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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.
In this article we'll cover:
Marketplace types
The term Marketplace, also called an exchange, can refer to either the Federally Facilitated Marketplace (FFM) or a State-based Marketplace (SBM). The type of Marketplace a consumer uses depends on the state where they live.
Federally Facilitated Marketplace (FFM)
Federally Facilitated Marketplace (FFM)
The FFM is operated by the federal government through the Centers for Medicare & Medicaid Services (CMS). Most states use the FFM.
Agents selling in FFM states must complete annual FFM certification to sell ACA plans. HealthSherpa supports enrollment submissions for all states that use the FFM.
State-based Marketplace (SBM)
State-based Marketplace (SBM)
SBMs, also called State-based Exchanges (SBEs), are operated independently by individual states. States that use an SBM have their own rules, Open Enrollment dates, and certification requirements that differ from the FFM.
HealthSherpa supports enrollment submissions in Georgia, which uses an SBM called Georgia Access. For all other states using an SBM, agents can get a quote and shop for plans using HealthSherpa. When it is time to apply and complete an enrollment submission, HealthSherpa will direct the agent to the state's SBM website.
While most states use the FFM, agents should review the Marketplace types for each state they plan to sell in annually.
On-exchange vs. off-exchange plans
Plans can be purchased either on-exchange or off-exchange. The key difference is whether the plan goes through the Marketplace, also called the exchange.
On-exchange plans
On-exchange plans
On-exchange plans are purchased through the Marketplace and are subsidy eligible.
Consumers complete a subsidy application where the Marketplace asks for information about the consumer’s household to determine eligibility for coverage and financial assistance. An enrollment submission takes place once the plan selection is finalized and the subsidy application is submitted.
Consumers do not have to be subsidy eligible to purchase Marketplace coverage, and they are not required to use financial assistance they may be eligible to receive.
Off-exchange plans
Off-exchange plans
Off-exchange plans do not go through the Marketplace and are not subsidy eligible.
Consumers do not complete a subsidy application. An enrollment submission takes place once the plan selection is finalized and the off-exchange application is completed.
Consumers who are subsidy eligible are not required to use financial assistance they may be eligible to receive, and can choose to purchase off-exchange coverage if desired.
All ACA-compliant plans must cover the same essential health benefits, whether the plan is purchased on-exchange or off-exchange. Plan availability and pricing can vary when shopping on-exchange vs. off-exchange, depending on the state and carriers.
Plan categories
ACA health plans are categorized into metal levels that reflect how costs are shared between the consumer and the carrier.
The four main metal levels on and off-exchange are:
Bronze: Lower monthly premiums and higher out-of-pocket costs for the consumer when care is used.
Silver: Mid-range premiums and cost sharing between the consumer and the carrier when care is used.
Gold: Higher monthly premiums and lower out-of-pocket costs for the consumer when care is used.
Platinum: Highest monthly premiums and lowest out-of-pocket costs for the consumer when care is used.
On-exchange plans, also called Marketplace plans, are subsidy eligible.
Subsidies
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).
Advance premium tax credit (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.
Cost-sharing reduction (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.
When the consumer completes a subsidy application, the Marketplace determines the tax household’s eligibility for coverage and financial assistance.
HealthSherpa & the Marketplace
HealthSherpa is an Enhanced Direct Enrollment (EDE) partner, which means agents can shop, apply, & manage enrollment submissions directly through the HealthSherpa account without leaving the platform for states using the FFM as well as in Georgia.
After an enrollment is submitted, additional milestones may be required for coverage to take effect. Review the overview of the enrollment journey for on-exchange plans, off-exchange medical plans, or off-exchange dental plans to learn more.
Frequently asked questions
Does HealthSherpa support enrollments for all states?
No. HealthSherpa supports enrollment submissions for all states that use the FFM. HealthSherpa also supports enrollments in Georgia, which uses an SBM called Georgia Access.
For all other states utilizing an SBM, agents can get a quote and shop for plans using HealthSherpa. When it is time to apply and complete an enrollment submission, HealthSherpa will direct the agent to the state's SBM website.
Does HealthSherpa display all available carriers in a consumer's area?
Plan display depends on the account type, whether the plan is on-exchange or off-exchange, and whether it is a medical or dental plan.
For on-exchange plans, HealthSherpa for Agents and Enrollee Assistance Full-Service accounts display all plans available in the consumer's ZIP code & county by default. Carrier-specific accounts display plans from a single carrier only. Review creating an account and carrier settings to learn more.
For off-exchange medical and dental plans, HealthSherpa supports select carriers and states. Review off-exchange medical plans and off-exchange dental plans for the current list of available carriers by state.
What is a Marketplace Eligibility Notice?
A Marketplace Eligibility Notice is an official letter from the Marketplace that is generated after a consumer's subsidy application is submitted. This notice explains the household's coverage eligibility and financial assistance, along with any follow-up actions needed to resolve DMIs & SVIs.
What are enrollment periods?
Enrollment periods determine when consumers can enroll in Affordable Care Act (ACA) coverage or change ACA plans. Outside of Open Enrollment, a consumer typically needs a qualifying life event (QLE) to qualify for a Special Enrollment Period (SEP).
Both on and off-exchange medical plans require the consumer to be within an enrollment period to enroll in or change ACA-compliant coverage. Off-exchange dental plans can be sold year-round and do not require the consumer to be within an enrollment period to enroll.
What does federal poverty level mean?
Subsidy eligibility for a tax household is based in part on the federal poverty level (FPL). The federal poverty level (FPL) is a measure of income updated each year that is used to determine eligibility for certain programs and benefits such as ACA subsidies, Medicaid, and the Children’s Health Insurance Program (CHIP).
The 2025 FPL chart will be used to determine subsidy eligibility during plan year 2026 Open Enrollment Period.
What does effectuate mean?
Enrollment effectuation means coverage begins. Coverage takes effect only after all required post-submission milestones are completed.
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.
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