If you’re losing Medicaid, you may be able to move to an ACA Marketplace health insurance plan without waiting for Open Enrollment.
Losing Medicaid or CHIP can qualify you for a Special Enrollment Period, giving you time to enroll in Marketplace coverage. Depending on your household income, you may also qualify for financial assistance that lowers your monthly premium and, in some cases, your out-of-pocket costs.
The important thing is to act before your enrollment window expires and compare what your new coverage will actually cost.
Here’s how to make the transition from Medicaid to Marketplace health insurance.
What Should I Do If I’m Losing Medicaid?
Start with the notice you received from your state Medicaid agency.
Confirm:
- Why your Medicaid coverage is ending
- The exact date your coverage ends
- Whether the decision appears to be based on accurate household and income information
- Whether other members of your household are also losing coverage
If you believe the state has incorrect or outdated information, contact your Medicaid agency before assuming you need different insurance.
If you’re no longer eligible for Medicaid, your next step is to determine whether you qualify for ACA Marketplace coverage and financial assistance.
Losing Medicaid is a qualifying event that can give you a Special Enrollment Period outside the normal annual Open Enrollment Period.
At BenZen, we provide Marketplace enrollment assistance in Florida, Georgia, Maryland, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia.
For states that use the federal Marketplace, we use HealthSherpa to help eligible consumers browse available Marketplace plans, compare estimated costs, and enroll online with broker assistance at no additional cost
Questions? Call (833) 700-3530 to connect with a licensed expert Monday–Friday, 9 a.m.–7 p.m. Eastern.
How Long Do I Have to Get Health Insurance After Losing Medicaid?
The enrollment rules for losing Medicaid or CHIP are more generous than the standard 60-day window associated with many other qualifying events.
If you’re losing Medicaid or CHIP, you may be able to enroll in Marketplace coverage before your current coverage ends and for an extended period afterward.
Don’t rely on a generic 60-day deadline. Check the Special Enrollment Period shown on your Marketplace application and your Medicaid termination date.
Our Special Enrollment Period guide explains how Marketplace enrollment outside Open Enrollment works.
Starting before Medicaid ends can make it easier to coordinate the effective date of your new insurance and avoid an unintended gap in coverage.
Can I Get Affordable Marketplace Insurance After Losing Medicaid?
Yes. For many people losing Medicaid because their income has increased, an ACA Marketplace plan is the natural next place to look for coverage.
Marketplace plans cover the ACA’s Essential Health Benefits and cannot deny you coverage or charge you more because of a pre-existing condition.
More importantly, don’t judge Marketplace coverage by the full-price premium.
Depending on your household and expected annual income, you may qualify for financial assistance that substantially reduces what you pay.
Premium Tax Credits
Premium tax credits can reduce your monthly Marketplace health insurance premium.
The amount of assistance you qualify for depends on factors including your expected household income, household size, and the cost of Marketplace coverage available to you.
If you’re losing Medicaid because your income recently increased, you may still qualify for significant Marketplace premium assistance.
Cost-Sharing Reductions
Some Marketplace shoppers can also qualify for Cost-Sharing Reductions (CSRs).
CSRs don’t primarily reduce your premium. They reduce what you pay when you use healthcare, including expenses such as:
- Deductibles
- Copays
- Coinsurance
- Out-of-pocket maximums
Cost-Sharing Reductions are available only with qualifying Silver Marketplace plans.
This makes Silver plans especially important to examine when you’re transitioning from Medicaid and qualify for CSRs.
How Much Will Health Insurance Cost After Medicaid?
There isn’t one price for Marketplace health insurance after Medicaid.
Your premium can depend on your age, location, household, income, available plans, and eligibility for financial assistance.
And the premium isn’t the only cost you should compare.
Look at:
Monthly premium: What you’ll pay each month after any applicable premium tax credit.
Deductible: What you may have to pay before the plan begins paying for certain covered services.
Copays and coinsurance: What you’ll pay when you visit doctors, fill prescriptions, receive lab work, or use other healthcare services.
Out-of-pocket maximum: The most you’ll generally have to pay during the plan year for covered, in-network services that count toward the maximum.
A plan with the lowest premium isn’t necessarily the least expensive plan for you overall.
If you regularly use healthcare or take prescription medications, a plan with a somewhat higher premium and better cost sharing could potentially cost less over the course of the year.
Which Marketplace Plan Should I Choose After Medicaid?
Marketplace plans are generally grouped into Bronze, Silver, Gold, and, where available, Platinum metal levels.
