The Medicaid coverage gap is a structural flaw in the ACA that Congress left unresolved when 10 states chose not to expand Medicaid. Federal law set 100% FPL as the floor for Marketplace premium tax credits because the law assumed every state below that threshold would be covered by expanded Medicaid. When those 10 states refused expansion, adults earning below 100% FPL found themselves in a gap: too high-income for their state's pre-ACA Medicaid program (which in most non-expansion states covers only pregnant women, children, the elderly, and people with severe disabilities at very low income thresholds), and too low-income to qualify for a single dollar of ACA subsidy. In 2026, the gap population in those 10 states sits at roughly 1.5 to 2 million people, per Kaiser Family Foundation (KFF) analysis. The 10 states are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. Texas alone accounts for over 700,000 gap adults. Understanding why the gap exists, which resources are still available inside it, and how to exit the gap through income adjustment or geographic relocation is essential for anyone landing on this page.
Several workarounds exist, though none of them match the clean solution that Medicaid expansion would provide. Federally Qualified Health Centers (FQHCs) operate in every state and provide primary care, dental, behavioral health, and pharmacy services on a sliding-fee scale tied to income. At below 100% FPL, most FQHC visits cost $0 to $40 per encounter, and FQHCs cannot turn away patients based on inability to pay. A second path is the Marketplace itself, but only if your income edges up to or above 100% FPL. At exactly 100% FPL ($15,960 for a single person in 2026), ACA subsidies kick in and can bring a Bronze plan premium to $0 per month after the premium tax credit. A third path is employment: most employer-sponsored insurance plans have employee-share premiums of $100 to $300 per month, with the employer covering 70% to 80% of the full premium under the ACA's employer mandate. Finally, if you have any children in your household, CHIP is year-round and available up to 200% to 300% FPL in all 50 states regardless of the coverage gap. This page maps each option against your exact income, so you know which doors are open and which require taking action first.
7 Steps to Get Coverage
Common Mistakes That Cost People Thousands
The most common and costly mistakes people in the Medicaid coverage gap make in 2026:
- Applying for ACA Marketplace subsidies with income below 100% FPL. Healthcare.gov will calculate $0 subsidy and show you a full-price plan you cannot afford. Subsidies require income at or above 100% FPL ($15,960 for one person in 2026). Report your realistic projected income accurately.
- Assuming non-expansion state Medicaid will cover you as an adult without a disability. In all 10 non-expansion states, Medicaid for non-pregnant, non-disabled adults is extremely limited. Texas caps working-adult Medicaid at approximately 18% FPL for parents. Florida does not cover most childless adults regardless of income. Do not assume Medicaid is an option without checking your specific state's limits at medicaid.gov.
- Not enrolling children in CHIP. CHIP covers children in households up to 200% to 300% FPL in all 10 non-expansion states, year-round, regardless of whether the adult parent qualifies for any coverage. Missing CHIP enrollment for a child while waiting to resolve adult coverage is a preventable gap.
- Not using FQHCs. Federally Qualified Health Centers are available in every county and provide sliding-scale care at $0 to $40 per visit for people below 100% FPL. Many people in the coverage gap are unaware FQHCs exist or assume they need insurance to use them. No insurance is required.
- Waiting for the federal government to close the gap. Congressional legislation to require all states to expand Medicaid has failed repeatedly. As of mid-2026, no federal mandate for expansion is pending. The coverage gap is a permanent feature of the current law unless individual states choose to expand.
- Missing the 60-day qualifying-event SEP window after a life change. If you lost job-based coverage, had a baby, or got married in the last 60 days, you may have an active SEP right now, even if your income is below 100% FPL, as long as you can project reaching 100% FPL by year-end. Do not let this window close without at least logging in to healthcare.gov to check.
Why the Coverage Gap Exists: The ACA Architecture Flaw in 2026
Federal law set 100% FPL as the minimum income for ACA Marketplace premium tax credits. Congress made this choice deliberately: the assumption was that Medicaid expansion would cover everyone below 100% FPL. The Supreme Court's 2012 NFIB v. Sebelius ruling made Medicaid expansion optional for states rather than mandatory. When 10 states chose not to expand, the gap snapped open. Pre-ACA Medicaid in non-expansion states typically covers: pregnant women (up to 200% FPL in most states), children under 19 (via CHIP), elderly and disabled adults (via SSI-linked Medicaid), and parents at very low incomes (Texas: 18% FPL, Alabama: 18% FPL, Mississippi: 27% FPL, Florida: 34% FPL). Childless adults without a disability generally qualify for nothing in non-expansion states, regardless of income level, unless a specific categorical program exists.
