inception (not including funding for COVAX, the global COVID-19 pandemic vaccine response), reaching $300 million in FY 2024. In addition, the Biden administration had pledged that the U.S. would provide approximately $1.6 billion to Gavi over its 2026-2030 funding period.
• While Congress again appropriated $300 million for Gavi in both FY 2025 and FY 2026, the Trump administration has not provided this funding to the organization, citing concerns about vaccine safety despite Gavi following globally recognized scientific standards and evidence.
• Gavi’s latest replenishment summit secured pledges of more than $9 billion, towards a target of $11.9 billion, for the 2026-2030 period, as well as additional financing from development finance institutions and manufacturers to support country recipients. Still, the loss of U.S. funding in the context of a constrained financing environment globally presents new challenges for reaching children in low- and middle- income countries with life-saving vaccines.

Created in 1999 and formally launched in January 2000, Gavi, the Vaccine Alliance (Gavi) is an independent public-private partnership and multilateral funding mechanism that “aims to save lives and protect people’s health by increasing coverage and equitable and sustainable use of vaccines.” Gavi’s main activities include supporting low- and middle-income countries’ access to new and underused vaccines for vulnerable children through financial support, technical expertise, and market-shaping efforts, such as negotiating with manufacturers, to help lower the cost of procuring vaccines. Gavi operates in five-year funding cycles, with a revised strategy and goals for each cycle. Each five-year strategy is accompanied by a vaccine investment strategy, which determines which vaccines will be made available to countries.

Gavi’s current five-year strategy, for the 2026-2030 period, which is its sixth strategy, includes four core goals:

1. introduce and scale-up vaccines,
2. strengthen health systems to increase equity in immunization,
3. improve sustainability of immunization programs, and
4. ensure healthy markets for vaccines and related products.

The current strategy emphasizes reducing the number of ‘zero-dose’ children with the goal of reaching no zero-dose children by 2030, in alignment with Immunization Agenda 2030; prioritizing programmatic and financial sustainability of country immunization programs; supporting targeted countries that have phased out of Gavi support or have never been eligible for Gavi support to maintain immunization progress; and providing more tailored approaches for Gavi countries to reach under-vaccinated populations, such as those living in remote or conflict settings, by encouraging countries to adopt strategies that reduce potential barriers to vaccination.

In addition to Gavi’s role in routine childhood immunizations, Gavi was one of the organizations leading COVAX, a multilateral effort that supported the equitable development, procurement, and delivery of COVID-19 vaccines globally that began in 2020 and ended in 2023. Gavi’s role in COVAX was to facilitate the procurement and delivery of COVID-19 vaccines, with particular emphasis on low- and middle-income countries. Provision of COVID-19 vaccines and funding support to countries was integrated into Gavi’s regular programming from 2024-2025 (COVID-19 vaccine support has been discontinued).

Organization

Gavi’s Secretariat, with its main headquarters in Geneva and an office in Washington, D.C., carries out the day-to-day operations of the partnership. Gavi does not have program offices or staff based in recipient countries but rather relies on country health ministries and World Health Organization (WHO) regional offices to implement programs. Gavi is led by a Chief Executive Officer (CEO), currently Sania Nishtar.

The 28-member Gavi Board sets Gavi’s funding policies and strategic direction, and monitors program implementation. It includes 18 “representative” seats, nine seats for independent individuals, and one ex-officio non-voting seat for Gavi’s CEO. The 18 representative seats, as specified in Gavi’s statutes, are as follows: donor country governments (5), implementing country governments (5), the WHO, the United Nations Children’s Fund (UNICEF), the World Bank, and the Gates Foundation, and one seat each for civil society groups, the vaccine industry in industrialized countries, the vaccine industry in developing countries, and technical health/research institutes. Additionally, several Board committees guide and advise the Board and the CEO on Gavi activities under their purview. The U.S. government was represented on Gavi’s Board as the Board member for the donor country government constituency until the end of 2025. With the suspension of U.S. support, the U.S. lost eligibility to hold a seat on the Gavi Board.

Funding

Since its 2000 launch, Gavi has received approximately $30 billion in financing, not including funding for COVAX (see Table 1).¹ Approximately four-fifths (80%) of Gavi’s funding came from contributions provided by donor governments and private organizations and individuals. The top three government donors were the United Kingdom, the U.S. and Norway, while the largest private donor was the Gates Foundation.

Donors support Gavi through direct contributions as well as funding commitments to innovative financing mechanisms, the proceeds of which help support Gavi’s overall financing. These innovative financing mechanisms include the International Finance Facility-Immunisation (IFFIm) and the Pneumococcal Conjugate Vaccine (PCV) Advance Market Commitment (AMC). The IFFIm was created in 2006 and uses donor funding commitments to back the issuance of special bonds in capital markets, essentially providing “up-front” financing to Gavi. The PCV AMC began in 2010, and though it ended in 2020, it supported accelerated access to pneumococcal vaccines through up-front funding commitments from donors and continues to do so through contracts with manufacturers that extend until 2029. The U.S. does not provide support to either of these mechanisms.² 

In addition to financing Gavi’s regular activities, donors pledged additional resources to support the Gavi COVAX Advance Market Commitment (COVAX AMC), a financial mechanism within COVAX that supported low- and middle-income countries through procurement and distribution of COVID-19 vaccines; through 2024, Gavi received $12.6 billion from donor governments, private philanthropy, and innovative financing mechanisms for the COVAX AMC for vaccine procurement, delivery, and logistics.³

Eligibility

Only low- and middle-income countries with a Gross National Income (GNI) per capita below or equal to $1,820⁴ are eligible for Gavi support. In 2025, 54 countries were eligible for Gavi support.

Recipient countries’ governments are expected to share responsibility for funding their national immunization efforts through Gavi’s co-financing requirements (introduced in 2008), determined according to country income level and transition status. As countries develop economically, they are expected to contribute a greater share of the funding required for immunization programs. Countries classified as low-income by the World Bank are initial self-financing countries, while countries between the low-income threshold and Gavi eligibility threshold ($1,820 GNI per capita) are in preparatory transition. Initial self-financing countries are responsible for co-financing the equivalent of $0.20 per dose each year. Countries in preparatory transition gradually increase their co-financing contribution each year.⁵ When a country’s income rises above the GNI per capita threshold, it moves into an eight-year “accelerated transition” period of increasing domestic financing share, after which the country is expected to fully fund its own immunization programs.⁶ As of 2025, 19 countries have transitioned out of Gavi financial support.

Additionally, Gavi offers limited support for countries that have transitioned out of Gavi eligibility and for middle-income countries that have never been eligible for Gavi support.⁷ Recognizing that many formerly and never Gavi-eligible countries experience low coverage rates and have yet to make key vaccine introductions, eligible countries can apply for “catalytic” funding to support the introduction of key missing vaccines (HPV, PCV, or rotavirus) or mitigation of backsliding.⁸

Country Support

Gavi provides grant financing to country programs in the following two support types:

• Vaccine support, including for vaccine introduction, targeted and routine campaigns, and
• Health systems and immunization strengthening (HSIS) support,⁹ to improve country data systems and to support cold chain equipment, health workforce, and community engagement.

Country allocation formulas for HSIS support are based on the following metrics: number of zero-dose children, coverage of essential vaccines,¹⁰ GNI per capita, and if a country is considered fragile or conflict-affected.¹¹ For vaccines, all countries are required to pay a share of the cost of their Gavi-supported vaccines.

Additionally, Gavi has provided country support through emergency response funding, including for Ebola vaccination during Ebola outbreaks¹² and for COVID-19, allowing for up to $200 million in reprogrammed Gavi support for the COVID-19 response in Gavi-eligible countries, and other support  for the COVID-19 response including through the creation of COVAX (which helped expand access to COVID-19 vaccines in lower-income countries) and the COVID-19 Vaccine Delivery Partnership (CoVDP, which aimed to improve COVID-19 vaccine coverage in certain COVAX countries, with a particular emphasis on countries that were below 10% coverage in January 2022).¹³ In 2022, Gavi supported 50 outbreak response vaccination campaigns. Gavi currently funds several emergency vaccine stockpiles, allowing for rapid deployment of vaccines during outbreaks, including for cholera, Ebola, meningitis, mpox,¹⁴ and yellow fever. In 2024, Gavi deployed vaccines from these emergency stockpiles to 20 countries.¹⁵

Since its launch in 2000, Gavi has provided approximately $29 billion to support country immunization programs (not including funding for COVAX).¹⁶ Over the past three years, 2023-2026, more than $8.1 billion has been disbursed, most of which has been for vaccine support (62%), followed by health systems strengthening (23%) (see Table 2).