The metal level describes how costs are generally divided between you and the insurance company. It does not indicate the quality of the healthcare you receive.
Bronze Plans
Bronze plans generally have lower premiums and higher costs when you use healthcare.
They may work for some shoppers focused heavily on monthly premiums, but compare the deductible and other out-of-pocket costs carefully.
Silver Plans
Silver deserves particular attention after losing Medicaid because Cost-Sharing Reductions are only available through eligible Silver plans.
If you qualify for CSRs, a Silver plan can have substantially lower deductibles and other out-of-pocket expenses than its standard benefits would suggest.
Gold Plans
Gold plans generally have higher premiums but lower costs when you receive healthcare.
They can be worth comparing if you expect frequent prescriptions, doctor visits, specialist care, or other regular healthcare expenses.
Don’t choose based on metal level alone. Plans at the same metal level can have different provider networks, prescription formularies, deductibles, copays, and other benefits.
What Should I Check Before Choosing a Marketplace Plan?
Moving from Medicaid to private health insurance can mean changes to your doctors, prescriptions, pharmacies, and out-of-pocket expenses.
Before enrolling, check:
- Whether your doctors and specialists are in network
- Whether your preferred hospitals and facilities are in network
- Whether your prescription medications are covered
- What formulary tiers your medications are on
- Whether prescriptions require prior authorization or step therapy
- Your deductible and whether it applies to prescriptions or office visits
- Specialist and primary-care copays
- Your out-of-pocket maximum
This is particularly important if you’re receiving ongoing treatment or managing a chronic health condition.
For example, if you’re managing Type 2 diabetes, our guide to health insurance for Type 2 diabetes explains how to compare Marketplace prescription coverage, formularies, and other diabetes-related costs.
Could My Children Still Qualify for Medicaid or CHIP?
Yes.
Health insurance eligibility doesn’t necessarily work the same way for every member of a household.
Even if your income makes you ineligible for Medicaid, your children may still qualify for Medicaid or CHIP because eligibility limits for children can be different.
That can result in a family having different types of coverage—for example, the parents enrolled in Marketplace coverage while the children remain enrolled in Medicaid or CHIP.
Your Marketplace application can help determine which programs members of your household may qualify for.
What If My Income Drops Again?
Medicaid eligibility can change when your household circumstances change.
If your income falls or your household changes, you may become eligible for Medicaid again.
Unlike Marketplace coverage, Medicaid and CHIP enrollment is generally available throughout the year for people who qualify.
Likewise, if your income changes while you’re receiving Marketplace financial assistance, update your Marketplace application. Your income affects the amount of premium tax credit and other assistance for which you may qualify.
How Do I Enroll in Marketplace Coverage After Medicaid?
Start by confirming the date your Medicaid coverage ends and gathering information about your expected household income.
You’ll also want information about:
- Household members who need coverage
- Current doctors and specialists
- Prescription medications
- Expected healthcare needs
- Your Medicaid termination notice
Then compare available Marketplace plans and any financial assistance for which you’re eligible.
Get Help With Marketplace Special Enrollment
Start with HealthCare.gov or your state’s Marketplace to determine whether you qualify for a Special Enrollment Period and review available coverage.
At BenZen, we provide Marketplace enrollment assistance in Florida, Georgia, Maryland, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia.
For states that use the federal Marketplace, we use HealthSherpa to help eligible consumers browse available Marketplace plans, compare estimated costs, and enroll online with broker assistance at no additional cost.
Questions? Call (833) 700-3530 to connect with a licensed expert Monday–Friday, 9 a.m.–7 p.m. Eastern.
The Bottom Line
Losing Medicaid doesn’t necessarily mean losing access to affordable health insurance.
If you’re no longer eligible, you may qualify for a Special Enrollment Period to move to ACA Marketplace coverage, and your income may qualify you for financial assistance that reduces your premium and out-of-pocket costs.
Start by confirming exactly when and why your Medicaid coverage is ending.
Then compare your Marketplace eligibility, financial assistance, doctors, prescriptions, deductible, and other healthcare costs before selecting a plan.
And remember that eligibility can differ within a family. Even if you move to Marketplace insurance, your children may still qualify for Medicaid or CHIP.
Related Articles
- Special Enrollment Periods: When you can enroll in Marketplace coverage outside Open Enrollment
- Best Health Insurance for Diabetes: How to compare Marketplace plans when you’re managing Type 2 diabetes
- Medicaid to Marketplace: What to do when Medicaid ends and how to compare Marketplace plans
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