NC Medicaid is the state's Medicaid managed care program, which expanded to cover most adults ages 19 to 64 in December 2023. In 2026, more North Carolinians face coverage loss than at any point since expansion launched, driven by two forces: the standard annual redetermination process and new federal requirements from the One Big Beautiful Bill Act (OBBBA), signed July 4, 2025. The OBBBA added work requirements for expansion adults (ages 19 to 64 without a qualifying disability), with tracking beginning December 2026 and enforcement starting January 1, 2027. Separately, immigrant eligibility restrictions under the OBBBA take effect October 1, 2026, removing certain lawfully present non-citizen groups from NC Medicaid eligibility. If you received a termination notice, you are not alone. Between 2023 and 2025, more than 272,000 North Carolinians were disenrolled from Medicaid following the end of pandemic-era continuous coverage protections, and many re-enrolled after correcting documentation errors.
Six steps guide you through the first 90 days after losing NC Medicaid: how to appeal your termination, how to apply for ACA Marketplace coverage through healthcare.gov before your 90-day Special Enrollment Period closes, and how 2026 subsidy rules affect your costs. The ACA subsidy cliff returned for 2026 after enhanced premium tax credits from ARPA and the Inflation Reduction Act expired January 1, 2026. Households above 400% FPL ($63,840 for a single person in 2026) no longer get premium tax credits, but most people losing NC Medicaid are far below that threshold and will qualify for significant subsidies. Check the Medicaid income limits to confirm your eligibility before deciding your next step, and use the ACA income limits to estimate your marketplace subsidy.
6 Steps to Get Coverage
Common Mistakes That Cost People Thousands
The most damaging mistakes North Carolinians make after losing NC Medicaid in 2026:
- Waiting past the 90-day SEP window. If you miss the 90-day marketplace enrollment period after losing NC Medicaid, you cannot get ACA coverage until November Open Enrollment, leaving months without insurance.
- Not filing an appeal. Many NC Medicaid terminations in 2026 stem from administrative errors, not actual ineligibility. Approximately 40% of terminations during the 2023 to 2025 unwinding period were procedural rather than income-based.
- Reporting last year's income instead of projected 2026 income. The ACA Marketplace calculates subsidies on your projected annual Modified Adjusted Gross Income for the current year, not prior-year income from a tax return.
- Enrolling in Bronze instead of Silver when income is below 250% FPL. Cost Sharing Reduction plans are only available on Silver tier plans. A Bronze plan at the same or lower premium may have a $6,000 to $10,600 deductible, while a CSR Silver plan may have a $500 deductible.
- Forgetting to separately enroll children in NC Health Choice. NC Health Choice (CHIP) covers children through age 18 at incomes up to 211% FPL. Even if adults in the household lose NC Medicaid, children often still qualify.
- Assuming the OBBBA work requirement is already in effect. Work requirement tracking begins December 2026 and enforcement starts January 1, 2027. A termination notice in 2026 citing work requirements before that date should be appealed immediately.
Why NC Medicaid Terminations Are Rising in 2026
NC Medicaid expanded in December 2023, bringing approximately 600,000 additional North Carolinians into coverage. Annual redeterminations for this expansion population began in 2024 and continue through 2026. North Carolina's annual redetermination process reviews your income, household size, and eligibility documentation every 12 months. Renewals can be triggered by changes reported by the Social Security Administration, the IRS, or employer data exchanges, even if your income has not changed significantly. If the state sends a renewal form and it is not returned within the deadline, NC Medicaid automatically terminates coverage regardless of whether your income still qualifies.
The One Big Beautiful Bill Act adds two new 2026 to 2027 termination triggers. Starting October 1, 2026, certain immigrant populations that were previously eligible lose coverage under the new federal restrictions. Starting January 1, 2027, expansion adults ages 19 to 64 without qualifying disabilities must complete 80 hours per month of work or qualifying activities to retain NC Medicaid. Exemptions include pregnant individuals, people with documented medical conditions, full-time students, caregivers of dependents under age 6, and American Indian and Alaska Native tribal members. Tracking of work activities begins December 2026, meaning beneficiaries should start documenting qualifying activities now to avoid a coverage gap at enforcement.