Results

Gavi reports it has helped to immunize more than 1.2 billion children in supported countries, including more than 72 million in 2024 alone, and supported 58 different vaccine introductions and preventive campaigns and 50 outbreak response campaigns in 2024. Additionally, Gavi support has helped avert more than 20.6 million deaths and contributed to more than $280 billion in economic benefits, since its launch in 2000. Additionally, according to Gavi, its support has led to improved child health and immunization indicators across its supported countries. For example, the average vaccine coverage across multiple key Gavi-supported vaccines –  including the human papillomavirus (HPV) vaccine, inactivated polio vaccine, and pentavalent vaccine (the vaccine providing protection against diphtheria, tetanus, pertussis, hepatitis B, and Hib),¹⁷ among others –  was 63% in Gavi-supported countries in 2024, up from 48% in 2019.¹⁸ Lastly, Gavi’s work has contributed to vaccine market-shaping; for example, Gavi reports that its influence has helped lower the cost of the HPV vaccine from a price per dose of $4.50 in 2015 to $2.90 in 2022.¹⁹

The U.S. government has supported Gavi since its creation. President Clinton made the initial U.S. pledge to the newly formed partnership in 2000, and the U.S. provided its first contribution in 2001. Prior to the second Trump administration, the U.S. supported Gavi through financial contributions, participation in Gavi’s governance, and by providing technical assistance, but the current administration has not provided funding to the organization (see below).

Additionally, the U.S. had supported other global immunization activities that complemented Gavi’s  efforts, providing bilateral (country-to-country) support for immunization through USAID (before its dissolution), CDC, and other agencies, focusing on strengthening routine immunization systems to deliver vaccines. However, the U.S. government is currently reorganizing how it supports global health programs, including immunization activities, under its “America First Global Health Strategy” which includes the development of bilateral agreements with countries. Given that Gavi was the mechanism through which the U.S. supported vaccine procurement, it is not yet clear how these agreements will support procurement going forward. See also the KFF fact sheet on the Trump administration’s foreign aid review and the proposed reorganization of U.S. global health programs.

Financial Support 

The U.S. supported Gavi with direct contributions starting in 2001, with funding reaching $300 million in FY 2024, its highest level. Additionally, in response to the COVID-19 pandemic, the U.S. provided $4 billion in FY 2021 emergency funding to Gavi for COVID-19 vaccine procurement and delivery support under COVAX, making the U.S. the largest donor to COVAX (32% of $12.6 billion received overall).²⁰In addition to its financial support for COVAX, the U.S. donated the largest number of COVID-19 vaccines to other countries. While Congress appropriated $300 million for U.S. contributions to Gavi in FY 2025 and FY 2026 (see Figure 1), the current administration has not provided funding to Gavi after citing concerns about vaccine safety despite Gavi following globally recognized scientific standards and evidence.²¹ See the KFF budget tracker and the KFF fact sheet on the U.S. Global Health Budget: Maternal & Child Health (MCH) for details on historical appropriations for Gavi, and also the KFF fact sheet on the Trump administration’s foreign aid review and the status of U.S. support for Gavi.

Governance Activities

The U.S. had historically played a role in Gavi’s governance, including as a Board and committee member, but with the suspension of U.S. funding by the Trump administration, the U.S. is no longer eligible to hold a Board seat.  

Technical Support

The U.S. had historically provided Gavi with technical support and expertise in the design, implementation, and evaluation of its programs in the field through partnerships with several U.S. agencies. For example, Gavi’s accelerated vaccine introduction programs had been conducted with technical support from the Centers for Disease Control and Prevention (CDC) and the now-dissolved U.S Agency for International Development (USAID), along with other partners.

1. This amount includes proceeds for 2000-2024 and pledges for 2025. ↩︎
2. For further information about restrictions on U.S. support for these innovative financing mechanisms, see KFF, Innovative Financing Mechanisms for Global Health: Overview and Considerations for U.S. Government Participation, Sept. 2011. ↩︎
3. KFF analysis of Gavi cash receipts data. Gavi, “Cash Receipts 31 December 2024,” https://www.gavi.org/news-resources/document-library/cash-receipts. ↩︎
4. For countries to be eligible for Gavi support, their most recent GNI per capita must be at or below $1,820, or the country’s average GNI per capita over the last three years must be at or below $1,820. ↩︎
5. Countries in the first year of the preparatory transition phase co-finance the equivalent of $0.20 per dose, the same as initial self-financing countries. For each subsequent year, countries in preparatory transition co-finance a 15% increase of the total fraction paid in the prior year. Gavi, “Co-financing policy,” https://www.gavi.org/sites/default/files/programmes-impact/our-impact/01_Gavi-Alliance-Co-financing-Policy-60.pdf. ↩︎
6. Countries in the first year of the accelerated transition phase co-finance the equivalent of the prior year’s total fraction plus 15%, the same as countries in preparatory transition. For each year after, the amount per dose increases linearly until the country is fully financing each vaccine after the eighth year and end of Gavi support. Gavi, “Co-financing policy,” https://www.gavi.org/sites/default/files/programmes-impact/our-impact/01_Gavi-Alliance-Co-financing-Policy-60.pdf. ↩︎
7. Countries eligible for this limited funding include those above the Gavi eligibility threshold ($1,820 GNI per capita) but below the World Bank lower-middle income threshold ($4,495 GNI per capita) or those that are eligible to borrow from the International Development Association. Gavi, “Annex D: Report to the Board, July 24-25 2025,” https://www.gavi.org/sites/default/files/%20/board/minutes/2025/24-25-july06%20-%20Annex%20D%20-%20Framework%20for%20Gavi%20Funding%20to%20Countries.pdf. ↩︎
8. Support for backsliding mitigation is only available to former Gavi-eligible countries. Gavi, “Annex D: Report to the Board, July 24-25 2025,” https://www.gavi.org/sites/default/files/%20/board/minutes/2025/24-25-july06%20-%20Annex%20D%20-%20Framework%20for%20Gavi%20Funding%20to%20Countries.pdf. ↩︎
9. HSIS support only available for Gavi-eligible countries. Gavi, “Annex D: Report to the Board, July 24-25 2025,” https://www.gavi.org/sites/default/files/%20/board/minutes/2025/24-25-july06%20-%20Annex%20D%20-%20Framework%20for%20Gavi%20Funding%20to%20Countries.pdf. ↩︎
10. Includes coverage of first-dose diphtheria, tetanus, and pertussis containing vaccine (DPT1), coverage of DTP3, and coverage of second-dose measles containing vaccine (MCV2). Gavi, “Annex D: Report to the Board, July 24-25 2025,” https://www.gavi.org/sites/default/files/%20/board/minutes/2025/24-25-july06%20-%20Annex%20D%20-%20Framework%20for%20Gavi%20Funding%20to%20Countries.pdf.    ↩︎
11. Gavi, “Annex D: Report to the Board, July 24-25 2025,” https://www.gavi.org/sites/default/files/%20/board/minutes/2025/24-25-july06%20-%20Annex%20D%20-%20Framework%20for%20Gavi%20Funding%20to%20Countries.pdf.    ↩︎
12. Gavi, “500,000 doses of Ebola vaccine to be made available to countries for outbreak response,” webpage, https://www.gavi.org/news/media-room/500000-doses-ebola-vaccine-be-made-available-countries-outbreak-response. ↩︎
13. CoVDP phased out its operations in June 2023 as the partnership was not set up to be a permanent structure. WHO, “COVID-19 Vaccine Delivery Partnership,” webpage, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/covid-19-vaccine-delivery-partnership; Devex, “Exclusive: A COVID-19 initiative for vaccine delivery is winding down,” 11 January 2023, https://www.devex.com/news/exclusive-a-covid-19-initiative-for-vaccine-delivery-is-winding-down-104724. ↩︎
14. Gavi, “Gavi 6.0 Funding Guidelines,” https://www.gavi.org/sites/default/files/support/guidelines-2026/gavi-60-funding-guidelines-annexes.pdf#page=43 ↩︎
15. Gavi, “Vaccine stockpiles,” https://www.gavi.org/vaccineswork/vaccine-stockpiles-guide. ↩︎
16. KFF analysis of data provided by Gavi on disbursements by program area and year. KFF personal communications with Gavi, March 19, 2026. ↩︎
17. The vaccines included in Gavi’s breadth of protection measure include: the third dose of the pentavalent vaccine, third dose of the pneumococcal conjugate vaccine, first dose of the rubella-containing vaccine, last dose of the rotavirus vaccine, second dose of the measles-containing vaccine, yellow fever, meningococcal A, Japanese encephalitis, and last dose of the HPV vaccine. Gavi, “Gavi 2024 Annual Progress Report,” https://www.gavi.org/sites/default/files/programmes-impact/our-impact/apr/Gavi-2024-Annual-Progress-Report.pdf#page=17.    ↩︎
18. Gavi, “Gavi 2024 Annual Progress Report,” https://www.gavi.org/sites/default/files/programmes-impact/our-impact/apr/Gavi-2024-Annual-Progress-Report.pdf#page=17. ↩︎
19. As another example of Gavi’s market-shaping influence, Gavi and UNICEF recently announced an agreement to make R21/Matrix-M malaria vaccines more affordable for Gavi countries through the IFFIm mechanism. UNICEF, “Gavi and UNICEF announce equitable pricing deal for malaria vaccine to protect 7 million more children by end of decade,” https://www.unicef.org/press-releases/gavi-and-unicef-announce-equitable-pricing-deal-malaria-vaccine-protect-7-million. ↩︎
20. The U.S. announced it would donate 500 million Pfizer doses to COVAX at the G7 Summit in June 2021. However, a portion of these doses were purchased using funds appropriated to Gavi ($2 billion for 300 million Pfizer doses), while the remaining 200 million doses were purchased using $1.5 billion in other emergency funds from the American Rescue Plan Act. To avoid double-counting, Gavi counts the U.S. funding that was contributed to Gavi under its COVAX funding contributions, with only 200 million of the doses – those purchased directly by the U.S. – counted as COVAX vaccine dose donations. KFF personal communication with Gavi, Nov. 12, 2021; White House, “FACT SHEET: President Biden Announces Historic Vaccine Donation: Half a Billion Pfizer Vaccines to the World’s Lowest-Income Nations,” June 10, 2021; Gavi, “COVAX AMC Donors Table,” Apr. 7, 2022, https://www.gavi.org/sites/default/files/covid/covax/COVAX-AMC-Donors-Table.pdf; Gavi, “Cash Receipts 31 December 2024,” https://www.gavi.org/news-resources/document-library/cash-receipts. ↩︎
21. Secretary Robert F. Kennedy Jr. (@SecKennedy), https://x.com/SecKennedy/status/1937986463510982869 [X post], June 25, 2025; Gavi, “Statement,” https://www.gavi.org/news/media-room/statement-response-25-june-2025; Reuters, “Exclusive: US conditions funding to global vaccine group on dropping mercury-based preservative from shots,” https://www.reuters.com/business/healthcare-pharmaceuticals/us-conditions-funding-global-vaccine-group-dropping-mercury-based-preservative-2026-01-28/. ↩︎

