Introduction

The Patient Protection and Affordable Care Act (ACA) created the Health Insurance Marketplace® to help enroll people in qualified health plans (QHPs) and provide eligible individuals with financial assistance for coverage purchased through the Marketplace.

The ACA

The primary goal of the ACA is to broaden access to health insurance coverage. To achieve this goal, the ACA:

• 1Provides a premium tax credit (PTC) to help subsidize coverage.

• 2 Gives consumers tools to make informed choices about their healthcare coverage.

• 3 Puts in place strong consumer protections. 

Agents and brokers play an integral role in helping individuals understand and act on the coverage protections that the  ACA offers. 

Access to Care

The ACA makes care more accessible by:

• Creating the Health Insurance Marketplace®* through which qualified individuals may compare and purchase plans, and eligible individuals who do not have access to government-sponsored coverage, affordable employer-sponsored coverage (ESC), or certain other types of coverage can receive financial assistance. 

• Providing qualified individuals with Marketplace financial assistance: advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs).

• Expanding Medicaid in states that took this opportunity to cover individuals whose household incomes up to or below 133% of the federal poverty level (FPL). 

Requirements Under the ACA

The ACA include a broad set of health insurance requirements that establish the type of coverage health insurers must make available to consumers. These include: 

• Extension of dependent coverage of children up to age 26. 

• Expansion of the “guaranteed issue” requirement to ensure that health insurance issuers offer group and individual market policies to any eligible employer and individual in a state, regardless of health status. 

• Requirement to provide coverage for recommended preventive services without cost sharing. 

• Prohibition on coverage limitations or exclusions based on pre-existing conditions.

• Prohibition on precluding a qualified individual’s participation in an approved clinical trial, or discriminating against that individual based on such participation.

• Introduction of a medical loss ratio (MLR) rule to ensure that at least 80% of the premium dollars in the individual and small group markets (and 85% in the large group market) paid to a health insurance issuer are spent on providing healthcare services or quality improvement activities. 

• Requirement to cover essential health benefits (EHB) for individual and small group policies.

• Prohibition on annual and lifetime dollar limits on EHB.

• Establishment of rating variation standards that permit premium rates in the individual and small group markets to vary based only on age, number of covered family members, geographic location, and tobacco use. 

• Prohibition on rating individual and small group health insurance policies based on the individual’s health status, or the health status of individuals within a family.

Guaranteed Issue and Guaranteed Renewability

The ACA generally requires health insurance issuers* to offer all of their non-grandfathered** individual market and group market plans to any eligible applicant in the state. It also requires health insurance issuers to accept any eligible employer and individual who applies for those policies, subject to certain exceptions. This provision is called “guaranteed issue” or "guaranteed availability." 

Individual market coverage offered through and outside the Marketplace may restrict guaranteed issue coverage to certain specified Open Enrollment (OE) and Special Enrollment Periods (SEPs). Additionally, the ACA generally requires health insurance issuers to renew or continue in force coverage at the option of the policyholder. This is called “guaranteed renewability.” 

To ensure continuity of coverage for consumers if an issuer is undergoing a corporate reorganization, a product transferred from one issuer to a different issuer within an issuer’s controlled group may be considered to be the same product for purposes of guaranteed renewability if certain criteria are met. A controlled group is a group of two or more related entities that is treated as a single employer under the Internal Revenue Code. For example, a parent company and its subsidiaries may be considered to be within the same controlled group. 

Coverage for Individuals with Pre-existing Health Conditions

Effective for plan years beginning on or after January 1, 2014, the ACA prohibits group health plans and non-grandfathered health insurance plans from limiting or excluding coverage related to pre-existing health conditions, regardless of the age of the covered individual. A pre-existing condition is any health condition or illness that was present before the coverage effective date, regardless of whether medical advice or treatment was actually received or recommended.

Young Adult Coverage

Under the ACA, health plans that allow coverage of children as dependents must make dependent coverage available to children up to age 26.* These young adults can join or remain on a parent’s plan even if they: 

• 1 Are married (coverage requirement does not extend to a married child’s spouse) 

• 2 Are not living with a parent

• 3 Are not attending school 

• 4 Are not financially dependent on a parent 

• 5 Are eligible to enroll in their own employer’s plan

• 6 Have or adopt a child

Medical Loss Ratio (MLR)

The ACA limits the proportion of premiums that a health insurance issuer can spend on things other than medical claims and improving the quality of the healthcare of its enrollees. MLR is a basic financial measurement that generally shows how much of the premium dollars a health insurance issuer spends on healthcare expenses, as opposed to profits or administrative costs. A health insurance issuer that does not spend enough of its premium dollars on healthcare services or quality improvement activities must provide rebates to individuals and employers. 

In general, if a health insurance issuer uses an average of 80 cents out of every premium dollar to pay customers’ medical claims and to conduct activities that improve the quality of care, the company has an MLR of 80%. An MLR of 80% indicates that the health insurance issuer is using the remaining 20 cents of each premium dollar for profits and administrative costs, including salaries and other expenses. MLR is not calculated at the individual policy level, but at the state level for each issuer and separately for the small group, large group, and individual markets. 

The ACA sets minimum MLR standards for different markets, as do some state laws. Federal law requires health insurance issuers in the large group market (in most states, more than 50 employees) to spend at least 85% of premium dollars on medical care. The ACA also requires issuers in the small group market (in most states, 50 or fewer employees) and individual markets to spend at least 80% of premiums on medical care.

Functions of a Marketplace

Depending on its operating model, a Marketplace may carry out various functions in its role of providing access to affordable health insurance coverage, including:

• Certifying health plans to participate in the Marketplace as QHPs*

• Determining or assessing individuals’ eligibility for enrollment in Medicaid or CHIP

• Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing compliance with certification requirements

• Determining individuals’ eligibility for enrollment in a QHP through the Marketplace

• Determining individuals’ eligibility for APTC and CSRs

• Facilitating individuals’ enrollment in a QHP

*HHS relies on states to certify QHPs to meet the Marketplace certification standards in certain areas (if feasible and appropriate). 

The Centers for Medicare & Medicaid Services (CMS)

CMS is the federal agency that runs the FFM, Medicare, Medicaid, and CHIP. For more information, visit CMS.gov. You will learn more about the role of CMS as it relates to Marketplace-registered agents and brokers in the Maintaining Compliance module.

The Health Insurance Marketplace®

The Health Insurance Marketplace® is a service that helps people shop for and enroll in health insurance. CMS operates the Health Insurance Marketplace®, available at HealthCare.gov, for most states. Some states run their own Marketplaces called State-based Marketplaces (SBMs).

The Health Insurance Marketplace® (also known as the “Marketplace” or “Exchange”) provides health plan shopping and enrollment services through websites, call centers, and in-person help.

State-based Marketplaces (SBMs)

Some SBMs received HHS approval to utilize the federal platform to perform all eligibility and enrollment functions, as well as some consumer assistance functions, for their Individual Marketplace, and in some instances the SHOP*, and are considered SBM-FPs. In these Marketplaces, agents and brokers must comply with the same FFM registration and training requirements before they may facilitate enrollments through the federal platform. States that operate an SBM-FP must establish and oversee certain standards for agents, brokers, and QHP issuers that are no less strict than those that apply in the FFM.

*The Small Business Health Options Program (SHOP) helps small business owners provide medical and/or dental insurance to their employees. Some smaller employers qualify for tax credits if they enroll in SHOP insurance.

Agents and Brokers

Regardless of Marketplace type, each state maintains its own licensing requirements for agents and brokers. 

Roles Within the Marketplace

Agents and brokers who participate in the Marketplace have a number of roles and responsibilities to perform, play a critical role in the enrollment process, and contribute to the overall success of the Marketplace. 

1.- Enrollment

Agents and brokers can assist individuals with enrollment in QHPs through the Individual Marketplace, as well as assist small employers with selecting and enrolling in SHOP coverage.

2.- Eligibility

Agents and brokers may also assist qualified individuals with obtaining eligibility determinations for financial assistance through the Marketplace. 

3.- Medicaid/CHIP

If consumers are potentially eligible for Medicaid or CHIP, Marketplace-registered agents and brokers can help these consumers connect with the appropriate state agency to apply for this coverage.

Role Summary 

Agents and brokers assisting consumers in the Marketplace must comply with applicable federal and state law,   including licensing requirements, system access terms and conditions, conflict of interest prohibitions, and confidentiality provisions. Additional details regarding compliance will be covered in the Maintaining Compliance module. 

Navigators, Certified Application Counselors (CACs) and EAP Assisters

In addition to licensed agents and brokers, there are two types of assisters that operate within the Marketplace: Navigators and CACs. Under a limited contract with CMS, there will be a third assistant type, Enrollment Assistance Personnel (EAP).

Navigators 

Organizations that are approved by and receive grants from CMS have certified Navigators who, among other required duties, must assist consumers in applying for and enrolling in health coverage through the Marketplace free of charge. Navigators must also conduct public education activities to raise awareness about the Marketplace. They must also assist consumers with certain post-enrollment issues like exemptions, appeals, Marketplace-related components of the PTC reconciliation process, understanding basic concepts and rights related to health coverage and how to use it, and referrals to licensed tax advisers, tax preparers, or other resources for assistance with tax preparation and tax advice related to Marketplace coverage.

    CACs

Staff members and volunteers of approved CAC-designated organizations (CDOs), such as, but not limited to, community health centers, healthcare providers, and certain social service agencies. Marketplace CACs are certified directly by those CDOs. Participation as a CDO is voluntary and not funded by the Marketplace. Like Navigators, CACs perform Marketplace application and enrollment assistance. In general, CACs are not required to perform outreach, education, or post-enrollment assistance, though they may choose to do so.

EAPs

Under a 19-month contract with CMS, EAPs employed with Cognosante will assist with the “Medicaid unwinding” efforts. They will provide outreach and impartial, free, in-person and virtual enrollment assistance to impacted consumers in specific counties within 12 FFM states: AZ, FL, IL, LA, MI, MT, NC, OK, SD, TN, TX and UT. EAPs will also collaborate with CACs in other FFM states to maximize outreach opportunities.

Navigator and CAC Compliance

Navigators in the Marketplace are required to disclose in plain language to the FFM and consumers certain non-prohibited relationships they may have with health insurance and stop-loss insurance issuers, including if they sell lines of insurance (e.g., auto, life, homeowner’s policies) not covered under the restrictions*. If there are any prohibited conflicts of interest**, then they cannot serve as a Navigator under the grant. 

CACs are required to disclose to consumers any potential conflicts of interest, including any relationships with issuers of QHPs or insurance affordability programs. 

Further, all of these Marketplace assisters are required to provide information in a fair, accurate, and impartial manner. They must also protect consumers’ personally identifiable information (PII) and inform consumers about all of the QHPs and insurance affordability programs for which they are eligible. They may not receive compensation directly or indirectly from any health insurance issuer or issuer of stop-loss insurance in connection with the enrollment of any individuals or employees in a QHP or non-QHP

*For a range of non-prohibited disclosures, see 45 CFR 155.215(a)(1)(iv).

**For prohibited conflicts of interest, see 45 CFR 155.210(d).

Requirements for Navigator and CAC (Assister) Impartiality

Assisters in the Marketplace cannot make specific plan recommendations to consumers. 

Facilitating Enrollment

Assisters may facilitate enrollment in a QHP in the following ways: 

• Providing comprehensive information about the substantive benefits and features of a plan and, if applicable, any specific provider or pharmaceutical needs.

• Clarifying the similarities and distinctions among all the plans for which the consumer is eligible.

• Assisting consumers with making informed decisions in the plan selection process, consistent with the consumer’s expressed interests and needs. 

Plan Recommendations

If assisters are asked by a consumer to recommend a specific plan, they should remind the consumer that they are prohibited from making plan recommendations because federal standards require assisters to remain fair and impartial. However, in those circumstances where a consumer has requested a plan recommendation, the assister may, consistent with the consumer’s expressed needs and desires, determine that it is appropriate to inform the consumer of the general availability of agents and brokers who are state licensed and registered with the Marketplace, and who can make specific plan recommendations (provided that agents and brokers are permitted to do so under state law).

Directing Consumers

The assister may direct the consumer, if requested by the consumer, to general listings of Marketplace-registered agents and brokers (e.g., Find Local Help)

) or, if requested by the consumer, to more specific listings, if those listings are created using objective sorting criteria, such as by geographic proximity. However, the assister should not make a referral to any specific agent, broker, or web-broker.

Guidelines

Agents, brokers, and web brokers are not prohibited from working with Marketplace assisters, although they should follow these guidelines:

• Agents and brokers should understand the constraints placed on Navigators and CACs in the Marketplace.

• If unable to assist a consumer with, for example, applying for Medicaid through a Marketplace, the agent or broker should make sure the consumer knows that local Navigators and CACs may be available to provide assistance. They may also help direct the consumer to the appropriate state Medicaid agency, if applicable.

• Agents and brokers can find Navigators and CACs by going to Find Local Help at HealthCare.gov)

• Agents and brokers can participate in community events.

• Agents and brokers should not attempt to establish an exclusive referral relationship with Navigators and CACs. Assisters, including Navigators, are strictly forbidden from endorsing specific agents, brokers, or web brokers or referring consumers to specific agents, brokers, and web brokers.

Agents and brokers must not offer assisters consideration of any kind (direct or indirect, cash or in-kind) that could be tied to the compensation they receive from a health insurance or stop-loss insurance issuer for assisting a consumer with enrolling in a QHP or non-QHP.

Knowledge Check

Marketplace agents and brokers have distinct roles from other Marketplace assisters such as Navigators and CACs. Choose which of the following responsibilities apply to only agents and brokers, only Navigators and CACs, or apply to all agents, brokers, Navigators, and CACs. In the knowledge checks below you will match the role to the correct type of assister. 

• Can assist individuals with applying for and enrolling in QHPs and refer them to Medicaid/CHIP when applicable

• Contact information can be found by going to Find Local Help at HealthCare.gov 

• Must protect consumers’ PII 

• May not mislead consumers or provide them false information

Agents, brokers, Navigators, and CACs

• Can make specific plan recommendations to consumers

• May assist small employers with selecting and enrolling in SHOP coverage 

• May receive compensation from a health insurance issuer

Only agents and brokers 

• Cannot make specific QHP recommendations to consumers 

• Must conduct public outreach and education activities to raise awareness about the Marketplace 

• May not receive compensation directly or indirectly from any health insurance issuer 

• May not assist in SHOP enrollment

Only Navigators and CACs (assisters) 

Knowledge Check Explainer

Agents, brokers, Navigators, and CACs:

• Can assist individuals with applying for and enrolling in QHPs and refer them to Medicaid/CHIP when applicable

• Contact information can be found by going to Find Local Help at HealthCare.gov 

• Must protect consumers’ PII 

• May not mislead consumers or provide them false information

Only Navigators and CACs (assisters):

• Cannot make specific QHP recommendations to consumers 

• Must conduct public outreach and education activities to raise awareness about the Marketplace 

• May not receive compensation directly or indirectly from any health insurance issuer 

• May not assist in SHOP enrollment 

Only agents and brokers 

• Can make specific plan recommendations to consumers

• May assist small employers with selecting and enrolling in SHOP coverage 

• May receive compensation from a health insurance issuer 

Who is Eligible to Enroll in the Individual Marketplace?

Basic Requirements

Individuals can use the Individual Marketplace to explore their health insurance coverage options, even if they already have insurance (e.g., through employer-sponsored coverage). To be eligible to obtain insurance through the Marketplace, individuals must: 

• 1 Be a resident of the state where they will apply for coverage and enroll in a QHP.

• 2 Be a U.S. citizen or national, or a lawfully present non-citizen, and expect to remain so for the entire period coverage is sought.

• 3 Not be incarcerated, other than incarceration pending the disposition of charges.

Hardship Exemptions

There are circumstances that affect consumers' ability to purchase health insurance coverage and which qualify them for a hardship or affordability exemption for the purpose of obtaining catastrophic coverage. Only individuals under age 30 or individuals of any age with hardship or affordability exemptions may purchase a catastrophic coverage plan. Catastrophic plans typically have high deductibles, and mainly protect individuals with very high medical costs. To make the determination, the Marketplace considers whether an individual has experienced a qualifying hardship. 

The following provides a description of each type of hardship exemption event:

• Homeless - The individual becomes homeless.

• Eviction/Foreclosure - The individual has been evicted or is facing eviction or foreclosure.

• Utility Shut-off - The individual has received a shut-off notice from a gas, water, or electric company.

• Domestic Violence - The individual recently experienced domestic violence.

• Family Member - The individual recently experienced the death of a close family member.

• Disaster - The individual recently experienced a fire, flood, or other natural or human-caused disaster resulting in substantial damage to individual property.

• Bankruptcy - The individual filed for bankruptcy.

• Medical Expenses - The individual incurred medical expenses that resulted in substantial debt.

• Family Care Expenses - The individual experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member.

• Dependent Child - The individual expects to claim a child as a tax dependent who has been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child.

• Eligibility Appeal - As a result of an eligibility appeals decision, the individual is determined eligible for enrollment in a QHP through the Marketplace, APTC, and/or CSRs for a period of time during which they were not enrolled in a QHP through the Marketplace.

• Non-Medicaid Eligibility State - The individual was determined ineligible for Medicaid because their state did not expand eligibility.

• Other - The individual experiences some other hardship in obtaining health insurance. Examples of other hardship circumstances that consumers may experience include:

  • The individual lives in a service area where there are no Marketplace QHPs available for the applicable plan year.

  • The individual lives in a service area where there is only one issuer offering Marketplace QHP coverage for the applicable plan year and the person can show that the resulting lack of choice has precluded them from obtaining coverage under a QHP.

  • The individual has a hardship in obtaining health insurance because they live in a service area where all affordable Marketplace QHPs offered for the applicable plan year provide coverage of abortions, contrary to the individual’s beliefs, and the absence of any affordable plan without such coverage causes a hardship in obtaining health insurance.

A consumer who has an affordability exemption may purchase a catastrophic plan, regardless of age. To qualify for an affordability exemption, the lowest-priced coverage available to the consumer would cost more than the applicable contribution percentage of the consumer's household income. Find more information on HealthCare.gov(opens in a new tab)

.

Are the following individuals eligible to obtain coverage through the Marketplace? 

• U.S. citizen or national 

• Lawfully present non-citizen 

• Incarcerated individual pending the disposition of charges 

• Residents of the state in which they are applying for coverage 

• Individuals under 18 with a non-applicant parent 

• Individuals recently experiencing hardships such as homelessness, natural disasters, or domestic violence

Eligible

Are the following individuals eligible to obtain coverage through the Marketplace? 

