Five 2026 Health Insurance Changes for Practice and Firm Owners

Published September 26, 2026 · Daniel Griffin, Licensed Independent Advisor · NPN #22052447

KFF went through this year’s sign-up numbers to see who left the marketplace. People earning more than 400% of the poverty line were 7% of everyone who signed up in 2025. They were 48% of the drop.

A lot of those people own something: a law practice, a dental office, a two-partner CPA firm, a brokerage. They lost their premium tax credit on January 1, looked at the full price, and left.

Some of them were right to. But four other rules changed at the same time, and two of them matter more to an owner than to anyone on a payroll. Here are all five, with the numbers.

2025 and 2026, Side by Side

Sources for every row are listed at the end of this post.

1. The Income Ceiling Came Back

From 2021 through 2025 the premium tax credit had no income limit. Whatever you earned, you paid no more than 8.5% of household income for the benchmark Silver plan, and the credit covered the rest. That rule expired on December 31, 2025.

For 2026 the credit stops at 400% of the federal poverty line: $62,600 for one person, $84,600 for two and $128,600 for a family of four. Those figures use the 2025 poverty guidelines, which are the ones that govern 2026 coverage. A dollar over and the credit is zero.

Age is what makes this expensive. A 60-year-old pays a little more than twice what a 40-year-old pays for the same plan, and the old 8.5% cap was what held that down. Take a married couple, both 60, who own a small practice in Texas and have $120,000 of household income. The average benchmark plan for the two of them costs about $2,807 a month in 2026, or $33,689 for the year. Under the old rule they’d have paid $10,200 of that. This year they pay all of it: about $23,500 more for the same plan.

How sharp that line is: the one-dollar subsidy cliff.

2. Guess Low, and You Now Pay Back Every Dollar

The credit is paid in advance, based on what you tell the marketplace you expect to earn. When you file, the IRS compares that guess with what you actually made.

Until this year a household under the 400% line had some protection if the guess came in low. On a 2025 return the most a single filer could owe back was $375, $975 or $1,625, depending on income, and $750, $1,950 or $3,250 for everyone else. From the 2026 tax year those limits are gone. Whatever you were overpaid, you repay.

Owners get this wrong more than most people, because nobody sets their pay but them. Say you’re 45 and open your own practice in Florida this year, expecting a thin first year: $30,000. The marketplace pays about $617 a month toward your plan. The practice does better than planned and you finish at $60,000, still under the line. On $60,000 your credit was only worth $274 a month, so you owe back the difference, about $4,116. Under last year’s rules the bill would have stopped at $1,625.

The fix is dull and it works: update your income on the marketplace application whenever the year changes shape, and the monthly credit adjusts from then on. Commission income makes all of this harder; that is covered in the realtor clawback post.

3. Every Bronze Plan Now Comes With an HSA

Before 2026, many Bronze plans couldn’t be paired with a health savings account. Either the out-of-pocket limit was above the HSA ceiling, or the plan paid for something other than preventive care before the deductible, and either one disqualified it.

The 2025 tax law fixed that. For months starting January 2026, every Bronze plan and every catastrophic plan sold as individual coverage through a marketplace counts as HSA-eligible, whatever its deductible. The IRS filled in the details in Notice 2026-5: the identical plan bought off the marketplace counts too, and so does a Bronze plan paid for with ICHRA money.

The 2026 contribution limits are $4,400 for one person and $8,750 for a family, plus $1,000 more at 55 or older. In the 24% federal bracket a full family deposit saves $2,100 in federal income tax before any state tax, and whatever you don’t spend stays in the account from year to year. People noticed: KFF counts 40% of 2026 sign-ups in a Bronze plan, up from 30% in 2025.

Two catches. The change covers individual plans only; the IRS says a Bronze plan a small employer offers through SHOP, the small-business marketplace, still has to meet the regular HSA rules. And a medically underwritten plan, the kind priced on your health and sold off the marketplace, works with an HSA only if it meets those regular rules on its own.

Catastrophic plans opened up at the same time. They used to be sold only to people under 30 or with a hardship exemption. From 2026, CMS grants that exemption to anyone who can’t get a premium tax credit because of their income, which includes everyone above the 400% line, on or off the marketplace. A catastrophic plan has a very high deductible, covers preventive care and at least three primary care visits a year before it, and can’t be combined with a premium tax credit. For a healthy owner above the line it’s now a real option, and it counts for an HSA too.

How the First and Third Changes Fit Together

Read this part twice if your income sits near the line.

An HSA deposit comes off your income before the marketplace measures it. CMS confirmed that in an April 2026 answer to agents: HSA contributions lower the modified adjusted gross income your credit is based on, and for someone close to the cutoff that can decide whether there’s a credit at all.

Take a married couple, both 50, in North Carolina, with $90,000 of household income. That’s over the $84,600 line for two, so on paper they get nothing. Now say they pick a Bronze plan and put $8,750 into a family HSA. Their income for the credit drops to $81,250, and at that figure the credit is worth about $1,109 a month, roughly $13,300 for the year. The $8,750 hasn’t gone anywhere. It’s sitting in an account they can spend on medical bills tax-free.

