Health Plan FAQ’s

The Affordable Care Act (ACA) saw record enrollment in 2022–2025 because the American Rescue Plan Act (ARPA) temporarily made Marketplace coverage much more affordable. ARPA lowered premiums for nearly everyone and eliminated the old “subsidy cliff,” allowing higher‑income households to qualify for help.

But ARPA was always temporary — and because Congress did not extend it, the enhanced subsidies expired on January 1, 2026. Now we’re seeing the full impact on 2027 enrollment.

Here’s what’s happening.

1. Premiums Increased for Millions of Households

When ARPA expired, the old subsidy formula snapped back into place. That means:

• People with middle and higher incomes lost part or all their premium tax credits.
• Some households saw premiums rise by $100–$300 per month (or considerably more).
• Older adults (50–64) were hit hardest because their unsubsidized premiums are highest.

Result: Many consumers who stayed enrolled in 2026 are now shopping harder, downgrading plans, or dropping coverage entirely for 2027. Others have left the marketplace and enrolled in lower cost alternatives like short term health insurance or ERISA-covered plans like group plans built on an individual chassis.

2. The “Subsidy Cliff” Returned

Under ARPA, no one paid more than 8.5% of household income for the benchmark plan.

Now that ARPA is gone:

• Households above 400% of the Federal Poverty Level have lost subsidies completely.
• A 60‑year‑old couple making $80,000 can now face $1,500–$2,000 monthly premiums or more with no help.

Result: Enrollment among higher-income older adults is declining sharply for 2026. As mentioned above, others have left the marketplace and enrolled in lower cost alternatives like short term health insurance or ERISA-covered plans like group plans built on an individual chassis.

3. More People Are Switching to Lower‑Cost Plans

Consumers who remain in the Marketplace are shifting to:

• Bronze plans
• High‑deductible plans
• Plans with narrower networks
• Catastrophic‑style options

Result: Enrollment numbers may stay high, but plan quality and coverage levels are dropping.

4. Low‑Income Enrollment Is Holding Steady

This group still receives very strong subsidies, even without ARPA.

Result: Enrollment among low‑income individuals remains stable — the biggest declines are in the middle‑income and older‑adult segments.

5. Overall Impact on 2026 Enrollment

Here’s the big picture:

Enrollment is becoming more polarized.

• Low‑income enrollment: steady
• Middle‑income enrollment: declining
• Older adults without subsidies: sharply declining
• Plan switching increasing
• Average premiums paid by consumers: rising

Why?

Because ARPA’s enhanced subsidies were the single biggest driver of ACA affordability — and without them, many households simply can’t absorb the higher costs.

Bottom Line

The expiration of ARPA’s enhanced subsidies has reshaped the ACA landscape for 2026:

• Premiums are higher
• Subsidies are smaller
• The subsidy cliff is back
• More people are downgrading plans or switching to non-ACA-qualified plans
• Enrollment is shifting toward lower‑income groups
• Middle‑income and older adults are feeling the squeeze

This means more people need help navigating higher costs.

The Affordable Care Act establishes an Open Enrollment Period (OEP) during which individuals and families must enroll UNLESS they have a "qualifying life event."

The Open Enrollment Period for 2026 plans on healthcare.gov ran from November 1, 2025 through January 15, 2026. Those enrolling by December 15 had a January 1, 2026 effective date, whereas those enrolling between December 16, 2025 and January 15, 2026 had a February 1 effective date. Some states do not participate on healthcare.gov and are permitted to have different dates for open enrollment.

One of the four provisions being challenged in Columbus II, Case No. 1:26-cv-02215 of the Final Rule issued in May 2026 reduces the Open Enrollment Period for 2027 plans to the period November 1 to December 15, 2026 on healthcare.gov and to a six consecutive period starting no earlier than November 1 and ending no later than December 31, 2026 on the state exchanges. Oral argument is scheduled for July 8, 2026, with a ruling expected in the Summer of 2026. No injunction has been issued in Columbus II. The 2027 rule's provisions therefore remain in effect unless and until the court acts.

Contact your local state exchange for details if your state does not participate on healthcare.gov. Look here for information about state Exchanges (these are also referred to as “marketplaces.”) See FAQ 7 for an explanation of Exchanges.

A Special Enrollment Period lets you enroll in health coverage or switch plans outside of Open Enrollment, or during Open Enrollment for an earlier coverage start date. You must have a Qualifying LIfe Event (QLE) to qualify for a Special Enrollment Period.

If you experience a Qualifying Life Event, you generally have 60 days from the date of that event to enroll in or change your coverage through a Special Enrollment Period (SEP).

The effective date of coverage for a plan obtained through a Special Enrollment Period is typically the first day of the month following your enrollment.

Exception: if you are adding a newborn or newly adopted child, coverage may be retroactive to the date of birth or adoption.