NC Medicaid vs ACA Marketplace: Which Fits Your 2026 Income?
NC Medicaid provides free, comprehensive coverage with no monthly premiums and minimal copayments (typically $1 to $4 per service) for adults at or below 138% of the Federal Poverty Level. For 2026, that threshold is $22,025 per year for a single adult and $45,540 for a family of four. NC Medicaid covers doctor visits, hospitalizations, mental health and substance use disorder treatment, prescription drugs (with a preferred drug list), dental care for adults (preventive and emergency services), and vision care. The ACA Marketplace fills the gap for North Carolinians above 138% FPL. Premium tax credits apply for incomes between 100% and 400% FPL. At 150% FPL ($23,940 single in 2026), benchmark Silver plan premiums after tax credits typically range from $0 to $30 per month in North Carolina. At 250% FPL ($39,900 single in 2026), typical Silver plan premiums after credits run $60 to $150 per month. Above 400% FPL ($63,840 single in 2026), the subsidy cliff means no premium tax credits are available in 2026.
NC Medicaid vs ACA Marketplace eligibility by income, 2026 (48 contiguous states + DC)| Income level | NC Medicaid | ACA Marketplace subsidy | Best choice |
|---|
| Under 100% FPL ($15,960 single) | Eligible (expansion adults) | Not eligible for credits | NC Medicaid |
| 100% to 138% FPL ($15,960 to $22,025 single) | Eligible (expansion adults) | Eligible (backup if Medicaid denied) | NC Medicaid first |
| 138% to 250% FPL ($22,025 to $39,900 single) | Not eligible (over limit) | Eligible + CSR Silver available | CSR Silver plan |
| 250% to 400% FPL ($39,900 to $63,840 single) | Not eligible | Eligible for premium tax credits | Marketplace Silver/Bronze |
| Over 400% FPL ($63,840+ single) | Not eligible | No premium tax credits (2026 cliff) | Full-price Marketplace or employer plan |
CSR = Cost Sharing Reduction. Only available on Silver plans for enrollees under 250% FPL. The enhanced PTCs from ARPA/IRA expired January 1, 2026, and the 400% FPL cliff applies to all 2026 Marketplace coverage.
Source: HHS ASPE 2026 FPL Guidelines, CMS ACA premium tax credit thresholds, medicaid.ncdhhs.gov
Documents You Need to Appeal NC Medicaid or Enroll in the Marketplace in 2026
Three documents stop most NC Medicaid appeals in their tracks when missing: the original termination notice (which states the reason and your rights), proof of current income, and proof of NC residency. For ACA Marketplace enrollment, the healthcare.gov system requires you to verify the loss-of-coverage qualifying life event, which means uploading your NC Medicaid termination letter or a state-issued confirmation of the coverage end date. Gather all six items below before starting your appeal or marketplace application to avoid processing delays.
- NC Medicaid termination letter or notice of action (required for SEP verification at healthcare.gov)
- Proof of current income: recent pay stubs (last 30 days), unemployment award letter, or self-employment profit and loss statement
- Social Security numbers for all household members applying for coverage
- Proof of NC residency: utility bill, lease agreement, or mortgage statement dated within the last 60 days
- Immigration documents if applicable (green card, visa, or other status documentation for lawfully present non-citizens)
- Birth certificates or adoption records for any children being added to the new plan
NC Medicaid Income Limits by Household Size, 2026
North Carolina Medicaid expansion covers adults ages 19 to 64 at or below 138% of the Federal Poverty Level. NC DHHS updates its income tables on April 1 each year when the federal HHS poverty guidelines are finalized. The thresholds below reflect the post-April 1, 2026 guidelines. Pregnant individuals qualify at a higher threshold (211% FPL for most categories). Children qualify through NC Health Choice at incomes up to 211% FPL. Non-expansion categories (elderly, blind, disabled adults, and certain caretaker relatives) may have different thresholds. Verify at medicaid.ncdhhs.gov or through NC ePASS for your specific household.
Frequently Asked Questions
How long do I have to get new coverage after losing NC Medicaid?
