The Medicaid coverage gap in plain words

What is the Medicaid gap?

Medicaid is a government health program for people with low incomes. The Affordable Care Act, the 2010 federal health law, let states expand Medicaid to cover more adults. Under the expansion, adults with incomes up to 138 percent of the federal poverty level can qualify. The federal poverty level is a yearly income line the government uses to measure poverty.

The same law set up Marketplace plans with help paying the monthly cost for people with higher incomes. KFF is a health policy research group. It explains that the lowest income where this help starts was set at 100 percent of the federal poverty level. The idea was that people below that line would be covered by Medicaid.

Then the Supreme Court made expansion a choice for each state, and some states said no. In those states, an adult can earn too much for the state's regular Medicaid and still earn too little for Marketplace help. That is the Medicaid gap.

KFF describes people in it as having incomes too high for their state's Medicaid program but too low to qualify for Marketplace subsidies. KFF's July 2026 estimate is about 1.2 million adults.

States that have not expanded Medicaid

KFF says ten states have not adopted the expansion as of October 2026. They are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin and Wyoming.

Two details are worth knowing before you rely on this list. First, KFF says Georgia and Wisconsin cover some adults up to the poverty line through special state programs. For that reason, KFF reports no coverage gap in those two states. Second, the list can change when a state votes or a court rules. Check your state's Medicaid office or KFF before you rely on it.

Why some adults are left out even in non-expansion states

In states that did not expand, Medicaid usually covers only certain groups. These include children, pregnant women, some parents, and people who are elderly or have a disability. For adults without children who are not disabled, the answer in many of these states is no, no matter how low the income is. KFF notes that Texas has the lowest eligibility level for parents in the country, at 15 percent of the federal poverty level.

This is why a person working part-time, or a person with no income at all, can be told they do not qualify for anything. It is not a mistake on your part. It is how the rules are built.

What should I do first if I might be in the gap?

1. Fill out a Marketplace application anyway. HealthCare.gov says to apply even if your income looks too low, because each state has coverage options and the application checks all of them.
2. Look at the groups your state does cover. If you have a child, are pregnant or have a disability, you may qualify under a different rule.
3. Report any change in your income. HealthCare.gov says that if your expected yearly income rises into the range for savings, you can contact the Marketplace within 60 days of the change.
4. Ask the Marketplace about a catastrophic plan if you do not qualify for savings. This is a low-premium plan with high out-of-pocket costs.

Applying is free, and nothing bad happens if the answer is no. You get an official answer to keep.

How to tell if you are in the gap

The simplest way is to apply and read the answer. You are probably in the gap if three things are true. You live in a state that has not expanded Medicaid, and your household income is below the poverty line. The application must also say you do not qualify for Medicaid or for savings on a Marketplace plan. If you are not sure what your household counts as, the application asks the questions for you.

Keep a copy of the written result. Some clinics and hospital assistance programs ask for proof of your income or of a denial, and a copy of the answer can save you time. Ask each place what it accepts before you gather papers.

What if my income or my state changes?

The gap is not always permanent. If your income goes up, you may move into the range where Marketplace savings are available. HealthCare.gov asks you to update your application within 60 days of the change.

If you have a baby, become disabled or have another big life change, the Medicaid rules for your group may apply. States can also change their minds, so an expansion vote could close the gap where you live. Until then, the options in the next section are your safety net.

Where to get care while you are in the gap

Not having coverage does not mean you have no options. These choices were built for exactly this situation.

• Community health centers are federally funded clinics that adjust their fees by income and family size and serve everyone, even if they cannot pay. HealthCare.gov specifically points people in this situation to them. Read what a community health center is.
• Sliding scale clinics charge based on what you earn. Our guide on sliding scale clinics explains how they work.
• Cash-pay doctors and direct primary care charge a flat price or monthly fee, usually $50 to $200 a month for direct primary care. This is not insurance, but it can make everyday care predictable. Search our directory for options.
• Hospital financial assistance can lower or erase a hospital bill. See our guide on hospital financial assistance.
• Free clinics, run by charities and volunteers, may offer basic care. Call first to ask who they serve.

What about my state?

Rules and local programs differ. We have written two state guides, one for Kansas and one for Texas. If you live in another state without expansion, start with your state Medicaid office and HRSA's Find a Health Center tool.

What if I have an emergency?

If you think you are having an emergency, call 911 or go to the nearest emergency room right away. Emergencies include chest pain, trouble breathing, heavy bleeding and signs of a stroke.

Federal law requires an emergency room to examine and stabilize you whether or not you have insurance. If a bill comes later, ask about financial assistance. This page is general education and not medical advice.