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Off-exchange medical plans

Shop for off-exchange medical plans & submit an off-exchange enrollment.

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Written by Amber Blank
Updated this week

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Off-exchange medical plan shopping is available in the HealthSherpa account and allows agents to submit an off-exchange enrollment.

In this article we’ll cover:

Off-Exchange medical plans are not available within HealthSherpa Enrollee Assistance Full-Service account types.

Overview

The term exchange refers to the Marketplace, either the Federally Facilitated Marketplace (FFM) or a State-based Exchange (SBM). The Marketplace determines the tax household’s eligibility for coverage and financial assistance.

Off-exchange medical 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.

Enrollment submission flow

An enrollment submission takes place once the plan selection is finalized and the off-marketplace application is submitted. With consent, agents can assist consumers with enrollment submission.

During the Open Enrollment Period (OEP) or when assisting consumers who are not already on the Clients page, enrollment submission for off-marketplace plans begins with plan shopping.

Use the quoter to review available plans with the consumer. Use discovery questions to narrow options and identify a plan that fits the consumer’s needs.

After a plan is selected, complete the consumer’s off-marketplace application.

If the consumer is within an enrollment period, review alternative plans if desired, then confirm the consumer’s final selections to submit the enrollment.

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 to resume the enrollment submission flow.

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.

Off-exchange medical plans may be a good fit for:

  • Households that make too much to qualify for a subsidy through the Marketplace

  • Individual coverage health reimbursement arrangement (ICHRA) consumers who want to use employer funds along with their own funds to pay for premiums

  • Health reimbursement arrangement (HRA) early retiree consumers who prefer off-exchange plan pricing over similar Marketplace coverage

Available carriers

Off-exchange medical plans are currently available in HealthSherpa for select carriers and states.

Available off-exchange medical carriers in HealthSherpa

  • Ambetter: AL, AR, AZ, DE, FL, GA, IA, IL, IN, KS, KY, LA, MI, MO, MS, NC, NE, NH, NJ, NV, OH, OK, PA, SC, TN, TX, WA

  • Anthem: CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, VA, WI

  • Antidote: AZ, OH

  • Blue Cross Blue Shield of Arizona: AZ

  • Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas: IL, MT, NM, OK, TX

  • Blue Cross Blue Shield Kansas City: KS, MO

  • Blue Cross Blue Shield of South Carolina: SC

  • CareSource: GA, IN, KY, MI, NC, NV, OH, WV

  • CHRISTUS: LA, TX

  • Cigna: AZ, CO, FL, GA, IL, IN, MS, NC, TN, TX, VA

  • Health First: FL

  • Molina Healthcare: CT, FL, OH, TX

  • Mountain Health Co-Op: ID, MT

  • Oscar Health Insurance: AL, AZ, FL, GA, IA, IL, KS, MI, MO, MS, NE, NJ, NY, OH, OK, PA, TN, TX, VA

  • United Healthcare: AL, AZ, CO, FL, GA, IA, IL, IN, KS, LA, MA, MD, MI, MO, MS, NC, NE, NJ, NM, NY, OH, OK, SC, TN, TX, VA, WA, WI, WY

  • Wellpoint: FL, TX

Getting a quote

Agents can start plan shopping at any time by clicking the drop-down menu on the Quote button, and selecting Quote Off-Ex Medical.

With consent, enter the consumer’s ZIP code, age, and gender into the quoter.

Add additional people to the quote

If additional people in the household are applying for coverage, add them in the Applicants section.

ICHRA eligibility

An individual coverage health reimbursement arrangement (ICHRA) is a type of health reimbursement arrangement (HRA) that an employer offers to employees. Depending on how the employer sets it up, an ICHRA can reimburse employees for individual health insurance premiums and other qualified medical expenses, such as copayments and deductibles.

If the consumer is offered an ICHRA, add their ICHRA information.

Review available plans with the consumer and narrow options based on the consumer’s needs.

Viewing available plans

Plan results display below the quoter after the consumer’s information is entered.

Review plans

Each plan card shows key details to review, such as:

  • Network

  • Metal level

  • Monthly premium after any estimated ICHRA is applied

  • Deductible

  • Out-of-pocket maximum

Use the sort option in the top right corner to change how plans are sorted.

The plan results page may look different depending on the HealthSherpa account type.