• Non-citizen who is not lawfully present 

• Incarcerated individual (not pending disposition of charges)

• A household with no residents of the state in which they are applying for coverage 

• Individuals under 18 without an adult filing the application

Ineligible

Knowledge Check Explainer

The following individuals are eligible to obtain coverage through the Marketplace:

• U.S. citizen or national 

• Lawfully present non-citizen 

• Incarcerated individual pending the disposition of charges 

• Residents of the state in which they are applying for coverage 

• Individuals under 18 with a non-applicant parent 

• Individuals recently experiencing hardships such as homelessness, natural disasters, or domestic violence

The following individuals are ineligible to obtain coverage through the Marketplace:

• Non-citizen who is not lawfully present 

• Incarcerated individual (not pending disposition of charges)

• A household with no residents of the state in which they are applying for coverage 

• Individuals under 18 without an adult filing the application

An individual with a primary home in the state in which they are applying for coverage 

Resident of the state, 

• eligible to apply for coverage

An individual planning to visit another state temporarily during the year 

• Residency is not established if there is no intent to have a primary residence

Residency may be established in more than one state if there is a primary residence for part of the year 

An unhoused individual with no home address, who is staying with a friend, in a shelter, or outdoors in the state in which they are applying for coverage 

• Resident of the state, eligible to apply for coverage 

Knowledge Check Explainer

An individual with a primary home in the state in which they are applying for coverage is a resident of the state, eligible to apply for coverage.

For an individual with two primary homes in different states in which they are applying for coverage, residency may be established in more than one state if there is a primary residence for part of the year 

For an individual planning to visit another state temporarily during the year, residency is not established if there is no intent to have a primary residence.

An unhoused individual with no home address, who is staying with a friend, in a shelter, or outdoors in the state in which they are applying for coverage is a resident of the state, eligible to apply for coverage.

The Marketplace and other Coverage

The Marketplace and other Coverage

While any individual meeting these criteria may enroll in QHP coverage through an Individual Marketplace if a consumer is eligible for or enrolled in another form of minimum essential coverage (MEC), they will be ineligible for financial assistance to help pay for the cost of a QHP. MEC includes affordable ESC, Medicare, Medicaid that counts as qualifying coverage, CHIP, TRICARE (the Department of Defense healthcare program), certain types of veteran's health coverage through the Department of Veterans Affairs, and certain other types of coverage. Consumers enrolled in ESC are ineligible for financial assistance regardless of coverage affordability.

If an individual completes an application for coverage with financial assistance and learns that they are eligible for Medicaid or CHIP or has questions about other government-sponsored programs like Medicare or TRICARE, you can help guide them through next steps. 

Individuals who are Eligible for Medicare

You may receive eligibility questions for other government-sponsored programs, such as Medicare. The Marketplace does not determine eligibility for the Medicare program. The Marketplace application system will not prevent individuals from enrolling if the consumers indicate they are eligible for or enrolled in Medicare, but the individuals will be ineligible for financial assistance. Medicare is a health insurance program for:

• People age 65 or older who have paid Medicare taxes for at least 40 work quarters (a total of 10 years)

• People under age 65 with certain disabilities

• People of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant)

• Certain individuals exposed to environmental health hazards

Consistent with the longstanding prohibition on the sale of duplicate coverage to Medicare beneficiaries, it is illegal to sell or issue a QHP to a Medicare beneficiary with the knowledge that the QHP duplicates the beneficiary’s Medicare benefits. You should direct your Medicare-eligible clients to Medicare.gov(opens in a new tab)

 for more information about the Medicare enrollment process and time frames.

For additional information on Medicare costs and the 40 work quarters requirement, please refer your clients to Medicare.gov)

Individuals who are Eligible for TRICARE

You may also receive eligibility questions for TRICARE, another kind of government-sponsored program. The Marketplace does not determine eligibility for the TRICARE program. The Marketplace application system will not prevent individuals from enrolling if the consumers indicate they are eligible for or enrolled in TRICARE, but the individuals will be ineligible for financial assistance. 

TRICARE is a healthcare program serving Uniformed Service members, National Guard/Reserve members, survivors, retirees, and their families worldwide. 

Some kinds of TRICARE do not qualify as MEC. If your client has Direct Care or Line of Duty TRICARE coverage, it should not be reported on the Marketplace application. You should direct your clients to tricare.mil(opens in a new tab)

 for more information about this program.

Veterans Health Administration (VHA) Program

VHA is the health system for military veterans (from the Army, Navy, Marines, Air Force, or Coast Guard). All veterans should apply to the VHA to determine eligibility.

 The Marketplace will not prevent individuals from enrolling if the consumers indicate they are eligible for or enrolled in VHA coverage, but the individuals will be ineligible for financial assistance.

The Marketplace and Medicaid

Medicaid Overview

Medicaid is a federal and state partnership to provide healthcare coverage for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. To qualify for Medicaid, an individual must qualify for a mandatory or optional eligibility group covered by their state and may need to meet financial eligibility requirements. To be eligible for Medicaid, individuals generally need to satisfy federal and state requirements regarding residency; citizenship or satisfactory immigration status; household income; and, in some cases, resources/assets.

When a consumer submits a Marketplace application requesting financial assistance, the Marketplace determines eligibility for financial assistance, Medicaid, and CHIP (Note: In some states, the Marketplace assesses, rather than determines, Medicaid and CHIP eligibility). When a consumer submits a Marketplace application without requesting financial assistance, the Marketplace determines eligibility to enroll in a QHP only.

Medicaid is jointly funded with federal and state dollars, but is administered at the state level. State-based Medicaid programs often have different names in each state, like “MassHealth” in Massachusetts and “SoonerCare” in Oklahoma. It is important to be familiar with the program in every state in which you operate. If you are working with consumers who may be eligible for Medicaid, they can apply through the Marketplace, and their information will be passed on to the state Medicaid agency if they qualify. They can also choose to apply directly through the appropriate state Medicaid agency.

Medicaid, CHIP, and the ACA

The ACA significantly streamlined the eligibility standards and enrollment processes for Medicaid and CHIP, and it authorized states to expand Medicaid coverage for adults. You will learn more about Medicaid expansion later in this module. Even if a state did not expand Medicaid, it will still cover eligible pregnant individuals and children, and parent(s)/caretaker relatives up to income levels that vary by state. In most states, pregnant individuals and children in households with income significantly above the FPL may be eligible for Medicaid or CHIP. If a pregnant individual is already enrolled in Marketplace coverage and wants to keep their current coverage, they can choose not to report their pregnancy on their Marketplace application.

Medicaid and Pregnancy

Consumers who do qualify for Medicaid and CHIP based on pregnancy can continue receiving Medicaid coverage after their pregnancy during the postpartum period, and the duration of such continued coverage varies by state. In many states, Medicaid and CHIP coverage for such individuals now continues for 12 months after their pregnancy ends. Agents and brokers should inform consumers about the length of their state’s Medicaid and CHIP coverage during the postpartum period. For more information, you can visit your state’s Medicaid (opens in a new tab) CHIP(opens in a new tab) website.

Eligibility

When an individual indicates on their Marketplace application that they are interested in help paying for health insurance, the Marketplace conducts an eligibility assessment or determination, depending on the state, for Medicaid and CHIP for each household member indicated as needing health coverage. Certain household members may qualify for Medicaid or CHIP, even if other household members do not. Additionally, a household member may qualify for Medicaid, for example, due to a disability or having high medical needs, while other household members may qualify for Marketplace coverage (with or without APTC/CSRs). 

Medicaid and Marketplace Coverage

Individuals who are determined to be eligible for Medicaid that is considered MEC or CHIP are ineligible for APTC and income-based CSRs to help pay for a Marketplace plan premium and covered services, if applicable. If an individual who is determined eligible for Medicaid that is considered MEC or CHIP wants to enroll in a Marketplace plan, they will have to pay the full cost for their share of the Marketplace plan premium and covered services. Individuals who are determined eligible for Medicaid coverage that does not count as MEC (e.g., individuals eligible for Medicaid coverage limited to family planning services, tuberculosis-related services, or treatment of emergency medical conditions, etc.) do not have the same restriction and if otherwise eligible, can enroll in Marketplace coverage with APTC and income-based CSRs. To learn more about which Medicaid coverage counts or does not count as MEC by state, please visit HealthCare.gov (opens in a new tab)

CHIP Overview

CHIP provides no-cost or low-cost health insurance coverage to uninsured children under age 19 in families with qualifying incomes that are too high to qualify for Medicaid coverage. It also covers qualified pregnant individuals in some states. Like Medicaid, the costs for CHIP are shared by the federal government and state governments, and states can choose to impose cost-sharing for children enrolling in CHIP. CHIP operates under different names in each state, such as “BadgerCare” in Wisconsin and “Washington Apple Health for Kids” in the state of Washington. CHIP provides comprehensive benefits. To find CHIP information by state, visit InsureKidsNow.gov(opens in a new tab)

Overview of Medicaid Expansion

Under the ACA, states may expand Medicaid eligibility to cover non-elderly, non-pregnant adults ages 19–64 with a household income up to or below 133% of the FPL who are not otherwise eligible for and enrolled in Medicaid coverage and are not entitled to or enrolled in Medicare Parts A or B. This is known as "Medicaid expansion." 

Some states have not expanded Medicaid to this population. In those “non-expansion states,” the above consumers who have household income under 100% of the FPL may be eligible to enroll in a Marketplace plan without APTC and CSRs. However, immigrant consumers with incomes below 100% of the FPL and who are ineligible for Medicaid based on their immigration status but who meet immigration rules for Marketplace coverage may be able to receive APTC and CSRs.  

A comprehensive map showing Medicaid expansion status by state is available on the Medicaid.gov (opens in a new tab)website.

Regardless of whether a state expands its Medicaid eligibility, all state Medicaid programs must: 

• Use modified adjusted gross income (MAGI) as the income methodology for most children, pregnant individuals, parents, and adults;

• Consider assets in determining eligibility for individuals whose financial eligibility is not based on MAGI; and

• Streamline income-based rules, systems, and verification procedures.

• 
  

Medicaid and CHIP Eligibility Determinations

Overview

Assessments and determinations for Medicaid and CHIP eligibility are made based on each state's applicable Medicaid MAGI-based income standards and other eligibility requirements, like rules regarding citizenship and immigration status, as well as verification rules and procedures, consistent with federal regulations.

Medicaid Screening

In addition to evaluating applicants for Medicaid eligibility based on MAGI financial methodologies, the Marketplace also does a quick screening of anyone listed on a Marketplace financial assistance application to assess whether the individual might be eligible for Medicaid based on other factors, such as being age 65 or older, disabled, or in need of long-term care services.

Other Considerations

If an individual indicates on the application that they are age 65 or older, disabled, or needs long-term care services, or if the Social Security Administration indicates that the individual is disabled, then the Marketplace will send the application to the state Medicaid agency for Medicaid consideration based on non-MAGI financial methodologies. 

Full Eligibility Determination

The state agency will conduct a full eligibility determination and notify the individual whether they are eligible for Medicaid on a basis other than MAGI. If an individual is determined eligible for non-MAGI Medicaid and that coverage meets the requirements to be considered MEC (or “qualifying coverage”), the individual will be ineligible for APTC or for income-based CSRs, if applicable. In most cases, non-MAGI Medicaid is considered qualifying coverage. While awaiting the state’s non-MAGI determination, the individual can enroll in Marketplace coverage with APTC and CSRs, if otherwise eligible.

Medicaid and CHIP Programs by State

Since Medicaid and CHIP programs vary by state, you should familiarize yourself with the Medicaid and CHIP programs for the state(s) in which you operate as an agent or broker. Additional information is available through your state Medicaid and CHIP agencies; or to learn more about a state Medicaid or CHIP program and other available options, use the insurance and coverage finder at HealthCare.gov(opens in a new tab)  or visit Medicaid.gov (opens in a new tab)  or InsureKidsNow.gov (opens in a new tab)

Determination and Assessment States

In some states, known as determination states, the Marketplace may make the final eligibility determinations for Medicaid and CHIP coverage, consistent with certain Medicaid and CHIP regulations and state-specific policies.

In other states, known as assessment states, the Marketplace makes preliminary assessments of eligibility for Medicaid and CHIP coverage; state Medicaid/CHIP agencies make the final eligibility determinations, consistent with Medicaid and CHIP regulations and state-specific policies. In assessment states, there is a possibility that the Marketplace will assess an individual potentially eligible for Medicaid or CHIP, and then the state Medicaid/CHIP agency may determine the individual ineligible for Medicaid or CHIP. In this case, the state agency will notify the individual of their ineligibility for Medicaid or CHIP and send the updated application information back to the Marketplace via a secure transaction.

Note: The decision as to whether a state is an assessment or determination state is made by the state Medicaid/CHIP agency and applies to all applications for Medicaid and/or CHIP that are submitted to the Marketplace for that state.

Notification

Upon receiving the application information from the state agency, the Marketplace sends a notice to the household contact of the consumers found ineligible for Medicaid/CHIP, letting them know they should come back to the Marketplace to see if they’re eligible for enrollment in a Marketplace plan with APTC/CSRs. If the consumers originally applied during open enrollment or during a special enrollment period and they are denied Medicaid eligibility after their initial enrollment period has ended, they may qualify for a Special Enrollment Period to enroll in Marketplace coverage.

Application Transfer

If a consumer starts their application at the state Medicaid/CHIP agency, and the state finds the individual ineligible for Medicaid or CHIP, the state will send the consumer’s application to the Marketplace via a secure transaction. Based on this information, the Marketplace will send a notice to the household contact of the application (see sample notice here (opens in a new tab) letting them know that they should come in and submit a Marketplace application if they’d like to see if they or someone on the application qualifies for Marketplace coverage and financial assistance.

Medicaid Denials and the Marketplace

For households applying for Marketplace coverage and financial assistance, if applicants are not assessed/determined by the Marketplace as Medicaid/CHIP eligible, they will be evaluated for eligibility for Marketplace coverage with APTC/CSRs. Those applicants in assessment states that are not assessed eligible for Medicaid or CHIP have the opportunity to request that the state make a full determination of eligibility; if that option is selected, the consumer’s application information is sent to the state Medicaid/CHIP agency via secure transaction. 

Medicaid Continuous Enrollment Condition Unwinding

Since the onset of the novel coronavirus disease of 2019 (COVID-19) Public Health Emergency (PHE), state Medicaid agencies made policy, programmatic, and system changes to respond effectively to the pandemic. State Medicaid agencies also made changes to qualify for the temporary Federal Medical Assistance Percentage (FMAP) increase under Section 6008 of the Families First Coronavirus Response Act (FFCRA).* As a condition of receiving the increased FMAP, state Medicaid agencies were required to maintain continuous enrollment for most Medicaid (and in some cases, CHIP)* beneficiaries who were enrolled on or after March 18, 2020. Under the Consolidated Appropriations Act (CAA) of 2023, the expiration of the Medicaid continuous enrollment condition and receipt of the temporary FMAP increase is no longer linked to the end of the COVID-19 PHE. The continuous enrollment condition ended on March 31, 2023, and the FFCRA’s temporary FMAP increase will be gradually reduced and phased down, which began April 1, 2023, and will end on December 31, 2023.

The March 31, 2023 end of the continuous enrollment condition meant that state programs began to return to normal eligibility and enrollment operations, including processing Medicaid terminations for individuals who are determined no longer eligible; this return to normal operations is known as “Medicaid unwinding.”

States have up to 12 months to initiate, and 14 months to complete, a renewal for all individuals enrolled in Medicaid, CHIP, and the Basic Health Program (BHP) following the end of the continuous enrollment condition. Beginning April 1, 2023, states claiming the temporary FMAP increase under the FFCRA have been able to terminate enrollment for ineligible individuals enrolled in Medicaid, following a redetermination.

During Medicaid unwinding, some individuals will lose their current Medicaid or CHIP coverage and need to transition to other health insurance, such as coverage through a Health Insurance Marketplace®. The earliest date that impacted individuals could lose Medicaid/CHIP coverage was April 1, 2023. CMS is conducting a multi-pronged effort to help facilitate continuity of coverage for impacted individuals as they transition from Medicaid or CHIP to Marketplace coverage.

*States have flexibility with respect to the design of CHIP in their state. The FFCRA 6008(b)(3) continuous enrollment condition does not apply to individuals enrolled in a separate CHIP, but does apply to individuals enrolled in a “Medicaid expansion CHIP” program (wherein the state has expanded Medicaid eligibility to optional targeted low-income children and meets the requirements of the CHIP program, rather than operating the program separately from Medicaid). However, some states, using state-only funds, opted to maintain eligibility for individuals determined ineligible for separate CHIP. States have the option to submit a COVID-19 Section 1115 demonstration application for CMS consideration requesting expenditure authority to enable the state to claim federal financial participation (FFP) for such CHIP beneficiaries through the end of the Medicaid continuous enrollment condition unwinding period, or until a redetermination is conducted during the Medicaid continuous enrollment condition unwinding period. 

Knowledge Check

In the knowledge checks below you should match the consumer to the type of coverage they may be eligible for.

Valentina, a pregnant consumer with income under their state’s threshold.

• May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) 

Mohammed, a 70-year-old consumer with income under their state’s threshold.

• May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) 

Correctly selected

Jaime, a consumer that is only eligible for Medicaid with limited benefits.

• May be Eligible for Marketplace Coverage 

Naomi, a Medicare-eligible consumer with a disability in a household that otherwise qualifies for APTC.

• May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) 

Ines, a non-pregnant adult consumer with household income over 100% of the FPL in a state that has not adopted Medicaid expansion.

• May be Eligible for Marketplace Coverage

Leandro, a 35-year-old consumer with household income under 133% of the FPL in a state that has adopted Medicaid expansion.

• May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) 

Nida, a consumer that received a denial letter from their state Medicaid agency stating they did not submit requested documents.

• May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) 

Diego, a 17-year-old consumer in a household with income above 133% of the FPL and below their state limit for CHIP.

• May be Eligible for Medicaid or CHIP Coverage (refer to specific state eligibility rules) 

Maggie, a consumer that received a denial letter from their state Medicaid agency stating they are no longer eligible due to income changes.

• May be Eligible for Marketplace Coverage

Immigrant Households and the Marketplace

Immigrant households have important Marketplace eligibility details to consider.

In order to buy private health insurance through the Marketplace, a person must be a U.S. citizen, U.S. national, or be lawfully present in the United States. The term “lawfully present” includes immigrants who have*:

• “Qualified non-citizen” immigration status (e.g., Lawful Permanent Resident or Green Card holder, Conditional Entrant Granted before 1980)

• Humanitarian statuses or circumstances (e.g., Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, victims of trafficking)

• Valid non-immigrant visas

• Legal status conferred by other laws (e.g., temporary resident status, Legal Immigration Family Equity Act, Family Unity individuals)
  
  

*For a more complete list, visit HealthCare.gov(opens in a new tab)

. Lawfully present immigrants may be eligible for APTC and CSRs to help pay for a Marketplace QHP premium and covered services if they meet the other eligibility criteria for these programs.

When completing a Marketplace eligibility application, individuals applying for coverage may be asked questions about their immigration status, asked to provide specific immigration identification numbers, and need to attest to having an eligible immigration status. 

In the application, lawfully present immigrants should select the document type from the drop-down list that corresponds with their current documentation and status. For samples of the document's consumers can use to show their immigration status, review HealthCare.gov(opens in a new tab)

. For more information, see the Assister Guide to the Immigration Section of the Online Marketplace Application

Marketplace Eligibility for Mixed Immigration Status Households

Some immigrant households are of “mixed immigration status,” with members having different immigration and citizenship statuses. Those households may have members who are not eligible to buy health coverage through the Marketplace, alongside other household members who are eligible to use the Marketplace as citizens or lawfully present immigrants. For example, parents who are not lawfully present may have a child who is a U.S. citizen and can apply for health coverage, with or without financial assistance, for that child through the Marketplace.

