Losing Medicaid after a raise in North Carolina

Tasha Greene is 34 and lives in east Charlotte with her children, Jaylen, 9, and Maya, 6. She is an administrative assistant at a small property management office off Central Avenue, where she handles leases, rent payments and maintenance calls. The office doesn’t offer health insurance.

The 3 of them have been on North Carolina Medicaid. Tasha’s coverage came through the expansion that started December 1, 2023, for adults 19 to 64. In January 2026 her office gave her a raise, to $39,000 a year.

Her Medicaid renewal came up in May. The state’s letter said her income was now over the limit for adults and her Medicaid would end on June 30. Jaylen and Maya would keep theirs.

Does losing Medicaid let you buy a marketplace plan outside open enrollment? Yes. On HealthCare.gov, losing Medicaid opens a Special Enrollment Period: a plan can be picked as early as 60 days before Medicaid ends and within 90 days after. A plan picked before Medicaid ends starts the first of the month after.

Tasha and her children are fictional; the rules come from HealthCare.gov, CMS and the state, and the income figures from the IRS and HHS.

Losing Medicaid, in brief

North Carolina uses HealthCare.gov, so these are its rules:

• What counts. Losing Medicaid or CHIP is a loss of coverage, a qualifying life event that opens a Special Enrollment Period.
• The window. A plan can be picked as early as 60 days before Medicaid ends. After it ends, HealthCare.gov says the plan must be picked “within 90 days after the date coverage ended.” Most other windows are 60 days.
• When the new plan starts. Picked on or before the last day of Medicaid: the first of the month after Medicaid ends. Picked later: the first of the month after picking.
• Proof. The marketplace may ask for documents proving the loss. After picking a plan, there are 30 days to send them.
• Medicaid itself has no window. Medicaid and CHIP applications are open any time of year.

Tasha’s story

The renewal letter

The letter came in the first week of May. Tasha read it at the kitchen table on a Thursday night, after the kids were asleep.

In North Carolina, adults qualify for Medicaid on income alone below 138% of the poverty guideline. For a household of 3, that line is about $36,777 a year. With her raise, Tasha earns $39,000, about $2,200 over it.

Children’s Medicaid has a higher income limit than adults’, which is why Jaylen and Maya stayed on.

Her first thought was that her raise had cost her Medicaid. By the weekend she had a list of questions: when exactly her coverage ended, what her options were, and whether each option kept her doctor.

The clock

Her window opened 60 days before June 30, at the start of May, so it was already open when the letter came. It would stay open 90 days after her Medicaid ended, until late September.

But the start date of her new plan depended on when she picked it. A plan picked on or before June 30 would start July 1, the first of the month after her Medicaid ended. A plan picked in July, August or September would start the first of the month after she picked it, with a gap in between. Tasha wanted no gap, so she aimed for June.

Keeping the family’s care

The children’s care was settled. They stay on Medicaid and keep seeing the pediatrician on The Plaza who has seen Maya since she was born.

Her own care was the open question. Since she got Medicaid, Tasha has seen the same nurse practitioner at a family clinic near her apartment for her checkups. Before looking at a single premium, she wrote the clinic’s name on a sticky note to check against each plan’s network.

Estimating her income

The premium tax credit is based on household income for the whole calendar year. Tasha claims Jaylen and Maya on her tax return, so her household is 3 people. Neither child has income or files a tax return, so household income is Tasha’s alone.

Her raise took effect in January, so $39,000 is her pay for 2026 as a whole. She has no other income. Her estimate was $39,000.

She checked it against 3 lines for a household of 3:

• 138%, about $36,777. The Medicaid limit for adults. She is over it.
• 150%, $39,975. At or below it, a Silver plan comes with cost-sharing reductions at the 94% level. She is $975 under it.
• 400%, $106,600. Above it, there is no premium tax credit in 2026. She is well under it.

Her office offers no health coverage, so there was no job-based plan to weigh against the credit.

Weighing her options

The premium tax credit can be used on any metal level. Cost-sharing reductions come only with a Silver plan.

A standard Silver plan has a 70% actuarial value. At Tasha’s income, from 100% to 150% of the poverty guideline, a Silver plan comes with cost-sharing reductions that raise it to 94%. Higher actuarial value means the plan pays a bigger share of covered costs, through lower deductibles and copays.

Tasha wanted the lower deductibles and copays. She decided to look only at Silver plans, and only at ones with her clinic in their network.

Picking a plan

On Tuesday, June 16, Tasha filled in the application on HealthCare.gov at the kitchen table. She reported losing Medicaid on June 30, a household of 3, and income of $39,000, with only herself asking for coverage. The application found her eligible for the premium tax credit, and for cost-sharing reductions with a Silver plan.

She went through the Silver plans one at a time and checked each provider directory for her clinic. Some listed it and some didn’t. Among the ones that did, she picked the plan with the lowest monthly cost after the credit. Because she picked it before June 30, it would start on Wednesday, July 1. No gap.

She chose to have her credit paid in advance each month, based on her $39,000 estimate. That’s why the estimate matters, and why she’ll report any change to it.

The paperwork

The marketplace may ask for documents proving the loss of Medicaid, and there are 30 days after picking a plan to send them. Tasha kept the state’s letter with the June 30 end date in the folder where she keeps the kids’ school forms, ready to send if asked.

