KFF: Nine Things to Know About the 2027 ACA Open Enrollment Period

The Affordable Care Act (ACA) Marketplace open enrollment period for 2027 begins in most states on November 1, 2026. The previous year brought the end of enhanced premium tax credits, the start of provisions in the 2025 budget reconciliation law known as the “One Big Beautiful Bill Act,” and new Trump administration regulations that changed Marketplace coverage. Those developments are expected to shape enrollment again for 2027.

Below are nine key developments to watch.

1. Premiums are rising sharply, though subsidies will still help most enrollees.

Insurers proposed a median premium increase of 15%, and finalized benchmark silver premiums are rising by an average of 13% for 2027. That marks a second straight year of double-digit proposed increases. In states using Healthcare.gov, benchmark silver premiums are up 11%, while state-run Marketplaces are seeing an average increase of 16%.

Insurers say the main driver is a larger-than-usual increase in the cost of care. That pressure is not limited to ACA Marketplaces; some employer plans have also faced steep cost growth.

Marketplace insurers also point to the expiration of enhanced premium tax credits and the resulting changes in the risk pool. KFF’s review of insurer filings found that insurers attributed about four percentage points of premium growth on average to risk-pool changes in 2026, and they expect a similar effect in 2027.

Most enrollees will still receive subsidies that soften these increases. But people with incomes above 400% of the federal poverty level will be hit hardest because they no longer qualify for premium tax credits and must pay the full price of coverage. Higher premiums could also push some healthier people to leave the market, worsening the risk pool and adding more upward pressure on prices.

2. Enrollment has dropped after the enhanced tax credits expired, and it may keep falling for other reasons.

Marketplace enrollment declined after the enhanced premium tax credits ended. During the most recent open enrollment period, plan selections fell by 1.2 million from the prior year. By February, effectuated Marketplace enrollment, meaning people paying premiums and staying covered, was down 12% from the year before, to 19.2 million people. Broader individual-market data suggest the decline continued through the first half of the year. In that larger market, enrollment fell 18% by midyear, from 25.2 million to 20.5 million, a drop of more than 4.6 million.

Several insurers say they expect continued deterioration in 2027 because the enhanced tax credits ended. Some people who managed to keep coverage may no longer be able to afford it.

As discussed below, anti-fraud efforts and new eligibility limits affecting certain immigrants could also reduce enrollment. In its latest projections, the Congressional Budget Office estimated that ACA Marketplace enrollment would fall from a peak of 22.4 million to 13.1 million.

3. More insurers are leaving than entering the Marketplaces.

The number of participating insurers is expected to decline again in 2027. As of late October, 11 carriers had said they planned to leave at least one state, while seven had announced plans to enter a new state. The smaller market created by the loss of enhanced premium tax credits has raised concerns about the risk pool and insurer participation. The impact will differ by state, but some consumers will have fewer plan choices in 2027. Cigna, for example, is exiting the individual market in all 11 states where it currently operates.

Insurer exits can reduce competition and leave consumers with fewer options for plans and provider networks, while also disrupting coverage for some people.

4. Some state-based Exchanges have replaced lost federal subsidies with state aid.

Some states that run their own Exchanges are using state dollars to offset the loss of enhanced premium tax credits, and several are continuing or expanding that help. New Mexico went the farthest by fully replacing the lost federal assistance for Marketplace enrollees. Even as national enrollment fell, New Mexico saw Marketplace enrollment grow. The state is continuing the program.

Other states offered more limited aid and may broaden it further. California is continuing state-funded premium subsidies and is expanding eligibility to partially replace lost enhanced tax credits for households with incomes between 165% and 200% of the federal poverty level. Previously, only households between 138% and 165% FPL qualified for that assistance. New Jersey has also kept subsidy programs in place, while Rhode Island and Virginia created new state-specific subsidies for the 2027 plan year. These state programs may help some people afford coverage, though support varies by state and income.

5. Federal anti-fraud actions may affect enrollment totals and reduce access to broker help.

Recent federal efforts aimed at Marketplace broker fraud could influence enrollment counts, the availability of enrollment assistance, and some broker practices. Some consumer-facing requirements tied to fraud prevention have been paused temporarily because of court action.

In September, HHS said it had cancelled coverage for about 760,000 people CMS identified as “phantom” enrollees, meaning they may have been enrolled by a broker or agent without knowing it. HHS also sent insurers a list of roughly 1.2 million people to review. These people were enrolled by an agent or broker, had not made a premium payment, and were missing a Social Security number or immigration document that could be verified in real time. If insurers could not reach them or confirm they had claims, CMS cancelled their coverage. Some people have since had coverage restored, which suggests the review process may have swept up some legitimate enrollees. Others may not regain coverage.

HHS is also imposing new safeguards on certain agents, brokers, and web-broker practices that can expose consumers to improper or fraudulent enrollments. This follows investigations into brokers and related entities that moved people into different plans or enrolled them without their knowledge. The HHS Notice of Benefit and Payment Parameters for 2027 updates conduct standards for agents, brokers, and web-brokers, including bans on offering cash, rebates, or cash equivalents to steer consumers into coverage; falsely saying consumers will always qualify for zero-dollar insurance or premiums; and giving false information about enrollment timing and deadlines. Agents, brokers, and web-brokers must also provide marketing materials to HHS when requested for monitoring, audit, or enforcement purposes. If they use outside entities to produce marketing materials, those entities must follow the same rules.

