Between April 2023 and December 2024, states completed Medicaid redeterminations for more than 94 million enrollees and disenrolled approximately 24 million people whose coverage had been continuously protected during the pandemic. Most of them had options. A significant share did not enroll. Brokers working the individual market in 2026 are still finding clients from this population, and the standard loss-of-Medicaid workflow does not map cleanly onto all of them.
Key Takeaways
- The COVID-era Medicaid continuous enrollment provision expired April 1, 2023. States completed annual redeterminations through December 2024, disenrolling approximately 24 million people. CMS data shows roughly 70 percent were removed for procedural reasons rather than confirmed income ineligibility.
- Loss of Medicaid coverage opens a 60-day Marketplace Special Enrollment Period under 45 CFR 155.420(d)(1). The window starts from the termination date, not from the notice date — a distinction that can cut several weeks from the time available to enroll.
- In Medicaid expansion states, disenrollees whose income exceeded the Medicaid threshold typically land at or above 138 percent FPL and qualify for APTC. In non-expansion states, adults below 100 percent FPL have no subsidized coverage pathway and fall into the coverage gap.
- The income figure used for Medicaid redetermination and the MAGI required for Marketplace APTC calculation are not identical. Former Medicaid clients often need a fresh income projection before the broker can run an accurate quote.
- Clients who were enrolled in Medicaid between 2020 and 2023 and have since dropped off an agency's radar represent a reachable pipeline ahead of AEP 2026. Many are uninsured, not enrolled elsewhere.
What produced 24 million disenrollments
The Families First Coronavirus Response Act prohibited states from disenrolling any Medicaid beneficiary as a condition of receiving enhanced federal matching funds starting in March 2020. That provision held for three years. During that time, states could not remove even people whose income had risen well above the Medicaid threshold or who had moved out of state. Enrollment grew to more than 94 million people by early 2023.
When continuous enrollment expired on April 1, 2023, states faced a compressed redetermination window for the largest Medicaid population in the program's history. CMS data shows roughly 70 percent of disenrollees were removed for procedural reasons: the state attempted contact for income verification, the enrollee did not respond within the deadline, and the state terminated coverage. The enrollee may have had unchanged income and still qualified for Medicaid. Many did not know they had been disenrolled until they presented an insurance card at a provider and it failed.
The procedural vs. income distinction matters for the broker. A client disenrolled for procedural reasons may still qualify for Medicaid and should be screened for Medicaid re-eligibility before a Marketplace quote is started. Enrolling a Medicaid-eligible client in a Marketplace plan blocks their Medicaid enrollment and creates a premium obligation that would otherwise not exist.
Four coverage paths after Medicaid disenrollment
Which path a former Medicaid client follows depends on income, state expansion status, and the reason for disenrollment. This table maps the common scenarios.
| Scenario | Income range | Coverage outcome | Broker action |
|---|---|---|---|
| Disenrolled because income exceeded Medicaid limit | 138%+ FPL (expansion) / 100%+ FPL (non-expansion) | APTC-eligible Marketplace enrollment | Run MAGI calculation. Quote Silver first for clients at 100 to 250 percent FPL where CSR applies. |
| Disenrolled for procedural reasons (paperwork not returned) | Varies — income may not have changed | May requalify for Medicaid in expansion states; Marketplace if income moved above threshold | Screen for Medicaid re-eligibility first. Do not enroll in Marketplace if client still qualifies for Medicaid. |
| Disenrolled in non-expansion state, income below 100 percent FPL | Below 100% FPL | Coverage gap — no Medicaid, no APTC eligible Marketplace option | Document the gap. No subsidized Marketplace enrollment is possible. Flag for any state-level coverage programs. |
| Disenrolled client aged into a state work requirement category | Varies by state waiver | Depends on state Medicaid waiver rules and current income | Check state Medicaid rules. If no Medicaid path, run income test for Marketplace eligibility. |
Illustrative scenarios. Actual eligibility depends on state Medicaid expansion status, household size, and the current plan year's FPL thresholds.
The 60-day SEP timing trap
Loss of Medicaid coverage triggers a 60-day Special Enrollment Period under (d)(1). The window starts from the termination date, not from when the state sends notice or when the client realizes they are uninsured. A client who receives a termination letter in March noting that coverage ended January 31 has a SEP window from January 31. If they call a broker in late March, they may have fewer than two weeks left to enroll.
This timing gap is specific to the unwinding because many disenrollments were noticed late. The state often sent notice at the time of termination, but the notice went to an address the client had not updated. Clients who did not open the letter, whose mail was forwarded to an old address, or who received notice in a language they did not read faced the same short window once they finally understood what happened.
Brokers who encounter an unwinding client outside the 60-day window have limited options absent a new qualifying life event. For the full documentation requirements and how to verify SEP eligibility, see the Medicaid-to-Marketplace SEP mechanics guide.
Income documentation: MAGI vs Medicaid income calculation
Most Medicaid clients have never computed their MAGI in the ACA sense. Many do not know their income changed. The state's redetermination process uses Medicaid MAGI, which is an income concept defined at and is closely related to ACA MAGI but not identical in all cases. For the Marketplace enrollment, the broker needs a projected annual income for the current coverage year.
Three specific income types create discrepancies between what the state counted and what the Marketplace requires. Social Security income enters Marketplace MAGI at the gross amount before Medicare Part B deductions. Tax exempt municipal bond interest adds back to MAGI. Foreign income excluded under adds back to MAGI. A client who was right at the Medicaid threshold can come out slightly higher on Marketplace MAGI, which can affect the APTC calculation. For gig and seasonal workers, the income projection is genuinely uncertain and should be documented as a range with the lower bound used for the initial enrollment. For a full breakdown of these income additions, see the ACA MAGI income types guide.
