Newsletter

ACA OPEN ENROLLMENT STARTED: WHAT TO EXPECT

Affordable Care Act plan open enrollment started November 1. Those who enroll by December 15 will have a plan effective date of January 1. Those who enroll between December 16 and January 15 will have an effective date of February 1, 2026.

This year’s open enrollment comes with a great deal of uncertainty. One of the reasons for the government shutdown is that enhanced tax credits that were implemented in 2021 because of legislation passed early in the Biden Administration are set to sunset as of December 31, 2025. Unless and until action is taken to extend the subsidies, subsidies will not be available to households with modified adjusted gross incomes that exceed 400% of the Federal Poverty Level ($62,600 for an individual; $84,600 for a couple; and $128,600 for a family of four; see the schedule in the next article for other family sizes). (Under current law which is sunsetting December 31 those making over 400% of the Federal Poverty level were given subsidy eligibility if the cost of the second lowest cost Silver plan in their geographic area exceeded 8.5% of income; this provision will be eliminated unless provision for paying these subsidies is included in any new legislation signed by the President.)

Without the enhanced tax subsidies, premiums are rising significantly, particularly for middle income beneficiaries. 

As is also true for Medicare Annual Enrollment, we expect high call volumes and questions about 2026 plans. 

Aetna is leaving the Affordable Care Act market nationally, and anyone on an Aetna plan will need to change plans. Molina will continue to offer plans to existing clients but is not enrolling new members in Florida. At least one new carrier will enter the market in Broward County.

Because of the uncertainty we encourage everyone to prepare projections of their 2026 income as soon as possible.

If legislation is passed to extend subsidies, it is completely unknown how these enhanced subsidies will be applied. The subsidies could be calculated and automatically applied to those who have already enrolled in 2026 plans. Alternatively, the government may either extend the open enrollment period or create a special enrollment period so that people can enroll in plans using the enhanced subsidies.

Accordingly, we recommend that individuals wait a week or two before contacting us regarding what to do for 2026. Traditionally, we suggest that clients don’t do anything in the first week of November because there usually are system glitches that need to be corrected. This year we’re suggesting that people wait until November 15 until enrolling. By that date we hope that everything will be resolved concerning 2026 subsidies and plan offerings.

Please contact us on our cell at 786-970-0740 if you have any questions before we’re in contact with you.

HOW WILL TAX SUBSIDIES BE CALCULATED FOR 2026 PLANS?

The Federal Poverty Level ("FPL") is used to determine eligibility for a subsidy. The Affordable Care Act (ACA) defines income as your “Modified Adjusted Gross Income” (MAGI).

You’re eligible for a subsidy for 2026 if your household income is between 100% (in non-Medicaid expansion states including Florida) or 138% (in Medicaid expansion states) depending on the number of individuals in your family up to 4 times that amount (i.e., 400% of the FPL).

Starting with enrollments effective January 1, 2026, you’re currently NOT eligible for a tax subsidy if your income is more than 400% of the Federal Poverty Level. In most cases your subsidy will be lower than it was in 2025 (and you won't be eligible for a subsidy at all if your projected earnings exceed 400% of the FPL).

Moreover, you're not eligible for a tax subsidy if your income is below your state's level for Medicaid eligibility.

The FPL changes each year and is used for determining eligibility for subsidies. The Federal Poverty Levels at 100% of FPL for 2026 plans are as follows:

• $15,650 for a single individual
• $21,150 for a family of 2
• $26,650 for a family of 3
• $32,150 for a family of 4
• $37,650 for a family of 5
• $43,150 for a family of 6
• $48,650 for a family of 7
• $54,150 for a family of 8

Federal Poverty Level Guidelines For 2026 Plans

Every year, the Federal Poverty Level (FPL) (see below) changes based on the cost of living. Individuals and families need to understand where they fall on the FPL so they know (1) whether they may qualify for Medicaid in their state (modified adjusted gross income either below 100% in non-Medicaid expansion states like Florida, or 138% of the FPL for states that have enacted Medicaid expansion); (2) if they’re eligible for a tax subsidy (also called an Advanced Premium Tax Credit; see below) because they earn between 100/138% and 400% of the FPL; or (3) if they’re eligible for a Cost Sharing Reduction if they purchase a silver plan and earn less than 250% of the FPL and also earn above the Medicaid threshold in their state.

