The Medicaid coverage gap — and how to navigate it.
In states that didn't expand Medicaid, millions of low-income adults fall into a peculiar trap: they earn too much for their state's traditional Medicaid program, but too little for ACA Marketplace subsidies. This page explains how the gap happened, who's in it, what legitimate options exist, and how a careful income projection can change your eligibility.
Key takeaways
- The "gap" exists in states that didn't expand Medicaid — adults earning under 100% FPL get caught between programs
- Florida and Texas are the largest non-expansion states; expansion status varies and changes over time
- Your state's FQHC community health center offers sliding-scale primary care for people in the gap
- Non-profit hospitals are required to have financial assistance programs — ask for the policy before bills go to collections
- Honest income projection at or above 100% FPL can unlock ACA premium tax credits — we walk through this carefully
On this page
What the coverage gap actually is
When the Affordable Care Act was written, it assumed every state would expand Medicaid to adults up to 138% of the federal poverty level (FPL). A 2012 Supreme Court decision made that expansion optional. Several states declined — and that's where the gap comes from.
In a non-expansion state, adults with income below 100% of FPL often find that:
- They earn too much for their state's traditional Medicaid program, which usually covers only very specific categories (children, pregnant women, people with disabilities, some very-low-income parents)
- They earn too little for ACA Marketplace premium tax credits, which by statute start at 100% of FPL in non-expansion states
The ACA was designed on the assumption that Medicaid would cover everyone below 138% of FPL, so the subsidies were never built to go below 100%. When a state didn't expand, a zone was left in the middle with no affordable option.
The rough estimate of the gap: income from near-zero up to 100% of FPL (for a single adult in 2026, that's a modest annual income; the exact figure varies by year). Above 100% FPL, ACA subsidies kick in. Below it, in non-expansion states, most adults without children or a qualifying category have no program to catch them.
Non-expansion states in 2026
As of 2026, a handful of states have not adopted ACA Medicaid expansion. Florida and Texas are the two largest by population, which is why you'll often see the gap discussed in connection with those states. A smaller number of other states remain non-expansion as well.
The list has changed over time as states have voted in expansion. If you're not sure where your state stands right now, check with your state Medicaid agency or a licensed ACA advisor — it directly affects which options apply to you.
In expansion states, this gap doesn't exist: Medicaid typically covers adults up to 138% of FPL, and ACA subsidies take over above that. The same person at the same income can have very different options depending on which state they live in.
Options if you're in the gap
None of these are a perfect substitute for comprehensive insurance, but together they can reduce the exposure of being uncovered.
Community health centers (FQHCs)
Federally Qualified Health Centers offer primary care, preventive care, and often dental and behavioral health on a sliding-fee scale based on income and family size. They are not insurance, but for many people in the gap they're the most practical way to access ongoing primary care. HRSA's Find a Health Center tool lists locations.
Employer coverage
If any employer in the household offers a group plan — even part-time-eligible coverage at some employers — that's often the best option for someone in the gap because subsidies aren't available and employer contributions can make the plan affordable. Worth a direct conversation with HR.
Hospital financial assistance
Non-profit hospitals are required to have financial assistance (charity care) policies. These can cover or reduce bills for people below certain income thresholds — sometimes up to 200% or 300% of FPL. If you need care, ask the hospital's financial counselor before the bill goes to collections.
Short-term plans — with heavy caveats
Short-term, limited-duration plans are not ACA-qualified, are not required to cover essential health benefits, and commonly exclude pre-existing conditions. They may offer catastrophic-style protection for a healthy person for a short window — and they can leave someone with a new diagnosis holding a very large bill. Read the exclusions carefully before assuming a short-term plan is real coverage.
Not sure if you're in the gap?
Tell us your state, household size, and rough annual income — we'll tell you in five minutes whether you're in the gap, eligible for the Marketplace, or eligible for Medicaid. Free, confidential, no obligation.
The 100% FPL threshold — and projecting income honestly
In non-expansion states, crossing the 100% FPL line is the difference between "no program" and "eligible for ACA premium tax credits, which can reduce a Marketplace plan's premium to very little." The Marketplace uses your projected income for the coverage year, not last year's income.
For people with variable or hard-to-predict income — self-employed, gig workers, people restarting work after a break — it's worth projecting income carefully and honestly:
- Include all reasonable revenue sources: employment, self-employment net income, interest, rental income, taxable retirement withdrawals, and other taxable income
- Estimate on the higher end of a realistic range rather than the lowest plausible number
- Keep records of the assumptions you made
- Reconcile on your tax return — if actual income came in above or below the estimate, the subsidy trues up then
Important: this is about realistic projection, not misrepresentation. Deliberately overstating income to obtain subsidies is not legal. A licensed advisor can walk through your situation, help you estimate fairly, and explain how the reconciliation works at tax time.
Frequently asked
If I'm in the gap, is there any ACA coverage I can buy?
What if my income changes mid-year?
Are there state-specific programs for people in the gap?
Can a health sharing ministry replace insurance for someone in the gap?
Does the gap affect my kids?
Stuck in the gap and not sure what to do?
Talk through your options with a licensed SilverEdge advisor. We'll look at your income, your state, and any employer coverage available, then map out the legitimate options in front of you.