The Medicaid Coverage Gap in 2026: What to Do in a Non-Expansion State

In nine states, there is an income range where no health program will take you. Earn too little and the ACA marketplace won't discount your premium by a single dollar. Earn a bit less than that and your state's Medicaid still says no. A single adult in Texas, Florida, or Georgia making under $15,960 a year can land in exactly this spot — too poor for subsidized coverage, not poor enough (or not in the right category) for Medicaid.

Roughly 1.4 million adults are caught here, in what's called the Medicaid coverage gap. It is not a paperwork mistake or a temporary glitch. It's a structural hole that opened when some states declined to expand Medicaid — and in 2026 the exits from it are narrower and pricier than they used to be. Here's exactly why the gap exists, which states it hits, and the moves that actually work if you're in it.

Why the gap exists: the 100% FPL floor

Two rules collide to create the gap. The first is on the marketplace side: ACA premium tax credits — the discounts that make a Healthcare.gov plan affordable — only start once your projected annual income reaches 100% of the federal poverty level (FPL). In 2026 that floor is $15,960 for one person and $33,000 for a family of four. Below that line, in a non-expansion state, the marketplace offers you a plan but zero help paying for it.

The second rule is on the Medicaid side. When the ACA was written, the plan was for Medicaid to cover everyone under 138% FPL and for marketplace subsidies to cover everyone over 100% — a deliberate overlap with no gap. That only works in states that adopted Medicaid expansion. The states that didn't expand kept their old, far stricter rules, which cover only narrow groups — very-low-income parents, pregnant women, people with disabilities, and the aged. A childless adult with no disability generally cannot get Medicaid at any income in those states. So the "under 138%" half of the plan never arrived, and everyone below 100% FPL fell through.

Where the gap is real (and the one exception)

As of 2026, ten states have not adopted Medicaid expansion. Nine of them have a true coverage gap:

• Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming.

The tenth, Wisconsin, is the exception that proves the rule: it never formally expanded, but a long-standing state waiver covers adults up to 100% FPL — so its residents hand off cleanly to marketplace subsidies at that same line, and effectively no one falls through. Every other state on the list expanded Medicaid and has no gap at all.

If you live in one of the nine, your state page spells out who its Medicaid program actually covers. Start with the big ones: Texas, Florida, Georgia, and Kansas, or browse all state guides. And don't assume expansion is coming to rescue you soon — none of the nine has a scheduled expansion on the books for 2026.

Your real options if you're in the gap

1. Re-check your projected income — carefully and honestly

Marketplace subsidies key off your reasonable, good-faith estimate of this year's total household income — not last year's tax return. Many people underestimate because they forget to count everything the marketplace counts: self-employment and gig income, a spouse's earnings, unemployment benefits, and more. Add it all up using the income definition that actually applies (MAGI). If an honest projection reaches 100% FPL, you qualify for premium tax credits — and you were never really in the gap.

There's a genuine protection here worth knowing: if you make a good-faith estimate at or above 100% FPL, enroll with advance premium tax credits, and your actual year-end income comes in below 100% FPL, the IRS generally does not claw back the credits you already received. This is a real safe-harbor rule, not a loophole — it exists precisely because incomes fluctuate. What it is not is permission to invent a number. Reporting income you don't expect to earn is fraud and can trigger repayment. The honest version — counting all your income and projecting realistically when your hours or gigs are picking up — is the one that holds up.

2. Check whether a Medicaid pathway is still open to you

Non-expansion states still cover specific groups, sometimes at very different income limits than the headline "adult" rule. It's worth confirming whether any of these fit before you assume you're stuck:

• Parents and caretaker relatives — covered, but usually only at very low income limits that vary sharply by state.
• Pregnancy — pregnancy-related Medicaid reaches well above 100% FPL in every state, so a pregnant applicant is almost never in the gap.
• Disability, blindness, or age 65+ — separate SSI-linked pathways with their own income and asset tests.
• Medically needy / spend-down — some states let you "spend down" high medical bills to qualify.

Your state Medicaid guide lists the categories and limits your program actually uses.

3. Get care while you're uninsured

Being in the gap doesn't mean going without care. Federally Qualified Health Centers (FQHCs) charge on a sliding scale based on income — often a nominal fee — regardless of insurance status; find one through the federal HRSA locator. Nonprofit hospitals are also required to offer financial assistance (charity care) for people below certain income levels, which can wipe out or steeply cut an emergency bill. Ask for the financial-assistance application before you pay.

4. What to avoid: short-term "insurance"

5. Know your re-check triggers

The gap is rarely permanent. Any of these can move you out of it, and most open a special enrollment window:

• Your income rises to 100% FPL (a new job, more hours, seasonal work).
• You become pregnant, or a disability is determined.
• You turn 65 and become eligible for Medicare.
• You move to a state that expanded Medicaid — where the gap doesn't exist.

A note on 2026's Medicaid work requirements

You may have read that new Medicaid work requirements are taking effect — states must implement them by January 1, 2027. Here's why they're mostly not your problem if you're in the coverage gap: work requirements apply to the expansion population — the adults covered up to 138% FPL in states that expanded. Non-expansion states don't have that group to begin with, so there's nothing for the requirement to attach to. If you're in the gap, the barrier isn't a work rule; it's the missing expansion itself. (If you're in an expansion state and worried about keeping coverage, that's a separate situation we cover here.)

Frequently asked questions

Sources: KFF, "How Many Uninsured Are in the Coverage Gap"; HealthCare.gov, Savings on premiums; HRSA Find a Health Center; HHS 2026 Federal Poverty Guidelines. Reviewed by The SubsidyCalc Editorial Team.