Agents working in the Affordable Care Act (ACA) Marketplace will encounter consumers who may be eligible for, currently enrolled in, or transitioning between government health programs. Understanding these different programs helps agents guide consumers to the right option.
In this article we'll cover:
Marketplace
An Affordable Care Act (ACA) Marketplace is an official health insurance exchange where consumers can shop for ACA health plans, apply for coverage, & find out whether they’re eligible for financial assistance.
Medicaid
Medicaid is a government health program that provides free or low-cost coverage for people with low income. Eligibility is based on household income and rules set by both the state and federal government.
Unlike Marketplace coverage, Medicaid applications are accepted year-round. If a consumer is found eligible for Medicaid during the Marketplace application process, they will be directed to their state's Medicaid agency to complete enrollment.
Consumers who are eligible for Medicaid are generally not eligible for subsidies.
CHIP
The Children's Health Insurance Program (CHIP) is a state-run program that provides free or low-cost health coverage for children in families who earn too much to qualify for Medicaid but cannot afford private insurance. Some states also extend CHIP coverage to pregnant individuals.
CHIP applications are accepted year-round. If a child qualifies, coverage can begin right away.
Children who qualify for CHIP are generally not eligible for subsidies. While a child who qualifies for CHIP may be included on a family Marketplace plan, their portion of the premium typically does not qualify for subsidies.
An exception applies in states with a waiting period before CHIP coverage begins. During that waiting period, children may qualify for subsidies. Once the waiting period ends and CHIP coverage is available, subsidy eligibility for those children typically stops.
Many families choose to have parents covered by a Marketplace plan with subsidies, while their children are covered by CHIP.
Medicare
Medicare is a federal health insurance program primarily for people age 65 and older. Some younger people also qualify due to a qualifying disability, End-Stage Renal Disease (ESRD), or ALS (amyotrophic lateral sclerosis).
Consumers who are enrolled in Medicare are not eligible for Marketplace subsidies and should not enroll in Marketplace coverage. Learn more about Medicare and the Marketplace here.
HealthSherpa is an ACA enrollment platform. Agents who work with consumers approaching Medicare eligibility or who have Medicare leads have two options within HealthSherpa:
HealthSherpa for Medicare: A separate enrollment platform where agents can shop, enroll, & support consumers enrolled in Medicare. Agents can switch to HealthSherpa for Medicare using the Candy box icon in the top right corner of the HealthSherpa dashboard.
Medicare Referrals program: Agents who are not certified to sell Medicare can refer Medicare leads to HealthSherpa's Medicare team. The Medicare team completes a needs analysis & helps the consumer enroll in a Medicare plan.
Resources
Some consumers fall into a coverage gap: their income is too high for Medicaid but too low or too high to qualify for a subsidy on a Marketplace plan. Agents can help these consumers understand their available options.
When a consumer doesn't qualify for Medicaid or a subsidy
When a consumer doesn't qualify for Medicaid or a subsidy
Coverage options to review with the consumer
Purchase a Marketplace plan at full price without using financial assistance
Consider off-exchange plans sold directly by carriers, confirming the plan is ACA-compliant
Look at high-deductible health plans (HDHPs) paired with a health savings account (HSA)
Check eligibility for a Catastrophic plan (available to consumers under 30, or those with a hardship or affordability exemption)
Join an employer plan if the consumer or a family member has access to one
Use COBRA or state continuation coverage if the consumer recently lost job-based insurance (compare costs with Marketplace plans before recommending)
Additional considerations
Some states offer additional programs or a Basic Health Program
Pregnant individuals and children may still qualify for CHIP or Medicaid even if the adults in the household do not
Hospitals and community health centers may provide financial assistance or charity care
Federally Qualified Health Centers (FQHCs) offer no-cost or low-cost care based on income
Prescription savings programs and generic drug options can help reduce costs
Short-term or limited-benefit plans exist but may exclude pre-existing conditions and essential health benefits; agents should review these plans carefully with the consumer before enrollment
Because Medicaid and CHIP applications are accepted year-round, agents should encourage consumers in a potential coverage gap to recheck their application and confirm that household size and income were reported correctly before ruling out eligibility.
Consumers going through a difficult time can access programs that may help with food, child care, and household expenses. Agents can share the following resources with consumers as needed.
Emergency resources for consumers
Emergency resources for consumers
Food assistance
SNAP (Supplemental Nutrition Assistance Program): Federal program providing monthly benefits for groceries
Feeding America: Locates local food banks
Food Pantries: Locates food pantries by state or ZIP code
WIC Program (Women, Infants, and Children): Nutrition & food support for pregnant individuals, new parents, & young children
Meals on Wheels America: Meal delivery for seniors & individuals with limited mobility
Help paying bills
USA.gov Help Paying Bills: Official guide to assistance with rent, utilities, medical bills, & more
Frequently asked questions
What is a subsidy?
A subsidy is federal financial assistance designed to lower the cost of health insurance purchased through the Marketplace. Subsidy eligibility can consist of both advance premium tax credit (APTC) and cost-sharing reduction (CSR).
APTC: A dollar amount that may be applied on a consumer's behalf to their monthly health insurance premium. APTC can be applied to all metal levels and may appear as Estimated savings in HealthSherpa.
On-exchange dental: If a consumer has leftover APTC dollars after selecting the Marketplace health plan, remaining APTC may be applied to the portion of the on-exchange dental premium that covers pediatric dental essential health benefits.
CSR: A discount applied to silver level plans that lowers deductibles and out-of-pocket costs for care and prescription drugs. Consumers who are eligible for APTC may also be eligible for CSR. Consumers who are not eligible for APTC are not eligible for CSR.
Additional resources
For help using HealthSherpa or for other assistance, contact Agent Support. Agent Support is available by phone at (888) 684-1373, by email at Agent_Support@HealthSherpa.com, or by chat directly from your account.