If you are applying for the first time or changing carriers, you must make your first payment (called a "binder payment") prior to the effective date of coverage or as otherwise specified by the carrier.

When you apply for a plan on healthcare.gov, you will receive an eligibility verification notice. This notice will indicate the amount of household income you projected for the year, the amount, if any, of your advance premium tax credit (subsidy) that reduces your gross premium, and what documents, if any, you are required to submit to healthcare.gov. You may be required to submit proof of income, citizenship, and/or immigration status, and you also may be required to submit documentation proving your eligibility for the SEP.

Please contact us at 786-970-0740 (Cell) for further information.

Qualified Health Plans (see FAQ 6) must have networks. A network is a group of healthcare providers or pharmacies who are contracted with the insurance carrier to provide medical services or prescription drugs at a discounted rate.

ACA networks in many cases are smaller and more restrictive than they were before the ACA became effective. Before the ACA, PPO (Preferred Provider Organization) plans with large networks were common. These plans permitted you to go either in- or out-of-network (you would have paid more for going outside-of-network). While PPO plans still exist on the ACA Marketplace in some areas, they tend to carry higher premiums and are less widely available than before.

Most ACA plans today offer one of the following network types:

• EPO (Exclusive Provider Organization): Allows you to use any participating provider without a referral, but you must use network providers except in a medical emergency.
• HMO (Health Maintenance Organization): Requires you to use network providers except in an emergency. Some HMO plans require referrals to see specialists; others do not.
• PPO (Preferred Provider Organization): Covers both in-network and out-of-network care without requiring referrals, but at a higher premium.
• POS (Point of Service): Allows out-of-network care but requires a referral from your primary care doctor to see a specialist.

If a particular provider is important to you, check before you enroll to determine whether your desired provider accepts that plan. If not, you may want to select a different plan (if available) whose network includes that provider.

Please note that networks and network provisions can change each year and that providers can leave networks at any time when their contracts with the carrier expire.

All Affordable Care Act plans must cover ten categories of services called "Essential Health Benefits" ("EHB"):

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative services (helping people regain skills lost due to illness or injury) and habilitative services (helping people with developmental disabilities or long-term conditions acquire or maintain skills)
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including dental and vision care for children under age 19*

*Pediatric dental and vision coverage is an essential health benefit for children under 19. It must be made available to you — either as part of your health plan or as a separate stand-alone dental plan — but you are not required to purchase it. Adult dental and vision services are not essential health benefits and are generally not included in standard ACA health plans, though some plans may offer them as optional add-ons.

Plans that cover these essential health benefits and meet additional requirements are referred to as "Qualified Health Plans" ("QHPs"). Those additional requirements include:

• Limits on cost-sharing (deductibles, copays, and out-of-pocket maximums may not exceed federally set annual caps)
• No annual or lifetime dollar limits on essential health benefits
• Coverage of pre-existing conditions without waiting periods or additional charges
• An adequate network of providers
• Non-discrimination in coverage based on race, national origin, age, gender identity, sexual orientation, or other protected characteristics

Note for 2027: CMS has finalized a rule that maintains the prohibition on routine adult dental services as an essential health benefit, reversing a 2024 policy that had briefly opened the door for states to add adult dental as an EHB. Adult dental and vision coverage therefore remain outside the required EHB categories going forward.

Exchanges are marketplaces where individuals and families can:

• Learn about their health coverage options,
• Qualify for premium tax credits and Cost Sharing Reductions ("CSR") [see FAQs 14 and 17 for an explanation],
• Compare health insurance plans based on costs, benefits, and other important features,
• Choose a plan, and
• Enroll in coverage.

Exchanges come in three types:

• Federally Facilitated Marketplace (FFM): Run entirely by the federal government through HealthCare.gov. For 2026, 28 states use this model.
• State-Based Exchange (SBE): Run entirely by the state, with its own website and call center. For 2026, DC and 20 states have fully state-run exchanges — examples include "Access Health Connecticut," "Covered California," "Pennie" (Pennsylvania), and "GetCoveredNJ."
• State-Based Exchange on the Federal Platform (SBE-FP): The state administers its own exchange but uses HealthCare.gov for enrollment. For 2026, 3 states use this model.

You can find out what type of exchange operates in your state and find your marketplace to compare plans and enroll.

Important: Premium tax credits and Cost Sharing Reductions are only available if you enroll through an exchange — either directly through the exchange website, through a carrier's direct link to the marketplace, or through an authorized web-based enrollment partner called an Enhanced Direct Enrollment (EDE) entity (see FAQ 22 for a description). If you are eligible for financial assistance, enrolling off exchange means you forfeit that assistance, which could cost you thousands of dollars per year. Please call us at 786-970-0740 (Cell) for help with your enrollment.

Those who do not qualify for premium tax credits or a CSR can also shop for coverage off-exchange — directly through brokers, agents, or insurers — and will see the same ACA-compliant plans at the same prices without needing to use the exchange website.