• The Dobbs decision had a major impact on abortion access across the U.S., resulting in state laws that restrict or prohibit the provision of abortion in a large swath of the nation. In addition to state laws affecting the provision of abortion, some states have addressed abortion coverage options under Medicaid or private insurance by implementing new state laws or in response to court decisions on cases that challenged funding restrictions. Since Dobbs, six states (of a total of 13 states) have implemented policies that require abortion coverage in private plans, and five states have eliminated Medicaid coverage restrictions. 
• Among the 37 states that do not have laws prohibiting abortion, 17 states and D.C. follow the Hyde Amendment restrictions, which restrict the use of federal funds for all abortions with the exceptions of pregnancies resulting from rape or incest or endanger the life of the pregnant person. However, twenty states use state funds to pay for abortions for Medicaid enrollees beyond the Hyde Amendment restrictions, up from 16 states in 2019. Despite the expansion of abortion funding for Medicaid enrollees, over half of women of reproductive age (15-49) with Medicaid coverage live in a state that follows the Hyde Amendment restrictions (33%) or has a law banning the provision of abortion (19%).
• Federal and states policies also shape access to coverage for abortion in private insurance plans. States are responsible for regulating fully insured individual, small, and large group plans, including Affordable Care Act (ACA) marketplace plans. Among the states that do not ban the provision of abortion, four impose Hyde-like restrictions on the circumstances under which state regulated private plans may cover abortion.
• The ACA allows states to enact laws barring all plans participating in the state marketplace from covering abortion. As of January 2026, 25 states prohibit abortion coverage in their ACA Marketplace plans. In contrast, 13 states require all state regulated plans, including Marketplace plans, to include abortion coverage regardless of the circumstances, and the remaining 12 states and D.C. are silent on the issue.
• A review of the 2026 Marketplace plans in the 12 states and D.C. that have no specific laws requiring or prohibiting abortion coverage finds six states have no Marketplace plans that include abortion coverage. The remaining six states and D.C. have at least one plan in the 2026 Marketplace that includes abortion coverage on the exchange.
• Abortion coverage remains a focal point of debate in Congress and a target for investigation by the Trump administration. During the failed 2025 negotiations to extend enhanced premium tax credits, there were proposals to ban the use of federal ACA tax credits for Marketplace plans that include abortion benefits. Since then, the administration has issued guidance on the management of non-federal premium funds that ACA plans are required to collect and segregate if they offer abortion coverage and launched investigations aimed at further restricting abortion coverage within these plans.

While the 2022 Dobbs decision overturning Roe v. Wade eliminated federal abortion protections and allowed states to ban the provision of abortion, federal and state restrictions on abortion coverage persist even in states without laws that prohibit abortion. State and federal efforts to address insurance and Medicaid coverage of abortion services began soon after the 1973 Supreme Court’s Roe v. Wade decision legalizing abortion and have continued to the present day. Since 1977, the Hyde Amendment, which bans the use of any federal funds for abortion, allowing only exceptions for pregnancies that endanger the life of the pregnant person, or that result from rape or incest, has been a major barrier to coverage of abortion services for low-income women.

Decades later, the issue of abortion coverage was at the heart of many debates in the run up to the passage of the Affordable Care Act (ACA) and subsequently led to renewed legislative efforts at the state level to limit coverage of abortions, this time in private insurance plans. Further federal restrictions on abortion coverage are still being debated in current day policy discussions. Most recently, there have been proposals to ban the use of federal ACA tax credits for Marketplace plans that include abortion as a covered benefit. This policy was recently discussed as part of the failed negotiations to extend the federal tax credits in the fall of 2025. In March 2026, the Trump Administration launched investigations to ascertain whether states that require health insurance plans to cover abortion are violating the Weldon Amendment, a federal law that that prohibits federal funds from going to state or local governments that “discriminate” against health care entities which refuse to provide, pay for, cover, or refer for abortions.

This brief reviews current federal and state policies on Medicaid and insurance coverage of abortion services in the U.S. and presents national and state estimates on the availability of abortion coverage for people enrolled in private plans, Marketplace plans, and Medicaid.

Over 1.1 million abortions occurred in the United States in 2025. Federal and state laws, as well as insurers’ coverage policies, shape the extent to which individuals can have coverage for abortion services under both publicly funded programs and private health insurance plans. People who seek an abortion but do not have coverage for the service have to shoulder the out-of-pocket costs of the services (though some clinics offer abortion services on a sliding scale based on income). The cost of an abortion varies depending on factors such as location, facility, timing, and type of procedure. The median cost of a medication abortion is $563, whereas the median cost of a second-trimester abortion is $1,000. Though the vast majority (~93%) of abortions are performed in the first trimester of pregnancy, the costs are challenging for people with lower incomes. Approximately 4% of abortions are performed at 16 weeks or later in the pregnancy. For people with medically complicated health situations or who need abortions later in pregnancy, the costs can be prohibitive. In some cases, individuals find they have to delay their abortion while they take time to raise funds, or they may first learn of a fetal anomaly later in pregnancy when the costs are considerably higher. Prior analysis has found that 43% of women ages 18-49 could not handle a $500 emergency expense using their savings. Across the U.S. abortion coverage restrictions disproportionately affects low-income people, who have limited ability to pay for abortion services with out-of-pocket funds.

Since 1977, federal law has banned the use of any federal funds for abortion unless the pregnancy is a result of rape, incest, or if it is determined to endanger the pregnant person’s life. This rule, also known as the Hyde Amendment, is not a permanent law; rather it has been attached annually to Congressional appropriations bills for the Department of Health and Human Services (HHS) and has been approved every year by Congress. The Hyde Amendment restricts federal abortion funding under Medicaid, Indian Health Service, Medicare, and the Children’s Health Insurance Program. Over the years, similar language has been incorporated into a range of other federal programs that provide or pay for health services for people who could become pregnant, including the military TRICARE program, the Peace Corps, the Federal Employees Health Benefits program and federal prisons. The Department of Veteran Affairs, which provides coverage for military veterans and their families, does not cover abortion nor abortion counseling for their beneficiaries, with limited exceptions for people whose life is endangered. State level policies also have a large impact on how insurance and Medicaid cover abortions, particularly since states are responsible for operating Medicaid programs and regulating insurance plans.