Non-expansion states and the coverage gap
Texas, Florida, Georgia, Wyoming, and several other states had not expanded Medicaid as of mid-2026. Adults below 100 percent FPL in those states do not qualify for Medicaid beyond categorical eligibility, and they also do not qualify for Marketplace APTC. The result is the coverage gap: income too high for Medicaid, too low for a Marketplace subsidy.
A broker encountering a non-expansion-state client below 100 percent FPL after Medicaid disenrollment is in a position where the correct answer is that no subsidized option currently exists. Documenting that conversation is worth the extra minute. Clients in this situation are worth following up with if their state expands Medicaid, if their income rises above the 100 percent FPL threshold, or if a qualifying life event opens an SEP. For a state-by-state overview, see the ACA coverage gap and Medicaid expansion post.
Building a re-engagement outreach for this population
Brokers with books that include former Medicaid clients should run a targeted review in Q3 2026. The profile to look for: a client record where the last noted coverage status was Medicaid, the last contact was between 2020 and 2023, and there has been no AEP outreach since. These clients were not necessarily lost. They may have been deferred because Medicaid covered them. They may now be uninsured.
A practical agency workflow: segment the CRM by last-noted coverage type, filter to former Medicaid enrollees, then cross-check for any AEP enrollment activity since 2023. The gap list is the outreach queue. Run a brief income screen on each contact before quoting. A client whose income has not changed since 2023 but who was previously just above the Medicaid threshold is a likely APTC-eligible Marketplace client. The enhanced APTC structure that caps premiums as a percentage of income means that even clients in the 200 to 400 percent FPL range often see substantially subsidized Silver plan options.
Agencies using Quotit or similar platforms often have historical client data with notes from pre-pandemic enrollment conversations. Those notes frequently include income figures and coverage history that make the initial income screen faster. The outreach itself does not require a formal appointment. A brief call or email confirming current coverage status is enough to determine whether a quote is warranted.
FAQ
Questions brokers ask about working with clients affected by the Medicaid unwinding.
What was the ACA Medicaid unwinding and when did it happen?
The Medicaid unwinding refers to the large-scale redetermination process that followed the expiration of the COVID-era continuous enrollment provision on April 1, 2023. The Families First Coronavirus Response Act had prohibited states from disenrolling Medicaid beneficiaries as a condition of receiving enhanced federal matching funds since March 2020. Once that protection expired, states had 12 months to complete annual redeterminations for all enrollees, a population that had grown to more than 94 million people by early 2023. States processed redeterminations through late 2024, and CMS data shows approximately 24 million people were disenrolled during that period. Roughly 70 percent were removed for procedural reasons rather than a verified income change.
Does Medicaid disenrollment during the unwinding qualify for a Marketplace SEP?
Yes. Loss of Medicaid coverage is a qualifying life event under 45 CFR 155.420(d)(1) and triggers a 60-day Special Enrollment Period on the ACA Marketplace. The window begins on the date of Medicaid termination, not on the date the enrollee receives the notice from the state. For unwinding disenrollments, some states worked with CMS to set up enhanced enrollment support pathways, but the standard 60-day rule still applies to most cases. A client who discovers months after termination that they were disenrolled has no SEP available unless a new qualifying event has occurred in the interim.
What income level qualifies for Marketplace APTC after Medicaid disenrollment?
In states that expanded Medicaid, the Marketplace APTC eligibility floor starts at 138 percent FPL, the same threshold as the Medicaid upper limit. In non-expansion states, it starts at 100 percent FPL. The subsidy scales with income under the ACA cap, limiting premium contributions to a set percentage of household income. Adults disenrolled because their income crossed the Medicaid threshold often land in the 100 to 250 percent FPL range where APTC on a Silver plan with CSR provides the most meaningful cost-sharing relief. Running the APTC estimate before presenting plan options is essential because the credit amount determines whether Silver or Bronze is the right starting point.
Why is the income documentation step more complicated for Medicaid unwinding clients?
Medicaid uses a modified adjusted gross income test, but the specific income calculation states apply during redeterminations can differ from the precise MAGI required for Marketplace APTC. A client disenrolled for income often had income close to the Medicaid threshold, and by the time they are enrolling in Marketplace coverage, income may have changed again. Many former Medicaid enrollees have variable income from gig work, seasonal employment, or self-employment. The Marketplace requires a projected annual MAGI for the current coverage year, not the figure the state used for redetermination. Brokers should use the ACA MAGI rules — adding back tax-exempt interest, gross Social Security before Medicare deductions, and excluded foreign income — rather than the number the client quotes from memory.
Are there still people from the Medicaid unwinding who need coverage in 2026?
Yes. The formal unwinding largely concluded by December 2024, but surveys from KFF and Urban Institute estimated that a meaningful fraction of disenrollees remained uninsured six months or more after disenrollment. Some clients enrolled in Marketplace coverage on their own or through a navigator. Others did not act. Brokers with clients in their CRM who were last noted as Medicaid-enrolled between 2020 and 2023 and who have not been contacted since should treat Q3 2026 as a re-engagement window. Clients who could not afford a Marketplace plan in 2023 may qualify for more substantial APTC in 2026 if the enhanced subsidies remain in effect. A brief outreach before AEP costs little and surfaces both uninsured clients and clients whose Medicaid has since lapsed for a second time.