Keep in mind that individuals who are not lawfully present can apply for health coverage for their household member(s) who are lawfully present without having to provide a Social Security Number (SSN) or other proof of lawful presence. You should not ask individuals applying on behalf of others any questions about their citizenship or immigration status because the information is irrelevant to the eligibility determination for the applicant.

Mixed immigration status households can apply for insurance affordability programs, including QHP coverage, APTC, and/or CSRs through the Marketplace, and for Medicaid/CHIP.

To effectively help mixed immigration status households, you should do the following: 

• Be mindful that a consumer's immigration status may be a sensitive topic.

• Correctly identify the applicant(s) by asking consumers whether they are seeking health coverage for themselves or on behalf of someone else.

• Make it clear that providing an SSN is optional for non-applicants but providing one may help the consumers avoid needing to verify their income later. Marketplace applicants who have an SSN are required to provide it on their application.

In which of the following situations would individuals be required to input their citizenship/immigration status on the application in order to be eligible for a QHP? 

• Applicants on a financial assistance application 

• Applicants on a non-financial assistance application 

Knowledge Check Explainer

The correct answers are applicants on a financial assistance application and applicants on a non-financial assistance application. Non-applicants are not required to input their citizenship/immigration status on the application. Applicants, regardless of whether or not they apply for financial assistance, must attest to their citizenship/immigration status to determine if they are eligible to enroll in a QHP. 

You are working with two new clients who are attempting to apply for coverage on behalf of their child, John. During the application, John’s parents inform you that their child is a first-generation U.S. citizen. Should you also ask the parents about their citizenship/immigration status if they are not applying for coverage themselves? 

• No

Knowledge Check Explainer

The correct answer is no. Only applicants are required to provide their citizenship/immigration status. 

Based on your conversation with this family, John is eligible to enroll in a QHP as a U.S.-born citizen. How would you answer the following application questions for John?

• The correct answer is yes, John is a U.S. citizen or U.S. national, and no, John is not a naturalized or derived citizen. John is a citizen who was born in the United States, so he would not be a naturalized or derived citizen. 

Marketplace Protection for Members of Federally Recognized Indian Tribes and ANCSA Shareholders

The Marketplace provides certain protections for members of federally recognized Indian Tribes and Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders. Consumers who are members of federally-recognized Indian Tribes or shareholders in ANCSA Corporations can: 

• 1 Enroll in QHPs or change plan selections through the Marketplace throughout the year, not just during the yearly Open Enrollment Period (OEP). (Note: This provision also applies to dependents who are enrolled or are enrolling in a Marketplace QHP on the same application and at the same time as the consumer who is a member of a federally-recognized Indian Tribe or shareholder in ANCSA Corporations.)

• 2 Qualify for APTC depending on household income and other eligibility criteria.

• 3 Enroll in a zero cost-sharing or limited cost-sharing plan, at any level of coverage.

  • Consumers who are members of federally-recognized Indian Tribes or shareholders in ANCSA Corporations with household income between 100% and 300% of the FPL can enroll in a zero cost-sharing plan, which means these consumers will have no copayments, deductibles, or coinsurance when receiving care from Indian healthcare providers or when receiving EHB through a QHP. There is no need for a referral from an Indian healthcare provider when receiving EHB through the QHP.

  • Consumers who are members of federally-recognized Indian Tribes or shareholders in ANCSA Corporations with household income below 100% and above 300% of the FPL can enroll in a limited cost-sharing plan, which means these consumers have no copayments, deductibles, or coinsurance when receiving EHB through the QHP if they receive a referral from an Indian healthcare provider.

You meet with Manisa and Mato, members of a federally-recognized Indian Tribe who are interested in learning more about the Marketplace benefits that are offered to them as Tribal members. They are accustomed to receiving their care from an Indian healthcare provider.  

Which of the following is NOT an accurate statement for you to share with Manisa and Mato? 

• It’s February, so they can’t enroll in a new plan or change their current plan selection until the next annual OEP begins. They should come back to your office in the fall to select a plan then. 

Knowledge Check Explainer

The correct answer is it’s February, so they can’t enroll in a new plan or change their current plan selection until the next annual OEP begins. They should come back to your office in the fall to select a plan then. Consumers who are members of federally-recognized Indian Tribes or shareholders in ANCSA Corporations can enroll in QHPs or change plan selections through the Marketplace throughout the year, not just during the yearly OEP.

Small Business Health Options Program (SHOP)

SHOP Overview

Generally, employers that employed one to 50 full-time and full-time equivalent (FTE) employee(s) (one to 100 in some states) on average, on business days during the preceding calendar year, and that employ at least one employee on the first day of the plan year are small employers that can be eligible to purchase SHOP plans. Eligible small employers and their employees do not enroll in SHOP plans through HealthCare.gov. Instead, small employers seeking to purchase a SHOP plan should visit HealthCare.gov to receive a SHOP eligibility determination and to see the SHOP plans in their area. 

Eligible small employers will purchase a SHOP plan through an issuer, and their SHOP-registered agents or brokers can assist with this process. Eligible small employers who offer and enroll in SHOP plans may be eligible to receive the Small Business Health Care Tax Credit, which may be worth up to 50% of the employer’s contribution toward premium costs (up to 35% for tax-exempt employers). Eligible small employers should apply for the Small Business Health Care Tax Credit through the Internal Revenue Service (IRS) when they file their tax returns.

For more information on the Small Business Health Care Tax Credit, visit IRS.gov (opens in a new tab) 

IRS.GOV (OPENS IN A NEW TAB)

The IRS has released guidance (opens in a new tab)  on qualifying for the Small Business Health Care Tax Credit that may apply to small employers in areas with no available SHOP plans. 

IRS GUIDANCE (OPENS IN A NEW TAB)

If you want to learn more about how to register to assist small employers with SHOP health insurance, visit the SHOP Resources page(opens in a new tab)

. Participating in SHOP as an Agent or Broker

All agents and brokers who wish to participate in the SHOP in the FFM and SBM-FPs must read and sign the “Agreement Between Agent or Broker and CMS for the Small Business Health Options Programs of the Federally-facilitated Exchanges and State-based Exchanges on the Federal Platform” (SHOP Privacy and Security Agreement) annually prior to assisting small employers with selecting and enrolling in SHOP coverage. You can access this Agreement via the Marketplace Learning Management System (MLMS).

The Agreement must be signed prior to an agent or broker helping clients purchase a SHOP plan. Small employers seeking assistance with purchasing a SHOP plan can use Find Local Help(opens in a new tab)

 to search for a SHOP-registered agent or broker who has signed this Agreement to help them find and purchase a SHOP plan.

Key Reminders for Completing FFM Agent and Broker Registration

Agents and brokers who participate in the Marketplace must complete all steps of the FFM registration process prior to assisting consumers with selecting and enrolling in QHPs through the Individual Marketplace and prior to assisting small employers with SHOP eligibility. This includes agents and brokers who act as the authorized representative for a web-broker or other business entity and enter the web-broker’s or agency’s National Producer Number (NPN) on a consumer’s application. These steps include:

• • Completing remote identity proofing when setting up a CMS Enterprise Portal account used to access the MLMS.

  • Completing an agent/broker profile on the MLMS, including correctly recording the agent’s or broker’s NPN (opens in a new tab)

  • Updating agent/broker profile information on the MLMS if anything changes, such as your contact information.

• Agents and brokers who are returning to the Marketplace after participating in a previous year should have already completed identity proofing and, if so, do not need to repeat this step again. However, these individuals should ensure they are using the same FFM User ID they used previously, and should ensure their contact information and NPN are correct in their MLMS profiles.
  
  Agents and brokers who want to participate in the Individual Marketplace must complete the assigned training courses and pass the exams through the MLMS or through an HHS-approved vendor. Training is optional for agents and brokers who only intend to participate in the SHOP. All agents and brokers who wish to participate in the Marketplace must read and accept the applicable Marketplace Agreement(s) with CMS on the MLMS.
  
  For more information on the requirements for completing FFM agent and broker registration, see the "Registration and Training” section on the Agents and Brokers Resources webpage(opens in a new tab)

National Producer Number

• Agents and brokers must enter a correct NPN in their MLMS profile and should verify it is correct to receive credit for completing training.

  • The NPN can be up to 10 digits long and must not begin with a zero.

  • The NPN must not include any special characters or letters.

  • The NPN is generally not the same as the agent’s or broker’s state license number. 

  • Agents or brokers should be sure to use their NPN, not a state license number.

  • Agent and broker NPNs can be found at: www.nipr.com/PacNpnSearch.htm (opens in a new tab)

    1. 1. • Entering an inaccurate NPN could result in denial of compensation/credit by an issuer. To update or confirm the NPN associated with an MLMS profile, select the "Complete Agent Broker Training" hyperlink on the Agent Broker Registration Status page of the CMS Enterprise Portal. Selecting the link will open the agent's or broker's MLMS profile and, from there, the individual can update or confirm the NPN listed.
            
            Agents and brokers must also have a valid state health line of authority (LOA) to participate in the Marketplace. In some states, such as Florida, Texas, Utah and Wisconsin, this NPN validation requirement means agents and brokers must have at least one issuer appointment in their resident/home state. 

Registration Completion List

• CMS maintains the publicly accessible FFM Registration Completion List(opens in a new tab)

• . The NPNs for Marketplace agents and brokers who have completed all steps of the FFM registration process for the applicable plan year will appear on the Registration Completion List, which reflects registration data as of the date of the list. The information on this list may be used to confirm that an agent or broker has successfully completed the FFM registration requirements for the Individual Marketplace and/or the SHOP for the applicable plan year. It also facilitates states and other stakeholders with conducting agent and broker oversight, monitoring, and enforcement activities. Issuers use the Registration Completion List to determine if an agent or broker is eligible to be compensated for assisting with a Marketplace enrollment or re-enrollment. Only those who have completed registration at the time of enrollment may be compensated for an enrollment (or were registered at the time of the prior enrollment for a passive re-enrollment).
  
  The Registration Completion List includes a column that indicates when an agent’s or broker’s NPN has been validated and confirmed to have an active licensure status and approved health-related LOA by the state(s) where they plan to sell Marketplace coverage, based on the National Insurance Producer Registry database(opens in a new tab)

• . While invalid NPNs may remain on the Registration Completion List for a short amount of time, only agents and brokers with a validated NPN will display and be searchable by consumers using the Find Local Help tool, be eligible to participate in Help On Demand, and be able to utilize the Classic Direct Enrollment or Enhanced Direct Enrollment pathways. Agents and brokers who do not resolve their NPN validation issues will eventually be removed from the Registration Completion List and moved to the Registration Termination List, lose their ability to assist consumers with Marketplace coverage, and no longer be eligible to receive compensation for Marketplace enrollments.
  
  Agents and brokers who have questions about the Registration Completion List should contact the Agent/Broker Email Help Desk at FFMProducer-AssisterHelpDesk@cms.hhs.gov.
  
  

Plan Year 2024 Cultural Competency Module

Disclaimer

The information in this training was current at the time it was published or uploaded onto the Web. Eligibility policies and Marketplace requirements may change so links to the source documents have been provided within the document for your reference. This training is not intended to grant rights. It may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage learners to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of the requirements.

Please note that the Centers for Medicare & Medicaid Services (CMS) is an agency within the U.S. Department of Health & Human Services (HHS). For simplicity, we will refer to CMS throughout although in some cases the authority may reside with HHS.

Where to Get Additional Information

Agents and brokers are also encouraged to regularly attend Marketplace agent and broker webinars and office hours, access the resources for agents and brokers webpage(opens in a new tab)

, and read Marketplace emails to receive important operational updates and stay current on changing Marketplace policies and regulations.

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

Introduction

In this course you will:

• 1 Learn about health disparities in the U.S.

• 2 Review strategies to assist individuals and families from historically underserved communities and help them understand the coverage options available through the Marketplaces

• 3 Learn the importance of the Marketplace application race and ethnicity questions and how to explain their impact to concerned consumers

Objectives

After completing this module, you should:

• 1 Better understand the barriers certain individuals and families in the U.S. may face when enrolling in Marketplace coverage

• 2 Be able to create a plan to assist consumers with diverse life experiences that may differ from your own

• 3 Be aware of the resources available to you from the Marketplace when assisting consumers from historically underserved communities

Introduction to Health Disparities

Following the Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government(opens in a new tab)

, the Centers for Medicare & Medicaid Services (CMS) is continuing to engage in initiatives to understand and better address health disparities and advance equity in access to health coverage, especially within historically underserved and uninsured populations.

• Racial and ethnic disparities in insurance coverage have improved under the Affordable Care Act (ACA) but continue to persist.

• Insurance coverage is critical to improving overall health outcomes for historically underserved and uninsured populations. 

Underserved populations facing disproportionate health disparities include people from racial and ethnic minorities, members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, individuals with limited English proficiency (LEP), and rural communities.

• Black individuals comprise approximately 13% of the U.S. population but 16% of uninsured individuals

• Hispanic individuals represent 19% of the U.S. population but account for 29% of uninsured individuals

• LGBTQ+ individuals are more likely to report delaying care, less likely to have a usual source of care, and more likely to be concerned about medical bills than their non-LGBTQ+ counterparts

• Uninsured rates in rural areas were 2-3 percentage points higher than in urban areas over the 2010–2019 period, and this problem persists today. It is important to note that nearly one in five Americans live in a rural area.

Agents and brokers play a crucial role in sharing knowledge and resources, assisting consumers with obtaining coverage that best fits their needs, and supporting consumers year-round.

General Best Practices

CMS encourages agents and brokers to serve as many consumers in their community as possible. To successfully serve the largest number of consumers possible, here are some best practices to incorporate into your work.

Try to consider all relevant factors as well as the unique consumer scenarios that may impact a consumer’s ability to obtain coverage. Some things to consider are:

• Being authentic in interactions with consumers is important. Acknowledge, respect, and accept cultural differences among consumers.

• Avoid stereotypes – consumers from the same background or from the same region may differ greatly in their traditions, customs, and opinions about health and coverage.

• Not all consumers have reliable access to Wi-Fi or Internet, or access to a computer or smartphone. This is especially true for consumers in rural areas as they may have limited cellphone reception and access to internet service. Agents and brokers can help these consumers with filling out paper applications if applying online is not possible and offer remote assistance services. Remember: You cannot log into a client’s HealthCare.gov account for them.

• For consumers newly living in the U.S., the health system in their country of origin may be very different than in the U.S. It may be useful to take a minute to learn from them about their initial understanding, so you can ensure your explanations of the U.S. system make sense and clear any confusion.

• Consumers may need assistance assessing their options for transportation to providers covered by different plans. This may be especially important for rural consumers who may not have reliable access to public transit or other transportation.

• Use ”people first” language (e.g. person with LEP, rather than LEP person).

Lack of Consumer Trust

Consumers may be hesitant to apply for Marketplace coverage, or work with someone unfamiliar. To ease their concerns, you can:

• Work with local organizations/municipalities to distribute information and provide enrollment assistance.

• Utilize word-of-mouth referrals to relay that you are a trustworthy resource.

• Offer clear, plain language explanations to any potential areas of confusion. Often times industry jargon can come across intimidating and can inhibit authentic connection.

Communication Barriers

Language and translation or interpretation support is important. You can research your community to identify the most common languages spoken, and utilize local translators, or the Marketplace Call Center translation services, to assist consumers.

For assistance locating translation and interpretation services, review these frequently asked questions(opens in a new tab)

.

Low Health Insurance Literacy

One of agents’ and brokers’ most important roles is as a translator for complex health insurance information. Improving health literacy and providing education is vital to ensuring that consumers choose the plan that is right for them.

• Don’t wait to be asked. Consumers may be uncomfortable or ashamed to say they don’t understand – explain concepts like premiums, deductibles, copays, etc., and share reliable information sources.

• Ensure consumers review provider directories before enrolling in coverage and understand the importance of staying in-network.

Serving Consumers with Limited English Proficiency

When interacting with or referring to consumers with LEP, agents and brokers should:

• Speak directly to consumers, not to the person accompanying them or a translator, unless requested by the consumer.

• Ask consumers about their goals and priorities.

• Maintain the capacity and accommodations to help consumers compare and understand insurance options, including translation services.

• Be willing to spend extra time and be patient.

When interacting with or referring to consumers with LEP, agents and brokers should not:

• Assume a consumer needs translation assistance and instead offer assistance if it seems to be needed or if a consumer requests it.

• Make assumptions about what a consumer is capable of understanding.

Working with Community Organizations

Agents and brokers can work with trusted community-based organizations to connect with underserved and/or underinsured communities who may need enrollment assistance.

• 1 Community centers, community events, and faith-based organizations are great places to find and engage with consumers. Identify “hub” locations in the community.

• 2 Seek support from local and municipal agencies that provide social services (i.e., county health, housing, homeless shelters, and food banks).

• 3 Seek opportunities to do public service announcements.

• 4 Hold events in accessible locations (i.e., near public transportation).

• 5 Collaborate with rural communication networks, such as local leaders, nonprofits, and civic and business organizations, to disseminate materials and engage consumers in conversations.

You work for an organization with an office in a rural area where the population includes religious missionaries from other countries. Consumers in the area speak nine languages in addition to English and Spanish. You want to be ready to serve this population effectively by making consumers feel comfortable and well-informed about their choices. How would you prepare to best serve this population?  

• Research the languages spoken in this community and locate language assistance services, including interpretation and translation services at no charge to the consumer with LEP. 

• Be sure your office has materials in the languages spoken in this community. 

Knowledge Check Explainer

The correct answers are to research the languages spoken in this community and locate language assistance services, including interpretation and translation services at no charge to the consumer with LEP, and be sure your office has materials in the languages spoken in this community. Ensure the individuals providing language assistance are qualified to do so and avoid the use of unqualified individuals, including family members and minors, as interpreters. Be sure your center has materials available in the languages spoken in the community.

At a tabling event to promote your services, a consumer advises you that they don’t have access to the internet but need health insurance as their job does not offer benefits. You have a plan in place to assist consumers without internet access and set up a time for them to meet with you at your office to apply for Marketplace coverage. Do your actions adhere to best practices?

• Yes

Knowledge Check Explainer

The correct answer is yes. It is a best practice to have a plan in place to assist a variety of consumer scenarios. This ensures you’re able to assist the largest number of consumers possible, therefore helping more people acquire health coverage.

Your colleague is establishing an agency in a community where a high percentage of the population speaks Spanish as their primary language. They mention they will only offer services in English and do not have a plan for how they will assist this predominantly Spanish-speaking community. Do your colleague’s actions adhere to best practices? 

• No

Knowledge Check Explainer

The correct answer is no. Your colleague’s plans do not adhere to best practices, which encourage agents and brokers to offer services in the dominant languages of their community or have plans for how to assist consumers who speak those languages. You could remind them of this best practice and of the Marketplace Call Center’s language translation line.

A 25-year-old consumer will age off their parent’s insurance soon and is not familiar with how health insurance works. You take the time to explain what the Marketplace is, the differences between premiums, deductibles, and copays, and help them understand what staying in network means. Do your actions adhere to best practices? 