Carriers can’t inquire or base premiums for Affordable Care Act Plans on health conditions nor can they exclude pre-existing conditions. The only factors that can be considered in determining premiums are age, smoking status, size of the family unit, and geography (usually county of residence).

ACA plans have a maximum "out-of-pocket limit" — the most you can pay toward covered, in-network expenses in a calendar year. Once you reach this limit, the plan pays 100% of covered in-network costs for the rest of the year.

The out-of-pocket maximum includes deductibles, copays, coinsurance, and prescription drugs included in the plan's formulary. It does not include your monthly premiums, and it does not cap what you might owe for out-of-network care.

The federal government sets a maximum permitted out-of-pocket limit each year that no ACA-compliant plan may exceed. Here are the current and upcoming limits:

These maximums have increased nearly every year the ACA has been in effect. The only exception was 2025, when the limits were reduced slightly from the 2024 amounts of $9,450 (individual) and $18,900 (family). The 2027 limits represent the largest single-year dollar increase in the ACA's history — a $1,400 increase per individual — driven in part by the significant premium increases that occurred in 2026.

Plans may set out-of-pocket maximums lower than the federal cap, and many do. The federal figures above represent ceilings, not typical plan amounts.

In some cases, a plan's deductible and out-of-pocket maximum are the same — meaning once you meet the deductible, the plan covers 100% of remaining costs. More commonly, a plan's deductible is lower than its out-of-pocket maximum, and the plan applies coinsurance (a percentage you pay) on covered services after the deductible is met until the out-of-pocket maximum is reached, at which point the plan covers 100% of in-network covered costs for the rest of the year.

For purposes of ACA premium rating, tobacco use is defined as using tobacco products four or more times per week, on average, within the past 6 months. This includes cigarettes, cigars, chewing tobacco, and pipes. The rules for e-cigarettes and vaping devices are less clear — the FDA classifies these as tobacco products, and some insurers do apply the surcharge to vapers, so check with the specific carrier.

The ACA permits insurers to charge tobacco users a surcharge of up to 50% more than the non-tobacco-user premium (i.e., up to 1.5 times the base premium). This is the only health-status-related behavioral factor that can be used to rate premiums in the individual and family ACA market.

Important caveats:

• The surcharge is unchanged on healthcare.gov and still applies. However, more than a dozen states and Washington, D.C., none of which participate on healthcare.gov, have restricted or eliminated the tobacco surcharge entirely. Check the rules in your state.
• If you receive a premium tax credit (subsidy), the tax credit is applied to the base premium before the tobacco surcharge — meaning you pay the full surcharge out of pocket and cannot use your subsidy to offset it.
• ACA plans are required to cover tobacco cessation programs as a preventive benefit at no cost to you.

COBRA is not replaced by the Affordable Care Act, but individuals should carefully consider the effects of electing COBRA instead of purchasing an ACA Marketplace plan.

How the timing works: Losing job-based coverage is a Qualifying Life Event (see FAQ 3) that opens a 60-day Special Enrollment Period to enroll in an ACA Marketplace plan. This 60-day window runs concurrently with your COBRA election window — meaning you don't have to decide between COBRA and a Marketplace plan immediately. You can take the full 60 days to compare your options. If you elect COBRA, you can still switch to a Marketplace plan during that initial 60-day SEP window, or during any future Open Enrollment period.

Critical warning — do not drop COBRA voluntarily: If you elect COBRA and later decide to cancel it or stop paying premiums outside of Open Enrollment, that does not create a new Special Enrollment Period. You would have to wait until the next Open Enrollment period to get Marketplace coverage, unless you experience another qualifying life event. The only ways to trigger an SEP to switch from COBRA to a Marketplace plan outside of Open Enrollment are:

• Your COBRA coverage is exhausted (runs out after its maximum duration, typically 18 months).
• Your former employer stops contributing to your COBRA premium cost
• It is still within 60 days of your original loss of job-based coverage

Cost comparison: In most cases, individuals will find ACA Marketplace plans less expensive than COBRA, particularly if they qualify for premium tax credits — which are not available on COBRA. Contact us at 786-970-0740 (Cell) for help comparing your options.
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Certain individuals can qualify for a catastrophic plan. These are health plans that cover all ten Essential Health Benefits and ACA-required preventive services, but with very high deductibles and lower monthly premiums than other ACA plans. They are designed to protect you against worst-case medical costs such as a serious illness or major injury.

Before you meet the deductible, catastrophic plans cover at least three primary care visits per year and all ACA-required preventive services at no cost. For virtually all other services, you pay 100% of costs until you reach the deductible. Once the deductible is met, the plan covers 100% of covered costs for the rest of the year. The deductible and the out-of-pocket maximum are the same amount — $10,600 for an individual in 2026 and $12,000 in 2027.

