Paul Sanchez
As of 2025, 19 US states and Washington, D.C., have fully state-run marketplaces for health insurance, with their own websites, call centers, and funding for Navigator programs. Twenty-eight states rely on the federal government for their marketplaces. The Affordable Care Act (ACA) called for the creation of a marketplace in each state, but the implementation of these varies. Some states have expanded their Medicaid programs to cover more people, and nine states have state-funded health insurance subsidy programs.
| Characteristics | Values |
|---|---|
| Number of states with state-funded health insurance subsidy programs | 9 |
| States with state-funded subsidy programs | New York, Vermont, Washington, Minnesota, Oregon, and 4 others |
| States with fully state-run Marketplaces | 19, plus Washington, DC |
| States relying fully on the federal government for their Marketplaces | 28 |
| Open enrollment period | November 1 to January 15 in most states |
| Annual open enrollment period in 2026 | November 1 to December 15 in every state |
| States with Basic Health Programs | New York, Minnesota, Oregon |
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What You'll Learn
State-funded health insurance subsidies
Health insurance can be expensive and difficult to afford for people with lower or moderate incomes. In response to this, the Affordable Care Act (ACA) provides subsidies to lower premiums and insurers offer plans with reduced out-of-pocket (OOP) costs for eligible individuals. These subsidies are available in the form of premium tax credits and cost-sharing reductions. In addition to federal subsidies, several states have created additional state-funded subsidy programs. For instance, Washington offers state-based premium subsidies (Cascade Care Savings) for enrollees with incomes up to 250% of the federal poverty level (FPL), provided they select a standardized Silver or Gold plan.
Other states are considering implementing state-funded health insurance subsidies. In Pennsylvania, the Pennie Board of Directors has recommended a sliding-scale premium subsidy for gold and silver plans for households earning between 151% and 300% of the FPL. However, funding for this proposal was still uncertain as of March 2025. Similarly, Georgia, Maryland, and Minnesota are exploring the idea of state-funded subsidies to mitigate the impact of expiring federal subsidy enhancements.
The ACA has also established the Basic Health Program, which allows states to create coverage programs for individuals with incomes between 138% and 200% of the FPL. The federal government provides funding equal to 95% of the marketplace subsidy for this program. Minnesota and New York are the only states currently operating this program.
Eligibility for state-funded health insurance subsidies varies by state, and each state sets its own income limits and plan specifications. These state-specific programs supplement the federal subsidies provided by the ACA, making health insurance more accessible and affordable for residents.
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State-run health insurance marketplaces
As of 2025, 19 states and Washington, D.C. have fully state-run marketplaces for health insurance. This means that these states oversee the marketplace, operate their own website and call center, and fund their own navigator programs. Examples include GetCoveredNJ, Pennie, Vermont Health Connect, and Washington Healthplanfinder. Twenty-eight states rely fully on the federal government for their marketplaces, using the HealthCare.gov website and customer service call center, and receiving federal navigator funding.
State health insurance marketplaces, or exchanges, can vary in terms of enrollment platforms, carrier availability, and rates. For example, most states have an open enrollment period from November 1 to January 15, with coverage effective either on January 1 or February 1, depending on when the person enrolls. However, some state-run exchanges have different deadlines. Additionally, some states have expanded their Medicaid programs to cover more people and offer lower costs.
New York, for instance, has a state-run health insurance marketplace called NY State of Health. This marketplace offers individuals, families, and small businesses a place to shop, compare, and enroll in a low-cost, quality health insurance plan. Certified Application Counselors, Marketplace Facilitated Enrollers, and Navigators assist New Yorkers in understanding their coverage options and choosing the right plan.
Another example of a state-run health insurance marketplace is GetCoveredNJ, which serves as New Jersey's official health insurance marketplace. This platform allows individuals and families to compare and select health insurance plans that best suit their needs and budgets. It provides a range of tools and resources to help users understand their options and make informed decisions about their healthcare coverage.
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Medicaid expansion
The Affordable Care Act (ACA) has expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025). This has provided states with an enhanced federal matching rate (FMAP) for their expansion populations. However, the expansion of Medicaid is voluntary for states, and some have chosen not to expand their programs. This means that some adults with incomes below 100% of the federal poverty level do not qualify for Medicaid and cannot afford Marketplace insurance plans.
In states that have expanded Medicaid coverage, individuals can qualify based on their income alone. If a household income is below 133% of the federal poverty level, the individual qualifies for Medicaid. However, a few states have chosen to use a different income limit. The expansion has particularly benefited those with children, pregnant individuals, and those with disabilities.