Yes

Knowledge Check Explainer

The correct answer is yes. As an agent or broker, you are the expert in navigating health insurance, so it is important to take the time to explain and make sure your client has a good understanding of how health insurance works without them having to ask.

Race and Ethnicity Questions in the Marketplace Application

CMS routinely analyzes data regarding characteristics of who is signing up for coverage and how Marketplace applicants move through the online workflows in order to measure Marketplace effectiveness and determine whether there is a need for policy, operational, or outreach/marketing updates.

One of the barriers to making informed decisions about such potential updates is that consumers, or individuals filling out applications on behalf of consumers, often do not answer the optional race and ethnicity questions in the Marketplace application. In the Marketplace, non-reporters of race and ethnicity data are disproportionately Black and Latino, leading to an underrepresentation of individuals within these groups.

CMS encourages all agents and brokers to take the time to ask consumers to respond to these optional questions. This information will help CMS reduce health disparities, prevent discrimination, promote equity for all communities and Federally-facilitated Marketplace (FFM) consumers, and better follow its mission to improve healthcare coverage. CMS asks this question in order to ensure that outreach is reaching all communities equitably and that the application process does not unintentionally create barriers for particular individuals or groups. 

CMS will use this data to identify possible application, enrollment, and/or coverage barriers and disparities for all communities seeking coverage through the FFM. In addition, the question about language preference will help CMS assess language needs of the populations being served, and help CMS and insurers ensure that services are ready.

Video

The video below demonstrates how to complete this section of the Marketplace application.

Streamlined Marketplace Application Drilldown - Race and Ethnicity Questions

This video will walk through the optional race and ethnicity questions in a Marketplace application, explaining the importance of answering these questions and how the U.S. Department of Health and Human Services (HHS) uses this information to ensure eligible individuals have equitable access to affordable coverage that meets their needs.

Hacer clic para VIDEO

Medicaid, CHIP, & "Public Charge" Status

Applying for or receiving Medicaid or Children’s Health Insurance Program (CHIP) benefits, or getting savings for health insurance costs in the Marketplace, doesn't make someone a "public charge (opens in a new tab)

." This means it won’t affect their chances of becoming a Lawful Permanent Resident or U.S. citizen.

There's one exception for people receiving long-term care in an institution at government expense, like in a nursing facility. These people may face barriers getting a green card.

Your client expressed concern about what the government will be doing with their race and/or ethnicity information. How can you respond to alleviate their concerns? 

• Telling them CMS de-links the data from their individual account, and uses race and ethnicity data – in summary - to identify possible application, enrollment, or coverage barriers and disparities for all communities seeking coverage through the FFM. 

Knowledge Check Explainer

The correct answer is telling them CMS de-links the data from their individual account, and uses race and ethnicity data – in summary - to identify possible application, enrollment, or coverage barriers and disparities for all communities seeking coverage through the FFM. This information is extremely important to CMS for creating policies and programs that better serve underserved and uninsured communities. Participants can be comfortable knowing this question is informative and safe to answer.

Plan Year 2024 Enrolling Consumers in Coverage Module

Introduction

Agents and brokers can set themselves up for success during Open Enrollment (OE) through adequate preparation. During this course you will:

• Explore the differences between using the Marketplace pathway on HealthCare.gov and those offered by a Centers for Medicare & Medicaid Services (CMS) approved web-broker

• Understand how to get compensated for Marketplace enrollments

• Learn about tools consumers can use to connect with you for assistance

• Identify where to get help when you need it

• 
  

Objectives

Consumers enrolling in Marketplace coverage will need to answer a series of questions about their household to determine eligibility to enroll in coverage and for financial assistance programs offered through the Marketplace. During this course you will:

• Learn when consumers can enroll in Marketplace coverage

• Explore differences between financial assistance programs in the Marketplace

• Understand how to assist consumers with Health Reimbursement Arrangements (HRAs)

Preparing to Enroll Consumers

Compensation in the Marketplace

The Marketplace does not directly appoint or compensate agents, brokers, or web brokers. Agents, brokers, and web brokers who participate in the Marketplace are compensated in accordance with their agreements with qualified health plan (QHP) issuers and any applicable state-specific requirements. The Marketplace does not set compensation levels.

• 1 To receive compensation for enrolling consumers in a QHP through the Marketplace, an agent or broker generally needs to be appointed and have a compensation arrangement with that QHP issuer in accordance with state law. Issuers in some states have the discretion to compensate an agent or broker who does not have an appointment at the time they assisted with enrollment but who otherwise complies with applicable federal and state requirements. For example, in some states agents and brokers have 15-45 days to obtain an appointment after assisting a consumer.

• 2 To become appointed with a particular QHP issuer, agents and brokers should contact the QHP issuer directly, or contact their state regulators, such as the state Department of Insurance (DOI). Contact information for states can be found at the National Insurance Producer Registry.

• 3 To the extent permitted under applicable federal and state requirements, QHP issuers provide compensation directly to agents, brokers, and/or licensed entities with whom they have a contractual relationship for assisting qualified individuals, qualified employers, and qualified employees in enrolling in QHPs through the Marketplace. Compensation is solely at the discretion of QHP issuers; some issuers may not compensate agents and brokers for assisting consumers with some or all enrollments in Marketplace QHPs.

• 4 An agent's or broker’s National Producer Number (NPN) must be entered on a Marketplace application to receive compensation from QHP issuers with which the agent or broker has an appointment for assisting a consumer with that application. If an agent or broker who has completed the Federally-facilitated Marketplace (FFM) registration for the applicable plan year at the time of providing assistance with the enrollment has a reason to believe that their NPN (or agency/brokerage NPN) should have been included on a Marketplace enrollment transaction, but was not, the agent or broker may contact the respective QHP issuer directly to discuss the situation. CMS expects that a QHP issuer would issue compensation to an affiliated agent or broker who has completed the applicable FFM registration requirements if it is determined from the issuer’s, agent’s, or broker’s records that the agent or broker did in fact assist the consumer, but the NPN was erroneously left off the application. Such records may include a consent form from the consumer, an Agent of Record (AOR) form, a Broker of Record (BOR) form, or similar documentation to demonstrate that the consumer was the agent’s or broker’s client for the enrollment in question. Agents and brokers should also work directly with the consumer to revise their application to add the NPN. 

• 5 A QHP issuer must pay the same compensation for QHPs offered through the Marketplace as it does for similar health plans offered in the state, but outside the Marketplace. In fact, this compensation approach is a required condition of the QHP certification process for QHPs offered in the Marketplace. Agents or brokers with evidence demonstrating that QHP issuers are not compensating agents and brokers inside and outside the Marketplace the same may send their concern, along with supporting documentation, to the Agent/Broker Email Help Desk at FFMProducer-AssisterHelpDesk@cms.hhs.gov. 

• 6 QHP issuers are also prohibited from structuring agent and broker compensation arrangements to discourage marketing to and enrolling consumers with significant health needs (e.g., paying lower commission for higher metal level plans (Platinum and Gold), which are associated with higher utilization). If you believe an issuer’s compensation arrangement or marketing practice is discriminatory, contact CMS at marketconduct@cms.hhs.gov or your state DOI.

• 7 Finally, QHP issuers who compensate agents and brokers for OE must compensate them at the same rate for special enrollments occurring during the same plan year. Failing to do so would violate the Affordable Care Act’s (ACA’s) guaranteed availability provisions.

Connecting with Consumers

CMS makes available two tools to help consumers connect with agents and brokers in their area for assistance: Find Local Help and Help On Demand. 

With Find Local Help, consumers have the ability to search and produce a list of agents and brokers in their area. Consumers then can reach out to an agent or broker directly for assistance.

Help On Demand is a consumer assistance referral system that quickly connects individuals on HealthCare.gov with Marketplace-registered, licensed agents and brokers in their area who can provide immediate assistance with Marketplace plan selection and enrollment.

Find Local Help Tool at HealthCare.gov

HealthCare.gov has a tool called Find Local Help(opens in a new tab)  that enables consumers and small employers to search for local agents and brokers, based on their ZIP codes, who can assist them throughout the Individual Marketplace or Small Business Health Options Program (SHOP) application and enrollment process. This tool provides professional contact information for agents and brokers who have completed Marketplace training and registration for the applicable plan year and have an active state license that is approved for a health-related line of authority (LOA) by the state(s) where they plan to sell Marketplace coverage. Find Local Help (opens in a new tab) includes details regarding an agent’s or broker’s contact information, hours of operation, and years of service making it easy for consumers to get assistance. Find Local Help also has a feature that consumers can use as a filter to identify agents and brokers who can assist them in the language of their choice. 

• Agents and brokers can update their information displayed in the Find Local Help tool by updating their Find Local Help/Help On Demand profile setting within the Marketplace Learning Management System (MLMS). To update or confirm the Find Local Help information associated with a MLMS profile, select the “Complete Agent Broker Training” hyperlink on the Agent Broker Registration Status page of the CMS Enterprise Portal. Selecting the link will open the agent’s or broker’s MLMS profile; from there, you can update or confirm your contact information and Find Local Help listing preference.

Agents and brokers can also opt out of being listed in Find Local Help when establishing their MLMS profile.

Sign up for Help On Demand 

Help On Demand is a consumer assistance referral system* that quickly connects consumers seeking assistance with Marketplace-registered, state-licensed agents and brokers in their area who can provide immediate assistance with Marketplace plans and enrollments. Only agents and brokers who have completed required Marketplace training and registration for the applicable plan year and the Help On Demand specific coursework, have an active state license that is approved for a health-related LOA by the state(s) where they plan to sell Marketplace coverage and have signed the applicable agreements are eligible to participate in Help On Demand. 

Consumers can request to have an agent or broker contact them directly by selecting the Help On Demand link available on HealthCare.gov or from consumer enrollment email messages sent out by the Marketplace. After the consumer enters their contact information, Help On Demand matches the consumer with an agent or broker who is available, speaks the consumer’s language, and is registered with the Marketplace and licensed in the consumer’s state. If more than one agent or broker meets these criteria, Help On Demand generally directs the referral to the agent or broker who is geographically closest to the consumer. For more information regarding Help On Demand, visit the resources at CMS.gov (opens in a new tab)

* Help On Demand is a CMS-contracted service developed and hosted by Help On Demand (formerly known as BigWave Systems). Help On Demand referrals are not provided by CMS or the Marketplace and they do not constitute an endorsement by the Department of Health & Human Services (HHS) or the U.S. Government of the individual agents or brokers. 

. Know Where to Get Help

Agent/Broker Resources Webpage

The Resources for Agents and Brokers in the Health Insurance Marketplaces webpage (opens in a new tab) is the primary outlet for agents and brokers to receive information from CMS about working in the Health Insurance Marketplace and the SHOP. Within the site, the General Resources webpage contains a dynamic list of resources that provide helpful information, including guidance, regulations, previous webinar slides, quick reference guides, and more. Agents and brokers can filter the list by date, topic, title, and type of resource. Agents and brokers can also find guidance on specific topics such as registration and training, Help On Demand, and more!

Agent and Broker Frequently Asked Questions (FAQs)

The Agent and Broker FAQs (opens in a new tab) website provides answers to commonly asked questions about working in the Marketplace and helping clients enroll in and maintain coverage. Agents and brokers can search by question category, keyword, or part of the question. Most responses also include links to additional resources to help when assisting clients.

Help Desks

This resource(opens in a new tab)  provides information on the help desks available to agents and brokers who assist consumers through the FFM, the types of inquiries handled, contact information, and hours of operation.

Working with the Marketplace Call Center

Consumers can provide you with consent to access their account information, including checking the status of their submitted Marketplace application. To act on behalf of a consumer at the Marketplace Call Center, your client must call the Marketplace Call Center at 1-800-318-2596 and provide your name and NPN or conduct a three-way call with you on the line with them. They must authorize you every 365 days. You are only able to check the status of Marketplace applications with which you are affiliated (i.e., are listed on the application as the assisting agent or broker).

Note: This authorization is not the same as ensuring your NPN is on the consumer’s application for payment purposes with issuers.

Jose, a Marketplace agent, forgets to include his NPN on a transaction when enrolling a consumer in a QHP. What should Jose do to ensure he is compensated for the enrollment? Select all that apply.  

• Contact the respective QHP issuer directly about the compensation issue, and work with the consumer to update their Marketplace application to include Jose’s NPN moving forward. 

• Work only with the consumer directly to update their Marketplace application to include his NPN. 

Knowledge Check Explainer

The correct answers are to contact the respective QHP issuer directly about the compensation issue, work with the consumer to update their Marketplace application to include Jose’s NPN moving forward, and to work only with the consumer directly to update their Marketplace application to include his NPN. In this scenario, an agent or broker may contact the respective QHP issuer directly to discuss the situation. CMS expects that a QHP issuer would issue compensation to an affiliated agent or broker who has completed the applicable FFM registration requirements if it is determined from the issuer’s, agent’s, or broker’s records that the agent or broker did in fact assist the consumer, but the NPN was erroneously left off the application. Records include consumer consent form, an AOR form, etc. The agent or broker should also work directly with the consumer to update their Marketplace application to include their NPN moving forward.

Enrollment Pathways

The Marketplace Pathway

In the Marketplace pathway, the consumer logs directly into the HealthCare.gov site, using their own Marketplace user account. After the consumer logs in, you then work with the consumer to complete the application. The Marketplace application will prompt the consumer to enter your name and NPN to indicate that you assisted the consumer. You should always instruct consumers to enter your NPN to ensure the NPN will persist on the enrollment transaction if your client experiences a change in circumstance and updates their enrollment.

The consumer will encounter a screen with the heading “Application Help” and the question “Is a professional helping you complete your application?” After the consumer selects “Yes” a question will appear, “Which type of professional is helping you?” Make sure the consumer selects the "Agent or Broker" box on this screen. This will produce a new set of fields, including one labeled “National Producer Number,” which is where the consumer should enter your name and NPN to record your assistance with the Marketplace application.

If the consumer is re-enrolling and entered a different agent’s or broker’s NPN for the prior plan year, the screen will be pre-populated with that agent’s or broker’s NPN. The consumer should update all information that is pre-populated (e.g., the agent's or broker's name and NPN) as may be appropriate. For more information on recording your NPN on Marketplace applications, review the How to Instruct Consumers to Insert Your NPN on Marketplace Applications(opens in a new tab) resource. 

Note: the HealthCare.gov application allows identifying information from both an agent/broker and an assister or navigator on the same application. Agents and brokers should not remove any pre-populated assister or navigator information from an application. For the purposes of compensation, only the agent/broker NPN will be sent to the issuer on the enrollment transaction.

Web-brokers

A business entity registered with the Marketplace that develops and hosts a non-Marketplace website that interfaces with the Marketplace to assist consumers with direct enrollment in QHPs offered through the Marketplace. 

Web-brokers generally offer online resources for agents and brokers, such as enrollment and client management functionality. Under the Classic Direct Enrollment (DE) pathway, CMS approved web-brokers can provide a website that enables consumers and/or agents and brokers working with consumers to apply for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs) and select and enroll in an Individual Marketplace QHP through the web-broker’s website. Consumers using the Classic DE pathway are able to initiate the QHP shopping experience on a web-broker’s website, connect securely to the HealthCare.gov website to complete the eligibility application and determination process, and return securely to the web-broker’s site to compare plans and select a QHP.

Some web-brokers may also offer the Enhanced Direct Enrollment (EDE) pathway, which operates without the redirect to and from the HealthCare.gov website and allows the consumer to complete the eligibility application and plan selection on the web-broker’s website. Through secure data transfers, the Marketplace will determine a consumer’s eligibility for QHP coverage, Medicaid, or the Children’s Health Insurance Program (CHIP), as well as the applicable APTC or CSR amounts. Web-brokers approved to participate in the EDE pathway may provide a range of custom features and capabilities, enabling agents and brokers to assist clients more easily with year-round policy and client relationship management.

All web-brokers must comply with applicable federal requirements for the content and user functionality of their websites, including providing language access services, as well as the FFM privacy and security requirements for collecting and handling consumer information. Web-brokers offering the Classic DE pathway and/or EDE pathway must also retain an independent third-party auditor to validate compliance with certain program requirements.

Agents and brokers may find a web-broker who is approved by CMS to offer these services via the Issuer and DE Partner Directory(opens in a new tab)

Overview of the Classic DE Pathway

QHP issuers and web-brokers with approved DE websites may offer different levels of service on their websites to agents and brokers assisting consumers. Through the Classic DE pathway, you may log on to an agent/broker landing page at HealthCare.gov that is available only through the Classic DE pathway. From there, you may assist consumers in the Marketplace with completing an application on the HealthCare.gov website and obtaining an eligibility determination for insurance affordability programs from the Marketplace. If a consumer is eligible for a QHP, you may assist that consumer in selecting a plan on the QHP issuer’s or web-broker’s website.

As part of the Classic DE pathway, you can also modify a consumer’s application after a plan selection has already been made (e.g., report a change in income or add a newborn during a Special Enrollment Period (SEP)). You should contact your approved Classic DE partner to determine whether it supports changes to a consumer’s application outside of the Open Enrollment Period (OEP), because not all do. You may use the IssuerandDEPartnerDirectory(opens in a new tab)  to search for approved DE partners by state.

In this pathway, your name and NPN are typically transmitted electronically to the issuer when the consumer’s enrollment is submitted in accordance with how your Classic DE account was set up by the respective QHP issuer or web-broker. As a best practice, you should manually enter your name and NPN on each consumer's application when using the Classic DE pathway to assist consumers with Marketplace enrollments. The Marketplace cannot successfully credit an agent or broker for an enrollment with partial agent or broker information; if an NPN is provided, the agent's or broker’s first name and last name must also be provided. Although you drive the Classic DE pathway process to assist consumers with completing their application, consumers have the ultimate legal responsibility for completing their applications and attesting to the accuracy of the information contained therein.

Enhanced Direct Enrollment Pathway

Some approved DE partners offer enhanced functionality, known as EDE. In this pathway, registered agents and brokers affiliated with approved QHP issuers or web-brokers have the ability to assist individuals in applying for and enrolling in Marketplace coverage directly from the QHP issuer’s or web-broker’s website. Through the EDE pathway, agents and brokers can facilitate the entire enrollment experience for a consumer on the QHP issuer's or web-broker's website, including the ability to obtain an eligibility determination from the Marketplace, without a need for the consumer to visit HealthCare.gov. 

EDE partners may offer a range of client management functions for you to more easily assist consumers year-round. These capabilities may vary, but will include the ability to upload documents to resolve data matching issues (DMIs) and SEP verification issues (SVIs), view the status of those issues, download Marketplace notices (such as the Eligibility Determination Notice (EDN) and Form 1095-A), and request coverage cancellations and terminations. 

While each EDE partner’s implementation of the EDE pathway may vary slightly, to assist consumers using this pathway, follow these general steps:

Application

Consent

Obtain and document consumer consent that you have permission to: 1) conduct an online person search, 2) assist with completing a Marketplace application, 3) assist with plan selection and enrollment, and 4) assist with ongoing account/enrollment maintenance.