Who qualifies:

• Under age 30 — anyone under 30 qualifies automatically.
• Age 30 or older — you may qualify if your income makes you ineligible for premium tax credits (either below 100% FPL or above 400% FPL), if the lowest-cost Bronze plan available to you is unaffordable, or if you have experienced certain personal hardships such as homelessness, domestic violence, bankruptcy, or a natural disaster.

Important: You cannot use premium tax credits or Cost Sharing Reductions with catastrophic plans. If you qualify for a subsidy, a subsidized Bronze plan will almost always cost you less and have a lower deductible.

New in 2027 — Multi-year plans: Starting in 2027, insurers may offer catastrophic plans with terms of up to ten consecutive years. Plan benefits are locked in for the duration, but premiums are still reviewed and adjusted annually. Multi-year plans may also cover certain high-value services — such as chronic disease management — before the deductible is met, an approach intended to keep enrollees healthier and reduce overall medical costs.

Catastrophic plans are not available in all areas and not all carriers offer them. Please contact us at 786-970-0740 (Cell) for help determining whether a catastrophic plan is right for your situation.

The Federal Poverty Level ("FPL") is used to determine your eligibility for a subsidy (see FAQ 14). The Affordable Care Act defines income for this purpose as your "Modified Adjusted Gross Income" (MAGI), explained further in FAQ 14.

How the FPL works for ACA subsidies: There is a one-year lag in how FPL numbers are applied. The FPL published in January of one year is used to determine subsidy eligibility for ACA plans effective the following year. So the 2025 FPL figures (published January 2025) are used for 2026 plans, and the 2026 FPL figures (published January 2026) will be used for 2027 plans.

You are eligible for a subsidy if your household MAGI is:

• At or above 100% FPL (non-Medicaid expansion states, including Florida) or above 138% FPL (Medicaid expansion states), AND
• No more than 400% FPL

The 400% income cap (the "subsidy cliff") returned in 2026 after Congress allowed the enhanced subsidies to expire at the end of 2025. If your income is even one dollar above 400% FPL, you receive no federal subsidy at all.

2026 Subsidy Eligibility [Based On 2025 Federal Poverty Levels (FPL)]

Note: Household size means the total number of people in the household for tax purposes, regardless of how many are enrolling in an ACA plan. Separate, higher FPL guidelines apply in Alaska and Hawaii.

2027 Subsidy Eligibility [Based On 2026 Federal Poverty Levels (FPL)]

Note: Household size means the total number of people in the household for tax purposes, regardless of how many are enrolling in an ACA plan. Separate, higher FPL guidelines apply in Alaska and Hawaii.

Subsidy (Advance Premium Tax Credit)

The ACA provides subsidies to help individuals and families pay their monthly health insurance premiums. Depending on age and county of residence, an unmarried individual or a family filing a joint return who earns between 100% (or 138% in Medicaid expansion states) and 400% of the FPL will generally be eligible for a subsidy — unless affordable employer group coverage has been offered to them.

Federal Poverty Level and Cost Sharing Reductions

Cost Sharing Reductions are offered only on Silver plans. The following thresholds determine eligibility for each CSR level:

• Level 6 (strongest reduction): MAGI between 100/138% and 150% FPL
• Level 5: MAGI between 150% and 200% FPL
• Level 4: MAGI between 200% and 250% FPL

Employer Coverage And The Family Glitch Fix

Before 2023, employees and families could only qualify for a Marketplace tax subsidy if the employee's share of the lowest-cost self-only premium exceeded a set percentage of household income — known as the "family glitch," which affected roughly 5 million people. Since 2023, affordability is assessed separately for the employee (based on self-only coverage cost) and for family members (based on the total cost of family coverage).

For 2026, employer-sponsored coverage is considered unaffordable — and employees or family members may potentially qualify for Marketplace subsidies — if:

• The employee's share of the self-only premium exceeds 9.96% of household income, OR
• The family's share of the family premium exceeds 9.96% of household income, OR
• The plan does not provide minimum value (i.e., covers less than 60% of expected costs)

Under the FPL safe harbor for 2026, employers offering self-only coverage for no more than $129.90/month automatically satisfy the affordability standard for all employees.

The 2027 employer affordability percentage and FPL safe harbor dollar amount have not yet been announced by the IRS but are expected in mid-summer 2026.

The Affordable Care Act provides a tax credit — called an "Advance Premium Tax Credit" (APTC) — to help eligible individuals and families afford health coverage purchased through a Marketplace. The credit is paid directly to your insurance carrier each month, reducing your monthly premium. You can also choose to receive the full credit when you file your annual tax return instead.

