As state-based exchanges (SBEs ) prepare for Plan Year 2026, it’s clear that the upcoming Open Enrollment Period (OEP) will look markedly different from those in recent memory. Between the Marketplace Integrity and Affordability (MIA) rule, H.R. 1 (aka the One Big Beautiful Bill Act), and the scheduled expiration of enhanced Advance Premium Tax Credits (APTCs), the individual health insurance landscape is poised for major transformation.

These policy shifts are expected to significantly impact both premium affordability and consumer decision-making, posing challenges for SBEs. However, with the core mission of expanding access to affordable coverage in mind, these changes also present an opportunity. State-based exchanges are uniquely positioned to guide consumers through complexity, helping them compare options, understand their eligibility, and choose the plan that best fits their needs and budget.

What’s Driving Higher Costs in 2026?

Health insurance premiums in the individual market tend to rise each year, but 2026 is shaping up to be a particularly sharp increase. Several converging factors are at play:

  • Expiration of Enhanced Advance Premium Tax Credits: Enhanced APTCs – originally introduced under the American Rescue Plan Act (ARPA) in 2021 and later extended by the Inflation Reduction Act (IRA) – played a pivotal role in reducing premium costs. These temporary enhancements:
    • Increased subsidy amounts for most enrollees
    • Eliminated the income cap for eligibility, previously 400% of the federal poverty level (FPL)
    • Capped premium contributions to no more than 8.5% of household income for benchmark plans

Unless Congress extends these credits, enhanced APTCs will expire at the end of 2025, resulting in significantly higher premiums for many consumers – particularly middle-income earners who benefited most from expanded eligibility. A Peterson-KFF analysis estimates that if enhanced APTCs expire, exchange enrollees could face an average increase of 75% in their out-of-pocket (OOP) premium costs. Such a steep increase could drive younger, healthy enrollees out of the market, pushing premiums even higher for those who remain.

  • Rising Medical Costs and Premium Proposals: In addition to federal policy changes, ongoing medical inflation – driven by increased drug costs, labor issues, and greater utilization of health care, among other factors – is also contributing to carrier rate hikes. Preliminary filings show that Affordable Care Act (ACA) insurers are proposing an average premium increase of about 20% for 2026.
  • Higher Out-of-Pocket Maximums: For 2026, the maximum allowable OOP limit for an individual will rise to $10,600, up from $9,200 in 2025. This $1,400 increase further shifts costs onto consumers and may reduce the overall value proposition of exchange coverage in the eyes of some enrollees.

What This Means for State-Based Exchanges

For SBE administrators, these changes mean consumers will face a more complex – and potentially more expensive – enrollment process in 2026. Without clear guidance, confusion around premium increases, subsidy eligibility, or plan design could lead to reduced enrollment, particularly among healthier or middle-income individuals. To prevent this, proactive planning and transparent communication are essential to help consumers understand their options and make informed decisions. Following are some suggestions from GetInsured on key ways SBEs can support their customers during the upcoming Open Enrollment, which runs Nov. 1, 2025–Jan. 15, 2026, in most states.

Strategies for Supporting Consumers

  1. Start Consumer Education Early

Clear, early messaging will help prepare consumers for changes before sticker shock sets in. Educate consumers on:

    • Why premiums are going up
    • The impact of enhanced APTC expiration
    • What alternative plans or financial assistance options may be available in your state

Make sure messaging is consistent across all channels – website, email, call centers, and partner organizations.

  1. Prepare Frontline Staff and Navigators

Equip call center representatives, navigators, and certified enrollment counselors with updated scripts, FAQs, and escalation protocols. Training should focus on:

    • Explaining rate changes in plain language
    • Calculating new subsidy estimates under the standard APTC rules
    • Guiding consumers through plan comparisons with attention to total cost of care (not just premiums)
  1. Upgrade Digital Tools and Calculators

Online tools should allow consumers to quickly estimate their eligibility and premium costs under the 2026 subsidy structure. Plan comparison tools should also highlight:

    • Total estimated annual costs (including OOP expenses)
    • Differences between Bronze, Silver, and Gold plan values
    • Available cost-sharing reductions (where applicable)
  1. Segment and Target Outreach

Use consumer data to identify groups most affected by the changes – such as those earning above 400% FPL who may lose subsidies – and tailor outreach accordingly. For example:

    • Automated emails to warn of potential premium increases
    • Personalized notices encouraging plan shopping or re-enrollment
    • Educational webinars or community-based sessions
  1. Coordinate with Insurers

Stay in close contact with carriers throughout the rate review and plan certification process. Collaboration can ensure that marketing materials, plan names, and provider networks remain as stable and understandable as possible for returning enrollees.

Consumer Guidance

The 2026 plan year will test the resilience and adaptability of the ACA’s exchange infrastructure. As premium increases and policy shifts introduce new complexities, state-based exchanges remain uniquely positioned to provide trusted guidance, stability, and support to the consumers they serve.

As these changes unfold, the GetInsured team will be at the forefront, partnering with our SBE clients to navigate evolving policies, support effective outreach strategies, and ensure consumers are informed, equipped, and confident during Open Enrollment and beyond. We’re also proactively updating our technology to remain fully responsive to new regulatory requirements, ensuring that our platforms remain compliant and consumer friendly.

By preparing now, SBEs can lead a coordinated, transparent effort to sustain confidence in the exchange system – and help consumers continue to find essential value in their coverage.