Trey thought he had time. It was mid-December last year and like most folks juggling holiday plans and year-end stress, health insurance didn’t exactly take top priority. He figured he could just make his changes in January. After all, what’s the rush?
That assumption cost him thousands.
When his son ended up in the hospital on January second, Trey discovered his new policy wouldn’t take effect until February. He had missed the cutoff. The ER visit, follow-ups, and prescriptions all landed squarely on his credit card. That single month of out-of-pocket costs wrecked the family budget for half the year. He’s still paying it off.
But for 2026, the government is changing how the ACA Marketplace is going to work. And it is not going to be good for your health benefits if you aren't paying attention.
Texans Are Facing Major Shifts in 2026 ACA Health Coverage
Every year brings changes to ACA marketplace plans, but 2026 is shaping up to be wildly different from the last few years. There are three big changes on the horizon, and each one could hit your wallet hard with changes to health care costs.
If you’re one of the many Texans who will be shopping for a health insurance plan, here’s what you need to know.
1. Enhanced Premium Tax Credits Are Staying, But There Is A Catch
Many Texans like Trey who get health coverage from the health insurance marketplace receive a subsidy to help offset the size of their health insurance premiums. During the COVID era, the American Rescue Plan Act created additional health insurance subsidies to lower the cost of marketplace premiums. Those subsidies have stayed in place since.
During the posturing over the Big, Beautiful Bill that was passed by Congress and signed by the President over the July 4th holiday, there was a lot of conjecturing over those "super subsidies". The original rounds of the legislation had those subsidies removed from the ACA Marketplace. But in the end, they were kept in place to serve a specific purpose.
This is where the catch comes in for Texans on the lower end of the income scale. One of the other bi-products of the COVID era super subsidies was the expansion of the Medicaid rolls. Due to the economic turmoil, the income limits were increased so that more people could retain access to healthcare during that time period. The legislation just passed will shrink those rolls over time through lower income restrictions and other requirements placed on current recipients.
I'm not here to debate those merits, just state what is happening. The net result is that the people losing Medicaid will be forced into the ACA Plans found on the Marketplace. Those super subsidies were left in place to allow the Texans transitioning into the ACA Plans to obtain those plans at what should be very minimal monthly cost. So what does that mean in real terms for Texans like Trey?
In-Network Physician coverage for Obamacare plans in the urban areas of Texas is largely not great unfortunately. In Dallas-Ft Worth specifically, neither Cook Children's or Dallas Children's hospital systems accept ACA plans. Which is a major bummer for families with kiddos since they do have Medicaid access points in those systems. And this is just one example of a lack of coverage. This can make things challenging for those families that make too much money to be on Medicaid, but don't have access to an employer-based group health plan. As a result, many of these families are turning to cash pay options to see doctors they want to use.
Cash pay options for healthcare are plentiful when you begin to look and ask around for help. Many doctor's offices will negotiate a great price for care that will look far different than what they bill insurance since they get paid immediately and don't have to work through the insurance system. There are also doctors that do not take insurance at all and will gladly see your family.
But smart Texans like Trey know that they can't afford major services without insurance. That’s why more people in Texas are already looking into alternative health plans, including private options or catastrophic coverage. They allow you to pay cash for regular office visits, and then backstop those big things. These options may not be one-size-fits-all, but they can help you control costs without need of premium tax credits for marketplace premiums.
2. Out-of-Pocket Maximums Are Going Higher
Even if you get a decent monthly premium, what you pay when you actually use your insurance is rising too. The government has raised the maximum out-of-pocket limits again for 2026. This is the cap on how much you’ll pay in a year for covered services before your insurance kicks in everything else. In 2026, your individual max out of pocket expenses will be $10,600! 😱
That means if you hit the doctor more than expected, or if something major happens, like what happened to Trey, your total risk is now higher than it used to be. And it is certainly not cheap. It’s not just about your monthly payment. It’s about the total cost of risk.
Here’s what that means for Texans like Trey. You have to think in terms of total spend. Take your monthly premiums and multiply them by twelve. Add your maximum out-of-pocket costs that you can rack up. That number? That’s what you could be expected to pay next year. And most ACA regulated health plans still require you to make copays even after you hit that cap. Talk about a bum deal.
Private catastrophic plans are starting to make more sense for people who want to cap their out-of-pocket maximum without carrying a bloated monthly payment. If your family uses a direct primary care physician and doesn’t want to overpay for what they rarely use, this can be a real option.
3. The Open Enrollment Window Is More Important Than Ever
While there was a lot of posturing on shortening the ACA open enrollment window for 2026, they decided to not shorten it. You can still enroll up to January 15th for the year. However....
If you don’t have your plan selected and submitted by the end of the open enrollment period on January 15, your coverage will not begin on February first. And you will not have a chance to get coverage later either. You will just be stuck.
Think about it. January is full of colds, flu, urgent care visits, and hospitalizations. It’s one of the busiest months for medical providers, clinics, and hospitals. Kids start sports in the spring, and accidents happen. If you need help with securing testing for something major that pops up, good luck. Going without coverage simply because you missed the open enrollment period deadline could be catastrophic.
Agents used to have tricks to get you enrolled mid year. But the special enrollment period provisions are tightening up this year. You could be stuck worse than Trey was earlier this year.
So What Should You Do Right Now?
First, do not assume you’ll just roll into a new plan and figure it out later. You need to lock in your health insurance marketplace plan during the open enrollment period that occurs between November 1st and January 15th. That’s the only way to be protected when the calendar turns unless you qualify for a special enrollment period due to a job loss of other provision.
Second, stop looking only at premiums. Start thinking in terms of the total cost of risk. That means evaluating your maximum out-of-pocket costs, not just the sticker price on your monthly bill. Consider how much you’re really willing to pay if things go sideways.
Third, weigh your options. For some, traditional affordable care act coverage still makes complete sense. But if you’re losing Medicaid or subsidies and staring at a drastically higher premium, it may be time to compare it to a private or catastrophic health plan.
These options often have lower premiums, simpler benefit structures, and a defined safety net for major medical expenses. They don’t try to be all things to all people and they do require underwriting. They just work when things go wrong, and that’s what a lot of families actually need.
Texans Don’t Have to Figure This Out Alone
You don’t have to be an insurance expert. Especially where the affordable care act is concerned. That’s our job.
At Insurance For Texans, we help people like you and Trey navigate this process every day. We walk you through the math, help you weigh the pros and cons, and give you the straight answers you actually need. We’re not a giant call center of people who were working in a car wash last week. We’re right here in Texas, and we understand what these policies actually do.
If you’re overwhelmed, that’s okay. If you’re frustrated by all the jargon and policy details, you’re not alone. But if you wait too long, the health insurers will use the new rules to screw you. And that’s a situation nobody wants.
Click the button below to compare your options and make the right call while you still can.