Who qualifies: To receive a subsidy you must:

• Enroll in a Marketplace plan (subsidies are not available for off-exchange plans)
• Have household income between 100% and 400% of the Federal Poverty Level — or between 138% and 400% FPL if you live in a Medicaid expansion state (Florida has not expanded Medicaid, so the 100% floor applies here)
• Not be eligible for affordable employer-sponsored coverage, Medicare, or Medicaid

See FAQ 13 for the FPL income tables.

How to apply: We highly recommend that you apply with us through one of our web brokerage systems (see FAQ 22), but you can apply at healthcare.gov. After submitting your application you will receive an eligibility verification notice — a downloadable PDF in your Marketplace account. This document shows:

• Your subsidy amount, if any
• Your Cost Sharing Reduction eligibility, if any (see FAQ 17)
• Any documents you must submit and the deadline for doing so

Download and save this document, and keep your application ID, username, and password for future account access.

Document submission deadlines: If the Marketplace needs to verify information, you generally have:

• 30 days to submit proof of a Qualifying Life Event (marriage, move, loss of coverage, etc.)
• 90 days to submit income verification
• 95 days to submit proof of citizenship or immigration status

Failure to meet these deadlines can result in cancellation of your coverage or loss of your subsidy. Documents can be uploaded directly to your healthcare.gov account. If mailing, send photocopies only (not originals) to the address shown in your eligibility verification notice (currently in London, KY), and write your name, state of residence, and application ID on each page, including the barcode page from your notice.

Proof of a Qualifying Life Event (SEP verification): The rules around proof of a qualifying life event are in flux and differ between 2026 and 2027:

• In 2026: A federal court (City of Columbus v. Kennedy) blocked a CMS rule that would have required proof of most qualifying life events before coverage could begin. As a result, for most qualifying life events other than loss of coverage, you can currently self-attest without submitting documents upfront. Loss of coverage remains the exception and does require proof. Note that SEP enrollments are audited after enrollment, and if your eligibility cannot be verified, your coverage can be revoked retroactively — so always keep documentation of your qualifying life event.
• For 2027: CMS re-finalized the pre-enrollment verification requirement in its May 2026 final rule, with new supporting rationale intended to address the court's prior objections. If implemented, HealthCare.gov will be required to verify eligibility for at least 75% of new SEP enrollments before coverage begins. A new lawsuit challenging this provision (Columbus II, filed June 2026) is pending, so the ultimate outcome remains uncertain. We will update clients as this develops.

What is MAGI? Income for subsidy purposes is based on Modified Adjusted Gross Income (MAGI) — different from the Adjusted Gross Income (AGI) shown on your tax return. MAGI can be higher than AGI because it adds back certain items that AGI excludes. For example, MAGI includes your entire Social Security benefit whether taxable or not, while AGI includes only the taxable portion. Other differences involve tax-exempt interest and foreign income. Click here to learn more about how MAGI is calculated.

Important 2026 change — no repayment cap:

Starting with the 2026 tax year, if you underestimate your income and receive more in advance premium tax credits than you are entitled to, you must repay the full excess amount when you file your taxes. Prior law capped the repayment amount for most households; that cap no longer exists. Exception: If your actual income for the year ends up falling below 100% of FPL, you are not required to repay the APTC you received — provided you enrolled in good faith based on a reasonable income projection at the time of enrollment and did not intentionally misrepresent your income. This exception does not apply to households in Medicaid expansion states whose income falls below 138% FPL, as those households would generally have been directed to Medicaid rather than Marketplace coverage.

Changes for 2027 and beyond:

• Immigration eligibility tightens (effective January 1, 2027): Premium tax credit eligibility will be limited to U.S. citizens, legal permanent residents (green card holders), Cuban and Haitian entrants, and Compact of Free Association migrants. Other lawfully present immigrants — including refugees and asylees — will no longer qualify for subsidies, though they may still purchase Marketplace coverage without financial assistance.
• Active re-enrollment required (effective plan year 2028): Automatic re-enrollment in subsidized Marketplace plans ends beginning with plan year 2028. All enrollees will be required to actively verify their income and re-enroll each fall open enrollment period in order to continue receiving premium tax credits or Cost Sharing Reductions.

Please call us at 786-970-0740 (Cell) for help determining your subsidy amount and enrolling in a plan.

The Trump Administration has issued two major rules reshaping the ACA Marketplace — one in 2025 and one in 2026 — and both have been challenged in federal court by the same coalition of plaintiffs led by the City of Columbus.

A. The 2025 Rule And What Was Blocked (Columbus I)

In June 2025, CMS issued the "Marketplace Integrity and Affordability Final Rule." The same month, a coalition including the cities of Columbus, Baltimore, and Chicago filed suit in the U.S. District Court for the District of Maryland (City of Columbus et al. v. Kennedy et al., Case No. 1:25-cv-02114 — "Columbus I").

