It has been just over two months since the law became law. Budget Reconciliation Package or tax reforms known as President Trump's "Big Beautiful Act," which will Significant changes to Medicaid and the Affordable Care Act (ACA) in the country and in North Carolina.
According to the Charlotte Legal Defense Center (CCLA), the changes are scheduled to take effect starting this year, from August through 2028.
“This will significantly affect low-income people, immigrant communities and those who rely on coverage assistance programs,” the CCLA noted.
National impact
La Congressional Budget Office (CBO) estimates that, relative to its estimates of insurance coverage prior to the enactment of the law, the law will increase the number of people without health insurance by 2034 by 10 million, due to changes in Medicaid (7.5 million), the ACA Marketplaces (2.1 million), and other policies and interactions between different provisions (0.4 million).
Un full test Published in August by the Kaiser Family Foundation (KFF), notes that these legislative changes come at a time when enhanced premium tax credits for ACA Marketplace enrollees are set to expire at the end of this year.
“Combining the impact of the reconciliation law with the expected expiration of the ACA’s enhanced premium tax credits, CBO estimates show that the number of uninsured people will increase by more than 14 million by 2034,” the report states.
The impact in North Carolina
The analysis indicates that this policy is projected to increase the uninsured population in North Carolina by approximately 300 people, a change of approximately 3 percentage points. This estimate could vary between 220,000 and 370,000 based on a 25% uncertainty range.
“Of the total increase in uninsured people, 220,000 would become uninsured due to changes in Medicaid, 63,000 would become uninsured due to changes in the ACA, and 12,000 would become uninsured due to changes in Medicare and policy interactions,” the analysis states.
Related: One million Latinos at risk of losing their health insurance due to the end of tax credits
Key Changes to the ACA Marketplace
The CCLA summarized the key changes coming to the ACA health insurance market, and Medicaid in North Carolina which began on August 25:
Elimination of the Special Enrollment Period (SEP) for low-income individuals
Consumers earning less than 150% of the Federal Poverty Level (FPL) will no longer be eligible to enroll year-round. This change affects nearly 47% of those enrolled in 2025.
Market ban on DACA recipients
DACA recipients, newly eligible for coverage in 2025, will be excluded from coverage and their existing plans will be canceled.
Income verification review
Self-certification of income is being phased out. Applicants must now provide documentation if their tax information is missing or if their income is below 100% of the FPL.
Less time for data comparison
The additional 60-day grace period for resolving income inconsistencies has been eliminated. If not resolved within 90 days, benefits will end.
Late premiums may block coverage
Insurers can deny coverage to people with past unpaid premiums, regardless of how long ago the debt occurred.
ACA Marketplace Changes Coming in 2026
Stricter special registration verification
Consumers will have only 30 days to provide evidence of life changes such as wedding , birth or move.
Passive registration fee of $5
Consumers who passively re-enroll in a $0 premium plan must pay a fee or their plan will not be activated.
Automatic re-enrollment settings
Consumers will not be automatically moved to lower-cost plans, even if one is available.
Elimination of premium tax credits for certain immigrants
To those who are not eligible for Medicaid Due to their status and earning below 100% of the FPL, they will now be denied premium tax credits.
Gender-affirming care was removed as an essential benefit
States will no longer be able to include care for gender affirmation as an essential health benefit. States must fund this care directly if they wish to continue offering it.
Loss of enhanced premium tax credits and return of full refund rules
Unless Congress acts, 2026 marks the end of the enhanced subsidies and reinstates full repayment requirements for overpaid tax credits.
Permanent market changes in 2027-2028
Shortened open enrollment period
Open enrollment will now run only from November 1 to December 15 in most states.
Restrictions on the immigration-based premium tax credit
Most legally present immigrants lose eligibility for benefits, with exceptions for legal permanent residents, COFA migrants, and Cuban-Haitian entrants.
Impact of job requirements
Consumers who are disenrolled from Medicaid for failing to meet work requirements will also be ineligible for Marketplace subsidies.
Higher charges to maintain coverage
Beginning in 2028, automatic re-enrollment and continued subsidy will require a new active application and full documentation verification.
Related: What is the Health Insurance Marketplace in North Carolina and how does it work?
Medicaid Program Reforms
The CCLA also shared the significant structural and eligibility changes the Medicaid program will bring:
Changes from October 1, 2026
Narrow definition of “skilled immigrant”
Only specific groups will retain Medicaid eligibility.
Changes from January 1, 2027
Job Requirements for Expansion Adults
Adults ages 19 to 64 in the expansion category must report at least 80 hours per month of qualified work or activity (volunteering).
Shortened retroactive coverage window
Retroactive eligibility was reduced to one month for expansion adults and two months for others.
Eligibility redeterminations every 6 months
Replace the current annual review.
Changes from October 1, 2028
New cost-sharing requirements
Expansion adults with incomes between 100% and 138% of the FPL will be subject to up to $35 per service, with some key exemptions.
Privacy Concerns: Medicaid Data Shared with ICE
Between July 17 and September 9, 2025, the Centers for Medicare and Medicaid Services (CMS), supposedly shared personal data of Medicaid recipients with DHS/ICE, raising concerns about privacy protections. However, legal experts emphasize that:
- Applying for or continuing benefits does not increase immigration risk.
- Quitting programs will not erase existing data.
Related: One million Latinos at risk of losing their health insurance due to the end of tax credits
What should consumers do?
The CCLA suggests that to stay covered and minimize disruptions to health services, people should:
- Read and respond to notices from the ACA Marketplace and Medicaid offices.
- Actively update income and household information.
- declare taxes and reconcile premium tax credits.
- Pay your premiums on time or seek help.
- Get help from browsers to understand changes and requirements.
Republish our stories for free on your website or newspaper. We follow the Creative Commons license. Click the box and follow the instructions.