Log In

Log in to the QHP issuer’s or web-broker’s EDE site using only your login user name and password. CMS requires registered agents and brokers to re-verify their credentials for accessing an EDE website at least every 30 days. You may also assist consumers with creating an account on the QHP issuer’s or web-broker’s website. However, consumers should not share their login credentials with you and you should not share your login credentials with the consumers. The consumers may also wish to create a HealthCare.gov account so they can access Marketplace notices, upload documents, or update the application directly. See the Creating an Account resource for the steps for a consumer to create a HealthCare.gov account. When assisting a consumer for the first time in-person using an EDE partner’s website, you must identity proof the consumer by reviewing approved documents. See the Verifying Your Identity in the Marketplace tipsheet(opens in a new tab) for additional information. 

Search for Existing Application

Search to determine whether the consumer has an existing Marketplace application (see the “Tips to Avoid Duplicate Enrollments” section in this module). Agents and brokers may only conduct person searches for consumers who have given them consent to work with them for purposes of applying for and enrolling in a Marketplace plan. Conducting person searches for non-Marketplace enrollment purposes, e.g., to enroll them in a non-Marketplace plan, is not allowed.

Assist

Assist the consumer with completing their Marketplace application. For some partner websites, you may have to help the consumer complete a set of screening questions to verify the application can support the consumer’s circumstance. If consumers cannot be assisted through a QHP issuer's or web broker's EDE pathway because their circumstances are not supported by the hosted application, they will be directed to HealthCare.gov or redirected to a partner’s Classic DE pathway.

Eligibility Determination

Step 1: Review

Review the eligibility determination from the Marketplace on the partner’s website with the consumer.

Step 2: Resolve DMIs and SVIs

If the eligibility determination reflects that the consumer has an outstanding DMI or an SVI, assist the consumer with uploading the necessary verification documentation before the deadline indicated in the EDN.

DMI - Data Matching Issue

In Marketplace insurance, DMI stands for data matching issue1. Consumers may encounter a DMI when there’s a difference between certain information they entered on a Marketplace application and information the Marketplace receives from other trusted data sources1. When a DMI occurs, the Marketplace sends consumers an eligibility.

SVI - SEP Verification Issue (SVI): Verification requirements

EDN - Eligibility Determination Notice (Letter of Eligibility)

QHP - Qualified Health Plan

Plan Selection

STEP 1: Determine APTC Amount

If consumers are eligible to select a QHP, assist them in selecting the amount of APTC (if applicable) they would like to apply to their monthly insurance premiums. The consumer is now referred to as a “qualified individual” due to their positive eligibility determination. 

Advance premium tax credit

• Advance premium tax credit (APTC) A tax credit you can take in advance to lower your monthly health insurance payment (or “premium”).

STEP 2: Plan Selection

Assist the qualified individual with the plan selection process. Please note that when using a QHP issuer’s website you will only be able to help the qualified individual choose among QHPs offered by that specific QHP issuer. However, if you are working with a web-broker, the web-broker is required to display all Marketplace QHPs available in the service area. If the qualified individual wishes to enroll in dental coverage, assist the qualified individual with comparing and selecting a dental plan offered on the QHP issuer’s or web-broker’s site, or direct the qualified individual to go to HealthCare.gov to select a dental plan.*   

*Consumers cannot enroll in a Marketplace dental plan unless they are selecting a health plan at the same time.

STEP 3: Assist with Binder Payment

If the qualified individual needs to make the initial premium payment, assist the qualified individual in doing so. EDE websites include payment functionality that allows the qualified individual to make the initial premium payment directly, or that allows the consumer to redirect to the applicable QHP issuer website for the initial premium payment. Note that subsequent monthly premiums owed for coverage will be billed by the issuer and sent to the consumer for payment. 

STEP 4: Enrollment

If a qualified individual decides to enroll, the QHP issuer or web-broker submits the enrollment information to HealthCare.gov. When the Marketplace receives a QHP selection for a qualified individual, it promptly notifies the applicable QHP issuer of the requested enrollment and transmits the needed eligibility and enrollment information. Your agent or broker identifying information will be included in the official Marketplace enrollment record sent to the QHP issuer. 

How to Instruct Consumers to Insert Your National Producer Number on Marketplace Applications

If the consumer’s eligibility application has already been completed and the consumer has received an EDN, the consumer can submit a change in circumstances (CiC), where the consumer can enter your NPN on the eligibility application. If the consumer does not qualify for a SEP when the CiC is reported (and it is not during the OEP), CMS will still send any new NPN to the issuer on an 834 enrollment transaction after completion of the CiC.

Note: Resubmitting the application AND re-selecting the plan in plan compare is critical to ensure that CMS sends your NPN to the issuer on an 834 enrollment transaction.

Note: If you are assisting your client using a non-Marketplace website through a DE partner, please be aware that not all DE partners support the submission of a CiC that does not qualify for a SEP. If this is the case, your client can still use HealthCare.gov to report a life change and add your NPN to their application by following the instructions above. We encourage you to reach out to DE partners you work with to confirm if they support the submission of a CiC that does not qualify for a SEP, or if your client needs to use HealthCare.gov to report a life change and add your NPN to their application.

Knowledge Check

In the knowledge checks below you will match the description to the correct enrollment pathway. 

Consumers, with the assistance of an agent or broker, remain on HealthCare.gov throughout the entire application process.

• The Marketplace

Agents and brokers may be able to facilitate the entire enrollment experience for a consumer, including the ability to obtain an eligibility determination from the Marketplace, without a need for the consumer to visit HealthCare.gov. 

• Enhanced Direct Enrollment 

Agents and brokers visit both a DE partner’s site and the HealthCare.gov site while completing the application. 

• Classic Direct Enrollment 

Knowledge Check Explainer

In the Marketplace pathway, consumers, with the assistance of an agent or broker, remain on HealthCare.gov throughout the entire application process. Using Classic Direct Enrollment, agents and brokers visit both a DE partner’s site and the HealthCare.gov site while completing the application. With Enhanced Direct Enrollment, agents and brokers may be able to facilitate the entire enrollment experience for a consumer, including the ability to obtain an eligibility determination from the Marketplace, without a need for the consumer to visit HealthCare.gov.

Best Practices Across Enrollment Pathways

All enrollment pathways transmit the agent's or broker's identifying information, when included on the application, to the Marketplace and to the appropriate QHP issuer to facilitate the issuer’s payment for each enrollment transaction to those agents and brokers who have a contractual relationship with the issuer.

Regardless of the enrollment pathway used, you should never enter your own agent or broker professional or company email, phone number, or mailing address on a consumer’s application. Consumer accounts should only have the consumer's (or the consumer’s legally authorized representative's) email and mailing addresses. Only consumer emails and mailing addresses should be entered on Marketplace applications. With a consumer’s consent, the Marketplace sends important alerts and updates about coverage that may be missed if a consumer’s contact information is not in the system. These updates are often tailored to a consumer’s circumstances, so it is important that they are sent directly to consumers.

*Agents and brokers may find a QHP issuer or web-broker that is approved by CMS to offer the Classic DE pathway or the EDE pathway via the Issuer and DE Partner Directory (opens in a new tab)

Tips to Avoid Duplicate Enrollments

Prior to assisting a consumer using either the Classic DE or EDE pathways, you must determine whether the consumer has an existing current or future year application to avoid creating more than one application for the same consumer. Failure to follow these steps may cause duplicate enrollments that can create confusion for the consumer as well as the issuer.

To prevent creating a new application unnecessarily when using either the Classic DE or EDE pathways, see the Avoiding Duplicate Marketplace Applications tipsheet(opens in a new tab)

Tyler, 23, is currently enrolled in coverage through a Marketplace plan that includes himself, his sister and his father, who is the household contact. Tyler contacts you because he wants to get on his own plan. You help Tyler fill out his application on HealthCare.gov, then enroll in a plan. Later, Tyler calls you and is upset because the Marketplace terminated his father and sister’s coverage. What could have prevented this? 

• Tyler’s father should have removed Tyler from their family application prior to Tyler submitting his own application. 

Knowledge Check Explainer

The answer is Tyler’s father should have removed Tyler from their family application prior to Tyler submitting his own application. Because Tyler was listed on both applications and remained enrolled in his family’s plan when he enrolled in his own, the Marketplace system detected a duplicate enrollment and terminated one of the enrollments. Because Tyler’s father is the household contact, he has the ability to remove Tyler from the family application.

Last year, you helped Keisha create a Marketplace application and enroll in a plan. The last time you talked to her, she was satisfied with her plan so you do not reach out during this year’s OEP. Since she didn’t hear from you, Keisha creates a new Marketplace application during OE and enrolls in a new plan, without adding your NPN to her application. However, she has already been auto-reenrolled in her current plan. Which of the following would happen next? 

• The Marketplace cancels Keisha's auto-enrollment in the plan associated with last year’s agent-facilitated application and enrollment.

Knowledge Check Explainer

The correct answer is the Marketplace cancels Keisha’s auto-enrollment in the plan associated with last year’s agent-facilitated application and enrollment. Because she is enrolled in two QHPs, the Marketplace will cancel one of them (and the Marketplace will keep an active plan selection over an auto-reenrollment). Additionally, because you did not assist Keisha with this application, she did not add your NPN, and you will not receive a commission for her enrollment. 

After receiving two premium bills, Keisha calls the Marketplace Call Center to figure out what went wrong. She learns that in addition to the plan she actively selected, she was also auto-reenrolled in her current plan, so she works with the Help Desk to cancel that coverage and keep the plan she wanted. Which of the following would happen next?

• You lose your commission for Keisha’s reenrollment.

Knowledge Check Explainer

The correct answer is you lose commission for Keisha’s reenrollment. Because your NPN is associated with the coverage Keisha is canceling, you will not receive a commission for the new enrollment she selected without your help.

When Can Consumers Enroll in Marketplace Coverage?

Open Enrollment

Registered agents and brokers can assist consumers who are enrolling in health and/or dental coverage through the Marketplace from November 1 to January 15, each year during OE. 

Special Enrollment Period Eligibility

Qualified individuals may enroll in a QHP or change QHPs during or outside of the annual OEP if they qualify for an SEP based on certain qualifying events, which include:  

• Loss of qualifying health coverage

• Change in household size (e.g., marriage; gaining or becoming a dependent through birth, adoption, placement for adoption or foster care, or due to a child support or other court order)

• Permanent move

• Certain changes in eligibility for Marketplace coverage or help paying for coverage

•  Enrollment or plan error

• Other situations

For most SEPs, consumers have 60 days from the date of the triggering event to select a plan. Consumers may visit HealthCare.gov and answer a few questions to find out whether they qualify for an SEP to enroll in or change QHP coverage. Additionally, qualified individuals who do not receive timely notice of an SEP qualifying event and otherwise are reasonably unaware that a triggering event occurred are permitted to select a plan based on the date that they knew, or reasonably should have known, of their triggering event. This training does not cover all SEPs available to consumers to enroll in Marketplace coverage. For more information about the SEP qualifying events, see Understanding SEPs (opens in a new tab)

Common Special Enrollment Periods

Special Enrollment Period for Marriage

In some cases, consumers can qualify for an SEP due to a marriage. In order to qualify for an SEP due to a marriage, at least one spouse must demonstrate having qualifying coverage for one or more days during the 60 days preceding the date of marriage or demonstrate that at least one spouse lived in a service area where there were no QHPs offered through a Marketplace for at least one of the 60 days prior to the marriage date or during that individual’s most recent preceding Marketplace enrollment period (i.e., the Marketplace OEP or an SEP). Consumers are also exempt from the prior coverage requirement if they lived in a foreign country or in a U.S. territory for one or more days during the 60 days preceding the date of the qualifying event or if they are Indian as defined by Section 4 of the Indian Health Care Improvement Act. 

Current Marketplace enrollees who qualify for a marriage SEP to add a spouse are generally subject to plan category limitations (PCLs). This means current enrollees generally cannot use the marriage SEP to change their current plan, and new spouses can either join the current enrollee’s plan, or enroll separately, on the same application but in a different enrollment group, and choose from all available plan categories for coverage during the remainder of the plan year. If the current enrollee’s QHP's business rules do not allow the spouse and current enrollee to enroll in the enrollee's current QHP together, the Marketplace must allow the enrollee and the enrollee’s spouse to change to another QHP within the same level of coverage.

For a marriage SEP, QHP coverage through the Marketplace begins the first of the month following the consumer’s QHP selection (e.g., if a QHP is selected on June 28, the coverage effective date will be July 1). Consumers have 60 days after their marriage to select a plan. If the 60-day deadline is missed, applicants must wait until the next annual OEP, or qualify for another SEP, to enroll in or change plans.

Special Enrollment Period for Birth or Adoption

Consumers who gain or become a dependent due to a birth, adoption, placement for adoption, placement in foster care, or a child support or other court order can qualify for an SEP. Current Marketplace enrollees who qualify for an SEP due to gaining or becoming a dependent are subject to PCLs. This means current enrollees cannot use the birth or adoption SEP to change their current plan, and new household members can either join the current enrollee’s plan or enroll separately, on the same application but in a different enrollment group, and choose from all available plan categories for coverage that applies during the remainder of the plan year.

If the current enrollee’s QHP's business rules do not allow the dependent to enroll, the Marketplace must allow the enrollee and the enrollee’s dependents to change to another QHP within the same level of coverage. Consumers who qualify for this type of SEP will have coverage effective back to the date of the birth, adoption, placement for adoption, placement in foster care, or the child support or other court order. These consumers also have the option to call the Marketplace Call Center to request a coverage effective date of the first of the month following plan selection.

Consumers have 60 days after a birth, adoption, placement for adoption, placement in foster care, or child support or other court order to select a plan. If they miss the 60-day deadline, applicants must wait until the next annual OEP, or qualify for another SEP, to enroll in or change plans.

SEP for Denial of Medicaid/CHIP Ineligibility

Consumers who apply for coverage during the annual OEP through the Marketplace or at their state Medicaid/CHIP agency, are told that they may be eligible for Medicaid/CHIP, and are later determined ineligible for Medicaid/CHIP (outside of the OEP) can qualify for an SEP to enroll in Marketplace coverage, if otherwise eligible. Additionally, consumers who apply for coverage through the Marketplace during the window for enrollment through another SEP qualifying event and are assessed as eligible for Medicaid/CHIP, but later determined ineligible, can qualify for an SEP allowing them to enroll in Marketplace coverage, if otherwise eligible. This SEP provides consumers with an effective date that is appropriate based on the circumstances, which in the FFM is typically a prospective, accelerated start date, effective the first of the month after they select a plan. Consumers may qualify for an SEP if they lost qualifying health coverage in the past 60 days (or more than 60 days ago but since January 1, 2020) OR expect to lose coverage in the next 60 days.

Consumers who started their coverage application at the Marketplace can request a retroactive effective date (back to the date their coverage would have started if the Marketplace had originally determined them eligible for QHP coverage) if they originally applied during the annual OEP or due to a qualifying event. Consumers in this situation should call the Marketplace Call Center to request a retroactive coverage effective date.

.Medicaid Unwinding SEP

CMS has updated existing functionality to grant an Unwinding SEP to eligible consumers. Marketplace-eligible consumers who submit a new application or update an existing application between March 31, 2023, and July 31, 2024, and attest to a last date of Medicaid or CHIP coverage within the same time period, are eligible for an “Unwinding SEP.” Consumers who are eligible for the Unwinding SEP will have 60 days from the date they submit or update their application to select a Marketplace plan with coverage that starts the first day of the month after they select a plan. Consumers can also access the Unwinding SEP through existing questions on EDE partner applications that ask about a recent loss of Medicaid or CHIP coverage.

To help avoid gaps in coverage during the unwinding period, CMS recommends that you assist clients who have received notice from their state Medicaid or CHIP agency that they are no longer eligible for Medicaid or CHIP coverage in submitting a new application or updating an existing application on HealthCare.gov as soon as possible. This recommendation also applies to consumers whose Medicaid or CHIP coverage was terminated due to procedural reasons, so that the Marketplace can re-evaluate their eligibility for Medicaid, CHIP, or QHP coverage with APTC or CSRs, as applicable.

150% SEP

Until December 31, 2025, APTC-eligible consumers with expected household incomes at or below 150% of the federal poverty level (FPL) can select a plan under the 150% SEP by submitting a new application or updating an existing one online at HealthCare.gov, or with the help of an EDE partner, a Classic DE partner that supports SEPs, or the Marketplace Call Center. 

Unlike most other SEPs, the 150% SEP doesn’t have a deadline for consumers to select a plan. In other words, during the availability of the time-limited 150% SEP, consumers qualify as long as they’re APTC-eligible and have an expected household income that does not exceed 150% of the FPL. However, consumers must select a plan before the end of the calendar month they submit or update their application for their coverage to start on the first of the next month to avoid any potential gaps in coverage. For example, no matter if a consumer submits a new or updated application on April 1 or April 16, they’ll have until April 30th to choose a plan for coverage that starts May 1st.

The application automatically determines consumers’ eligibility for the 150% SEP. Throughout plan years 2022 through 2025, consumers eligible for this SEP are also generally eligible for free or low-cost plans with very low deductibles and out-of-pocket costs after application of financial subsidies. For additional information, please see the Marketplace Stakeholder Technical Assistance Tip Sheet on the Monthly SEP for APTC-Eligible Consumers with Household Income at or below 150% of the FPL

(opens in a new tab)

.

Knowledge Check 

In the knowledge checks below, you will determine which people with qualifying life events may be eligible to enroll in a QHP at the time of application. 

Applicants who permanently move within the same county. 

• Ineligible to Enroll in a QHP

An applicant who attests to being recently married with one spouse having qualifying coverage in the last 60 days.

• Eligible to Enroll in a QHP (If otherwise meets criteria to enroll in a QHP)

Applicants who permanently move to a new county and attest to having qualifying coverage in the last 60 days.

• Eligible to Enroll in a QHP (If otherwise meets criteria to enroll in a QHP)

Applicants who move from a foreign country.

• Eligible to Enroll in a QHP (If otherwise meets criteria to enroll in a QHP)

Applicants who submit an application on January 17 are not SEP-eligible. 

• Ineligible to Enroll in a QHP 

Applicants who gain a dependent due to birth or adoption and attest to having qualifying coverage in the last 60 days.

• Eligible to Enroll in a QHP (If otherwise meets criteria to enroll in a QHP)

Knowledge Check Explainer

The following consumers are eligible to enroll in a QHP, if they otherwise meet the criteria to enroll in a QHP:

An applicant who attests to being recently married with one spouse having qualifying coverage in the last 60 days

• Applicants who permanently move to a new county and attest to having qualifying coverage in the last 60 days

• Applicants who move from a foreign country

• Applicants who gain a dependent due to birth or adoption and attest to having qualifying coverage in the last 60 days

The following consumers are ineligible to enroll in a QHP:

• Applicants who permanently move within the same county

• Applicants who submit an application on January 17 and are not SEP-eligible

How long do consumers have after birth, adoption, or foster care to select a plan through an SEP? 

• 60 days

Knowledge Check Explainer

The correct answer is 60 days. Consumers have 60 days after a birth, adoption, placement for adoption, placement in foster care, or child support or other court order to select a plan.