In August 2025, the court issued a preliminary injunction blocking four specific provisions of the 2026 Rule. The government has appealed to the Fourth Circuit but the injunction remains in place. Here are summaries of the four rules the injunction blocked from being implemented:

• Open Enrollment Period--shortens the Open Enrollment window to six weeks from ten weeks (from November 1 through January 15 for healthcare.gov to November 1 through December 15).
• Pre-enrollment SEP verification — requires proof of a qualifying life event before coverage begins for most new SEP enrollments.
• Past-due premium rule — denies enrollment to consumers who owe past-due premiums to the same carrier
• Stricter income verification — would have required Marketplaces to verify income by asking for documentation (instead of accepting applicant’s self-attestation) when IRS has no tax return data to verify an applicant’s projected household income when applying for an advance premium tax credit.

B. The 2027 Final Rule And The New Lawsuit (Columbus II)

IIn May 2026, CMS issued the "2027 HHS Notice of Benefit and Payment Parameters for 2027 Final Rule" (also referred to as the “2027 Final Rule”), a sweeping new rule governing plan year 2027. On June 3, 2026, the same coalition described in section A, above, filed an entirely new and separate lawsuit (Columbus II, City of Columbus et. al. v. Kennedy et.al). challenging four major provisions of the 2027 Final Rule (see first 4 bullets under section C, below). Oral argument is scheduled for July 8, 2026, with a ruling expected in Summer, 2026. No injunction has as yet been issued in Columbus II. The 2027 rule's provisions remain in effect unless and until the court acts. We are monitoring this closely and will update relevant portions of the website regarding any changes.

C. Current Status Of 2027 Provisions

CHALLENGED IN COLUMBUS II—CURRENTLY IN EFFECT, RULING EXPECTED IN THE SUMMER, 2026:

• Shortened open enrollment period — November 1 through December 15, 2026 (six weeks instead of the prior ten-week window) for healthcare.gov and six consecutive weeks starting no earlier than November 1, 2026 and ending no later than December 31 for state exchanges. If the court issues an injunction, the prior window of November 1 through January 15, 2027 would be restored, with coverage starting January 1 for those enrolling on healthcare.gov by December 15 and February 1 for those enrolling between December 16 and January 15. (State exchanges would be permitted to retain the open enrollment periods they had for 2026 enrollments. See FAQ 2.
• Pre-enrollment SEP verification — CMS re-finalized the requirement that HealthCare.gov verify qualifying life events for at least 75% of new SEP enrollments before coverage begins. A similar provision was blocked in Columbus I for 2026.
• Past-due premium rule — insurers may require enrollees to pay off past-due premiums from a prior policy before activating new coverage, provided state law allows it. Insurers can add the unpaid balance to the new policy's premium and may decline to start coverage until both amounts are paid in full. This applies even if the enrollee switches to another insurer within the same corporate group. The policy reverses a prior consumer protection and does not sunset like many other 2026 rule provisions.
• Key self-attestation and documentation changes for 2027 and beyond — CMS converted what were explicitly temporary, Plan Year 2026-only verification tightenings into permanent standing policy for 2027 and beyond — self-attestation as an eligibility-verification pathway is now largely closed off rather than set to snap back once the "emergency" period ended.

IN EFFECT AND UNCHALLENGED—These Provisions Apply In Plan Year 2027 And Are Not Being Challenged In The Columbus II Litigation

• Lower exchange user fees—reduced from 2/5% to 1.9%, intended to put modest downward pressure on premiums.
• Greater state exchange flexibility—state-based exchanges gain broader authority over plan certification and network adequacy standards.
• Elimination of standardized plan requirements—insurers have more design flexibility; plan comparison may become harder for consumers.
• Higher Bronze plan out-of-pocket maximums—some Bronze plans may carry individual maximum-out-of-pocket maximums (MOOPS) up to $15,600 (130% of the standard cap) in exchange for lower premiums. Insurers using this option must also offer at least one standard Bronze plan within the regular cap.
• Multi-year catastrophic plans—plans of up to ten consecutive years are now permitted. The benefit design is locked in but premiums remain subject to annual adjustment. See FAQ 12

D. What To Watch For

The Columbus II ruling, expected in the Summer of 2026 could change the 2027 enrollment landscape significantly — potentially before open enrollment begins November 1. We will update this website concerning any court order that affects enrollment dates, SEP verification, or other 2027 provisions.

The single most time-sensitive issue for clients is the open enrollment period. Until a court rules otherwise, the 2027 open enrollment window is November 1 through December 15, 2026. If that changes, we will communicate it on this website.

Please call us at 786-970-0740 (Cell) with any questions.

These two new Frequently Asked Questions (FAQs) issued by healthcare.gov on December 30, 2025 address commonly asked questions for APTC (advanced premium tax credit or tax subsidy) repayment starting in Plan Year 2026 (i.e., when consumers are filing their federal taxes in 2027) based on recent legislative changes:

Are there limits to how much excess APTC consumers must pay back?