The expansion of Medicaid has increased federal spending, and several proposals have been raised to achieve federal Medicaid spending reductions. These include eliminating the enhanced match rate for the ACA expansion population and implementing a per capita cap on the federal share of Medicaid spending. If all states ultimately drop their Medicaid expansion coverage, up to 20 million enrollees could lose Medicaid coverage, increasing the number of uninsured individuals.
The impact of a per capita cap on the ACA expansion population would depend on states' responses to federal cuts. While some states may maintain their ACA expansion coverage and spending, others may drop their coverage over time as federal spending cuts increase. The effective federal match rate for the ACA expansion population would eventually fall below states' traditional match rates, shifting billions of dollars in costs to states over the next ten years.
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Special enrollment periods
A Special Enrollment Period (SEP) is a period of time outside of the yearly Open Enrollment Period when you can sign up for health insurance. You qualify for an SEP if you've had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child, or if your household income is below a certain amount. Depending on your situation, you usually have 60 days before or 60 days following the event to enrol in a plan.
- Losing health coverage: If you or anyone in your household lost qualifying health coverage in the past 60 days or expects to lose coverage in the next 60 days, you may qualify for an SEP. This includes losing coverage due to a change in household income that makes you ineligible for Medicaid or a premium tax credit.
- Gaining a new dependent: If you gained a new dependent or became a dependent of someone else due to a court order, you may qualify for an SEP. Coverage can start the same day as the effective date of the court order, even if you enrol in the plan up to 60 days afterward.
- Serious medical condition: If you faced a serious medical condition that prevented you from enrolling in health insurance on time, you may qualify for an SEP.
- Natural disaster: If you were affected by a natural disaster, such as an earthquake, flooding, or a hurricane, and lived in a county eligible to apply for "individual assistance" or "public assistance" by the Federal Emergency Management Agency (FEMA), you may qualify for an SEP. You have 60 days from the end of the FEMA-designated incident period to complete your enrollment.
- Misinformation or misconduct: If you were misinformed or prevented from enrolling in health insurance due to the misconduct or inaction of someone working in an official capacity to help you enrol, you may qualify for an SEP.
- Medicaid/CHIP eligibility: If you applied for Medicaid/CHIP coverage during Open Enrollment or a different SEP and were told you might be eligible, but your state agency later informed you that you were not eligible after the enrollment period had ended, you may qualify for another SEP.
It's important to note that not all states have expanded their Medicaid programs, and eligibility criteria may vary. Therefore, it's recommended to check with your state's official websites or the Marketplace Call Center to determine your specific eligibility for Special Enrollment Periods and health insurance options.
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Eligibility criteria
Medicaid is a joint federal and state program that provides health coverage to over 77.9 million Americans, including children, pregnant women, parents, seniors, and individuals with disabilities. The eligibility criteria for state medical insurance, or Medicaid, vary based on the state and the specific program. However, there are some general guidelines and mandatory eligibility groups that states must follow.
Firstly, income is a crucial factor in determining eligibility. The Affordable Care Act of 2010 established a new methodology for determining income eligibility based on Modified Adjusted Gross Income (MAGI). This allows individuals with incomes at or below a certain percentage of the federal poverty level (FPL) to qualify for Medicaid. The specific income threshold can vary by state and household size, but most states have chosen to expand coverage to adults with incomes at or below 133% of the FPL.
Secondly, certain demographic groups are given priority for Medicaid eligibility. These include low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI). For example, states with medically needy programs allow individuals with significant health needs whose income is too high to qualify under other groups to become eligible by "spending down" their income. Additionally, children up to age 19 who do not qualify for Medicaid may still be eligible for the Children's Health Insurance Program (CHIP), which has separate qualifications based primarily on income.
Lastly, an individual's health status and immigration status can also impact their eligibility for state medical insurance. Each state may have specific criteria, and it is recommended to check the official government websites for detailed information. These websites provide tools and resources to determine eligibility and apply for Medicaid or other low-cost health coverage options. It is worth noting that states must provide individuals with the opportunity to request a fair hearing regarding any denial of eligibility or erroneous actions taken by the state agency.
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Frequently asked questions
Nine states have state-funded health insurance subsidy programs that make coverage more affordable than federal subsidies alone.
The health insurance Marketplace was designed to provide coverage for individuals and families who are uninsured or already buying their own health insurance. This includes people who are self-employed, employed by a small business, or retired before the age of 65.
This depends on your state. Some states have their own Marketplaces, some rely on the federal government, and some are managed by both.
In most states, the open enrollment period is November 1 to January 15, with coverage effective either on January 1 or February 1. However, some state-run exchanges have different deadlines.
Federal subsidies are available in every state to reduce the amount that most enrollees pay for their coverage. State-funded subsidies, on the other hand, are typically based on how an individual's household income compares to the federal poverty level (FPL).