Consumers are eligible for the Medicaid/CHIP Denial SEP if they:

• Apply for Medicaid/CHIP during the last OEP

• Apply for Medicaid/CHIP during a SEP

Knowledge Check Explainer

The correct answers are if the consumers applied for Medicaid/CHIP during the last OEP, or if they applied for Medicaid/CHIP during an SEP. Consumers who apply for coverage during the annual OEP through the Marketplace or their state Medicaid/CHIP agency, are told they may be eligible for Medicaid/CHIP and are later determined ineligible can qualify for an SEP. Additionally, consumers who apply for coverage through the Marketplace during the window of enrollment through another SEP and are initially assessed eligible for Medicaid/CHIP, but later determined ineligible, can qualify for an SEP allowing them to enroll in Marketplace coverage, if otherwise eligible.

Multi-Tax Households

Tips for Assisting Consumers in Multi-tax Households

You may encounter situations in which a single household has more than one family member planning to file separate tax returns (e.g., domestic partners, parents with non-dependent children who file taxes). If the household is applying for help paying for coverage, the Marketplace application asks for each applicant’s tax filing status and who will be on the applicant’s federal income tax return as dependents for the applicable year.

Currently, the Marketplace cannot support people from different tax households enrolling in a QHP together on one application, if the applicants are applying for financial assistance. Therefore, individuals in different tax households applying for coverage through a Marketplace with financial assistance must submit separate applications for each tax household.

Step 1: Determine whether the household is applying for help paying for coverage. If no, then these instructions do not apply to the consumer you are assisting. 

Step 2: Determine if the application includes members of more than one tax household, each filing a tax return. If no, then these instructions do not apply to the consumer you are assisting. 

Step 3: Help these tax filers complete separate applications for each tax household or contact the Marketplace Call Center for help at 1-800-318-2596 (TTY: 1-855-889-4325).

• For each tax household, help the consumer list members of the tax household as applicants (needs coverage) on only ONE application. The consumers should list the other household members as non-applicants (doesn’t need coverage) on the application.

Each tax household application group will be on its own policy but can still select the same plan.

True or False. You’re helping a family of three fill out an application and wondering how many tax households there will be. Jack and Jill are married filing jointly and have one daughter, Jane, who they will claim as their dependent. You believe this is one tax household application. 

True

Knowledge Check Explainer

The correct answer is true. A tax household includes a tax filer (or tax filers, if married filing jointly) and the people they claim as dependents on a federal income tax return. Jack, Jill, and Jane comprise one tax household.

True or False. You’re helping a family of three fill out an application and wondering how many tax households there will be. Sonya and Jamar are domestic partners living together and have one daughter, Gabrielle. Jamar files a tax return, while Sonya files a separate tax return and claims Gabrielle as their dependent. Since the three live together, this is one tax household. 

False

Knowledge Check Explainer

The correct answer is false. A tax household includes a tax filer (or tax filers, if married filing jointly) and the people they claim as dependents on a federal income tax return. Since Jamar and Sonya are not married filing jointly and filing separate tax returns, this is two tax households. The number of tax households was not impacted by the three living together in this scenario.

Financial Assistance in the Marketplace

The Premium Tax Credit

The premium tax credit (PTC) helps eligible individuals and families afford health insurance coverage purchased through the Marketplace. After submitting an application to the Marketplace, an individual may be determined eligible to receive APTC. APTC is an amount paid by the government to an individual’s insurance company to reduce the amount the individual must pay each month for coverage in a QHP. The amount of APTC for which an individual is eligible is based on an estimation of the PTC the individual will be able to claim for the year of coverage. An individual may choose to apply some or all of the APTC for which they qualify towards premium costs. Alternatively, if individuals choose to forego APTC, they will receive the full benefit of the PTC by claiming it on their federal income tax return filed for the plan year.

APTC is paid on a monthly basis directly to the issuer offering the QHP. APTC and the PTC is not available for coverage purchased outside of the Marketplace or for an individual’s Marketplace coverage if the individual is eligible for affordable employer coverage that meets minimum value requirements or chooses to be covered by such coverage. An individual coverage HRA (ICHRA) is an example of employer coverage an individual may be offered. You will learn more about certain types of HRAs later in this module.

Who is Eligible for APTC?

To be eligible for APTC, an individual (for the year of coverage):  

• Must have projected household income that is at least 100 percent of the FPL for the family size of the enrollee (with exceptions for certain non-citizens).

• For coverage years from 2021 through 2025, the income limit to qualify for APTC depends on the costs of plans available based on the consumer’s age and where they live. If the benchmark plan costs more than 8.5 percent of the consumer’s household income, then the consumer could receive APTC if otherwise eligible. For coverage years before 2021 and after 2025 only, also must not be more than 400 percent of the FPL.

• Cannot be claimed as a dependent by another individual.

• If married, must file a joint income tax return (with exceptions for abused or abandoned spouses and individuals who qualify to use a head-of-household tax filing status). The eligibility rules for APTC are the same for all spouses, regardless of sex or gender.

• Must have at least one tax family member (a person claimed on the individual’s income tax return) enrolled in a QHP that is not a catastrophic plan through the Marketplace who is not eligible for other minimum essential coverage (MEC) (including employer-sponsored coverage (ESC) that meets affordability and minimum value standards, most Medicaid, CHIP, Medicare, and certain other forms of coverage).

Eligibility for APTC is based on the consumer’s projections of household income, tax family size, and other eligibility criteria, including who in the tax family (the applicant, the applicant's spouse if filing jointly, and dependents) may be eligible for other MEC for the benefit year. 

Eligibility for the PTC, however, is determined when the consumer files a federal income tax return for the plan year in which the consumer had Marketplace coverage, and the consumer uses the information from a Form 1095-A to complete IRS Form 8962. The PTC is based on actual household income, tax family size as shown on the tax return, and eligibility for other MEC. For more information on how consumers can meet the requirement to reconcile their APTC and PTC, please see HealthCare.gov (opens in a new tab)

. To learn more about ACA tax provisions, visit the 

Internal Revenue Service (IRS) ACA Tax Provision websitemopens in a new tab)

.

APTC is not available for the purchase of catastrophic coverage.

Eligibility for APTC with ESC

ESC is considered unaffordable for an employee if the amount the employee must pay for the lowest-cost self-only plan that meets the minimum value standard is more than a percentage of the worker’s projected household income. The percentage is 9.12% for plan years beginning in 2023. 

The IRS finalized a new rule on October 11, 2022, that changed the way affordability is determined for members of an employee’s family. Beginning in 2023, if a consumer has an offer of employer coverage that extends to the employee’s family members, the affordability of that offer of coverage for the family members of the employee will be based on the family premium amount, not the amount the employee must pay for self-only coverage.

A health plan meets the minimum value standard if both of the following apply:

• It is designed to pay at least 60% of the total cost of medical services for a standard population.

• Its benefits include substantial coverage of physician and inpatient hospital services.

If employees or their family members actually enroll in the ESC, then they are not allowed APTC for their Marketplace coverage regardless of whether the employer plan is affordable or meets the minimum value standard.

2023 Federal Poverty Level Chart

HHS issues poverty guidelines that are often referred to as the FPL. Starting November 1, 2023, the Marketplace will use the 2023 guidelines when making calculations for APTC and income-based CSRs for Plan Year 2024. View the 

HHS Poverty Guidelines Chart here(opens in a new tab)

. 

Plan Year 2024 Guidelines
For plan year (PY) 2024, beginning with the OEP that begins on November 1, 2023, determinations of eligibility for APTC and income-based CSRs will be based on the 2023 FPL from HHS’ 2023 Poverty Guidelines. Household income is determined by calculating a consumer’s modified adjusted gross income (MAGI). Note that Medicaid and CHIP assessments/determinations are currently based on the 2023 FPL from the HHS 2023 Poverty Guidelines until January or February 2024 when HHS releases the new guidelines for 2024. When HHS releases the new FPL guidelines for 2024, the Marketplace will continue using the 2023 guidelines for APTC and income-based CSR determinations until the beginning of the following OEP on November 1, 2024.

Calculating APTC

The maximum APTC a tax filer is allowed for a month is the lesser of two amounts:

• 1 The monthly premium for the essential health benefits (EHB) portion of the plan or plans in which the tax filer’s tax family enrolled (enrollment premium); and

• 2 The adjusted monthly premium for the tax filer’s applicable benchmark plan (benchmark plan premium) minus the tax filer’s monthly contribution amount, which is the amount that is 1/12 of the taxpayer’s filer household income multiplied by the applicable percentage. If the monthly contribution amount is equal to or more than the benchmark plan premium for the month, the maximum APTC for the month is zero.

An applicant’s benchmark plan premium is generally the second-lowest cost Silver plan (SLCSP) available to the applicant, adjusted for age, in the rating area where the applicant resides that covers the members of the applicant’s tax family who are enrolled in a Marketplace QHP and not eligible for non-Marketplace coverage (such as ESC), other than individual market coverage.

A tax filer’s monthly contribution amount is 1/12 of their projected annual household income multiplied by an applicable percentage available in the instructions for Form 8962. The applicable percentage is based on the tax filer’s projected household income as a percentage of the FPL. Lower income families will generally have a smaller contribution amount than families with higher household income

Income-based CSRs

CSRs reduce out-of-pocket costs, such as deductibles, coinsurance, and copayments, but not balance billing, such as from an out-of-network provider or for non-covered services. Eligibility for income-based CSRs is based on household income and generally requires the individual or family to enroll in a Silver plan category and be eligible for APTC. Agents and brokers are responsible for disclosing to consumers the higher out-of-pocket costs they may experience if they are eligible for CSRs and choose not to enroll in a Silver plan. Note that consumers who are members of federally recognized tribes or shareholders in the Alaska Native Claims Settlement Act (ANCSA) Corporations may receive CSRs if they enroll in a plan in any plan category, and those who qualify for a limited cost-sharing plan do not have to be eligible for APTC.

CSRs are not available for coverage purchased outside of the Marketplace.

Generally, individuals and families with household incomes between 100% and 250% of the FPL may be eligible to receive income-based CSRs. Consumers who are members of federally recognized tribes or ANCSA Corporation shareholders may qualify for additional cost-sharing benefits.

Eligibility for CSRs

The following are a consumer's eligibility criteria for income-based CSRs: 

• The consumer must meet the eligibility criteria for enrollment in a QHP through the Marketplace and for APTC.

• The consumer must be expected to have an annual household income of between 100% and 250% of the FPL or an annual household income of between 0% and 100% of the FPL if the individual is lawfully present but ineligible for Medicaid based on immigration status.

• The consumer must be enrolled in a Silver plan category QHP through the Marketplace.

The following are eligibility criteria for CSRs for consumers who are members of federally recognized tribes or shareholders of ANCSA Corporations: 

• The consumer must meet the eligibility criteria for enrollment in a QHP through the Marketplace.

• Consumers must be expected to have an annual household income that does not exceed 300% of the FPL to be eligible for a plan with all cost-sharing eliminated, which means these consumers will have no copayments, deductibles, or coinsurance when receiving care from Indian health care providers or when receiving EHB through a QHP. There is no need for a referral from an Indian health care provider when receiving EHB through the QHP.

• The consumer is enrolled in any plan category through the Marketplace, except for a catastrophic plan.

• Consumers with expected household incomes above 300% of the FPL may be eligible for a limited cost-sharing plan variation and have no copayments, deductibles, or coinsurance when receiving EHB furnished directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization (as each is defined in 25 U.S.C. 1603), or through referral under contract health services.

Income Calculation Tool

This video demonstrates how to use the Income Calculation Tool to assist consumers in estimating their annual income in the Marketplace application

Estimating income for a future coverage year - Income Calculating Tool Walkthrough 

Click for Video

What Income to Include in the Marketplace Application

The Marketplace uses MAGI to determine eligibility for savings. It’s not a line on your tax return.

• MAGI is the total of the following for each member of a household who’s required to file a tax return:

  • Adjusted gross income (AGI) on a federal tax return

  • Excluded foreign income

  • Nontaxable Social Security benefits (including tier 1 railroad retirement benefits)

  • Tax-exempt interest

  • MAGI does not include Supplemental Security Income (SSI)

MAGI - Modified Adjusted Gross Income

Modified Adjusted Gross Income (MAGI) The figure used to determine eligibility for premium tax credits and other savings for Marketplace health insurance plans and for Medicaid and the Children's Health Insurance Program (CHIP).

The chart below shows common types of income and whether they count as part of MAGI. If a consumer expects income types not shown or has additional questions, you should refer them to details on what the IRS counts as income(opens in a new tab)

Income Type Included as income Notes

Federal taxable wages (from your job) Yes     If your pay stub lists “federal taxable wages,” use that. If not, use “gross income” and the amounts your employer takes out of  your pay for childcare, health insurance, and  retirement plans. 

Tips Yes

j

Self-employment income Yes Include “net self-employment income” you expect - what you’ll make from your business minus business expenses. Note: You’ll be asked to describe the type of work you do. If you have farming or fishing income, enter it as either “farming or fishing” income or “self- employment,” but not both. See additional informationn on HealthCare.gov(opens in a new tab)

.

Unemployment compensation Yes Include all unemployment compensation that you receive from your state. Visit CareerOneStop's Unemployment Benefits Finder (opens in a new tab)

            for more information about unemployment in your state.

Social Security Yes Include both taxable and non-taxable Social Security income. Enter the full amount before any deductions.

Social Security Disability Income (SSDI) Yes Do not include SSI.

Retirement or pension income Yes Include most IRA and 401k withdrawals. (See details on retirement income in the instructions for IRS publication 104 0 (opens in a new tab)). Note: Don’t include qualified distributions from a designated Roth account as income.

Alimony Depends Divorces and separations finalized before January 1, 2019: Include as income. Divorces and separations finalized on or after January 1, 2019: Don’t include as  income.

Child support No

Capital gains Yes

Inestment income Yes Include expected interest and dividends earned on investments, including tax-exempt interest.

Rental and royalty income Yes Use net rental and royalty income.

Excluded (untaxed) foreign income Yes

Gifts No

Supplemental Security Income (SSI) No But do include Social Security Disability Income (SSDI).

Veterans’ disability payments     No

Worker’s compensation No

Proceeds from loans (like student loans,

home equity loans, or bank loans)     No

Child Tax Credit checks or deposits

 (from the IRS) No

Should the following types of income be included in Marketplace applications? 

• Worker’s compensation

• Capital gains from the sale of a main home if the profit is less than $250,000 ($500,000 for families filing jointly)

• Supplemental Security Income

• Child support

• Gifts

• Veteran’s disability payments

• Proceeds from loans

• Temporary Assistance for Needy Families (TANF) payments

• State tax refunds

• Alimony from divorces and separations finalized after January 1, 2019

• Non-taxable disability pensions

Answer: NO

Should the following types of income be included on Marketplace applications? 

• Tips and gratuities

• Capital gains from selling property or investments

• Social Security Income

• Social Security Disability Income

• Excluded (untaxed) foreign income

• Retirement or pension income

• Alimony from divorces and separations finalized before January 1, 2019

• Taxable Disability pensions

• Jury duty pay

• Canceled debts

• Proceeds from gambling, lottery winnings, or court awards

Answer: YES

Knowledge Check Explainer

The following types of income should be included on Marketplace applications:

• Tips and gratuities

• Capital gains from selling property or investments

• Social Security Income

• Social Security Disability Income

• Excluded (untaxed) foreign income

• Retirement or pension income

• Alimony from divorces and separations finalized before January 1, 2019

• Taxable Disability pensions

• Jury duty pay

• Canceled debts

• Proceeds from gambling, lottery winnings, or court awards

The following types of income should not be included on Marketplace applications:

• Worker’s compensation

• Capital gains from the sale of a main home if the profit is less than $250,000 ($500,000 for families filing jointly)

• Supplemental Security Income

• Child support

• Gifts

• Veteran’s disability payments

• Proceeds from loans

• Temporary Assistance for Needy Families (TANF) payments

• State tax refunds

• Alimony from divorces and separations finalized after January 1, 2019

• Non-taxable disability pensions

Assisting Consumers with Health Reimbursement Arrangements (HRAs)

Individual Coverage Health Reimbursement Arrangements 

What Is an ICHRA?

An ICHRA is a type of group health plan that reimburses medical expenses, like monthly premiums, and requires eligible employees and dependents to have individual health insurance coverage or Medicare Parts A (Hospital Insurance) and B (Medical Insurance) or Part C (Medicare Advantage) for each month they are covered by the ICHRA. Reimbursements from the ICHRA may include premiums and cost-sharing for individual health insurance coverage or for Medicare (as applicable).

How Will Consumers Know if Their Employer Offers Them an ICHRA?

An employee who is offered an ICHRA will generally get a written notice at least 90 days before the beginning of the ICHRA’s plan year. However, employees who become eligible during the plan year, or later than 90 days before the start of the plan year (such as newly-hired employees), will get their notice no later than the date on which their coverage under the ICHRA can begin. The employer notice will include key information about the ICHRA, such as the dollar amount of the HRA offer, the date that coverage under the HRA may begin, and whether the offer extends to dependents (among other things). For more information on the ICHRA employer notice, see the ICHRA Model Notice

(opens in a new tab) or the general HRA page(opens in a new tab)

ICHRA Impact on Eligibility for the PTC

It is important to understand and advise the consumers you assist that ICHRAs may impact their eligibility for the PTC for Marketplace coverage. 

• A PTC is not allowed for an individual’s Marketplace coverage if they are offered an ICHRA that is affordable. An ICHRA is considered affordable for an individual employee and their dependents if the monthly premium the employee would pay (after the employer’s reimbursement) for the self-only, lowest cost Silver plan available to them through the Marketplace in their area is less than a percentage of the employee’s projected household income, currently 9.12% of 1/12 of the employee’s yearly household income. The percentage for plan years beginning in 2024 will be available on HealthCare.gov(opens in a new tab)

• . This applies to employees as well as spouses and dependents of employees to whom the ICHRA offer extends.

• If the ICHRA is not affordable, a PTC is allowed if the employee offered the coverage “opts out” of the HRA and the other PTC requirements are met.*

• A PTC is not allowed for an individual’s Marketplace coverage if the individual chooses to be covered by an ICHRA, regardless of whether it is affordable.

• Use the “Is Your Individual Coverage HRA Offer Affordable?” online tool(opens in a new tab)

•  to help the consumers you assist determine if their ICHRA is or is not considered affordable.

For more information on ICHRAs, see: 

The HRA page at CMS.gov (opens in a new tab)

What's an ICHRA?(opens in a new tab)

Qualified Small Employer Health Reimbursement Arrangements

Small employers who do not offer group health coverage to their employees can help employees pay for medical expenses through a Qualified Small Employer HRA (QSEHRA). 

Consumers with a QSEHRA can use it to pay for health care costs incurred during the year (like a monthly premium) for MEC, including Marketplace coverage. These consumers, however, are allowed APTC for their Marketplace coverage only if the QSEHRA is considered unaffordable. If the QSEHRA is unaffordable, the consumer should lower the amount of APTC they apply to their monthly premiums by their monthly QSEHRA amount. When the Marketplace asks how much PTC the consumer wants to take in advance, they should subtract their monthly QSEHRA amount from the monthly APTC they would otherwise be eligible for. Thus, if the Marketplace finds them eligible for APTC, consumers should either forego APTC or choose an amount not more than the APTC for which they are eligible minus the QSEHRA amount provided to the consumer. 