She also wrote down another rule. Enrollees must report changes in income, household members, address and citizenship or immigration status within 30 days.

The first months

Her Medicaid covered her through June 30, and her Silver plan started on July 1. In August, Maya had her school checkup with the pediatrician, on Medicaid, the same as every year. In September, Tasha saw her nurse practitioner for her own checkup, now under her new plan, at the same clinic.

That fall her office had more lease renewals than usual, and her manager offered some overtime. Before saying yes, Tasha did the arithmetic on the 150% line.

The numbers

Household: 3 people, Tasha, Jaylen and Maya.

Poverty guideline used for 2026 coverage, 3 people: $26,650.

Estimated 2026 household income: $39,000.

Step 1. Income as a share of the guideline: $39,000 divided by $26,650 is about 1.46, or about 146%.

Step 2. The applicable percentage. For 2026 it rises on a sliding scale from 3.14% at 133% to 4.19% at 150%. At about 146%, it is about 3.96%.

Step 3. The expected contribution for the year: $39,000 times 3.96% is about $1,544.

Step 4. By the month: $1,544 divided by 12 is about $129.

Tasha is expected to pay about $129 a month toward the benchmark plan for her own coverage. The benchmark is the second-lowest-cost Silver plan where she lives. The premium tax credit covers the rest of the benchmark’s premium, whatever that premium is. If she picks a plan that costs more than the benchmark, she pays the difference on top of that $129. If she picks one that costs less, she pays less.

Step 5. Cost-sharing reductions. At about 146%, inside the 100% to 150% band, her Silver plan has a 94% actuarial value instead of the standard 70%. Cost-sharing reductions don’t come with Bronze or Gold plans.

The children. Jaylen and Maya qualify for Medicaid, so they can’t get the premium tax credit, and they don’t need it. They count in her household size, but they aren’t on her plan.

The limits. The credit is for household income from 100% to 400% of the poverty guideline ($106,600 for 3 people in 2026), on a plan bought through the marketplace, for someone not eligible for Medicaid, CHIP or affordable job-based coverage. Cost-sharing reductions are 94% from 100% to 150%, 87% over 150% to 200%, 73% over 200% to 250%, and none above 250%.

What could have gone wrong

Waiting until after June 30. Her window ran 90 days past the end of her Medicaid. But a plan picked in July, August or September would have started the first of the month after she picked it, leaving at least a month uninsured. Once the window closed, she would have needed another qualifying life event or open enrollment. The monthly window that used to exist for incomes at or below 150% of the poverty guideline ended August 25, 2025, so it is no longer a fallback.

Overtime past the 150% line. The 150% line for 3 people is $39,975, and Tasha is $975 under it. If overtime pushed her 2026 income past it, her cost-sharing reductions would drop from the 94% level to 87%, and her applicable percentage would move into the band that starts at 4.19%. She would report the change within 30 days. If her income came in higher than her estimate without an update, she would repay the extra advance credit at tax time. There is no repayment cap for tax years after 2025. If her income came in lower than her estimate, she may get more back.

Putting the children on her plan. They qualify for Medicaid, so they can’t get the credit on a marketplace plan. Keeping them on Medicaid also kept them with their pediatrician.

Skipping the network check. If her clinic hadn’t been in her plan’s network, she would have had to find a new nurse practitioner who was.

Coverage offered at work. If her office later offered health coverage that is affordable and meets minimum value, she couldn’t get the credit. In 2026, job-based coverage is affordable if the employee’s share for self-only coverage is no more than 9.96% of household income. She would report the offer.

Income falling back. If her hours were cut and her income fell back under the adult limit, she could apply for Medicaid again. Medicaid applications are open any time of year.

Questions to work through

What date does your Medicaid end? It’s on your notice. Pick a plan on or before that date, and the new plan starts the first of the next month. Your window stays open 90 days after it, but a later pick means a gap.

Who in your household still qualifies for Medicaid? Children’s Medicaid and CHIP limits are higher than adults’. The application checks children for Medicaid or CHIP first. Children who qualify can’t get the premium tax credit.

Is your doctor in the plan’s network? Check each plan’s provider directory before you pick, not after.

Where does your income fall? For a household of 3, 138% is about $36,777, 150% is $39,975 and 400% is $106,600. For other household sizes, divide your estimate by the poverty guideline for your household.

Could your income change this year? Overtime, a second job or another raise can move you past a line. Report the change within 30 days. There is no repayment cap for tax years after 2025.

Would a Silver plan give you cost-sharing reductions? Only if your household income is from 100% to 250% of the poverty guideline, and only with a Silver plan. A licensed broker can check this with you.

The short version

Tasha’s raise to $39,000 put her over North Carolina’s Medicaid limit for adults, and her Medicaid ended on June 30, 2026. Jaylen and Maya kept theirs. Losing Medicaid opened a Special Enrollment Period from 60 days before that date to 90 days after. She picked a Silver plan on HealthCare.gov on June 16, so it started July 1 with no gap. At about 146% of the poverty guideline for a household of 3, her expected contribution toward the benchmark plan for her own coverage is about $1,544 a year, or about $129 a month, and her Silver plan comes with cost-sharing reductions at the 94% level. Income past $39,975 would lower that to 87%, so she reports any change within 30 days.

This is a summary of how the rules work, not legal or tax advice. HealthCare.gov, your plan’s documents and your own tax situation have the final word.