Three cautions. You can make 2026 contributions up to the April 2027 filing deadline, but the credit is paid in advance, so the deposit has to be part of your income estimate when you apply. If the deposit never happens, change number two applies and the whole credit comes back at tax time. And if you also take the self-employed health insurance deduction, the two calculations feed into each other, so have your tax preparer run the final number. Retirement contributions lower the same income figure, which gives an owner with a SEP or a solo 401(k) more room than this example shows.

4. Direct Primary Care Stopped Costing You Your HSA

Direct primary care is the membership model: a flat monthly fee to a family doctor, internist or pediatrician, with no insurance claims for the visits. Until this year, joining one generally meant you couldn’t put money in an HSA, because the IRS treated the membership as coverage that paid before the deductible.

From January 2026 it doesn’t, as long as the fees stay at or under $150 a month for one person, or $300 when the membership covers more than one. The IRS’s own example puts a single membership at $1,800 a year. You can pay the fees from the HSA itself. They don’t count toward your insurance deductible, and a membership that costs more than the limit can still be paid from an HSA but stops you contributing while you’re in it.

If you own a medical practice, this works for you too. A family medicine, internal medicine, geriatric or pediatric practice that charges a flat membership can now take patients’ HSA money for it, and nurse practitioners, clinical nurse specialists and physician assistants count as primary care practitioners. The membership fee has to be the only payment for the care it covers, so a practice that also bills insurance for those same services doesn’t qualify. It also can’t include procedures that need general anesthesia, prescription drugs other than vaccines, or lab work beyond what a primary care office normally runs.

5. ICHRA Is Now a “CHOICE Arrangement,” and the January Deadline Is October 3

HealthCare.gov now calls individual coverage HRAs “CHOICE Arrangements.” The IRS still calls them ICHRAs, and the rules didn’t change with the name. An employer of any size can offer one if it has at least one employee who isn’t an owner or an owner’s spouse. The allowance can differ by class of employee (full-time and part-time, salaried and hourly, by location) and by age, up to 3 to 1.

What moved for 2026 is the affordability line. The allowance counts as affordable when the cheapest Silver plan in the employee’s area, after the allowance, costs them less than 9.96% of household income, up from 9.02% in 2025. An affordable offer takes that employee off the premium tax credit, so it’s worth checking before you set the amount. Firms with fewer than 50 full-time employees can use a QSEHRA instead, which is simpler and is capped at $6,450 a year for one person and $13,100 for a family in 2026.

Both need a written notice to eligible employees at least 90 days before the plan year starts. For a plan year that begins January 1, 2027, that’s October 3, 2026. Missing it on a QSEHRA carries a penalty of $50 per employee, up to $2,500 a year. If either one is on your list for next year, that’s the date to work back from.

Neither one covers you, though, if you’re a sole proprietor, a partner or own more than 2% of an S corporation. The rules don’t treat you as an employee, so your own coverage stays on the individual side, with the self-employed health insurance deduction.

For what an affordable allowance actually costs in your state, worked out from what these staff roles earn there, see the guides for law firms, dental practices, medical practices, CPA firms, real estate brokerages and financial advisory firms, or the ICHRA guide.

Where That Leaves You

If your household is well above the line, the credit isn’t coming back, and the real question is what you’re paying full price for. For an owner in that spot it usually comes down to three choices: a Bronze plan with an HSA, a catastrophic plan if you qualify, or a medically underwritten plan priced on your health rather than your income, which you won’t find on the marketplace. Which one wins depends on your age, your state and your health history, and the answer can change from one year to the next.

That's the comparison a licensed agent runs. Open Enrollment for 2027 starts November 1 and prices are going up again (the dates and what’s changing), so October is a good month to do it.

Sources

• IRS, Notice 2026-5: Bronze and catastrophic plans as HSA plans (Q&A 4 to 8), direct primary care limits and rules (Q&A 11 to 20).
• IRS, Questions and Answers on the Premium Tax Credit: no repayment cap for tax years after 2025; no income limit for 2021 through 2025.
• IRS, 2025 Instructions for Form 8962, Table 5: the 2025 repayment limits.
• IRS, Rev. Proc. 2025-25: 2026 applicable percentages and the 9.96% affordability line.
• IRS, Rev. Proc. 2025-19: 2026 HSA contribution limits.
• IRS, Rev. Proc. 2025-32: 2026 QSEHRA limits.
• IRS, Notice 2017-67: the QSEHRA 90-day notice and penalty.
• CMS, Agent and broker FAQ on HSA contributions and marketplace income, April 9, 2026.
• CMS, catastrophic plan hardship exemption fact sheet, September 4, 2025.
• HealthCare.gov, CHOICE Arrangements: who can offer one, classes, the 90-day letter and 2026 affordability.
• KFF, What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles, May 19, 2026: who left and the shift to Bronze.
• KFF, Marketplace Average Benchmark Premiums, 2026: the state benchmark figures behind the examples.

The examples use KFF’s 2026 average benchmark Silver premium for a 40-year-old in each state, scaled to age with the federal default age curve, the IRS 2026 applicable percentages and the 2025 poverty guidelines. They are estimates for illustration, not quotes; your own county, ages and income will give a different number. Nothing here is tax advice; confirm HSA and credit decisions with your tax preparer. Medically underwritten coverage is not available in every state and acceptance depends on health history. Nothing here is an offer of coverage. Daniel Griffin is a licensed independent insurance agent, NPN #22052447, not tied to any single carrier and not affiliated with the U.S. government.