Consumers with a QSEHRA who do not limit their APTC will likely have to pay some or all of the APTC back when they file their federal income tax return. That is because the PTC they claim on their tax return must be reduced by the amount of QSEHRA their employer provided. 

To reduce the chances of having to pay money back, it is best for consumers with a QSEHRA to forego APTC. 

If they do use it, they should be sure to reduce the monthly amount of APTC by at least the monthly amount of their QSEHRA benefit. Consumers whose PTC claimed on their tax return is more than the APTC paid on their behalf for the year of coverage receive a net PTC that reduces the tax they owe or increases their refund. 

Visit HealthCare.gov(opens in a new tab)

 for more information that will help you assist consumers who are offered a QSEHRA, including worksheets to help them determine how much APTC they should use based on the amount of their QSEHRA.

Plan Year 2024 Marketplace Coverage Module

Introduction and Objectives

Introduction

In this module you will:

• 1 Learn the basic components of a qualified health plan (QHP)

• 2 Understand how QHPs are rated 

• 3 Explore the tools available for comparing plans

Objectives

After completing this module, you should be able to:

• 1 Help consumers understand the components of a QHP that will help determine whether it’s the right fit for them.

• 2 Be able to leverage the tools available on HealthCare.gov to compare QHPs and help consumers select the best plan for them.

Qualified Health Plans

Qualified Health Plan (QHP) Overview

The Marketplace offers only health insurance plans that are certified as QHPs. Insurance companies that offer QHPs on the Marketplace are known as issuers. 

QHP issuers must be licensed and meet certain transparency requirements. All certified QHPs must meet a minimum set of criteria, including: 

• Coverage, at a minimum, of a comprehensive package of benefits, known as essential health benefits (EHB). 

• Benefit design standards, including non-discrimination requirements and limits on cost sharing.

EHB

The Affordable Care Act (ACA) requires that non-grandfathered health plans offered in the individual and small group markets offer a comprehensive package of benefits, known as EHB. EHB includes items and services within 10 benefit categories. Among other things, the ACA requires that EHB: 

• Reflects appropriate balance among the 10 EHB categories 

• Does not discriminate based on age, disability, or expected length of life 

• Takes into account the health care needs of diverse segments of the population

EHB by State

Specific health care benefits may vary by state. Even within the same state, there can be differences between health insurance plans. When consumers fill out applications and compare plans, they will see the specific health care benefits each plan offers.

Categories of EHB

EHB must include items and services within at least the following 10 categories: 

1. Maternity and newborn care 

2. Pediatric services (under certain circumstances, pediatric oral care may be excluded from a health plan’s coverage if the benefits are available as part of a Marketplace-certified stand-alone dental plan (SADP))

3. Preventive and wellness services and chronic disease management 

4. Prescription drugs 

5. Mental health and substance use disorder services, including behavioral health treatment

6. Laboratory services 

7. Rehabilitative and habilitative services and devices 

8. Hospitalization 

9. Emergency services 

10. Ambulatory patient services, such as doctor visits

Visit HealthCare.gov(opens in a new tab) for more information on EHB. 

Out of Pocket Cost Limits

Generally, all non-grandfathered health plans must limit cost sharing for enrolled individuals in the following ways: 

• Deductibles, coinsurance, and copayments cannot be applied to certain recommended preventive services.

• Annual cost-sharing limits cannot exceed specified amounts. (For 2023, the maximum annual limitation on cost-sharing is $9,100 for an individual and $18,200 for families enrolled in individual or group market plans.)

Service Area

The geographical area covered by a QHP is known as a service area. Consumers seeking to enroll in a QHP must reside within the service area for the QHP.

Plan Categories

In addition to covering EHB and limiting cost sharing (including maximum out-of-pocket costs), non-grandfathered coverage in the individual and small group markets must also provide certain plan categories.

The plan categories are Bronze, Silver, Gold, and Platinum in ascending order. These categories, sometimes referred to as “metal levels,” help consumers and the agents and brokers who assist them to compare coverage options and determine which plans best fit the consumers’ needs.

These categories are determined by the actuarial value (AV) of the plan design. AV is calculated based on the average portion of the cost of providing EHB that is estimated to be paid by the health insurance plan for a standard population. The AV calculation is expressed in percentages. Usually, the higher the AV, the more enrollees pay in monthly premiums and the less they could pay in out-of-pocket costs. Because the AV of a plan design is calculated based on a standard population, it may not be indicative of all individuals’ experiences.

Here is the breakdown of the AV percentage of each plan level.

Platinum 90% AV (the health insurance plan pays on average approximately 90% of the cost of all EHB)

Gold 80% AV (the health insurance plan pays on average approximately 80% of the cost of all EHB)

Silver 70% AV (the health insurance plan pays on average approximately 70% of the cost of all EHB)

Bronze 60% AV (the health insurance plan pays on average approximately 60% of the cost of all EHB)

Expanded Bronze 58–65% AV.  A plan may use this option if it either covers and pays for at least one major non-preventive before the deductible or meets the requirements to be a high-deductible health plan within the meaning of 26 U.S.C. 223(c)(2).

There are some limitations on a qualified individual changing plan categories, so consumers should be aware of the restrictions of each coverage option. These limitations will be covered in the next module, Assisting After Enrollment. 

QHP Networks

For QHP certification, a plan that uses a provider network must have an adequate provider network available to its enrollees. A QHP must:

• 1 Offer a network that is sufficient in number and types of providers, including mental health and substance abuse disorder providers, to ensure access to all services without unreasonable delay.

• 2 Make a good faith effort to provide written notice of discontinuation of a provider 30 days prior to the effective date of the change or otherwise, as soon as practicable, to enrollees who are patients seen on a regular basis by or who receive primary care from a provider whose contract is being discontinued. Additionally, if the provider is terminated without cause, allow an enrollee in an active course of treatment with that provider to continue treatment until it is complete or for 90 days, whichever is shorter, at in-network cost-sharing rates.

• 3 Include a sufficient number and geographic distribution of essential community providers, where available, to ensure reasonable and timely access to a broad range of such providers for low-income and medically underserved populations in the QHP’s service area.

Standards for network adequacy and essential community providers may differ in State-based Marketplace on the Federal Platform (SBM-FP) states.

Silver and Gold Plan Availability

Each issuer, in each medical market it covers – individual or Small Business Health Options Program (SHOP) - must offer at least one Silver and one Gold QHP in each service area where the issuer offers coverage through the Marketplace, and must make its QHPs available for enrollment through the Marketplace for the full plan year for which the plan was certified. 

Plan Marketing Names

For PY24, CMS will require that QHP plan and plan variant marketing names include correct information, without omission of material fact, and do not include content that is misleading. This policy will help consumers applying for coverage to understand references to benefit information in plan and plan variant marketing names, and to use this information to make an informed plan selection.

The Mental Health Parity and Addiction Equity Act

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prohibits most group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable financial requirements (such as coinsurance) and treatment limitations (such as visit limits) on those benefits than they do on medical/surgical benefits. The Affordable Care Act extended MHPAEA provisions to also apply to individual health insurance coverage, and the requirements are applied to both individual and small group market coverage in connection with the EHB requirement described on the previous page (coverage of MH/SUD services is one of the 10 EHB categories). 

For more information, please see: 

• The Mental Health Parity and Addiction Equity Act Factsheet(opens in a new tab)

•  Frequently Asked Questions(opens in a new tab)

•  about Affordable Care Act Implementation and Mental Health Parity

You helped your client, Ahmad, complete the Marketplace application and he’s ready to select a plan. You’ve helped him narrow down his options to two plans, one Gold and one Bronze. Ahmad wants to understand why the Gold plan has a much higher premium than the Bronze plan. Both are health maintenance organization (HMO) plans within the same issuer product. What is the correct response? 

• The Gold plan has a higher premium, but has lower out-of-pocket costs for essential health benefits than the Bronze plan. 

Knowledge Check Explainer

The correct answer is the Gold plan has a higher premium, but has lower out-of-pocket costs for EHB than the Bronze plan. Plan categories are determined by the AV of the plan design. AV is calculated based on the average portion of the cost of providing EHB that is estimated to be paid by the health insurance plan for a standard population. Usually, the higher the AV, the more enrollees pay in monthly premiums and the less they could pay in out-of-pocket costs.

Other Types of QHPs

      Catastrophic Plans

In addition to the four plan categories, issuers in the individual market can offer catastrophic plans. Eligibility for catastrophic plans is limited to: 

• Individuals under age 30 before the plan year begins.

• Individuals age 30 or older who have a certification from the Marketplace that they qualify for a hardship or affordability exemption. The required contribution percentage is used to determine whether individuals age 30 or older qualify for an affordability exemption that would enable them to enroll in catastrophic coverage. 

There is no specific AV for catastrophic plans. Catastrophic plans have specific cost-sharing requirements related to the annual cost-sharing limit that do not apply to plans in the four plan categories. Nevertheless, catastrophic plans have several benefits. They: 

• Offer lower premiums, on average, than Bronze, Silver, Gold, or Platinum plans 

• Cover at least three primary care visits before reaching the deductible 

• Cover recommended preventive services without cost sharing 

• Protect enrollees with a maximum out-of-pocket cost limit (The limit changes annually; for 2023, the maximum annual out-of-pocket limitation on cost sharing is $9,100 for an individual and $18,200 for a family.)

Stand-alone Dental Plans

Adult dental coverage is not an EHB and generally is not required to be included in the package of benefits offered by a health plan in the individual or small group market, including through the Marketplace. However, consumers can purchase an SADP through the Federally-facilitated Marketplaces (FFMs) and SBM-FPs, if they qualify for and enroll in a QHP. 

Pediatric dental care is an EHB that health insurance issuers must offer as part of a medical QHP if it is not otherwise available in the Marketplace through a Marketplace-certified, SADP. SADPs offered through the Marketplace must include the pediatric dental EHB and are certified as meeting many of the same standards as QHPs. In the individual Marketplace, a consumer must first enroll in a Marketplace medical QHP before purchasing an SADP.

Age Rating

• Health insurance issuers selling non-grandfathered coverage in the individual and small group markets generally are not allowed to charge an older adult more than three times the rate of a 21-year-old based on age. 

• States can establish their own age curve or default to the federal age curve. 

• Federal age bands: 0-14

  • 1. 1. 1. • One-year bands between ages 15-64

Family Rating

Family premiums are based on the premiums for each family member, including each family member’s age and tobacco use (subject to state law). The total family premium includes premiums for up to three dependent children under the age of 21 and per-member rates for adults. In the case of enrollment groups with more than three children, only the oldest three children are rated. However, under certain circumstances, states may require the use of uniform family tiers and multipliers. 

Tobacco Rating

• Health insurance issuers in the individual and small group markets generally cannot charge an individual who legally uses tobacco products more than 1.5 times the non-tobacco user’s rate based on tobacco use. 

• Tobacco rating can vary based on age (e.g., 1.2:1 for those under age 35). 

• For employer insurance plans, issuers may impose the tobacco rating factor only if a tobacco-related wellness program (such as a tobacco cessation program) that complies with federal rules regarding nondiscriminatory wellness programs is also offered. Enrollees are able to avoid the tobacco surcharge by participating in such a wellness program. 

The rating variation permitted for tobacco use can only be applied to the portion of the premium attributed to the individual family member. If one member of a family smokes, only the portion of the premium attributed to the individual’s own coverage will be affected. The portion of the premium for the other family members’ coverage is not affected.

Geographic Rating

• Premiums reflect geographic rating areas, which are set by the state. 

• For the individual market, the rating area is based on the primary policyholder’s address.

• For the small group market, rating area is based on:

  • The group policyholder’s principal business address; or

  • In some circumstances, the business address within the plan’s service area where the greatest number of employees work as of the beginning of the plan year; or

  • If there is no such business address, the rating area where the greatest number of employees within the plan’s service area live or reside as of the beginning of the plan year.

Your client, Jianxin (age 21), and his father, Aiping (age 64), are seeking your assistance with enrolling in a QHP. They live in the same county, are each single with no dependents, and are not part of the same tax household. You’ve assisted each of them in completing the Marketplace application and neither of them is eligible for advance payments of the premium tax credit (APTC) or cost-sharing reductions (CSR). Because they share many of the same doctors, they’ve selected the same Silver plan as the best fit for them. If Jianxin’s premium is $100, which of these would be an allowable premium for Aiping? 

• Answer: 300

Knowledge Check Explainer

The correct answer is $300. Health insurance issuers selling non-grandfathered coverage in the individual and small group markets generally are not allowed to charge an older adult more than three times the rate of a 21-year-old based on age.

You find out that Aiping is a tobacco user. How would that affect his premium?  

• Aiping's premium may be up to $450. 

Knowledge Check Explainer

The correct answer is Aiping’s premium may be up to $450. Health insurance issuers in the individual and small group markets generally cannot charge an individual who legally uses tobacco products more than 1.5 times the non-tobacco user’s rate based on tobacco use.

Helping Consumers Compare Plans

Easy Pricing

Within health plan categories, some plans are considered easy pricing plans. These plans are also known as standardized plan options. These plans have the same out-of-pocket costs within their health plan category for deductibles, out-of-pocket maximums, copayments, and coinsurance rates for a key set of EHB. They also include a range of benefits before a consumer reaches their deductible. For these easy pricing plans, consumers will only need to pay a copayment for services like primary care visits, urgent care visits, mental health and substance use disorder outpatient office visits, specialist visits, physical therapy, occupational therapy, speech therapy, and generic and preferred drugs – without first needing to meet the deductible.

The tables below represent the two sets of standardized plan options the Centers for Medicare & Medicaid Services (CMS) has finalized for Plan Year (PY) 2024.

Availability of Easy Pricing Plans

CMS introduced the requirement for FFM and SBM-FP issuers to offer standardized plan options at every product network type, at every metal level, and throughout every service area that they offer non-standardized QHP options beginning in PY 2023. CMS slightly modified this requirement for PY 2024 by specifying that FFM and SBM-FP issuers are no longer required to offer standardized plan options at the non-expanded Bronze metal level (but are still required to offer standardized plan options at the expanded Bronze metal level if a non-standard Bronze plan (non-expanded or expanded) is offered).

CMS also limits the number of non-standardized plan options that FFM and SBM-FP issuers offer through Marketplaces to four non-standardized plan options per product network type and metal level (excluding catastrophic plans), and dental/vision add-on in any service area, for PY 2024 as a condition of QHP certification.

1.- Quality Ratings

To help consumers decide what plan is right for them, the Marketplace displays “quality ratings” calculated using information health plans provide each year. See the

 Choosing a High-Quality Marketplace Health Plan tipsheet(opens in a new tab)

 for more information on quality ratings.  

Summary of Benefits and Coverage (SBC)

2.- Summary of Benefits and Coverage (SBC)

To help consumers compare the different features of health benefits and coverage, the ACA generally requires all group health plans and health insurance companies to provide individuals a “summary of benefits and coverage” that “accurately describes the benefits and coverage under the plan.”

The Summary of Benefits and Coverage (SBC) is a snapshot of a health plan’s costs, benefits, covered health care services, and other features that are important to consumers. SBCs also explain health plans’ unique features like cost-sharing rules and include significant limits and exceptions to coverage in easy-to-understand terms. 

Consumers may access the SBC within each health plan’s detailed view at HealthCare.gov or an approved Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) entity website. For additional information about SBCs, please see the Summary of Benefits and Coverage Fast Facts tipsheet(opens in a new tab)

3.- Silver Plans for CSR-Eligible Consumers

As a reminder, CSRs are discounts that lower the amount a consumer has to pay for deductibles, copayments, and coinsurance. The eligibility determination notice each consumer receives after completing the Marketplace application will identify if the consumer is eligible for CSRs. To qualify for CSRs based on a consumer’s household income, consumers must enroll in a QHP in the Silver category to get these extra savings. When assisting consumers to make a plan selection, agents and brokers should discuss the benefits of enrolling in a Silver plan if they are eligible for CSRs.

4.- Plan Compare Tools for Consumers

You can assist a consumer with searching for their doctors, medical facilities, and prescription drugs when they compare plans on HealthCare.gov. Just select their doctors, hospitals and other medical facilities, and prescription drugs before viewing their available plans. Then when the plan compare displays, HealthCare.gov will tell you if each plan covers them in network. This feature is also available within the See Plans & Prices Tool(opens in a new tab)

 without logging in. Approved DE and EDE partners may offer different functionality to allow agents and brokers to view available plans and search for doctors, medical facilities, and prescription drugs in the plan’s network. 

Knowledge Review

Roberto is a 20-year-old male who lives by himself in Lubbock County, Texas. Roberto’s projected annual income is $23,783, which is 175% of the Federal Poverty Level (FPL) and makes Roberto eligible for APTC and an income-based CSR. Roberto is single and will claim no dependents on his tax return. Below are examples of the Marketplace plans and savings Roberto might be eligible for. You are assisting Roberto with selecting the best plan for him. Click each card below to explore information you might want to share with Roberto about each of these plan choices.

Bronze

Estimated Monthly Premium: $0

Deductible: $4,000

Out-of-Pocket Maximum: $8,700

The Bronze plan may be the right choice for Roberto if he has no discretionary income to spend on premiums. In a best-case scenario where Roberto does not use coverage for the year, enrolling in $0 premium Bronze plan will save him less than $100 per year as compared to enrolling in a Silver or Gold plan. However, Roberto may be more likely to delay needed care in this plan.

Silver

Estimated Monthly Premium: $5.73

Deductible: $1,800

Out-of-Pocket Maximum: $1,800

Enrolling in a Silver plan with a small monthly premium of less than $10 per month could end up saving Roberto thousands of dollars in out-of-pocket costs over the year.

Gold

Estimated Monthly Premium: $1.85

Deductible: $750

Out-of-Pocket Maximum: $8,700

In a worst-case scenario, Roberto might have to pay almost $7,000 more out of pocket in a Gold plan compared to a Silver plan. 

Plan Year 2024 Maintaining Compliance Module

Introduction and Objectives

Agents and brokers who operate in the Health Insurance Marketplace® will gain access to personally identifiable information (PII). As an agent or broker, you are responsible for applying certain controls and implementing specific steps to protect information within the Marketplace. During this module you will:

• Learn the Federally-facilitated Marketplace (FFM) standards of conduct for an agent or broker.

• Understand requirements and best practices for accessing and storing PII.

• Know how to report any breaches of systems or information.

• Establish the proper uses for CMS systems.

• Explore penalties for non-compliance with Marketplace regulations.

FFM Standards of Conduct for Agents and Brokers

HHS has established standards of conduct for agents, brokers, and web-brokers who participate in the Marketplace in order to protect against conduct that is harmful to consumers or prevents the efficient operation of the Marketplace. See 45 C.F.R. § 155.220(j). Agents and brokers who participate in the Marketplace must:

• 1 Provide consumers with correct information, without omission of material fact, regarding the Marketplace, qualified health plans (QHPs) offered through the Marketplace, and insurance affordability programs.

• 2 Refrain from marketing or conduct that is misleading (including having a Direct Enrollment (DE) website that HHS determines could mislead a consumer into believing they are visiting the Marketplace or HealthCare.gov), is coercive, or discriminates based on race, color, national origin, disability, age, or sex. Purchasing or accepting sales leads from entities, such as a lead generation company, that engage in deceptive marketing practices or make statements that are false or deceptive may also violate this agent and broker requirement to refrain from marketing or conduct that is misleading. 