Subsidies (Also Called Advance Premium Tax Credits)

The Affordable Care Act requires that subsidies be provided to individuals and families who need help paying their monthly health insurance bills. Depending on age and county of residence, an unmarried individual or a family filing a joint return who makes between 100% (138% in Medicaid expansion states) and 400% of the Federal Poverty Level will usually be eligible for a subsidy (unless employer group coverage has been offered and the plan is not considered affordable under Federal guidelines).

Federal Poverty Level and Cost Sharing Reductions

Cost Sharing Reductions are offered ONLY for silver level metallic plans. The following chart indicates the various percentages (150, 200 and 250%) of the Federal Poverty Level that are used for determining eligibility for one of the three levels of Cost Sharing Reduction.

Unmarried individuals and families can be eligible for subsidies if their Modified Adjusted Gross Income (MAGI) is below the 400% level. Unmarried individuals and families can be eligible for a Cost Sharing Reduction if their Modified Adjusted Gross Income is less than 250% of the FPL; eligibility for a level 6 CSR is for MAGI to be between 100/138% (depending on the state's eligibility level for Medicaid) and 150% of FPL; level 5 eligibility is between 150 and 200% of FPL; and level 4 eligibility is between 200 and 250%.

THIS FPL CHART IS USED TO DETERMINE TAX SUBSIDIES AND COST SHARING REDUCTIONS FOR 2026 PLANS



We are committed to serving all our clients and to make sure that they have enrolled by December 15 so they have a plan available for January 1.

We do have a few clients who always contact us on or about November 1, and we will reach out to those clients.

As has been true in prior years, we also encourage ALL our clients to actively enroll in a 2026 plan rather than let healthcare.gov auto-renew their policies as of December 15 for January 1. The reason is that premiums for auto-renewed individuals could be based on outdated information and auto-enrolled individuals could face surprises when it comes time to reconcile their 2026 taxes. Actively enrolling (instead of allowing policies to auto-renew) reduces tax reconciliation issues.

Please call us on our cell phone at 786-970-0740 if you have any questions or need any help before we are in touch with you.

ALTERNATIVES TO ACA PLANS

Some individuals will find they can’t afford an Affordable Care Act plan because of the cost (either because they are not eligible for a subsidy and the cost is too high or their tax subsidy has been reduced and they need to find an alternative that costs less than their subsidized plan).

The following are alternatives to Affordable Care Act coverage:

Short-Term Health Insurance

The Administration announced on August 7, 2025 they are not prioritizing enforcement of regulations issued by the Biden Administration effective September 1, 2024 limiting the duration of short-term health insurance plans to three months plus one renewal month. Accordingly, carriers now offer plans with the same durations they were offering prior to the effective date of the Biden regulations. These plans do not provide all the essential health benefits required for ACA plans (e.g., preventive care, prescription drug coverage, and maternity benefits) but are considerably less expensive than non-subsidized or lowly-subsidized Affordable Care Act plans.

These plans are regulated by State Insurance Commissions. and provisions vary between states. Florida permits these plans to be bought for up to three years (with three one-year plans). However, states are permitted to mandate shorter durations, make these plans available only at certain times of the year, or, like California, not offer these plans at all.

Health (Hospital-Surgical) Defined Benefit Indemnity Plans

In today's market where health insurance is often unavailable or not affordable, a Health (Hospital-Surgical) Defined Benefit Indemnity plan can help families budget and pay for health care expenditures. By providing a choice between various levels of hospital, medical and outpatient coverage, individuals and families can choose a plan according to their health care needs.