Three states previously closed their coverage gaps through other means. Louisiana expanded Medicaid in 2016 and no longer has a gap population. North Carolina expanded in December 2023. South Dakota expanded in July 2023. As of June 2026, the remaining 10 non-expansion states are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming, per the Kaiser Family Foundation Medicaid expansion status tracker. Any state can still opt into expansion at any time by submitting a state plan amendment to CMS, which would make residents immediately eligible for Medicaid at 138% FPL. Georgia adopted a partial expansion in 2023 through its Georgia Pathways to Coverage program, which provides Medicaid to adults aged 19 to 64 who meet a work requirement of 80 hours per month and income up to 100% FPL. As of mid-2026, roughly 11,000 Georgians have enrolled, a fraction of the estimated 300,000 gap adults in that state.
FQHCs and Safety-Net Resources in Non-Expansion States in 2026
Federally Qualified Health Centers are the primary year-round care solution for coverage-gap adults. HRSA's 2026 data shows more than 1,400 FQHCs operating over 14,000 service sites nationwide, with particularly dense coverage in the 10 non-expansion states given the size of their uninsured populations. Texas has over 130 FQHC organizations. Florida has over 50. Mississippi and Alabama each have dense rural FQHC networks. Services covered under the sliding-fee schedule include: primary care visits, preventive care, immunizations, chronic disease management, behavioral health and substance use disorder treatment, dental care, pharmacy (with 340B pricing), and vision. The sliding-fee discount at below 100% FPL typically results in $0 to $40 per visit depending on the specific FQHC's fee schedule. Locate the nearest FQHC at findahealthcenter.hrsa.gov, which is HRSA's official locator tool, or call 1-877-464-4772.
Beyond FQHCs, several state-specific safety-net programs exist in the 10 non-expansion states. Texas's Children's Health Insurance Program (CHIP) covers children up to 201% FPL. Texas's CHIP Perinatal covers unborn children and extends some prenatal services to mothers. Florida's KidCare program is the CHIP brand covering children up to 210% FPL. Georgia's Pathways to Coverage program provides work-requirement-linked Medicaid to some gap adults. Mississippi operates Ryan White HIV/AIDS Program clinics that provide comprehensive care for people with HIV regardless of insurance status. In all 10 states, public hospital systems and county health departments offer charity care programs for uninsured adults. These programs are not an insurance substitute, but they provide a safety net for acute and episodic care while you work on a longer-term solution.
How to Reach the 100% FPL Floor and Unlock ACA Subsidies in 2026
ACA Marketplace subsidies begin at exactly 100% FPL and represent a sharp cliff: at $15,960 annual income for a single person in 2026 ($1,330 per month), premium tax credits drop the benchmark Silver plan to $0 per month in most non-expansion states. At $15,959, there is no subsidy at all. This is why understanding your exact projected income matters. ACA Marketplace subsidies are based on projected Modified Adjusted Gross Income (MAGI) for the entire calendar year 2026, not your income at the time of application. If you earn $800 per month from part-time work in January through October and then take a full-time job in November, your projected annual income may be well above 100% FPL for the year even though your monthly income in January looked sub-100%. Project your realistic total 2026 income before applying, and recalculate if circumstances change mid-year.
Several income sources count toward MAGI that gap adults commonly overlook. Unemployment compensation counts in full. Self-employment net income counts (revenues minus expenses). Interest and dividends count. Social Security disability income counts for most purposes. Cash wages count even if no W-2 is issued. If you are near the 100% FPL threshold, calculate whether any of these sources bring you above the floor. Report the higher projected income to healthcare.gov: the subsidy you receive will be based on that projection, and you will reconcile it at tax time on Form 8962 using your Form 1095-A. Under-reporting income to stay below 100% FPL does not help you (there is no subsidy below the floor anyway) and creates a tax reconciliation risk if income rises unexpectedly.
Documents Needed to Apply Once You Have a Coverage Path
Gathering documents in advance significantly speeds up any application. For a Marketplace plan (once income reaches 100% FPL or a qualifying event occurs), you need: photo ID or passport, Social Security numbers for all household members, proof of state residency such as a utility bill or lease dated within 60 days, documentation of projected 2026 income such as recent pay stubs, an employer letter, or a written self-certification for self-employment, and proof of your qualifying event if applying through a SEP (employer termination letter showing last day of coverage, birth certificate, or marriage certificate). For an FQHC, bring photo ID and any income documentation you have. FQHCs accept patients without documentation in many cases and will help with applications. For CHIP enrollment for children, you need: children's Social Security numbers, proof of the child's age (birth certificate), proof of state residency, and documentation of household income.
Frequently Asked Questions
What is the Medicaid coverage gap and which states have it in 2026?