Medicaid

The Medicaid program, a federally and state funded program, serves millions of low-income women and is a major funder of reproductive health services nationally. Approximately two-thirds of adult women enrolled in Medicaid are in their reproductive years. As discussed earlier, the federal Hyde Amendment restricts state Medicaid programs from using federal funds to cover abortions beyond the cases of life endangerment, rape, or incest, however, a state may use its own funds to cover abortions in other circumstances. Currently, 20 states use state-only funds to pay for abortions for women on Medicaid in circumstances different from those federal limitations set in the Hyde Amendment. In the years following the Dobbs decision, four states—Colorado, Delaware, Nevada and Rhode Island—have eliminated Medicaid abortion coverage restrictions, either via a new state law or a court decision. On April 24, 2026, the Pennsylvania Commonwealth Court ruled that the state’s ban on Medicaid coverage for abortion services was unconstitutional, but following an appeal from the state’s Attorney General on May 20, 2026, the court’s decision is paused while the appeal is pending. In 17 states that do not prohibit the provision of abortion and the District of Columbia, Medicaid programs do not pay for any abortions beyond the Hyde exceptions. The 13 states that currently have laws prohibiting abortion provision also follow the Hyde restrictions. Nearly half of women with Medicaid coverage live in states that use their own funds to pay for abortion services, beyond the federal Hyde limitations (Figure 1).

Since the Dobbs ruling, many states have enacted laws that prohibit or highly restrict abortion and do not necessarily allow exceptions for rape or incest. As of March 2026, thirteen states have laws that ban the provision of abortion, and while all of these laws contain exceptions to safeguard the life of the pregnant person, most do not have exceptions for cases of rape or incest, and therefore, would not allow for the provision of those services to Medicaid enrollees in those states. Most Medicaid enrollees living in states where abortion provision is prohibited are not able to use their coverage in their state for an abortion that qualifies as a Hyde circumstance and those who can travel out of state will most likely not be able to find a provider able to bill their home state’s Medicaid program.

Additionally, some states have extensive reporting requirements for cases of rape and incest. A 2019 GAO study found that some states have requirements for people claiming abortion coverage under Hyde that include provider certification of rape, incest, or life endangerment; beneficiary certification of rape or incest; official documentation (such as police report or report with a public health agency) of rape or incest; prior authorization by the state Medicaid program; and prior certification of counseling for the abortion. Since 2013, Iowa has required formal approval from the Office of the Governor to secure reimbursement for any abortions covered by Medicaid.

Although Hyde abortions are not accessible in states where laws prohibit the provision of abortion, federal courts have ruled that the Medicaid statute, as modified by the Hyde Amendment, requires states to pay for abortions that fall under the Hyde Exceptions and have blocked enforcement of state statutes that prohibit coverage for these exceptions. The Hyde Amendment requires coverage in cases of rape, incest, and life endangerment. In 1998, in a letter to all the state Medicaid directors explaining a change to the Hyde Amendment, Health and Human Services stated that: “All abortions covered by the Hyde Amendment, including those abortions related to rape or incest, are medically necessary services and are required to be provided by states participating in the Medicaid program.” However, a 2022 Congressional Research Service (CRS) overview of the Hyde Amendment, published after the Dobbs decision, lists open questions, such as whether payment for travel for abortion services also falls under the scope of the Hyde Amendment and conjectures that the interplay of state abortion laws and the Amendment may be relitigated. Despite this clear guidance, and court precedent, historically the Centers for Medicare & Medicaid Services (CMS) has not taken any enforcement action against states for failing to comply with covering abortion in all of the circumstances required by Hyde.

Private Insurance

States are responsible for regulating fully insured individual, small, and large group plans issued in their state. This includes plans available through the ACA marketplace and plans purchased by some employers for their workers. State laws have jurisdiction over whether abortion coverage is included or excluded in private plans that are not self-insured (which are regulated by the federal government under ERISA). Four states (Kansas, Missouri, Nebraska, Utah) that do have laws prohibiting the provision of abortion impose restrictions on the circumstances under which insurance will cover abortions (Appendix Table 1). Six states with highly restrictive abortion laws—Idaho, Indiana, Kentucky, North Dakota, Oklahoma, and Texas—also have private insurance restrictions in place. Utah limits private insurance plans regulated by the state from covering abortion unless the abortion is necessary to save the life of the mother or avert serious risk of loss of a major bodily function, if the fetus has a defect as documented by a physician that is uniformly diagnosable and lethal, and in cases of rape or incest. Kansas, Missouri, and Nebraska only allow fully insured private plans regulated by the state to cover abortion when it is necessary to save the woman’s life, and abortions under all other circumstances are not covered.

While some states allow insurers to sell riders for abortion coverage on the private market, a KFF analysis conducted prior to the Dobbs decision found that no insurers offered abortion riders to people insured through individually purchased plans, and only one insurance company in one state offered an abortion rider in the group market. The lack of abortion riders leaves people insured by private plans in these states with no option to secure coverage for abortion services. Utah law specifically prohibits abortion coverage riders.

Just as some states proscribe insurance plans from covering abortion, other states require plans to include abortion as a covered service. Currently, 13 states require all state-regulated private health plans, including Marketplace plans, to include coverage for abortion. Ten of these states also require no cost-sharing for abortion services—Illinois and Minnesota allow cost-sharing if there is cost-sharing for similar services in the plan, and Delaware only prohibits cost-sharing for abortions over $750. California and Washington require all plans, including individual and employer plans, to treat abortion coverage and maternity coverage neutrally, meaning that all plans are required to include both maternity and abortion coverage.

ACA Marketplace Plans

All plans offered on the ACA Marketplaces must provide coverage for 10 Essential Health Benefits (EHB), including maternity care and prescription drugs. Abortion services, however, are explicitly excluded from the list of EHBs that all plans are required to offer. Under federal law, no plan is required to cover abortion and states can enact laws that bar all plans participating in the state Marketplace from covering abortions. As of January 2026, 25 states have passed laws that prohibit abortion coverage in their ACA Marketplace plans and an additional 12 states and D.C. are silent on the issue. The remaining 13 states require all ACA plans to cover abortion (Figure 2). All 13 states with laws prohibiting the provision of abortion, except for West Virginia, have laws in place that also prohibit abortion coverage. Most state laws include narrow exceptions for pregnant people whose pregnancies endanger their life or are the result of rape or incest. The ACA prohibits plans in the state Marketplaces from discriminating against any provider because of “unwillingness” to provide abortions.

In a KFF review of the 2026 Marketplace plan statement of benefits and plan brochures in the 12 states and D.C. that have no laws requiring or prohibiting abortion coverage, six states (Iowa, Michigan, New Mexico, Nevada, West Virginia, and Wyoming) do not have any Marketplace plans that include abortion coverage (Figure 3). Six states (Alaska, Connecticut, Hawaii, New Hampshire, Rhode Island, and Virginia) and D.C. have at least one plan in their 2026 ACA Marketplace that includes abortion coverage. Although Michigan repealed their state’s ban on abortion coverage in Marketplace plans in 2023, this analysis found that while many plans in the state do not cover abortion, the statement of benefits in many other plans are silent regarding coverage or exclusion of abortion services. As a combined result of the state laws and insurance company choices, individuals in 31 states currently do not have access to a qualified health plan that includes coverage for abortions.

While the reasons why issuers in states that permit abortion coverage choose to exclude abortion coverage are not known, it is possible that the complexity of the requirements specific only to abortion coverage could be a deterrent to the plans. Plans that choose to include abortion coverage are also subject to additional reporting standards and audit requirements, and must also charge a separate premium for the coverage.

Compared to 2019, the last time KFF conducted a review of abortion coverage in ACA marketplace plans, more states now require abortion coverage in their marketplace plans (4 states vs 13 states). Six states (Colorado, Delaware, Massachusetts, Minnesota, New Jersey, Vermont) have passed laws following the Dobbs decision requiring all state regulated private plans, including ACA marketplace plans, to cover abortion services. Overall, 19 states and D.C. currently have Marketplace plans that offer abortion coverage, compared to 16 states and D.C. in 2019. Many of the states that now require coverage previously had no laws requiring or prohibiting coverage but had at least one plan that offered abortion coverage in 2019, including Vermont, Maryland, and Colorado. For individuals living in one of the six states and D.C. that have no laws requiring or restricting coverage and do offer at least one plan with abortion coverage, the actual availability of coverage depends on whether there is a plan offered in their area that includes abortion services since not all plans are offered across the whole state. For example, in Virginia, Kaiser Permanente plans are the only ones that offer abortion coverage for ACA Marketplace enrollees.  