You have 90 days from the date your NC Medicaid coverage ends to enroll in an ACA Marketplace plan through healthcare.gov. This is longer than the standard 60-day SEP for other coverage losses. For example, if your coverage ended June 1, 2026, your SEP window runs through August 30, 2026. NC Medicaid itself can be re-applied for year-round if your income drops back to 138% FPL or below. NC Health Choice (CHIP) for children is also year-round enrollment.
What is the SEP window after losing NC Medicaid and when does it start?
The Marketplace Special Enrollment Period for loss of Medicaid is 90 days. The 90-day clock starts on the day your NC Medicaid coverage ends, not the day you receive the termination notice. If you were notified late or did not receive notice, healthcare.gov may extend your SEP. Plans enrolled during this 90-day SEP start coverage on the first day of the month after you complete enrollment. File your marketplace application as early as possible to avoid a gap.
Can I appeal my NC Medicaid termination instead of switching to a Marketplace plan?
Yes. NC Medicaid termination notices include fair hearing rights. You typically have 30 days from the notice date to request a fair hearing through NC DHHS or your county Department of Social Services. If you appeal before your coverage end date, NC Medicaid must continue your coverage while the appeal is pending. Approximately 40% of Medicaid terminations during the 2023 to 2025 unwinding period were due to administrative or documentation errors, not actual income changes. Appealing is always worth considering before switching to a paid Marketplace plan.
Do I qualify for NC Medicaid if I lose my job in North Carolina in 2026?
Yes, if your projected 2026 annual household income is at or below 138% FPL. For a single adult, that is $22,025 per year in 2026. For a family of four, it is $45,540. NC Medicaid is year-round enrollment with no SEP deadline. Apply through NC ePASS at epass.nc.gov or call 1-888-245-0179. Processing typically takes up to 45 days, so apply immediately after income drops. If your income is above 138% FPL, check ACA Marketplace plans at healthcare.gov where subsidy-reduced plans may cost $0 to $200 per month.
What is NC Health Choice and do my children qualify after I lose NC Medicaid?
NC Health Choice is North Carolina's CHIP program for uninsured children through age 18. Children qualify at incomes up to 211% FPL (approximately $69,630 for a family of four in 2026). Enrollment is year-round and not subject to the 90-day Marketplace SEP deadline. Even if you as an adult lose NC Medicaid because your income rose above 138% FPL, your children may still qualify for NC Health Choice. Apply through NC ePASS at epass.nc.gov, through a local navigator, or at your county Department of Social Services.
What do the OBBBA work requirements mean for NC Medicaid in 2026?
The One Big Beautiful Bill Act added work requirements for expansion adults (ages 19 to 64 without qualifying disabilities) enrolled in NC Medicaid. Activity tracking begins December 2026, and enforcement with coverage loss begins January 1, 2027. The requirement is 80 hours per month of work, work training, volunteering, or education. Exemptions include pregnant individuals, people with medical conditions preventing work, caregivers of dependents under age 6, full-time students, and American Indian and Alaska Native tribal members. If you receive a termination notice in 2026 citing work requirements before January 2027, appeal it immediately.
How do I apply for ACA Marketplace coverage after losing NC Medicaid?
North Carolina uses the federal Marketplace at healthcare.gov, not a state exchange. Go to healthcare.gov, create or log into your account, and click 'report a life change.' Select 'lost Medicaid or CHIP coverage' as your qualifying event and enter the date your NC Medicaid ended. Enter your 2026 projected household Modified Adjusted Gross Income (MAGI). The system will show available plans in your county with subsidy estimates. If your income is under 250% FPL, compare Silver plans first for Cost Sharing Reductions. Submit your application and upload your NC Medicaid termination letter when prompted. Coverage starts the first of the month after enrollment.
What if I miss the 90-day SEP window after losing NC Medicaid?
If you miss the 90-day window, your options narrow significantly. You cannot enroll in an ACA Marketplace plan until the 2027 Open Enrollment Period, which runs November 1 through January 15, 2027 for coverage starting January 1, 2027. Exceptions exist if another qualifying life event occurs (marriage, birth, move to a new state, loss of job-based coverage). NC Medicaid itself is year-round, so if your income drops below 138% FPL at any point, apply immediately through NC ePASS. Children can still enroll in NC Health Choice year-round regardless of the adult SEP window.