In September, HHS also announced a tougher temporary restriction that pauses new agent and broker registration in the federally facilitated Marketplace and other Marketplaces on the federal platform until February 2027. CMS estimates that about 19,000 additional agents and brokers would have registered without that pause. Combined with lower Navigator funding, consumers may have less enrollment assistance available in 2027.

6. Some lawfully present immigrants will lose access to subsidized Marketplace coverage.

Lawfully present immigrants can currently receive subsidized ACA Marketplace coverage. That category includes lawful permanent residents, people on work visas, and humanitarian immigrants such as refugees, trafficking victims, and asylees. Undocumented immigrants cannot buy ACA Marketplace coverage, even at full cost. The types of immigrants who can purchase coverage have not changed for 2027, but the 2025 budget reconciliation law limits premium tax credit eligibility to only certain lawfully present immigrants:

• Lawful permanent residents
• Cuban and Haitian entrants, as defined in section 501(e) of the Refugee Education Assistance Act of 1980
• Lawful residents living in the United States under the Compact of Free Association

Other lawfully present immigrants, including refugees, trafficking victims, and asylees, may still buy Marketplace coverage, but they will no longer qualify for premium tax credits. Without subsidies, many may not be able to afford premiums and could drop coverage. The Congressional Budget Office estimates that this change will leave one million more people uninsured by 2035.

7. Enrollees will face the end of repayment caps.

Starting with the 2026 tax year, limits that once capped how much some enrollees had to repay in excess premium tax credits were eliminated under the budget reconciliation law. Since the first tax filings under these rules will not arrive until early 2027, consumers will pick 2027 coverage without seeing how an uncapped repayment system works in practice. People whose incomes end up higher than expected could face larger tax bills than anticipated, so careful income estimates and updates during the year will matter, especially for those near premium tax credit or cost-sharing reduction thresholds.

Some consumers may be able to lower their modified adjusted gross income through contributions to health savings accounts or traditional IRAs. Those contributions can increase premium tax credits or help people near 250% of the federal poverty level qualify for cost-sharing reductions. But HSA contributions are only available to people in HSA-eligible plans, and not everyone can afford to contribute. Because Marketplace assistance is based on projected annual income, people using this strategy may also need to update their estimates during the year.

8. People denied Medicaid for not meeting work rules will also be shut out of Marketplace subsidies.

Beginning in 2027, in states required to implement Medicaid work requirements, people who lose or are denied Medicaid coverage solely because they did not meet those requirements will also be ineligible for subsidized Marketplace plans in those states. Before the budget reconciliation law, someone denied or removed from Medicaid could still enroll in Marketplace coverage if they met the Marketplace rules. Since Medicaid eligibility is based on monthly income while Marketplace premium tax credits rely on an estimated annual income, some people may qualify for both at the same time, especially in expansion states. The affected group is likely small, but it could include people who recently lost jobs and would not meet work requirements.

When the law was enacted, Georgia was the only state with Medicaid work requirements. The law now requires 43 states and the District of Columbia to adopt them by the start of 2027. The ACA tax credit bar for people who fail Medicaid work requirements will apply to adults in expansion states and to those covered through Medicaid Section 1115 waiver programs that expand coverage. People who lose Medicaid because of these rules, including those who are working or qualify for an exemption but cannot navigate reporting requirements, may have trouble finding affordable coverage because they will remain ineligible for premium tax credits until they lose Medicaid for another reason, such as a change in income.

9. Lawsuits have delayed several new Marketplace rules for 2027.

Two final regulations that would make major Marketplace changes—the 2025 program integrity rule and the HHS Notice of Benefit and Payment Parameters for 2027—have been challenged in court, and many of their provisions are on hold for now. Four cases are moving through the legal system: the 2025 program integrity rule is being challenged in City of Columbus et al. v. Kennedy (Columbus I) and California et al. v. Kennedy (California I), while the 2027 Payment Notice is being litigated in City of Columbus et al. v. Kennedy (Columbus II) and California et al. v. Kennedy (California II). Some provisions of the 2027 Payment Notice are stayed while the cases continue.

The current status after several court rulings over the past year includes the following:

• Failure-to-reconcile rule: For 2027, consumers will not lose premium tax credits if they failed to file and reconcile earlier premium tax credits. For example, someone who did not file a tax return and reconcile for the 2025 tax year will not lose subsidies for 2027 coverage.
• Catastrophic plan eligibility expansion: A 2025 announcement broadened eligibility for catastrophic plans, including people who were not eligible for premium tax credits or other cost-sharing help because their projected income was below the federal poverty level or above 250% FPL. That expanded eligibility has been temporarily paused after a June ruling in Columbus II. As a result, only a limited group can enroll during open enrollment, including people under age 30, people whose Marketplace or employer coverage would cost more than 8.5% of income, and those who qualify for a hardship exemption.
• Other requirements are not being implemented for now, or have been vacated: CMS says it will not enforce a long list of final requirements because of litigation. These include certain income verification rules, network adequacy requirements, and the elimination of standardized health plans. Other requirements, including a rule that would block states from counting gender-affirming care as an essential health benefit and a rule that would have shortened open enrollment to nine weeks, have been vacated.

Source: KFF