The combination of federal and state abortion provision and coverage policies has constrained options in many states. Not surprisingly, for people living in the 13 states where the provision of abortion is prohibited, regardless of their type of insurance coverage, access to abortion services within their state is extremely limited or essentially nonexistent (except for abortion medications obtained through the mail). However, in many states without these laws, abortion coverage is also limited. In four of those states, people enrolled in Medicaid, private, and Marketplace plans, have practically no abortion coverage options (Figure 4). In eight additional states, individuals who qualify for Medicaid or who are insured through their state Marketplace also do not have access to abortion coverage; in five other states and DC, people enrolled in Medicaid have extremely limited coverage. Six of these states do not offer any 2026 Marketplace plans that include abortion coverage.

Special Rules for Billing and Payment for Marketplace Plans that Include Abortion Coverage

In the 19 states & DC that either require coverage of abortions in Marketplace plans or have no restrictions or requirements for abortion coverage but offer at least one plan that covers abortion, abortion coverage must be paid for using non-federal dollars. Plans must notify consumers of the abortion coverage as part of the Summary of Benefits and Coverage (SBC) explanation at the time of enrollment. The ACA outlines a methodology for states and insurers to follow to ensure that no federal funds are used towards coverage for abortions beyond the Hyde limitations. Any plan that covers abortions beyond Hyde limitations must estimate the actuarial value of such coverage by accounting for the cost of the abortion benefit (valued at least $1 per enrollee per month) and segregate these funds from other premium funds. This estimate cannot take into account any savings that plans may achieve as a result of the patients having abortions (such as the costs of prenatal care or delivery).

The segregated funds for abortion coverage that are sitting with the plans have grown over the last 15 years. In July 2025, Maryland allocated the funds remaining in these accounts to be used to help pay for expenses of patients who travel to Maryland for an abortion. In response to state actions and building interest to reallocate these funds to support abortion services, in December 2025, CMS issued new guidance addressing how ACA Marketplace plans use the segregated funds collected from enrollees for non-Hyde abortion coverage. The new guidance states that ACA plans only need to segregate the funds for the current coverage year. At the end of the plan year, after all claims have been paid, plans may treat the premium funds collected for the coverage of non-Hyde abortions the same as other premiums funds collected, meaning that the plans can keep the funds for other uses, not just for abortion services.

By the beginning of 2025, states had largely resumed more routine Medicaid enrollment operations following the unwinding of pandemic-era continuous enrollment provisions but with numerous reforms in place to streamline renewal processes and bolster enrollee communications. However, the passage of the 2025 reconciliation law in July 2025 introduced significant Medicaid eligibility and enrollment changes. Starting in January 2027, states that adopted the Medicaid expansion in the Affordable Care Act (ACA) along with Georgia and Wisconsin (states that expanded adult coverage through a waiver) must implement work/community engagement requirements (referred to as work requirements in this report) for the expansion or waiver populations. Expansion states must also shift to more frequent semi-annual renewal periods for expansion enrollees and impose cost-sharing on all nonexempt services on expansion enrollees with incomes between 100% and 138% of the federal poverty level (FPL). Other changes in the law affect all states, such as the elimination of eligibility for certain lawfully residing immigrants. The law also delays for 10 years enforcement of many changes included in a 2024 regulation that aimed to simplify eligibility and enrollment (Box 1). In part tied to federal Medicaid financing changes in the law, states also face more tenuous state budget conditions that could lead to further eligibility restrictions and reductions in benefits and provider rates as they seek to reduce spending on Medicaid. 

The 24th annual survey of state Medicaid and CHIP program officials conducted by KFF and the Georgetown University Center for Children and Families (CCF) provides a baseline of state Medicaid and CHIP eligibility, enrollment, and renewal policies in place as of January 2026 as they prepare to implement the changes included in the 2025 reconciliation law. Information collected through the survey highlights state policies and processes that will facilitate implementation of the requirements in the law and shows where states will need to make changes to comply with the new requirements. The survey also included questions about state decisions on implementation of work requirements. More detailed findings from those questions are included in a separate brief, An Early Look at Policy Decisions as States Get Ready to Implement Work Requirements. This report focuses on policies for children, pregnant individuals, parents, and other non-elderly adults whose eligibility is based on Modified Adjusted Gross Income (MAGI) financial eligibility rules (findings on eligibility and enrollment policies for non-MAGI populations are available in Medicaid Eligibility Levels for Older Adults and People with Disabilities (Non-MAGI) in 2026). Overall, 49 states and the District of Columbia responded to the survey (Florida did not respond). For purposes of this report, the District of Columbia is counted as a state.

Key Takeaways

• Many parents of older children in expansion states will be subject to new work requirements starting in January 2027. While the reconciliation law does not directly impact income eligibility levels, new work requirements and more frequent 6-month renewals for parents and adult enrollees in the ACA Medicaid expansion will make it more difficult for those adults to enroll in and retain coverage. Parents covered through the mandatory Section 1931 pathway – based on cash assistance eligibility thresholds in effect in 1988 — are exempt from work requirements, but parents in the expansion group with children ages 14 and over are required to meet the requirements. The median Section 1931 eligibility level in expansion states is 36% FPL, and as a result, some parents in the expansion group (i.e., those with incomes above those thresholds) who are not identified through data matching may need to verify they are exempt, and parents of children ages 14 and older with income above that level who are enrolled through the expansion will need to comply with the work requirements. In the ten states with the lowest Section 1931 eligibility levels (25% of the poverty level or less), many parents will need to meet the requirements or qualify for an exemption. Four expansion states cover parents up to 138% FPL through the Section 1931 pathway, creating an exemption from work requirements for all parents in those states.
• States continue to expand use of electronic communications and add features to online accounts and mobile apps—strategies that may help to maintain enrollment for individuals who remain eligible. States are increasingly using electronic communications through online accounts and text messages to send more frequent alerts and reminders to improve response rates at renewal. While just 14 states have mobile apps with enrollment features, these apps along with online accounts give enrollees more ways to manage their coverage. These strategies, already shown to ease administrative burden during the unwinding, could help expansion states assist enrollees navigate new requirements.
• States with Medicaid eligibility systems that are integrated with SNAP and decisions to adopt options to use SNAP data to enroll or renew Medicaid coverage could reduce the administrative burden of implementing work requirements and semi-annual renewals. Half of states have MAGI Medicaid eligibility systems integrated with SNAP eligibility and 15 states use verified income data from SNAP to enroll or renew Medicaid. SNAP data, in particular, can be used to verify compliance with work requirements or exemption status. States that do not currently share program data may need to establish data linkages to implement work requirements if required by CMS. While having an integrated eligibility system facilitates data sharing across programs, the reconciliation law also included changes to SNAP, so some states with integrated systems are having to make changes for both programs simultaneously.
• A small but growing number of states are using artificial intelligence (AI) in consumer assistance and eligibility and enrollment processes, including to perform some functions that may help with implementation of work requirements. Some states are using AI to review and extract information from uploaded documents and to enhance data matching, which could meaningfully reduce the paperwork burden that semi-annual renewals and work requirements will create. States are also using AI bots to assist enrollees in updating their contact information, saving eligibility or call center workers time in manually collecting and updating the information.
• The reconciliation law includes new administrative requirements for updating addresses and identifying deceased enrollees. The reconciliation law requires states to regularly obtain address information from reliable sources, including mail returned with a forwarding address, the USPS National Change of Address Database (NCOA), and managed care organizations (MCOs), by January 1, 2027. Two-thirds of states already use (MCO) or NCOA data. By January 2028, states must conduct data matching at least quarterly with the SSA’s Master Death File to identify deceased enrollees. Over half of states (29) already review the Master Death File on a quarterly or more frequent basis.
• Currently, 19 states charge nominal cost-sharing to Section 1931 parents, and 21 states charge cost sharing to ACA or waiver expansion adults, while the remaining states do not charge cost-sharing. Starting in October 2028, the reconciliation law requires states to impose cost sharing of up to $35 per service, with some exceptions, on ACA expansion adults with income 100%-138% FPL. CMS guidance is needed to clarify any flexibility that states may have in determining whether some or all non-exempt services must require cost-sharing. The limitation of $35 per service means that several states will have to lower cost-sharing on certain services, generally on inpatient hospital services, which could also implicate cost-sharing for 1931 parents or create inequity in how charges are assessed between low-income parents and ACA expansion adults.