The Medicaid coverage gap is the income band below 100% FPL where adults in non-expansion states have no access to either Medicaid (income too high for pre-ACA state limits) or ACA Marketplace subsidies (income too low for the 100% FPL floor). As of June 2026, the 10 states with the coverage gap are Alabama, Florida, Georgia (partial exception via Pathways), Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin (partial exception via BadgerCare waiver at 100% FPL), and Wyoming. The gap population is estimated at 1.5 to 2 million adults per KFF analysis. North Carolina (December 2023) and South Dakota (July 2023) closed their gaps by expanding Medicaid.
Can I get ACA subsidies if my income is below 100% FPL in a non-expansion state?
No. ACA Marketplace premium tax credits require income at or above 100% FPL in all states. At $15,959 annual income for a single person in 2026 (one dollar below 100% FPL), the Marketplace subsidy is exactly $0. Healthcare.gov will show you full-price plans ranging from $300 to $800 per month with no subsidy applied. You must project income at or above 100% FPL ($15,960 for one person in 2026) to receive any subsidy. If your projected income is just below the threshold, consider whether additional income sources such as part-time work, self-employment, or cash wages might bring you above the floor.
What free or low-cost health care can I get without insurance in the coverage gap?
Federally Qualified Health Centers (FQHCs) are your primary year-round option for care without insurance. FQHCs provide primary care, dental, behavioral health, and pharmacy services on a sliding-fee scale. At below 100% FPL, most visits cost $0 to $40 per encounter. Use the HRSA Health Center Finder at findahealthcenter.hrsa.gov to locate the nearest FQHC. Community health centers, public hospital charity care programs, and state-funded clinics also provide care. For prescription drugs, manufacturer Patient Assistance Programs (PAPs) provide medications at no cost to qualifying low-income patients. NeedyMeds.org and RxAssist.org maintain PAP directories.
Do my children qualify for CHIP if I am in the coverage gap?
Yes. CHIP eligibility is independent of the adult coverage gap. All 10 non-expansion states operate CHIP programs for children up to 19 years old at income thresholds of 200% to 300% FPL or higher. Texas covers children to 201% FPL, Florida to 210% FPL, Georgia to 247% FPL, Mississippi to 209% FPL, and Alabama to 321% FPL under ALL Kids. CHIP enrollment is year-round with no qualifying event required. Apply through healthcare.gov or your state's CHIP agency. If you have children in your household and they are not already enrolled in CHIP, do that immediately regardless of your own coverage status.
Does moving to an expansion state get me out of the coverage gap?
Yes, permanently. A move to any of the 40 expansion states plus DC removes you from the coverage gap. In those states, Medicaid covers adults with incomes up to 138% FPL ($22,025 for a single person in 2026) year-round with no enrollment window. The move must be a permanent relocation, not a temporary stay. A permanent move to a new state also triggers a 60-day Special Enrollment Period for Marketplace plans, so you have immediate coverage options in the new state. Apply for Medicaid in the new state within days of establishing residency. Coverage typically begins the first of the following month.
What happens if I have a baby or get married while in the coverage gap?
Having a baby or getting married are qualifying life events that open a 60-day Special Enrollment Period for the ACA Marketplace. However, if your income remains below 100% FPL, you still cannot receive subsidies on the Marketplace even with an active SEP. The baby's coverage is handled separately: newborns in households below 100% FPL in non-expansion states may qualify for CHIP depending on the state's CHIP income threshold for infants. Getting married may change your household income calculation, potentially pushing combined household income above 100% FPL and unlocking subsidies. Run the calculation at healthcare.gov before assuming the coverage gap still applies after marriage.
Is Georgia different from other non-expansion states for the coverage gap?
Partially. Georgia's Pathways to Coverage program, launched in July 2023, provides Medicaid to adults aged 19 to 64 who meet a work requirement of 80 hours per month of qualifying activity (employment, job training, education, volunteering, or caregiving) and income up to 100% FPL. As of mid-2026, approximately 11,000 Georgians have enrolled, far below the estimated 300,000 gap adults in the state. The program has significant enrollment barriers including the monthly work-reporting requirement. Eligible Georgians should apply through the Georgia Department of Community Health's Pathways portal at medicaid.georgia.gov. CHIP (PeachCare for Kids) covers Georgia children up to 247% FPL year-round regardless of Pathways eligibility.
What if my income increases to exactly 100% FPL mid-year? Can I enroll in the Marketplace?
An income increase alone does not trigger a qualifying life event SEP for the ACA Marketplace. However, if your projected 2026 annual income reaches 100% FPL or above at any point, you can enroll during the next Open Enrollment Period starting November 1, 2026 for 2027 coverage. If a separate qualifying life event (job change, marriage, birth) occurs around the same time as the income increase, the qualifying event opens the 60-day SEP. When you apply through healthcare.gov, report your projected annual income for the full calendar year, not just your current monthly rate. The subsidy calculation uses your full projected 2026 MAGI.
