effectuated enrollment

What is effectuated enrollment?

A person can enroll in a health plan (meaning they can create an account with the exchange or the health insurance company and make a plan selection) without paying any premiums. But if they don't pay their initial premium, the plan never actually takes effect – in other words, it doesn't get effectuated. So the term "effectuated enrollments" is used to describe the number of people who have enrolled in coverage and also paid whatever premiums are due in order for their coverage to take effect and remain in effect.

Millions of people enroll in individual market coverage through the ACA-created health insurance exchanges/Marketplaces each year. The federal government provides data early in the year regarding how many people selected a plan during open enrollment. But some of those people don't pay their initial premiums, and others stop paying their premiums (or actively cancel their policies) later in the year. So effectuated enrollment data give us a clearer picture of how many people actually have coverage.

In the individual market, people can cancel their coverage at any point during the year, or just stop paying their premiums and the coverage will terminate. But enrollment outside of open enrollment is mostly limited to those who experience a qualifying life event. (This differs from the employer-sponsored market, where in almost all cases, both enrollments and disenrollments are limited to open enrollment or a special enrollment period triggered by a qualifying life event.)¹ So effectuated enrollment in the individual market tends to peak early in the year, right after open enrollment, and then decline slowly throughout the year.

Will effectuated enrollment for 2026 be lower than it was in 2025?

Yes, effectuated enrollment will be lower in 2026 than it was in 2025.

• Fewer people selected plans during open enrollment, so the starting number is lower.
• Net premiums are significantly higher, leading more people to be unsure about whether they can afford their premiums for the whole year.
• The low-income special enrollment period, which had allowed year-round enrollment for low-income people since 2021, is no longer available. This special enrollment period had allowed more people to enroll throughout the year, without a specific qualifying life event, which helped to offset some of the normal attrition that we generally see throughout the year. This kept the effectuated enrollment numbers higher than they would have been without the low-income special enrollment period.

For 2026 coverage, the number of plan selections during open enrollment dropped to 23.1 million,² down from 24.3 million people who selected plans the year before.³

The reduction in the number of plan selections was a result of the expiration of federal subsidies enhancements, which pushed net premiums significantly higher than they had been in 2025. Effectuated enrollment is always lower than the number of people who select plans during open enrollment, because some people simply don't pay their initial premiums. But it's expected that the effectuated enrollment drop-off will be more significant in 2026 than it was in the last several years.

The official CMS report on early 2026 effectuated enrollment won't be available until at least mid-2026. But according to a Wakely analysis covering roughly 80% of the ACA-compliant individual market, about 14% of the people who selected plans during open enrollment did not pay their January premiums.⁴

And that's only part of the story, as some people whose coverage was automatically renewed for 2026 would have had a three-month grace period, meaning their coverage wouldn't have terminated for non-payment until the end of March. In addition, an early 2026 KFF survey found that 17% of returning Marketplace enrollees were unsure whether they would be able to afford to continue paying their premiums throughout 2026.⁵ Ultimately, the Wakely analysis projected that "average enrollment in the individual market could shrink 17% to 26% in 2026 compared to 2025 average enrollment."⁴