Eligibility Policies

The median eligibility level for children remains unchanged from prior years at 255% FPL, though the transition from separate CHIP program to a CHIP-funded Medicaid expansion among some states continued. Oregon transitioned its separate CHIP program for children to a CHIP-funded Medicaid expansion (M-CHIP). In M-CHIP states, children who are income eligible for CHIP receive all the benefits and protections associated with Medicaid; however, the child must be previously uninsured for the state to claim the enhanced federal match for CHIP. Utah also plans to convert its separate CHIP program to M-CHIP in mid-2026, which will bring the total to 23 M-CHIP states, up from 18 states 2016. Although not required to do so, 14 of 28 states with separate CHIP programs for children provide full Medicaid (EPSDT) benefits (Figure 2).

States must cover pregnancy for individuals with income up to 138% FPL, but most states (38) have an upper income limit for pregnancy coverage at or above 200% FPL. The upper income limit is the highest pregnancy income threshold among three pathways: Medicaid (all states), CHIP expansion for pregnancy (7 states), and CHIP-funded From Conception to the End of Pregnancy coverage (25 states) (Figure 3). The median eligibility level for pregnancy is unchanged at 213%. Two thirds of states (33) use federal funds through the Medicaid state plan option or a Section 1115 waiver to cover family planning services with a median income eligibility of 210% FPL.

The median income eligibility for parents in non-expansion states is 40% FPL while eligibility levels for both parents and adults without dependent children is 138% FPL in expansion states (Figure 4). Although D.C. lowered income eligibility for parents and adults, from 221% and 215% respectively to 138% FPL, it launched the DC Healthy Plan, a Basic Health Program that covers non-Medicaid residents with income between 138%-200% FPL.

Many parents of older children in expansion states will be subject to new work requirements starting in January 2027. States are required to cover parents and caretakers of children under age 18 who have income at or below the eligibility standard for cash assistance that was in effect as of May 1, 1988, through the Section 1931 pathway. The ACA expanded Medicaid eligibility for parents and created a new eligibility pathway for adults without dependent children with incomes up to 138% FPL. In states that adopted the expansion, many parents with income above the state’s Section 1931 level gained coverage. Parents covered through the Medicaid expansion who have children ages 14 or older will need to comply with the new work requirements. Some parents of older children in Georgia also gained coverage through the state’s partial expansion waiver program and will be subject to new work requirements.

The median eligibility for Section 1931 parents in expansion states is 36%; however, the levels vary widely across states. Four expansion states cover parents with income up to 138% FPL through the Section 1931 pathway, thus exempting all parents in their states from work requirements (all parents are also exempt in Wisconsin), and 11 other states have Section 1931 eligibility above 100% FPL. In the ten states with the lowest Section 1931 eligibility levels (less than 25% FPL), many parents will need to meet the requirements or qualify for an exemption (Figure 5).

Three quarters of states (38) cover lawfully residing children without a 5-year waiting period and over six in ten states (32) cover lawfully residing pregnant immigrants through Medicaid. In general, lawfully residing immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll. Through the 2009 Immigrant Children’s Health Insurance Act (ICHIA), states have the option to cover lawfully residing immigrant children and pregnant immigrants without a 5-year waiting period (Figure 6). Undocumented immigrants are not eligible to enroll in Medicaid or CHIP. While the reconciliation law restricted Medicaid and CHIP eligibility for certain lawfully residing immigrants, it did not eliminate the state option to cover lawfully residing children and pregnant individuals without the 5-year waiting period.

Eligibility Changes for Immigrants

States are preparing to send advance notices to lawfully residing immigrants who are losing eligibility because of restrictions in the reconciliation law. Beginning October 1, 2026, Medicaid eligibility for immigrants will be restricted to only LPRs or green card holders, certain Haitian and Cuban entrants, and COFA migrants residing in the U.S. Recent guidance clarifies that to implement these eligibility changes states will need to reverify individuals to confirm they have an eligible immigration status under the new rules. If states are unable to reverify an eligible immigration status, they will need to provide notice to individuals that they are no longer eligible and will be disenrolled. Prior to the guidance being released, more than half of states (28) said they plan to send one or more notices to inform affected immigrants of the eligibility change while 21 states have not yet established their policies regarding outreach and notices, most likely because they were waiting on formal guidance from CMS. Two states (New York and Oregon) plan to transition eligible immigrants who lose coverage to state-funded coverage. Although most states are still making decisions about the number and timing of notices, states that have made decisions report they will send between one and three notices between 30 days and more than 90 days in advance. Advance notice can help affected individuals plan for the loss of coverage and seek care for urgent or unmet needs before they become uninsured. Nearly half of states (22) plan to engage community-based organizations in conducting outreach to affected immigrant communities. Outreach through trusted, community-based organizations can help boost awareness among those who will be affected, and community partners may be able to help individuals consider alternatives, including how to access free or low-cost care.

Eligibility Policies for Incarcerated Individuals

As of January 1, 2026, states are required to suspend, rather than terminate, Medicaid eligibility for adults during incarceration. The Consolidated Appropriations Act of 2023 required states to suspend Medicaid for incarcerated adults so that coverage could be promptly reactivated if the individual requires an inpatient hospital stay of at least 24 hours while incarcerated and to facilitate resumption of coverage when the adult is released. Coverage suspension also allows states to take advantage of reentry waivers (currently approved in 19 states and pending in 9) to provide Medicaid coverage of medications, outpatient services, and mental health services prior to release.

Most states (46) receive information from the Corrections Agency to identify when an individual has been incarcerated for purposes of suspending Medicaid coverage, but the method for transferring the information varies. Half of the states (26) use two or more methods for obtaining the information, including direct data exchange between the Medicaid and Corrections Agencies (29 states), through a secure file transfer via email (19 states), through an alternative secure file transfer (20 states), or using a different form of communication between the two agencies (20 states) (Figure 7). Two states are still developing processes to share information between the agencies. States also rely on information provided directly by incarcerated individuals (35 states) or someone in their household (37 states) or by a third-party vendor (14 states). In over half the states (28), these processes remain mostly or fully manual, which increases the administrative burden for eligibility workers and can lead to delays in processing coverage suspensions.   

Over half of states (27) receive information from the Corrections agency prior to an individual being released from incarceration to reinstate coverage. In these states, the Medicaid agency is informed of the release between 90 days and a few days prior to release. The remaining states receive the information on the day of release or after release, either from the Corrections agency or from the formerly incarcerated individuals when they return to the community. Without data sharing and advance notice of release from incarceration from the Corrections agency, it may be difficult for Medicaid agencies to exempt individuals from work requirements during the three months post release as required.

Enrollment Policies

Uploading Documents

In advance of implementing work requirements, most states maximize options for individuals to submit verification documents. Once states implement work requirements, providing applicants and enrollees with multiple ways to upload documents will help minimize the number of people who are denied or lose coverage because they were unable to submit verification documentation. Documents can be submitted by mail (50 states), to a local office (49 states), by fax (48 states), through online accounts (46 states), via email (37 states), and through mobile apps in 13 of the 16 states with mobile apps (Figure 8).

Updating Contact Information

All states take multiple actions to update enrollee contact information, though some states will have to take additional steps to comply with requirements in the reconciliation law. The 2025 reconciliation law requires states to collect updated mailing addresses from reliable sources, including mail returned with a forwarding address, the USPS National Change of Address database (NCOA), and information from managed care plans. Starting January 1, 2027, states must contractually require all types of managed care organizations to transmit updated addresses for enrollees and must regularly check the NCOA. Currently, over half of states require MCO’s to provide updated contact information (29 states) or conduct routine data matches with NCOA (27 states), with 18 states using both sources (Figure 9). Two thirds of states (35) also check for updated information in SNAP or other programs, 29 states maintain a simple online change of address form, and 17 states have a dedicated phone option for reporting new contact information.

Although not required by the reconciliation law, many states accept updated contact information from reliable sources “as verified” and make a good faith effort to contact an individual when verification is needed. The 2024 eligibility and enrollment rule would have required states to accept the contact information received from reliable sources without having to conduct further verification, including confirming with the enrollee. Without requiring further verification, 36 states update addresses from returned mail with an in-state forwarding address, 28 states accept MCO-submitted changes, 24 states accept NCOA updates, 33 states use SNAP or other program information to update mailing addresses, and 12 states update returned mail without a forwarding address (Figure 10). The E&E rule would also have required states to make a good faith effort to contact an individual when mail is returned with no forwarding address or with an out-of-state address. Currently, when additional information to confirm an address is needed, 28 states send mail to the new address and 22 states send mail to the old address, requesting enrollee confirmation. States also attempt to reach the individual by phone (41 states), by email (24 states), or by text (20 states).