• 3 Obtain consent and document receipt of consent from the qualified individuals, qualified employers, or qualified employees prior to assisting with or facilitating enrollments through the FFM, making updates to an existing application or enrollment, or assisting an individual with applying for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSRs) for QHPs. More information regarding consumer consent will be presented later in this training. 

• 4 Document that eligibility application information has been reviewed by and confirmed to be accurate by the consumer or their authorized representative designated in compliance with § 155.227, prior to application submission.

Overview

 Agents and brokers must provide the Marketplace with correct information under Section 1411(b) of the Affordable Care Act (ACA). This includes, but is not limited to, entering an application for Marketplace coverage correct:

1.- Name and date of birth

The name and date of birth of each individual who is to be covered by the plan.

2.- Citizenship or immigration status and Social Security Number (SSN)

In the case of an enrollee whose eligibility is based on an attestation of citizenship of the enrollee, this requirement includes the enrollee’s SSN. In the case of an individual whose eligibility is based on an attestation of the enrollee’s immigration status, this requirement includes the enrollee’s SSN (if applicable) and such identifying information with respect to the enrollee’s immigration status.

3.- Household income projections

An agent, broker, or web-broker may only enter a household income projection for a consumer that the consumer or the consumer’s authorized representative has attested to and confirmed is an accurate estimate. 

4.- Mailing addresses

Mailing addresses that belong to, or that are primarily accessible by, the consumer or their authorized representative. The mailing address entered on the eligibility application must not be for the exclusive or convenient use of the agent, broker, or web-broker, and must be an actual residence or a secure location where the consumer or their authorized representative may receive correspondence, such as a P.O. Box or homeless shelter. Mailing addresses entered on eligibility applications may not be that of the agent, broker, or web-broker, or their business or agency, unless it is the rare situation where that address is the actual residence of the consumer or their authorized representative.

5.- Telephone numbers

Telephone numbers that belong to the consumer or the consumer’s authorized representative. A telephone number belongs to the consumer if they, or their authorized representative, are accessible at the number and have access to the number. Telephone numbers entered on eligibility applications may not be the personal number or business number of the agent, broker, or web-broker assisting with or facilitating enrollment, or their business or agency, unless the telephone number is actually that of the consumer or their authorized representative.

6.- Email addresses

Email addresses that belong to the consumer or the consumer’s authorized representative. Email addresses may only be entered on applications submitted to a Marketplace with the consent of the consumer or the consumer’s authorized representative. Properly entered email addresses are also required to adhere to certain guidelines set forth in regulation.

In Addition

Agents and brokers who participate in the Marketplace also must: 

• Protect consumers' PII in accordance with 45 CFR § 155.260(b)(3) and the FFM privacy and security standards required by the “Agreement Between Agent or Broker and the Centers for Medicare & Medicaid Services for Individual Market Federally-facilitated Exchanges and the State-Based Exchanges on the Federal Platform” (Individual Marketplace Privacy and Security Agreement) and/or the “Agreement Between Agent or Broker and CMS for the Small Business Health Options Programs (SHOP) of the Federally-facilitated Exchanges and State-based Exchanges on the Federal Platform" (SHOP Privacy and Security Agreement).

• Comply with all applicable federal and state laws and regulations.

Note that the FFM privacy and security standards require an agent, broker, or web-broker to provide a Privacy Notice Statement to consumers prior to collecting their PII. The Statement must describe the authorized uses and disclosures of any consumer PII that is collected. 

Obtaining Consumer Consent 

Assisting agents or brokers must obtain consumer consent directly from the consumer or their authorized representative. Consumer information received through third-party means, such as a lead-generator or another agent’s book of business, does not constitute consent in a manner that complies with 45 CFR 155.220. Though agents and brokers are currently required to obtain the consent of the individual, employer, or employee prior to providing such assistance (which includes before conducting person searches), or assisting an individual in applying for APTC and CSRs for QHPs, the 2024 Notice of Payment and Benefit Parameters introduced a new requirement that this consent be documented to include; the date consent was given, name of the consumer or the consumer’s authorized representative, the name of the agent, broker, web-broker, or agency being granted consent, a description of the scope, purpose, and duration of the consent provided by the individual or their authorized representative, as well as the process by which the individual or their authorized representative may rescind such consent. That documentation of the consumer’s consent must be maintained by the agent, broker, or web-broker for a minimum of 10 years and produced upon request by HHS in response to monitoring, audit, and enforcement activities conducted consistent with § 155.220(c)(5), (g), (h) and (k). CMS does not prescribe the specific method of documentation that is necessary to document receipt of consumer consent.

Agents, brokers, and web-brokers have flexibility to determine how they will meet the consent and recordkeeping requirements. While CMS does not specify a form to be signed, agents, brokers, and web-brokers can use an Agent of Record (AOR) or Broker of Record (BOR) form from an issuer or state Department of Insurance (DOI) to satisfy this requirement. New in Plan Year 2024, CMS has published a model agent/broker consent form. The form is available on the CMS website(opens in a new tab)

As stated above, at a minimum consent documentation must include:

• 1 The date consent was given. 

• 2 The name of the consumer or their authorized representative.

• 3 The name of the agent, broker, web-broker, or agency being granted consent. 

• 4 A description of the scope, purpose, and duration of the consent provided by the individual.

• 5 The process by which the individual may rescind such consent.

Agents, brokers, and web-brokers providing assistance verbally (such as over the phone) may obtain consent by engaging in a conversation with the consumer or their authorized representative that, at a minimum, contains the required elements of consent that are summarized above. This conversation should be documented in some fashion, such as through a voice recording software, email summary, text message or other method, and maintained by the assisting agent, broker, or web-broker. 

CMS does not specify an automatic expiration date for the consent because it could become burdensome for anyone consistently seeking services from the same agent, broker, or web-broker to have to repeatedly renew the consent. Therefore, the consent may last indefinitely, unless the individual, employer, or employee revokes it or indicates a specific revocation date in initial consent. Documents to demonstrate and record consent from Marketplace consumers must be appropriately secured and retained for 10 years. 

Documenting Consumer Review of the Eligibility Application

Agents, brokers, and web-brokers are required to document that eligibility application information has been reviewed by and confirmed to be accurate by the consumer or the consumer’s authorized representative prior to application submission.

Such documentation must be created by the assisting agent, broker, or web-broker and would require the consumer or their authorized representative to take an action, such as providing a signature or a recorded verbal confirmation, that produces a record that can be maintained by the agent, broker, or web-broker. 

Documentation must include the date the information was reviewed, the name of the consumer or their authorized representative, an explanation of the attestations at the end of the eligibility application, and the name of the agent, broker, or web-broker providing assistance. 

The documentation must be maintained by the agent, broker, or web-broker for a minimum of 10 years and produced upon request in response to monitoring, audit, and enforcement activities conducted consistent with § 155.220(c)(5), (g), (h) and (k). CMS does not prescribe the specific method of documentation that is necessary to document that eligibility application information has been reviewed and confirmed to be accurate by the consumer or their authorized representative.

As a reminder, entering an SSN on the Marketplace application is required if the consumer has an SSN. 

By not entering an SSN when the consumer has one you put them at risk of losing coverage or financial assistance        and yourself at risk of losing commissions. 

The best time to act is when you start a new application at initial enrollment or update an existing one at renewal!

     You can also update an application with missing information after submission.

Properly Entered Email Addresses

As a reminder, based on the agent and broker agreement that you sign annually, properly entered email addresses must adhere to the following guidelines:

1. The email address must be accessible by the consumer, or the consumer’s authorized representative designated in compliance with § 155.227, and may not be accessible by the agent, broker, or web-broker assisting the consumer; and

2. The email address may not have domains that belong to the agent, broker, or web-broker or their business or agency.

Collecting and Protecting Personally-Identifiable Information (PII)

Marketplace Definition of PII

PII is defined to have the meaning contained in Office of Management and Budget (OMB) Memoranda M-17-12 (January 3, 2017) and refers to information that can be used to distinguish or trace an individual's identity, either alone or when combined with other information that is linked or linkable to a specific individual. Section II(b) of the Individual Marketplace Privacy and Security Agreement and the SHOP Privacy and Security Agreement specifies the types of PII that an individual may encounter in performing the role of an agent or broker in the Individual Marketplace or SHOP. It is important that you are familiar with this federal definition and how it applies to Marketplace information.

A key component to the definition is that PII involves information that is linked or linkable to a specific individual. Therefore, if it is possible to link information to an individual, this information would be considered PII, even if it has not yet been linked to that individual.

Examples of PII include name, SSN, address, email address, phone number, and date of birth, among others. This is not an exhaustive list. 

Marketplace-Specific Rules for PII

The Marketplace needs to create and collect PII to determine eligibility for enrollment in QHPs and insurance affordability programs. Per the ACA and 45 CFR § 155.260(b)(3), the Marketplace; entities that gain access to PII submitted to the Marketplace; or entities that collect, use, or disclose PII gathered directly from Marketplace applicants (like agents and brokers) must also comply with appropriate privacy and security standards that are generally consistent with nine principles.

Prohibited Uses and Disclosures of PII

Agents and brokers who participate in the Marketplace must comply with the specification for prohibited uses and disclosures of PII contained in Appendix A of the Individual Marketplace Privacy and Security Agreement or the SHOP Privacy and Security Agreement.

• Agents and brokers shall not request information regarding citizenship, status as a national, or immigration status for individuals who are not seeking coverage for themselves on any application.

• Agents and brokers shall not use PII to discriminate, including employing marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs in QHPs.

• Agents and brokers shall not require individuals who are not seeking coverage for themselves to provide their SSNs, except if applicants’ eligibility for help with paying for coverage is reliant on tax filers’ tax returns and their SSN is relevant to verification of household income and family size.

Corrections to PII

Agents and brokers must offer individuals and entities an opportunity to request amendment, correction, substitution, or deletion of PII that is maintained and/or stored by the agent or broker if such individual or entity believes that the PII is not... 

• Accurate

• Timely

• Complete

• Relevant

• Necessary

 ...to accomplish a Marketplace-related function, or if the PII was obtained without the consumer’s consent. This is true except where the information in question originated from other sources, in which case the individual or entity should contact the originating source. Such requests must be granted or denied within no more than 10 business days of receipt and, if applicable, the PII should be corrected, amended, substituted, or deleted in accordance with applicable law.

Your client receives the following voicemail on their phone: 

Hello, my name is Rick and I’m calling on behalf of Affordable Health Care Agency for George Smith. I’m reaching out to confirm that you live at 1010 Blueberry Lane and this is a good phone number to reach you. We are hoping to confirm some information for your HealthCare.gov application. Please give us a call back when you can. Thanks!

Your client does not know this person or their agency. You should instruct your client to:4

• Instruct your client not to call back and to report the incident to the Marketplace Call Center.  

Knowledge Check Explainer 

The correct answer is to instruct your client not to call back and to report the incident to the Marketplace Call Center. It is important that you educate your clients on the importance of being cautious about sharing their information over the phone or via email or text message. If a consumer shares their information with someone other than their agent or broker, it may lead to the creation of data matching issues (DMIs) and fraud. 

Privacy Versus Security

Privacy and security are similar. They are operationally achieved through a blended approach of developing and implementing effective policies and procedures and applying proper controls to protect PII. However, they mean different things. 

Privacy is an individual’s right to control the use or disclosure of personal information.

Security is the mechanisms in place to protect the confidentiality, integrity, and availability of personal information and to prevent unauthorized or inappropriate access, use, or disclosure.

FFM Privacy and Security Standards

• 1 Individuals should be provided with a simple and timely means to access and obtain their PII in a readable form and format.

• 2 Individuals should be provided with a timely means to dispute the accuracy or integrity of their PII and to have erroneous information corrected or to have a dispute documented if their requests are denied.

• 3 There should be openness and transparency about policies, procedures, and technologies that directly affect individuals and/or their PII.

• 4 Individuals should be provided reasonable opportunity and capability to make informed decisions about the creation, collection, disclosure, access, maintenance, storage, and use of their PII.

• 5 Persons and entities should take reasonable steps to ensure that PII is complete, accurate, and up-to-date to the extent necessary for the person’s or entity’s intended purposes, and has not been altered or destroyed in an unauthorized manner.

• 6 Agents and brokers must comply with all other applicable state and federal laws related to the privacy and confidentiality of PII. Certain functions of agents and brokers may be subject to the privacy standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). It is always up to individual agents or brokers to understand which privacy laws and regulations their functions are subject to, and to fully comply with those laws.

• 7 These principles should be implemented, and adherence assured, through appropriate monitoring, and other means and methods should be in place to report and mitigate non-adherence and breaches.

• 8 PII should be protected with reasonable operational, administrative, technical, and physical safeguards to ensure its confidentiality, integrity, and availability, and to prevent unauthorized or inappropriate access, use, or disclosure.

• 9 PII should be created, collected, disclosed, accessed, maintained, stored, and used only to the extent necessary to accomplish a specific purpose and never to discriminate inappropriately.

Informed Consent

Any such consent that individuals give for disclosure of their PII serves as the basis of a use or disclosure and must:

• Be provided in specific terms and in plain language.

• Identify the entity collecting or using the PII, and/or making the disclosure.

• Identify the specific collections, use(s), and disclosure(s) of specified PII with respect to a specific recipient(s).

• Provide notice of an individual’s ability to revoke the consent at any time.

Securing Consent Documents

Consent documents must be appropriately secured and retained for 10 years. Individuals have the opportunity to rescind consent and terminate their relationship with an agent or broker at any time. The Individual Marketplace Privacy and Security Agreement and the SHOP Privacy and Security Agreement describe authorized functions for the Individual Marketplace and for the SHOP.

How Agents and Brokers may Create, Collect, Disclose, Access, Maintain, Store, and use PII 

Section II(a) of the Individual Marketplace Privacy and Security Agreement identifies the following authorized functions for which the agent, broker, or entity who established this account and whose name appears on the Marketplace Learning Management System (MLMS) account, may create, collect, disclose, access, maintain, store, and use PII in a Federally-facilitated Individual Marketplace and State-based Marketplace on the Federal Platform (SBM-FP) Individual Marketplace.

Handling of Federal Tax Information

Federal Tax Information (FTI) is classified as confidential and may not be used or disclosed except as expressly authorized by the Internal Revenue Code, which may require signed written consent of a taxpayer in certain situations. 

As an agent or broker operating in an Individual Marketplace, you are not authorized to access FTI obtained by a Marketplace from the Internal Revenue Service (IRS) verification service at any time. However, it is possible that you may encounter FTI if you are an agent or broker and also a tax return preparer or work closely (e.g., share an office) with a tax return preparer (even if for a small number of clients). In this case, you are subject to the tax return preparer disclosure rules set forth in Internal Revenue Code § 7216(opens in a new tab)

Privacy Notice Statement

Agents or brokers may create, collect, disclose, access, maintain, store, and use PII from individuals or entities only for the functions and purposes listed in the Privacy Notice Statement and any relevant agreements in effect at the time the information is collected, unless the Marketplace or the agent or broker obtains informed consent from such individuals.

Prior to collecting PII, agents and brokers must provide a Privacy Notice Statement that is prominently and conspicuously displayed on a public-facing website, if applicable, or on the electronic and/or paper form the agent or broker uses to gather and/or request the PII. 

The statement must be written in plain language and provided in a manner that is accessible and timely to people living with disabilities and with limited English proficiency. 

Appendix A Standard 2a in the Individual Marketplace Privacy and Security Agreement and the SHOP Privacy and Security Agreement contains more information on the requirements for a Privacy Notice Statement.

The statement must contain, at a minimum, the following information (agents and brokers should substitute the content in brackets with content that is specific to their operations.)

Privacy Notice Statement

We are authorized to collect personally identifiable information (PII) from you by [legal authority to collect PII]. Any PII we collect is used to [purpose of the information collection].

If you choose to give us PII, we may share this information with [to whom PII might be disclosed, and for what purposes]. PII is used or disclosed only under the following circumstances: [authorized uses and disclosures of any collected information].

[Indicate whether the request to collect PII is voluntary or mandatory under the applicable law]. If you choose not to provide us with the PII requested, or not to respond to certain questions, [effects of non-disclosure if an individual chooses not to provide the requested information].

Access to PII

Agents or brokers must implement policies and procedures that provide access to PII upon request. Access rights must apply to any PII that is created, collected, disclosed, accessed, maintained, stored, and used by the agent or broker to perform any of the authorized functions outlined in the Individual Marketplace Privacy and Security Agreement and the SHOP Privacy and Security Agreement.

If the consumer or entity… Then the agent or broker… 

Requests access to PII pertaining to the consumer

and/or the person the entity represents

Must review the request and grant or deny access      within 30   days of receipt of the request

Has not been specific regarding which PII they 

would like to access

 Should send the request back to the consumer or        entity and may offer to assist the consumer in            determining the consumer’s information needs.

Requests a paper or electronic copy of PII and/or 

requests that it be mailed

May charge a fee only to recoup costs for labor for copying the PII, supplies for creating a paper or a copy of the electronic media, and/or postage if the PII is mailed and may charge for any costs for preparing an explanation or summary of the PII, if the recipient has requested and/or agreed to receive such summary. 

What Standards are there for Business Partners?

Agents and brokers operating in the Individual Marketplace or SHOP must obtain prior written consent from CMS before subcontracting or delegating any of the agent or broker services or obligations.

You are also bound to require that persons with whom or businesses with which you partner or contract to perform or fulfill your authorized functions (herein, your “business partners”) comply with the FFM privacy and security standards. If you have a business partner that assists in performing Marketplace functions involving PII, you must legally obligate the business partner or associate to meet or exceed the same set of standards.

Beyond the requirement to meet or exceed standards, you may also want to consider addressing topics like these within legal agreements with business partners:

• How compliance is assessed.

• Validation steps for PII handoffs to ensure data quality and integrity.

Reporting Fraudulent Activity

As you provide assistance to clients seeking health coverage, you play an important role in observing and reporting any potentially fraudulent practices taking place in relation to the Marketplace. Examples of potential fraud or abuse include: 

• A client tells you they have been contacted by an individual seeking their personal and financial information.

• An individual or agent/broker submits false documentation to the Marketplace.

• An agent or broker is conducting person searches or enrolling consumers without their consent.

• An agent or broker is assisting consumers without a valid license or without completing FFM registration.

• An individual or agent/broker has disclosed a consumer’s PII.

• An individual or agent/broker discovers unauthorized changes were made to a consumer’s online application.

• An individual suspects a consumer or insurance company is providing false or misleading information to the Marketplace.

How to Report Fraudulent Activity 

Report the following activity to the applicable agencies:

Help Desk    Contact      Purpose

MS FFM Agent/Broker 

Email Help Desk FFMProducer-AssisterHelp

 Desk@cms.hhs.gov            Unregistered agents or brokers operating in the Marketplace

• Inappropriate agent or broker marketing, enrollment, or systems access practices including accessing or updating consumer PII without consumer consent

• Submission of false information to the Marketplace

HHS Office of Inspector

 General Hotline

• Link (opens in a new tab) HHS employee fraud or misconduct Grant and contract fraud

Federal Trade Commission Link(opens in a new tab) Identify theft

    Contact from someone posing to be from the government