To review a plan in more detail, click Plan details on the plan card. When available, the Plan details page also includes official carrier documents, such as the drug formulary & provider directory.

Refining plan results

Plan results can be filtered to narrow options based on the consumer’s needs. Start by identifying the consumer’s priorities and how they expect to use coverage.

Ask questions

Common questions to understand needs include:

  • Do you have any preferred providers or hospitals?

  • Do you travel often or need coverage outside your local area?

  • Do you take any prescription medications?

  • Do you go to the doctor often or infrequently, or have any upcoming procedures?

  • Is there anything you’d like to prioritize when looking for a plan?

Available filters can vary by HealthSherpa account type. When available, the Plan details page also includes official carrier documents, such as the drug formulary & provider directory.

Use filters & official carrier document to align plan results to the consumer’s needs.

Reminder on budget tradeoffs

Lowest monthly premium does not always mean lowest total cost.

When reviewing plan options, consider total possible costs the consumer may pay over the full plan year, including:

  • Monthly premium x 12 months: The amount the consumer will pay each month to have coverage, multiplied by 12 months.

  • Deductible: How much the consumer could pay for certain covered health services and prescription drugs before the plan pays anything.

  • Copayments and coinsurance: The amount the consumer could pay each time they get care, such as a set copayment for a visit or a percentage of charges.

  • Out-of-pocket maximum: The most the consumer could pay for covered services in a year. After this amount is reached, the plan pays 100% for covered services.

Sharing & comparing plans

From plan results, agents can save a quote, share plan options with a consumer, or compare plans side by side.

Save a quote as a lead

To create a lead from a quote, select Save Lead.

Enter the consumer’s basic information in the Save lead window, and the consumer will display on the Leads page.

Share plan option

Agents can share plan options at any time by selecting Share.

Agents can share the quote directly from the pop-up window or copy the link to share from an alternate email.

Consumers must create a HealthSherpa login to view personalized quotes.

Compare plans side by side

Select Compare on each plan card to include it in the comparison, then click Compare to view up to 5 plans side by side.

The comparison view shows key plan details side by side, including monthly premium, deductible, out-of-pocket maximum, and metal level.

To share the comparison view with the consumer, click Share.

Complete off-marketplace application

Plan shopping and the off-marketplace application are distinct parts of the flow that culminate in an enrollment submission.

Select Enroll or Enroll now on a plan card to continue with the enrollment submission flow.

Off-exchange medical plans require the consumer to be within an enrollment period to enroll in or change Affordable Care Act (ACA) compliant coverage.

Consumers who start plan shopping or start an off-marketplace application but have not submitted an enrollment display on the Leads page. After an enrollment is successfully submitted, the consumer moves to the Clients page.

Frequently asked questions

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 Exchange (SBM).

Off-exchange plans are not subsidy eligible. An enrollment submission takes place once the plan selection is finalized.

On-exchange plans are subsidy eligible. An enrollment submission takes place once the subsidy application is submitted and the plan selection is finalized.

Plan availability can vary when shopping on-exchange vs off-exchange, depending on the state and carriers. Affordable Care Act (ACA) compliant plans cover the same essential health benefits on-exchange and off-exchange.

Do off-exchange medical plans require an enrollment period?

Off-exchange medical plans require the consumer to be within an enrollment period to enroll in or change Affordable Care Act (ACA) compliant coverage.

Can DMIs and SVIs occur for off-exchange medical plans?

DMIs and SVIs are Marketplace verification follow-ups and can occur when a Marketplace enrollment is submitted. Off-exchange plans may still require eligibility checks or supporting documentation. When applicable, follow-up requests are communicated by the carrier.

What if the off-exchange medical plans option does not display?

Off-exchange medial plan quoting is not available for all HealthSherpa account types. If an agent does not see off-exchange medical plans displayed in the Quote drop-down, it typically means the functionality is not available for that account type.

What if the quoter says no results are found?

Off-exchange medical plans are only available for select carriers and states. If the off-exchange option displays but no plans show after switching to off-exchange, HealthSherpa does not yet support off-exchange medical plans with carriers in the selected state.

Can consumers enroll in off-exchange plans when using an agent’s marketing link?

When using an agent’s marketing link, consumers can only complete on-exchange enrollment submissions. Off-exchange plans in HealthSherpa are only available to agents.

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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