Over half of states review the Death Master File to identify any enrollee who is deceased, as will be required by the reconciliation law. Beginning in January 2028, the reconciliation law requires all states to review the Death Master File at least quarterly to determine if an enrolled individual is deceased. States may treat the information as factual and are not required to attempt to contact the individual to confirm its accuracy. However, they are required to reinstate coverage if an error is made in disenrolling an individual who is still alive. Currently, 30 states regularly review the Master Death file, and all but one review on a quarterly basis or more frequently (Figure 11). Beginning October 1, 2029, states also will be required to submit Social Security numbers and other personal enrollment information monthly to a new federal system to check for enrollment in more than one state, as well as at application and renewal. This system will replace the requirement that states use the Public Assistance Reporting Information System (PARIS) currently used to check for duplicate enrollment.

Use of AI

Several states are using AI in ways that could be applicable to implementing work requirements. Of 22 states using AI, 15 states are using AI to support eligibility and enrollment processes. Five states say they use AI to review and extract information -- such as social security numbers or income data -- from uploaded documents, and one state is using AI to enhance data matching, both functions that can facilitate implementation of work requirements (Table 1). Other uses of AI include helping eligibility workers find policy information (7 states), transcribing case worker notes and hearings (2 states), or using bots to enroll deemed newborns or collect updated contact information (2 states).

States are also using AI to support consumer assistance, most often through a chatbot to answer questions when individuals are viewing the website. Of the 14 states using AI to assist consumers, nearly all (13) have chatbots to answer questions on the website. A smaller number of states (5) report using AI to assist consumers during the application or renewal process. Chatbots are also used to provide updates to applicants and enrollees on the status of their case or to collect updated contact information.

Systems and Online Tools

Half of states (25) have SNAP and TANF integrated in their MAGI-Medicaid eligibility systems which may help to coordinate SNAP and Medicaid work requirements. In most cases, an individual who has met SNAP work reporting requirements can be automatically determined compliant with Medicaid work reporting requirements and adults without dependent children who are eligible for SNAP and not exempt from SNAP work requirements qualify for an exemption from the Medicaid work requirements. An integrated system makes it easier for states to share information across programs and identify individuals who meet work requirements or qualify for an exemption. Nearly three-quarters of states (36) also have integrated non-MAGI Medicaid, and 15 states have integrated child care subsidy eligibility.

Over half of states that operate their own state-based Marketplace (12 of 21 SBM states) have integrated eligibility for MAGI Medicaid and CHIP into their Marketplace eligibility system. Illinois became the 12^th state to integrate Medicaid and Marketplace eligibility systems (Figure 12). The remaining nine SBM states, as well as the two SBM states that use the Federally-facilitated Marketplace (FFM), have separate systems for determining eligibility for MAGI Medicaid and CHIP. Of the 30 states that rely on the Federally-facilitated Marketplace (FFM) for marketplace eligibility functions, eight allow the FFM to determine Medicaid eligibility (determination states) while the FFM assesses eligibility in 21 states (assessment states). The FFM relies on the state’s eligibility criteria and reliable data sources to make an assessment or determination. CMS has encouraged states to use the determination option as a strategy to reduce the workload when state administrative capacity is overwhelmed. However, it is unclear whether the FFM will be able to determine compliance with or exemption from Medicaid work requirements. Upcoming CMS guidance may provide some clarification.

The 12 SBM states with an integrated Marketplace and MAGI-Medicaid eligibility system are much less likely to have integrated non-health programs into their eligibility systems. Only Kentucky and Rhode Island have integrated SNAP, TANF, and the child care subsidy into the Marketplace/Medicaid eligibility system (Figure 13). Both states, plus New York, also have integrated eligibility for non-MAGI Medicaid.

All states have an online MAGI Medicaid application, and nearly all states (49) allow individuals to apply for one or more other benefits, including SNAP or TANF, through the online application even if the state’s eligibility systems are not integrated with the other programs. Multi-benefit MAGI Medicaid applications include non-MAGI Medicaid in 41 states, SNAP in 31 states, TANF in 29 states, child care subsidy in 18 states, and premium tax credits in 13 SBM states (Figure 14). In states that do not have integrated eligibility systems, the data collected from the multi-benefit applications are transferred to the systems that process eligibility for those programs. With the more extensive use of smart phones and other mobile devices along with more limited access to computers among low-income populations, 36 states have designed their online applications to reformat for mobile devices.

Online Accounts and Mobile Apps

Almost all states now have comprehensive online accounts through which individuals apply for Medicaid and manage their personal and enrollment-related information (Figure 15). In the past ten years, the number of states with online accounts increased from 39 to 49. Initially online accounts included a limited number of features; today most states report having a variety of features, including the ability to submit an application or renewal, view notices, report changes, and upload documents. Online accounts provide applicants and enrollees with a centralized location for most of their Medicaid enrollment information, and states can more quickly and cost-effectively connect with individuals if action is needed to enroll or maintain coverage.

Sixteen states have a Medicaid mobile ‘app,’ but features in the apps are generally more limited than in online accounts. Mobile ‘apps’ are specifically designed to work well on smartphones and tablets but offer fewer features. In 13 states, the mobile ‘app’ allows enrollees to view notices and upload documents while the ability to view application status is a feature in 11 states (Figure 16). However, only half of states (8) with mobile ‘apps’ accept applications and half (8) accept renewals for Medicaid. In 2 states (Delaware and Virginia), the mobile ‘app’ helps Medicaid enrollees with non-eligibility and enrollment actions like finding providers or selecting a managed care plan.

Online Portals for Community Assisters

Half of states (26) provide a separate web portal or protected access to the online account for entities that provide application assistance to help individuals apply for coverage (Figure 17). All states with online portals for assisters allow for the submission of the application and most (23 states) allow assisters to review the application status. In 21 states, including 19 that will be implementing work requirements, community assisters can submit renewal information and/or upload scanned or electronic documents through the portals, increasing their ability to assist consumers with providing documentation of compliance with work requirements or exemption status. About a third of states allow assisters to do other tasks such as reporting changes, viewing notices, and accessing renewal dates. States may designate the types of entities allowed to use the portal, which generally include federally qualified health centers and other health care providers, family-serving community-based organizations, MCOs, and federal or state navigators and assisters (Figure 18). Access to community assisters can extend the state’s capacity to help individuals comply with work requirements or seek an exemption.

Renewals and Changes in Circumstances

Renewal Policies

During the unwinding significant effort was dedicated by states and CMS to increase the rate of ex parte (automated) renewals and boost communication with enrollees through multiple modes to avoid procedural disenrollments of eligible individuals. States are maintaining most of the strategies put in place during unwinding to increase retention of eligible individuals.

State adoption of certain renewal strategies allowed during the unwinding could reduce the administrative burden on expansion states as they operationalize work requirements. During the unwinding, all states took advantage of flexible 1902(e)(14)(A) waiver authority to use alternative data and methods to verify income eligibility. Several of these strategies are available to states as state plan options with two-thirds of states (33) adopting one or more of the options. Fifteen (15) states, including 13 states that will need to implement work requirements, enroll and renew individuals based on a SNAP income determination and 8 states use a TANF income determination. The sharing of SNAP program data, in particular, will facilitate implementation of work requirements. Also helpful is the option for MCOs to assist members with renewals, which 10 states have adopted (Figure 19). Although MCO’s cannot determine if an individual meets the work requirements or qualifies for a medically-related exemption, they can assist members in understanding the new requirements and provide information to states that can be used to verify the exemption status of the enrollee. Half of states adopted the option to renew individuals reporting no income if data sources show no income, and 15 states renew individuals reporting income under 100% FPL when there is no conflicting data. However, these strategies are less useful when it comes to verifying compliance with work requirements.

States continue to expand the ways individuals can access their renewal date directly or through providers and assisters. Providing enrollees with numerous ways to confirm their renewal date reduces the likelihood that they will miss renewal notices. This access to renewal dates will be particularly useful as expansion enrollees transition to 6-month renewal periods starting in January 2027. Enrollees can directly access their renewal date in their online accounts in 44 states, mobile app in 13 of 16 states with apps, through the Medicaid call center in 48 states, or via text message from the state in 23 states (Figure 20). All states offer at least one source, and half the states provide renewal information through three or more options. Most states (42) also share renewal dates with entities that provide services or assistance to enrollees, including MCOs (39 states), FQHCs (16 states), other providers (18 states), pharmacies (12 states), and navigators and/or assisters (18 states).

