Medicaid expansion states and the coverage gap

What expansion changed

Medicaid's traditional groups for working-age people are parents and caretakers, pregnant women and people with disabilities. The Affordable Care Act added one more: every adult aged 19 to 64 with income up to 133% of the poverty line, who is not pregnant, not on Medicare and not eligible under another group. Adopting that group is a state decision. CMS records the choice in the last column of its table of eligibility levels, the one this site reads, dated December 1, 2023. With the 5-point disregard from 42 CFR 435.603, the line works out to 138% of the 2026 guideline.

The difference for a low-wage worker is stark. A single adult earning $12,000 a year, about $1,000 a month, qualifies for Medicaid in Ohio or North Carolina. The same person in Texas has no Medicaid group and, being under $15,650, no Marketplace tax credit either. Try your own figures in the mini-calculator above.

The 41 expansion jurisdictions

A few cases stand apart. DC covered adults far above the standard line until it lowered adults without children and parents to 138% on January 1, 2026, $1,835 a month for one person (DC Department of Health Care Finance). Minnesota, New York and Oregon keep the standard Medicaid line but cover adults above it and up to 200% of poverty through a Basic Health Program, up to $2,726 a month for one person; Minnesota's version is MinnesotaCare and Oregon's is OHP Bridge. For Oklahoma and Utah, CMS flags a section 1115 demonstration that covers some additional low-income adults, with conditions that vary.

The 10 states without expansion

In these states the parent and caretaker group is the only door for working-age adults who are not pregnant or disabled. The standards are low: $387 a month for a parent in a family of three in Texas and $660 in Florida. Many of these states set the standard in dollars by household size, and CMS shows the highest equivalent percentage, so the real figure for your household can be lower. Children, by contrast, are covered generously everywhere: $4,894 a month for a child of 6 to 18 in a Florida family of three.

Wisconsin is the borderline case. It did not adopt the expansion, but its waiver covers adults up to 95% of poverty, $1,330 a month for one person with the disregard. South Carolina has a waiver as well, which CMS describes as covering some additional low-income adults with limits on eligibility or benefits. Georgia is listed without expansion in the CMS table.

Who falls into the coverage gap

The premium tax credit, under section 36B of the tax code, starts at 100% of the poverty guideline of the year before coverage, so for 2026 plans the threshold is $15,650 for one person and $26,650 for three (HealthCare.gov). In an expansion state, income under that threshold means Medicaid. In a non-expansion state, it means nothing for an adult without children, and for a parent whose income is above the state's low standard. That band is the coverage gap.

Take a Florida parent with two children and $20,000 of yearly income. The parent is over the state standard of $7,920 a year and under the $26,650 where the credit begins: no coverage help for the parent. The two children qualify for Medicaid or Florida KidCare, because their line is $58,728 a year. If the parent's income rose to $26,650, the credit would start, and a benchmark silver plan would cost about 2.1% of income at that level under the 2026 table.

Two exceptions to the gap matter. A pregnant woman in the same situation qualifies for pregnancy Medicaid, whose lines are high in every state. And an adult with a disability may qualify through the disability pathways, which exist whether or not the state expanded.

From Medicaid to the Marketplace in an expansion state

In an expansion state there is no gap, but there is a handoff. Income between 100% of the 2025 guideline and 138% of the 2026 guideline could in theory open both programs; Medicaid comes first, because a person eligible for Medicaid cannot claim the premium tax credit. The credit takes over only above the Medicaid line, $22,020 a year for one adult in 2026. A single adult earning $24,000 a year is just past it. With a benchmark silver premium of $500 a month, an assumption for the example since premiums vary by county and age, the 2026 table sets her contribution at $87 a month and the credit at $413. Silver plans also carry cost-sharing reductions at that income, which lowers deductibles.

Because Medicaid counts monthly income and the credit yearly income, a worker whose hours swing can move between the two in the same year. Reporting changes on time keeps the switch clean, and it matters more than before: any advance credit above the credit you are finally owed is paid back in full on the tax return, since the repayment caps no longer apply from tax year 2026.

Where people in non-expansion states shop for coverage

Adults above the poverty line in the 10 non-expansion states buy subsidized plans through a Marketplace like everyone else. Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming use HealthCare.gov. Georgia runs its own, Georgia Access. The 2026 credit there follows the same federal table as in any state, so a household at 150% of poverty pays the same share of income in Texas as in Ohio, even though the benchmark premium differs.

The 2025 law in expansion states

Public Law 119-21 adds conditions that apply only to the expansion group and to adults covered by an equivalent waiver. From January 1, 2027, renewals come every 6 months instead of every twelve (section 71107), adults 19 to 64 must meet a 80-hour community engagement requirement unless exempt (section 71119), and coverage before the application month shrinks to 1 month for new applications (section 71112). From October 1, 2028, those above the poverty line pay copays set by the state (section 71120).

The work rule has a consequence for the Marketplace. An adult who would have been eligible for expansion Medicaid but for failing the community engagement requirement is treated as eligible for Medicaid when the tax credit is computed, so the credit is not available as a fallback. The details are in Medicaid work requirements, the exact limits by group in Medicaid income limits, and the credit for those above the line in the ACA subsidy calculator.