This FAQ clarifies that, beginning with Plan Year 2026 APTC reconciliation (when consumers are filing their taxes in 2027), there is no limitation on excess APTC consumers have to repay when filing their tax return and reconciling their APTC.

View this FAQ.

Are consumers required to pay back all of their APTC if they estimated their household income to be 100% or more of the FPL but their actual household income ends up being less than 100% of the FPL?

This FAQ clarifies that if consumers did not intentionally or recklessly misrepresent their household income when enrolling in the coverage, Internal Revenue Service (IRS) rules state that this consumer may still qualify for and claim the premium tax credit on their tax return even when the household income as reported on their tax return is below 100% of the FPL.

View this FAQ.

Consumers are required to report changes that affect their eligibility for Marketplace coverage and financial assistance, including changes related to their household income, family size, and offers of other health coverage. Additionally, consumers may want to consider accepting less APTC during Plan Year 2026 (which means they would pay a higher monthly premium amount to the issuer) in order to reduce the risk of having a tax liability when they file their federal income taxes for Plan Year 2026 in 2027.

A Cost Sharing Reduction (CSR) is a subsidy that lowers the amount you pay out-of-pocket when you use medical services — reducing your deductibles, copayments, and coinsurance. CSRs are provided at no additional cost to you and are separate from your premium tax credit. Receiving a CSR does not change the amount of your premium tax credit, and your premium tax credit is not used to pay for your CSR.

CSRs are available ONLY on Silver plans purchased through the Marketplace. They cannot be applied to Bronze, Gold, or Platinum plans, and they are not available on off-exchange plans.

Who qualifies: You may be eligible for a CSR if your household MAGI is between your state's Medicaid eligibility threshold and 250% of the Federal Poverty Level, and you are also eligible for a premium tax credit. See the FPL tables in FAQ 13 for the income amounts. In Florida, which has not expanded Medicaid, the lower threshold is 100% of FPL.

The three CSR levels: A standard Silver plan has an actuarial value of 70%, meaning the plan covers 70% of average medical costs and the enrollee pays 30%. CSRs increase that actuarial value significantly:

Note: Some carriers label these levels differently (e.g., A, B, and C), but they correspond to the same income ranges and actuarial values listed above.

Why Silver plans with CSR are often a better choice than Bronze plans:

Many people eligible for CSR have historically chosen Bronze plans because of lower premiums. However, Silver plans with CSR benefits often have premiums similar to Bronze plans — and significantly lower deductibles, copays, and out-of-pocket maximums. For example, in 2026 the average Bronze plan deductible is approximately $7,186, while a Silver plan with CSR at Level 6 can have an average deductible as low as $80. If you are at or below 250% of FPL, you should strongly consider a Silver plan before choosing Bronze — the CSR benefits are automatically built into the plan at no extra charge.

Note on auto-enrollment change: In 2024 and 2025, HealthCare.gov automatically moved certain Bronze plan enrollees who were eligible for Silver CSR plans into Silver plans when the net premium was similar. CMS ended this automatic crosswalk protocol for plan year 2026, so eligible enrollees will no longer be automatically switched. It is now up to you — or your agent — to actively compare Silver CSR plans against Bronze options.

Please call us at 786-970-0740 (Cell) for help.

"Coinsurance" - a percentage of your medical and drug costs that you pay out of your pocket.

"Copay" - the fixed dollar amount you pay when you receive medical services or have a prescription filled.

"Deductible" - the amount you pay for medical services and/or prescriptions before your plan pays for your benefits.

Plans sold on an exchange are primarily categorized into four health plan categories (also known as "metallic levels") - bronze, silver, gold, or platinum - based on the percentage the plan pays of the average overall cost of providing benefits to members.

While plans within the same metal level share the same target actuarial value, individual plans can differ significantly in how they structure that cost-sharing. For example, one Silver plan might have a lower deductible but higher copays, while another has a higher deductible but lower copays — both can have the same actuarial value. You should determine which features matter most to your situation before choosing a plan.

The four metal levels and their target actuarial values are:

• Bronze — 60% (you pay approximately 40% of average costs). Bronze plans have the lowest premiums but the highest out-of-pocket costs. Plans must fall within a permitted range of 58%–62% actuarial value. Note on Expanded Bronze: Some insurers offer Expanded Bronze plans, which have actuarial values ranging up to 65% — halfway between standard Bronze and Silver.
• Silver — 70% (you pay approximately 30% of average costs). Silver is the only metal level eligible for Cost Sharing Reductions (CSRs), which can raise the effective actuarial value to 73%, 87%, or 94% for eligible enrollees — making Silver plans potentially far more valuable than their base tier suggests. See FAQ 17 for details.
• Gold — 80% (you pay approximately 20% of average costs). Gold plans have higher premiums than Silver but lower deductibles and out-of-pocket costs. In states that practice "silver loading," Gold premiums can sometimes be lower than Silver premiums — worth checking in your area.
• Platinum — 90% (you pay approximately 10% of average costs). Platinum plans have the highest premiums but the lowest out-of-pocket costs. They are not available in all areas and generally make financial sense only for people who know they will have significant, ongoing medical expenses.

