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Applying refers to updating or beginning a consumer’s subsidy application so the Marketplace can determine the household’s eligibility for coverage and financial assistance. Agents can complete a subsidy application by searching the Marketplace or by selecting Enroll now after getting a quote.
In this article we’ll cover:
Applying for a subsidy is not applicable for Off-Exchange medical plans and Off-Exchange dental plans.
Subsidies at a glance
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.
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.
With consent, agents can begin the subsidy application process for a consumer by searching the Marketplace.
Searching the Marketplace
The Start application & Search Marketplace features allow an agent to search the Marketplace for existing applications and bring them into the HealthSherpa dashboard to service. Agents can also use these features to start a new application for consumers who may need to do so.
Start application & Search Marketplace
Start application & Search Marketplace
Selecting Start application or Search Marketplace opens the Marketplace search page. While the pages may appear different, the search criteria & Marketplace search functionality are the same.
With consent, enter the consumer’s information, then select Search the Marketplace.
If no results are found, verify the consumer’s information then search again or Create a new application if needed.
If the consumer has any existing Marketplace applications that match the information provided, search results populate.
Search results are sorted by plan year (most recent first), then application version (most recent first). When multiple results appear, consider using the hierarchy shown on the Marketplace search page, prioritizing statuses at the top of the list.
Claim an existing application when one exists, or create a new application when needed.
Claiming an existing application
Claiming an existing Marketplace application to the HealthSherpa dashboard allows the application to be managed by the agent, and generates an Enhanced Direct Enrollment (EDE) sync between the agent and the application.
To claim an existing application when one exists, select Apply or View in dash after searching the Marketplace.
Apply
Apply
Apply will appear when a consumer's application is not already associated with the HealthSherpa account. Select Apply next to the application to make updates to an existing application.
View in dash
View in dash
View in dash will appear when a consumer's application is already associated with the HealthSherpa account. Select View in dash next to the application to return to the client's Details page.
During the Open Enrollment Period (OEP), use the available renewal pathways to assist consumers who are already on the Clients page. To assist consumers who are already on the Clients page and seeking a Special Enrollment Period (SEP), edit the application from the client's Details page.
Claiming an application does not impact the National Producer Number (NPN) associated with the application.
Creating a new application
Creating a new application may be needed when no Marketplace search results are found or when a consumer needs a new Marketplace application (for example, if the consumer moved to a new state).
Select Create a new application to continue.
Agents can only start a new application after completing a Marketplace search for existing applications. Before creating a new application, HealthSherpa recommends using the Search by Social Security Number (SSN) function to confirm the consumer does not have any existing Marketplace applications.
Completing an application
The Marketplace application asks for information about the consumer’s household to determine eligibility for coverage and financial assistance.
Go to the agent training page for a live walkthrough of the subsidy application.
Using partial or no financial assistance
Consumers are not required to use any financial assistance they may be eligible to receive. Depending on which type of financial assistance a consumer qualifies for, there are different ways to adjust or opt out of using advance premium tax credit (APTC) and cost-sharing reductions (CSR).
Opting out of financial assistance entirely
Opting out of financial assistance entirely
Consumers can opt out of seeking financial assistance when completing a Marketplace application.
During the Marketplace application, consumers are asked whether they want to see if they are eligible for cost savings.
Selecting Yes allows the consumer to proceed with determining eligibility for financial assistance prior to purchasing Marketplace coverage.
Selecting No allows the consumer to proceed with purchasing Marketplace coverage without seeking financial assistance.
Subsidy-related sections will be omitted from the Marketplace application when No is selected.
Adjusting the APTC amount
Adjusting the APTC amount
Consumers may decide to reduce the amount of APTC applied when they are uncertain about their expected income for the year. Using less than the eligible amount of APTC can help limit the risk of owing money back to the IRS when reconciling at tax time.
Consumers who are eligible for APTC can adjust the amount applied to their monthly premium on the Confirm plan screen. Uncheck the box by I want to apply all of my savings.
Enter the dollar amount to apply each month. Any amount up to the full APTC amount can be entered, including zero.
CSR and metal level selection
CSR and metal level selection
CSR is automatically applied to silver level plans for consumers who are CSR eligible. Consumers who are eligible for CSR but do not want to use CSR can select a plan at a different metal level.
Reconciling APTC at tax time
Reconciling APTC at tax time
When a consumer files taxes, the IRS reviews the APTC applied during the plan year and compares it against the amount the consumer actually qualified to receive. This process is known as reconciliation.
Any difference is added to their refund or balance due. Depending on the plan year, consumers can be required to repay the full amount of excess APTC applied.
Plan year 2025: If the actual allowable credit differs from the APTC the consumer chose to use, the difference (subject to certain payback limits) will be subtracted from their refund or added to their balance due.
Plan year 2026 and beyond: There is no limitation on excess APTC consumers are required to repay. The full difference between the actual allowable credit and the APTC used will be applied to their refund or balance due.
Applying for a subsidy within the enrollment submission flow
Applying for a subsidy and plan shopping are distinct parts of the flow that culminate in an enrollment submission. Enrollment submission can begin with completing the subsidy application or with plan shopping.
Once the subsidy application is submitted to the Marketplace, a Marketplace Eligibility Notice is generated with the consumer’s final eligibility results.
If the consumer is within an enrollment period, proceed to plan results to review available plans and find a plan that fits the consumer’s needs.
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.
What do the terms off-exchange and on-exchange mean?
The term exchange refers to the Marketplace, either the Federally Facilitated Marketplace (FFM) or a State-based Marketplace (SBM). The Marketplace determines the tax household’s eligibility for coverage and financial assistance.
Off-exchange plans do not go through the Marketplace, so they are not subsidy eligible. An enrollment submission takes place once the plan selection is finalized and the off-exchange application is completed.
On-exchange plans are subsidy eligible. An enrollment submission takes place once the plan selection is finalized and the subsidy application is submitted.
Affordable Care Act (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.
What is an Enhanced Direct Enrollment (EDE) sync?
The Centers for Medicare & Medicaid Services (CMS) grants Enhanced Direct Enrollment (EDE) permission to agents for their enrollment submissions. This permission enables data syncs between the Marketplace and HealthSherpa.
When an application has an EDE data sync, the HealthSherpa dashboard shows the most up-to-date application information and the application can be serviced.
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, known as subsidies, along with any follow-up actions needed to resolve Data Matching Issues (DMIs) & Special Enrollment Period (SEP) Verification Issues (SVIs).
What are enrollment periods?
Enrollment periods are specified times of the year when consumers can enroll in or make changes to Affordable Care Act (ACA) coverage.
Does HealthSherpa support enrollments for all states?
No. HealthSherpa supports enrollment submissions for all states that use the Federally Facilitated Marketplace (FFM). HealthSherpa also supports enrollments in Georgia, which uses a State-based Marketplace (SBM) called Georgia Access.
For all other states utilizing an SBM, agents can get a quote and shop for plans using HealthSherpa. When it's time to apply and complete an enrollment submission, HealthSherpa will direct the agent to the state's SBM website.
What does federal poverty level mean?
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.
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.
Keywords: Search & Claim