More states are using timely and cost-effective electronic communications, adding methods of communication, and boosting capacity to communicate more frequently with enrollees. During the Medicaid unwinding states sought to increase awareness of renewals and encourage enrollees to respond to improve retention and reduce procedural disenrollments of eligible individuals. To alert enrollees to upcoming renewals, 22 states send advance notice most frequently through text messages, but also via email, regular mail, and robo-calls; 40 states send reminders to enrollees to submit renewal information; and 38 states take various actions to help individuals maintain or regain coverage after disenrollment, including by providing information about the 90-day reconsideration period during which enrollees can still submit renewal forms and documentation (27 states) and by providing MCOs with a list of members who have been procedurally disenrolled (17 states) (Figure 21). It is unclear how work requirements will intersect with the 90-day reconsideration period as states await additional guidance from CMS. 

Automatic Case Closures at Renewal

States have implemented additional measures to flag receipt of unprocessed renewal information to avoid automatically closing a case with a pending renewal. Most states (44) have eligibility systems that automatically close a case on or shortly after the renewal date if renewal information has not been received. But automatic case closure can result in a premature disenrollment if the renewal or other documentation has been received but is unprocessed. To avoid the extra work to disenroll and reenroll individuals, states have established processes to flag receipt of renewals or documentation in the multiple modes through which renewal information can be submitted, including online accounts, email, regular mail, call centers, and in-person offices, and remove cases from automatic closure (Figure 22). The number of states that flag information from any source increased to 38 from 33 in 2025. Having a process to avoid automatic case closure when documents have been received may be particularly important as states shift from a 12-month to a 6-month renewal cycle and as they implement work requirements for expansion enrollees. During this transition, expansion enrollees who are confused by the earlier than expected renewals or by the new work requirements may be late in responding to renewal notices. It is unclear whether expansion states will have to make any changes to their automated case closure systems when they implement work requirements.

Changes in Circumstances

Two-thirds of states use verified information from SNAP (34 states) and TANF (32 states) to update Medicaid information on a routine basis (Figure 23). If states receive all the information from the other programs that is needed to verify ongoing eligibility for Medicaid without requesting information from the individual, the state may set a new 12-month renewal date, which 24 states do when they receive data from SNAP data and 21 states do with information from TANF. For enrollees subject to work requirements, states will likely need guidance from CMS on what data from SNAP and/or TANF they can use to verify compliance or exemption status and whether states can set a new 6-month renewal date if the information is provided between renewal periods. If, however, the data indicates the individual is no longer eligible, states may terminate coverage but must send a termination notice at least 10 days in advance of case closure to provide enrollees with time to submit documentation verifying ongoing eligibility. The E&E rule requires states to provide at least 30 days to respond to provide documentation if the data indicates the individual is no longer eligible; however, this provision is subject to the 10-year moratorium on implementation. Currently, only nine states provide at least a 30-day response period. The short timeline for returning information can result in churn and increase state and MCO administrative burden to disenroll and then re-enroll an individual.

Fourteen (14) states (all expansion states, except Wisconsin) check other income data sources periodically to identify changes in circumstances, most often on a quarterly basis (Figure 24). Only five of these states provide 30 or more days for the individual to respond if the data check indicates the individual is no longer eligible. States are not required to conduct income checks between renewals, and without more CMS guidance, it is not clear how these periodic checks could impact semi-annual renewals or compliance with work requirements.

Premiums and Cost-Sharing

Current federal rules limit premiums and cost sharing in Medicaid and CHIP given enrollees’ limited ability to pay out of pocket costs. Under these rules, states may not charge premiums in Medicaid for enrollees with incomes less than 150% FPL without a waiver. Maximum allowable cost sharing varies by type of service and income in Medicaid. CHIP programs have more flexibility to charge premiums and cost sharing, but both Medicaid and CHIP limit total family out-of-pocket costs to no more than 5% of family income, and states are required to maintain tracking systems to cease cost-sharing once a family meets the cap.

Beginning in October 2028 states must implement mandatory cost sharing of up to $35 per service for ACA expansion adults with income between 100%-138% FPL. Certain services are exempt from cost sharing, including primary and preventive care, emergency services, family planning and pregnancy-related services, and mental health care and substance use disorder services. The law also excludes from cost sharing services received in federally-qualified health centers (FQHCs), certified community behavioral clinics, and rural health clinics. Prescription drugs are included in the mandate but the current rules limiting cost-sharing for prescription drugs remains in place. CMS guidance is needed to clarify any flexibility that states may have in determining whether some or all non-exempt services must require cost-sharing. The cap of 5% of household income still applies to total premiums and/or cost-sharing for all enrolled members of the household. The law also prohibits states from charging premiums to expansion adults subject to the new cost sharing requirements.

Cost Sharing for Parents and Expansion Adults

As of January 1, 2026, 19 states charge nominal cost-sharing to Section 1931 parents, and 21 states charge cost sharing to ACA or waiver expansion adults, while the remaining states do not charge cost-sharing (Figure 25). Cost sharing applies to all Section 1931 parents regardless of income, except in Wisconsin, which imposes cost sharing on parents with income 50% FPL or higher. Fifteen states charge cost-sharing to ACA or waiver expansion enrollees regardless of income. Three states limit cost-sharing to ACA expansion enrollees with income 100% FPL or above. Generally, charges among expansion states are well under $10 per service; however, four states charge more than $35 for any service. Alaska, Michigan, Utah, and West Virginia charge copays for a hospital inpatient stay of $50 or $75 per admission.

Children’s Premiums

Eighteen (18) states continue to charge premiums to children in CHIP in 2026 (Figure 26). That number is down from 30 states that charged premiums to children in CHIP and/or Medicaid in 2020. Only three states charge premiums at the lowest income of 133% FPL allowed in CHIP, while the median income at which premiums start is 163% FPL or $44,531 annually for a family of three. Alabama and Texas charge annual enrollment fees, Nevada charges quarterly premiums, and the remaining states charge monthly premiums. Six states charge a family-based premium regardless of the number of children. A dozen (12) states charge per child premiums with a maximum family premium in nine of those states. Nine states require prepayment of the first month in CHIP prior to enrollment. Once a child is enrolled, the 12-month continuous enrollment provision protects children from disenrollment following a missed premium payment.

• Table 1: Income Eligibility Limits for Children's Health Coverage as a Percent Of The Federal Poverty Level, January 2026 
• Table 2: Medicaid and CHIP Coverage for Pregnant Individuals and Medicaid Family Planning Coverage, January 2026 
• Table 3: State Adoption of Federal Options to Cover Immigrant Populations, January 2026 
• Table 4: Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level, January 2026 
• Table 5: Processes for Suspending Medicaid Coverage for Incarcerated Enrollees and Notification of Release, January 2026 
• Table 6: Method and Timing of Medicaid Agency Notification of Release of Incarcerated Individuals, January 2026 
• Table 7: Integration of MAGI-Medicaid Eligibility System with Marketplace Eligibility System, Non-MAGI Medicaid, and Non-Health Programs, March 2026 
• Table 8: Multi-Benefit Online Medicaid Applications, January 2026 
• Table 9: Online Medicaid Accounts, January 2026 
• Table 10: Security Features for Online Medicaid Accounts, January 2026 
• Table 11: Viewing Notices and Submitting Renewal Information Through Online Accounts, January 2026 
• Table 12: Medicaid Mobile App Features, January 2026 
• Table 13: Medicaid Mobile Apps, January 2026 
• Table 14: State Actions to Update Mailing Addresses, January 2026 
• Table 15: Verification of Received Information, January 2026  
• Table 16: Modes to Submit Verification Documentation, January 2026 
• Table 17: Master Death File, January 2026 
• Table 18: AI (Artificial Intelligence) Use to Support Consumer Assistance, January 2026 
• Table 19: AI (Artificial Intelligence) Use to Support Eligibility and Enrollment Processes, January 2026 
• Table 20: Online Portals for Community Assisters, January 2026 
• Table 21: Types of Organizations Authorized to Use Separate Web Portal, January 2026 
• Table 22: Advance Notice of Renewals, January 2026 
• Table 23: Reminders to Respond to Renewal Notice, January 2026 
• Table 24: Access to Enrollee Renewal Dates, January 2026 
• Table 25: State Actions to Help Individuals Maintain or Regain Coverage, January 2026 
• Table 26: Automatic Case Closures, January 2026 
• Table 27: Adoption of State Plan Options Allowed As 1902(e)(14)(A) Waivers, January 2026 
• Table 28: Use of Periodic Data Checks to Identify Changes in Income that May Affect Eligibility, January 2026 
• Table 29: Cost Sharing Requirements for Selected Services for Section 1931 Parents, January 2026 
• Table 30: Cost Sharing Requirements for Selected Services for ACA or Waiver Expansion Adults, January 2026 
• Table 31: Premiums and Enrollment Fees for Children, January 2026 
• Table 32: Notification of Eligibility Changes for Certain Lawfully Present Immigrants, January 2026 

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