The ACA Marketplace is where people without employer or government health coverage buy private insurance, often with a federal subsidy that lowers the monthly premium. For 2026, the rules tightened. The enhanced premium tax credits created by the American Rescue Plan and extended by the Inflation Reduction Act expired on January 1, 2026, restoring the original 400 percent federal poverty level income cap and raising the share of premiums enrollees have to pay themselves.1United States Congress. Enhanced Premium Tax Credit and 2026 Exchange Premiums Insurers priced in the change, and average premiums rose roughly 20 percent for the 2026 plan year on top of the smaller subsidies.
Who Qualifies
Three basic requirements decide whether you can buy a Marketplace plan at all: you must be a U.S. citizen, national, or lawfully present immigrant; you must live in the state where you’re applying; and you cannot be incarcerated, except while awaiting trial.2eCFR. 45 CFR 155.305 – Eligibility Standards Lawfully present includes permanent residents, most visa holders, refugees, and asylees. There is no age limit.
Anyone eligible can buy a plan, but financial help is a separate question. If you have access to other qualifying coverage, you generally cannot get premium tax credits. That includes Medicare, Medicaid, TRICARE, CHIP, and an employer plan considered affordable.3Centers for Medicare and Medicaid Services. Minimum Essential Coverage For 2026, employer coverage counts as affordable when your share of the self-only premium is 9.96 percent of household income or less.4Internal Revenue Service. Revenue Procedure 2025-25
One gap still hits the lowest earners. In states that did not expand Medicaid, adults with incomes under 100 percent of the federal poverty level often qualify for neither Medicaid nor Marketplace subsidies, leaving them without a subsidized route to insurance.
What Changed for 2026
From 2021 through 2025, temporary rules removed the 400 percent FPL income cap on premium tax credits and cut the share of income everyone was expected to contribute toward the benchmark premium. Both changes expired at the start of 2026.1United States Congress. Enhanced Premium Tax Credit and 2026 Exchange Premiums
The result is real dollars. A household at 200 percent of the poverty level was expected to pay about 2 percent of income toward the benchmark plan in 2025. For 2026, that same household is expected to pay 6.6 percent.1United States Congress. Enhanced Premium Tax Credit and 2026 Exchange Premiums Households above 400 percent FPL now lose subsidy eligibility entirely and pay full price. Insurers expected healthier customers to drop coverage once prices rose, and priced 2026 plans about 20 percent higher on average in response.
A second change lands at tax time. The caps that used to limit how much excess advance credit you had to repay if your income came in higher than projected are gone for 2026.5Internal Revenue Service. Fact Sheet – Premium Tax Credit (FS-2025-10) Previously, repayment for those under 400 percent FPL was capped between $350 and $3,350 depending on income and filing status. Now, if you received $5,000 more in advance credits than you actually qualified for, you owe the full $5,000 back.
How Premium Tax Credits Work
The premium tax credit is a federal subsidy that lowers your monthly premium.6Office of the Law Revision Counsel. 26 USC 36B – Refundable Credit for Coverage Under a Qualified Health Plan For 2026, it goes to households with income between 100 and 400 percent of the federal poverty level. The 2026 poverty level for a single person is $15,960, so the 400 percent ceiling for an individual is $63,840.7U.S. Department of Health and Human Services. 2026 Poverty Guidelines
Two numbers set your credit: your household income as a percent of the poverty level, and the cost of the second-lowest-cost silver plan in your area, known as the benchmark. You’re expected to contribute a set share of your income toward that benchmark premium, and the credit pays the rest. You can take the credit as an advance payment sent to your insurer each month, or claim the full amount on your tax return.
Cost-Sharing Reductions
If your income is at or below 250 percent of the federal poverty level and you enroll in a silver plan, you also get cost-sharing reductions.2eCFR. 45 CFR 155.305 – Eligibility Standards These lower your deductible, copays, and coinsurance rather than your premium. The lower your income, the deeper the reductions. At the bottom of the income range, a silver plan with CSRs pays out more like a platinum plan. This benefit only applies to silver-tier plans, which is why counselors often steer lower-income enrollees to silver even when a bronze plan looks cheaper on the sticker.
Plan Tiers
Every Marketplace plan sits in one of four metal tiers based on actuarial value, meaning the share of average medical costs the plan is designed to cover:8Office of the Law Revision Counsel. 42 USC 18022 – Essential Health Benefits Requirements
- Bronze covers about 60 percent of costs. The lowest premium, the highest costs when you use care.