Please call us at 786-970-0740 (Cell) to help determine which metal level best fits your situation.

You must make your first payment (called a "binder payment") before your coverage effective date for coverage to take effect. Reinstatement is not permitted if coverage lapses due to non-payment. We recommend paying by electronic funds transfer (EFT) whenever possible.

On-exchange plans: Payment is made directly to the carrier, not to HealthCare.gov. You have a grace period of up to 90 days, but any missed payments during that period must also be paid to retain coverage.

Off-exchange plans: Payment terms vary by carrier. Some require payment within 30 days of the first day of the coverage month; others allow up to 90 days. Check with your carrier for their specific rules. Missed intervening payments must also be made up.

If you are enrolling during a Special Enrollment Period: Due to court injunctions in City of Columbus v. Kennedy, CMS's rules requiring pre-enrollment verification of qualifying life events have been blocked. This means:

• Your coverage is not pended pending submission of proof of your qualifying life event — coverage begins on your effective date once you select a plan and make your binder payment.
• For loss of coverage SEPs, you must still submit proof of your loss of coverage within 30 days of selecting your plan. This is a longstanding requirement that predates the injunction and was not blocked.
• For all other qualifying life events (marriage, birth, move, etc.), you may self-attest and are not required to submit proof upfront on HealthCare.gov.
• However, SEP enrollments are audited after enrollment. If your qualifying life event cannot be verified after the fact, your coverage can be revoked retroactively. We strongly recommend collecting and retaining documentation of your qualifying life event regardless of whether upfront submission is required.
• For 2027: CMS re-finalized pre-enrollment verification requirements in its May 2026 final rule. A new lawsuit (Columbus II) is challenging this provision and its status remains pending. We will update clients as this develops.

Please call us at 786-970-0740 (Cell) for guidance on your specific situation.

There is no Federal tax penalty for not having a plan that complies with the Affordable Care Act.

However, five jurisdictions--California, District of Columbia, Massachusetts, New Jersey, and Rhode Island—have state tax penalties for not having ACA-qualified plans. These penalties are all calculated differently; check with your tax preparer for information about these penalties. Vermont has a mandate that non-Medicare eligible state residents must buy an ACA-qualified plan but there is no penalty for non-compliance.

A web brokerage system is a CMS-approved technology platform that allows licensed insurance agents to help consumers complete a full Marketplace application and enroll in a plan — without the consumer needing to visit HealthCare.gov directly. You provide your personal and income information to your agent, authorize the agent to act on your behalf, and the agent processes your application securely through the platform.

The standard for web brokerage today is Enhanced Direct Enrollment (EDE) — a technology that connects directly and securely to the Marketplace's back-end computer systems. We use Health Sherpa, one of the original and most widely used EDE platforms and the first entity approved by CMS to offer this technology. Think of EDE as a secure, government-approved data pipeline between Health Sherpa and HealthCare.gov: your information travels directly between the two systems in encrypted form, without you or your agent ever having to log into HealthCare.gov itself. This connection — called an Application Programming Interface, or API — works the same way your bank's mobile app communicates securely with your bank's servers. You see a clean, user-friendly interface on your phone, but behind the scenes your data is moving securely between systems. EDE works the same way: your agent works within Health Sherpa’s platform, but your eligibility and enrollment information flows directly and securely to and from the federal Marketplace in real time.

Through EDE, your agent can complete your eligibility application, compare plans, enroll you in coverage, and handle post-enrollment tasks such as reporting income or household changes, uploading documents, and downloading notices — all without leaving the platform. This is significantly faster and more seamless than working through HealthCare.gov directly. If Health Sherpa is not the right fit for a particular situation, we can also assist consumers who prefer to manage their own HealthCare.gov account directly.

How EDE is regulated: Before any entity can use EDE, it must pass extensive independent security and privacy audits. CMS reviews the results to ensure compliance with nearly 300 federal security and privacy standards, and EDE partners must sign a privacy and security agreement with CMS. Ongoing monitoring and annual re-certification are required.

Your rights and our obligations: We are prohibited from asking for your HealthCare.gov username or password, and we cannot access HealthCare.gov as if we were you. Before we can assist you, you must give us your written or recorded telephonic consent to complete a Marketplace application; assist with plan selection and enrollment; conduct a person search; and assist with ongoing account maintenance. You must also personally validate your income information and agree to the attestations required by the Marketplace.

We follow all applicable privacy, security, and informed consent requirements regardless of the enrollment method used.

Please call us at 786-970-0740 (Cell) for enrollment assistance.