ACA Enhanced Premium Tax Credits at a Standstill
We’re now a full month into Open Enrollment and enhanced premium tax credits have still not been extended. The impact on enrollees is happening now, as people seek out alternative options for coverage, which may not include the comprehensive benefits outlined under the Affordable Care Act (ACA) standards. ACA Marketplace plans are required to ensure 10 essential health benefits, as a floor for all plans on Healthcare.gov. These include Rehabilitation and Habilitation supports for people with disabilities who are building or regaining mental and physical skills. Enrollees are assured of the availability of coverage for:
- Ambulatory patient services (typically referred to as outpatient care you get without extended stay in a health facility or hospital)
- Prescription drugs
- Laboratory services
- Emergency services
- Hospitalization (for surgery and overnight stays)
- Preventive and wellness services (including cancer screenings) and chronic disease management
- Mental health and substance use disorder services, including behavioral health treatment (includes counseling and psychotherapy)
- Pregnancy, maternity, and newborn care (both before and after birth)
- Pediatric services, including oral and vision care
Beyond these benefits, plans may also include dental and vision care for adults, or medical management programs for chronic health needs like diabetes. This additional coverage depends on the plan, and the state requirements. Birth control and breastfeeding equipment and counseling are also required under the ACA. However, availability of abortion services and male reproductive care are only available on some plans. Without a right to contraception enshrined in law, the future of reproductive healthcare make be facing further challenges in the year ahead. Maintaining the coverage of these essential health benefits continues to be a focus of healthcare advocacy efforts.
While the passage of the ACA helped to standardize private health plans available nationwide, enrollees continue to navigate a complex range of options. The majority of insured Americans experience challenges with using their health insurance, especially those who are the most regular health care users. The Commonwealth Fund warns that the usability of insurance will worsen if current benefits and cost-sharing standards are eroded, and alternative health insurance marketplaces and plans are allowed to grow. These developments will only erode the availability of care for those with greater health needs and increase costs overall.
As you advise consumers about their options in the ACA Marketplace, you may also want to educate them on the dangers of so-called “junk plans” which are not subject to the same base-level requirements and consumer protections as Marketplace plans. In fact, short-term plans are not subject to ACA consumer protection requirements, including the provision of EHB coverage. Additionally, the ACA protects people who have preexisting conditions and higher health needs, but those on junk plans might have their coverage cancelled if they develop a new health condition. The low upfront cost hides the limited coverage and benefits caps baked-in to their business model. It may even be a challenge to purchase one of these plans for many people with disabilities, who could be denied coverage, or charged a higher premium on the basis of their health status. Consumers who are researching more affordable coverage options are likely to see these plans highlighted in sponsored advertisements at the top of their search results. Notify your consumers to be aware of the limitations of short-term limited duration plans, association health plans, health sharing ministries, and Farm Bureau plans, which are available in some states and make sure they are selecting a plan that meets their unique needs.
Some eligible enrollees may also be considering Catastrophic Health Plans, which boast lower premiums in exchange for deductibles as high as $10,600 for individuals. While they offer comprehensive coverage and may seem appealing to some enrollees, these plans have the highest level of cost sharing. This amounts to enrollees paying the highest share of out-of-pocket costs in the forms of either their deductible, co-payments, or co-insurance.
As advocates wait for a possible extension of the enhanced tax credits, the Urban Institute has offered a list of essential questions that any proposal must address in order to meet the affordability needs of consumers. Without adequate protections, the overall costs to people with disabilities are likely to increase, as insurers shift the cost burden to enrollees. Ensuring truly affordable healthcare means providing affordable options for people with preexisting conditions and complex health needs. Bad faith insurance company practices which discriminate against enrollees or impose barriers to care ultimately lead to more negative health outcomes and erode the ability of providers and patients to pursue the care options they need.
Tax Credit Impact Explainer
Tax credits have been an important mechanism to improve the affordability of Marketplace plans. By providing advance payment of tax credits during a plan year, consumers were able to pay lower premiums upfront. The Commonwealth Fund provides a clear timeline of their implementation and how they’ve supported enrollment increases over time. Premium tax credits were first available to those making up to 400% of the federal poverty line (FPL). Later, it became clear that this financial assistance created a benefits cliff that negatively impacted consumers with incomes just above 400% FPL (This amounts to $62,600 for an individual in 2025).
The enhanced premium tax credits (ePTCs) were implemented to smooth the benefits cliff for people making above 400% FPL. They also expanded affordability for people with lower incomes. Kaiser Family Foundation explains that with the expiration of ePTCs, premium payments for some enrollees may increase to over 25% of their annual income, with high variation in how this will impact enrollees across the country. People above 60 years old will experience some of the highest increases in their premiums with these changes. The loss of these affordability protections will disproportionately impact people with disabilities across the lifespan.
Open Enrollment Reminder – Monday, December 15th is the last day to enroll for consumers who want their coverage to start on January 1, 2026. Open Enrollment continues through January 15, 2026.
Notice: New Disability Research Listserv
People with disabilities have historically been underrepresented in health research. That’s why broad participation of people with disabilities in research from all backgrounds, ages, and parts of the country is so important. To support disability and health research, AAHD is proud to announce the launch of a new Research Listserv. We send monthly updates on health-related research studies relevant to people with disabilities. You can subscribe by updating your newsletter preferences. Just check the box to receive our “Research Listserv” updates, and complete the follow-up survey to help us better match studies to eligible participants.
Archives of our weekly updates are available on the NDNRC website. Follow AAHD’s other newsletters to stay current on research opportunities and policy developments supporting people with disabilities.