- Silver covers about 70 percent. Moderate premiums and the only tier eligible for cost-sharing reductions.
- Gold covers about 80 percent. Higher premiums, less to pay at the doctor.
- Platinum covers about 90 percent. Not sold in every market.
All tiers cover the same essential health benefits, including hospitalization, prescription drugs, maternity care, mental health services, and preventive care at no cost. For 2026, the federal cap on total in-network out-of-pocket spending is $10,150 for an individual and $20,300 for a family.
A catastrophic plan sits below bronze. Premiums are very low, the deductible is high, and coverage is minimal until you hit it, aside from three primary care visits per year and free preventive care. You generally have to be under 30 to buy one, though a hardship or affordability exemption can open it up to older enrollees.9HealthCare.gov. Catastrophic Health Plans
When You Can Enroll
Open enrollment for the 2026 plan year ran from November 1, 2025 through January 15, 2026.10eCFR. 45 CFR 155.410 – Initial and Annual Open Enrollment Periods Starting with the 2027 plan year, the window shrinks: November 1 through December 15, 2026, with every plan starting January 1. State-run exchanges can extend their deadlines but not past December 31.
Outside open enrollment, you need a qualifying life event to sign up or switch plans. Common triggers include losing other coverage, marriage, having or adopting a child, moving to an area with different plans, a change in immigration status that makes you newly eligible, and Marketplace or insurer errors that affected your enrollment.11HealthCare.gov. Special Enrollment Period Most events give you a 60-day window to enroll.12Centers for Medicare and Medicaid Services. Special Enrollment Periods Available to Consumers If you’re losing coverage, you can enroll up to 60 days before the loss to avoid a gap. Expect to provide documentation, such as a termination letter, marriage certificate, or birth certificate.
One route closed in 2025. The special enrollment period that let people at or below 150 percent of the federal poverty level enroll year-round was repealed effective August 25, 2025, and is not available for the 2026 plan year. A change in income alone no longer counts as an exceptional circumstance.
How to Apply
The application runs through HealthCare.gov in most states; about 20 states operate their own platforms. Either way, for each person seeking coverage you’ll need:13Centers for Medicare and Medicaid Services. Instructions to Help You Complete the Application for Health Coverage and Help Paying Costs
- Social Security numbers, or immigration document numbers for lawfully present non-citizens
- Income documentation such as pay stubs, W-2s, or your most recent federal tax return
- Employer coverage details, including whether the job offers insurance, what it costs, and whether it meets minimum value standards
- Household information covering the tax filer, spouse, and all tax dependents
The most consequential number on the application is your projected annual income for the coverage year. That figure sets your advance premium tax credit. Include wages, self-employment income, unemployment benefits, Social Security payments, and any other taxable income. Underestimate and you’ll collect too much advance credit and owe it back at tax time, with no repayment cap for 2026. Overestimate and your monthly subsidy will be smaller than it could be, though you’ll receive the balance as a refund.
After you submit, the Marketplace issues an eligibility determination notice showing whether you qualify, whether you get premium tax credits or cost-sharing reductions, and the exact advance credit amount. Read it before you pick a plan. Coverage does not start until you pay your first premium to the insurance company, and missing that deadline can cancel the enrollment.
Reporting Changes and Reconciling at Tax Time
Enrolling isn’t the end of the process. If your income, household size, or coverage situation changes during the year, update your application promptly.14HealthCare.gov. Reporting Income and Household Changes After You Are Enrolled A raise, a new job, a marriage, a lost dependent, or new access to employer coverage can all change your credit amount. Keeping the same advance credit after your circumstances change usually means owing money later.
Reconciliation happens on IRS Form 8962. You compare the advance premium tax credit you received during the year to the credit you actually qualified for based on your real income. Income higher than projected means paying the excess back. Income lower than projected means a refund. Because the repayment caps are gone for 2026, reporting changes as they happen matters much more than it used to.
Appealing a Marketplace Decision
If the Marketplace finds you ineligible or gives you a smaller subsidy than you expected, you have 90 days from the date on your eligibility notice to appeal.15HealthCare.gov. How to Appeal a Marketplace Decision Missing that deadline is not always fatal; you can request an extension by explaining why you couldn’t file on time. Common grounds for appeal include disputed income calculations, immigration status verification, and whether an employer plan qualifies as affordable. Gather documentation showing the correct figures before you file.