Note: these are not major medical plans and are legally referred to as Limited Benefit plans. They do not comply with the Affordable Care Act (for example they do not include all the minimum essential benefits).

Eligibility for these plans is based on medical underwriting and not all those who apply will be eligible for coverage. The plans have a 12-month pre-existing condition limitation, and pre-existing conditions are not covered until the policy has been in effect for twelve consecutive months.

Association Plans Available To Individuals And Families

We offer four major medical plans provided through the AFI Association and several limited day benefits plans offered through the BMI Association. These plans permit enrollment on a year-round basis and require successfully answering health questions to qualify. The plans utilize Cigna’s largest network.

They permit continuous enrollment (i.e., annual re-enrollment is not required), and members can remain enrolled with no age limit. They’re a very attractive option for those who desire more comprehensive coverage but either seek lower premiums than they would pay with an Affordable Care Act plan or who want to apply outside of open enrollment but don’t have a qualifying life event that would permit them to enroll in an ACA plan. None of these plans are available in Washington state.

These programs require answering medical questions to qualify. Enrollment must occur by the 20^th of the preceding month for coverage to begin the first of the following month, and premiums for subsequent months are payable on the 15th of the month.

SunCARE

We’ve recently introduced four programs offered by SunCARE which are exclusive to Sunshine Life & Health Advisors, LLC. These programs are designed to be lower-cost alternatives to Affordable Care Act plans for those who either receive no tax subsidies or want to find lower-cost alternatives to Affordable Care Act plans. Here are links to information and pricing for these four programs, listed in order of highest price and benefit level to lowest price and coverage level:

MedAccess

MedMax

MedValue

America’s Health and Wellness

The first plan utilizes a Cigna network, whereas the others use the First Health Network, which is owned by Aetna. So far the MedMax plan is proving to be the most popular plan. All these plans require successfully answering health questions to qualify; health questions are similar to those required for the Association plans described above, except there is only one health question required for the America's Health and Wellness plans.

Enrollment in these programs must occur by the 25^th of the month for coverage to begin the first of the following month, but during Open Enrollment individuals will be permitted to enroll up to the 28^th of the month.

Plans For Employees

We offer two different sets of plans where individuals agree to become part-time employees of companies who require them to participate in monthly surveys. As employees they become eligible for contributory coverage provided through the company.

Individuals must successfully answer health questions to become employees of either of these companies. Depending on the company, they receive either a 1099 or a K-2 form reporting their income, which must be reported on their tax return.

Medical Cost Sharing

We also offer medical cost sharing programs offered by Zion Health Share and One Share in Florida. We also offer these programs, as well as programs offered by Sedera, in most other states, and availability differs by state and program. These programs aren’t regulated by state departments of insurance, but are not available in all states (availability can vary by cost sharing organization and/or state).

These are not insurance programs but, instead, members participate in a community of like-minded people that share medical expenses. These programs can be up to 50% or more less expensive than traditional health insurance.

Supplemental Plans

These plans do not include all the ten Essential Health Benefits and do not otherwise comply with the Affordable Care Act. They include supplemental benefit plans like critical illness; cancer; accident medical expense; hospital illness indemnity plans; and hospital sickness plans. Plans can be bought up to age 65 in almost every state, and some can be bought after age 65 depending on the carrier and the state. Except for accident medical expense most of these types of plans require answering health questions to qualify.

Please contact us at 786-970-0740 to learn more about any of the above options and for help in enrolling..

About Paul Cholak

Paul has over forty years of benefits experience and has been Director of Employee Benefits for large companies, as well as a benefits consultant with major consulting firms. He understands the health and life insurance needs of individuals and families of all ages. He also has considerable experience in selling health and life insurance to employer groups.

He guides you through the steps of getting health and/or life insurance and is available to help you both BEFORE and AFTER you've made your purchase decision.