The term “ACA plans” or “ACA” often refers to Health plans intended for non-Medicare, non-Medicaid recipients. “ACA” stands for the Affordable Care Act. In this article we'll cover:
Steps you can take to get started
If you’re new to the ACA space, here are five steps you can take to get started:
Step one: Get licensed.
You’ll need to be licensed in any state that you wish to sell plans.
Step two: Get certified.
You’ll need to complete your marketplace certification(s) annually to sell ACA for the upcoming plan year. The certification required varies by state:
View the marketplace types by state here
If you wish to sell in states utilizing a “State-based marketplace using the federal platform” or a “Federally-facilitated marketplace” -
Select HealthSherpa’s FFM training during your MLMS training step
If you wish to sell in states utilizing a “State-based marketplace” -
Go here to locate the state(s) you wish to sell within. Note there is a link to each State’s respective exchange in bullet three.
Step three: Get appointed.
You’ll need to secure appointments with carriers if you wish to sell plans on their behalf. Appointments with carriers often vary by state, by carrier, and by line of business (ex. ACA vs Medicare). You’ll secure appointments with carriers by reaching out to those carriers directly; there is often a broker or producer section of their website you can reference as a starting place. To see a list of available carriers by state visit HealthCare.gov’s Rate Review page.
Step four: Create your HealthSherpa for Agents account.
HealthSherpa is where you will complete your ACA enrollments.
Creating a new account is free, fast, and easy. Most agents are able to go through this process in 3-4 minutes. Head over to HealthSherpa, click on the blue "Start Enrolling Faster'' button, enter your email address, and follow the steps to create a new account.
If you’re a part of an agency, make sure to ask your agency admin for their unique "join code.” You can enter this code during the account creation process or after you’ve created an account; this will connect your new account to your agency’s account
Step five: Register for a free HealthSherpa platform training.
Ready to learn more about your HealthSherpa for Agents account? Our team hosts live webinars so you can get familiar with HealthSherpa’s powerful shopping, enrollment and marketing tools designed to help you grow your business. Register for a training session in English or in Spanish.
Additional Resources:
CMS General Resources - loads of resources, tips, and videos on a variety of topics
AB video learning center here
HealthSherpa Agent Support: 888-684-1373, agent_support@healthsherpa.com
FAQs
Getting Started:
What is an “NPN?”
What is an “FFM User ID?”
As an ACA agent or broker, you will create your Federally-facilitated Marketplace (FFM) user ID when you complete the FFM registration process through the Centers for Medicare & Medicaid Services (CMS) Enterprise Portal for the first time.
You are required to have your own unique FFM user ID. CMS does not allow agents to share credentials.
To recover your FFM user ID, you will need to return to the CMS Enterprise Portal and follow the prompts on the ‘Forgot User ID’ page. After submitting accurate information, an email containing your user ID will be sent to the email address on your profile. If you run into any trouble with this recovery process, you can reach out to the Marketplace Service Desk at CMS_FEPS@cms.hhs.gov or CMS broker support at 855-267-1515 for help.
CMS does not allow you to have more than one FFM user ID. If you are having trouble accessing your account, contact CMS.
Plan Shopping:
What do the terms “off-exchange” and “on-exchange” mean?
The term exchange simply refers to the Marketplace - the federally facilitated marketplace or a state-based exchange, respectively. Off-exchange plans are not eligible for subsidies and may be purchased without completing a subsidy application via the Marketplace. On-exchange plans are eligible for subsidies and require a subsidy application be completed in addition to the plan selection. The quantity and plan options available may vary when shopping on-exchange vs off-exchange, however, on-exchange and off-exchange plans cover the same essential health benefits required by the ACA.
If I know my customer is not subsidy eligible, am I limited to off-exchange plans?
No, customers who know they are not subsidy eligible may still shop for on-exchange plans.
If your consumer is certain they will not be subsidy eligible, but does want to shop on-exchange policies, they may simply answer ‘no’ to the question within the subsidy application that asks “would you like to see if you’re eligible for cost savings.”
However, it is usually a good idea to answer “yes” to this question and fill out the eligibility application to be sure. If your consumer’s circumstances change later in the year and they become eligible for a subsidy, they may be eligible for a refund when they file taxes for the months they did not receive a subsidy.
When are binder payments due?
Binder payments are often due by the plan's effectuation date, but can vary carrier to carrier as well as by qualifying life events (i.e. Special Enrollment Periods). Consumers should check with their insurance carrier regarding binder payment deadlines to ensure their plan
How do I narrow down plan options for my consumer?
Narrowing down plan options can feel overwhelming to a consumer. As their licensed agent, consider asking questions that help you identify how the consumer plans to use their coverage. Perhaps questions such as:
Are there any providers you would like to have access to?
How regularly do you go or would you like to be able to go to a doctor?
Are there any medications you take?
Do you travel outside of your state often? Is it important to have non-emergency coverage when and if you do?
If a minor injury takes place, where would you prefer to go for care?
Subsidy Application:
SSNs for all!
Although a Social Security Number may be listed as “optional” on certain portions of the subsidy application, it is actually required for both the primary applicant and all dependents who are applying for coverage unless someone does not have one (eg. an immigrant or newborn baby). When an SSN is missing, an income, immigration or citizenship Data Matching Issue (DMI) may be generated. In order to resolve DMIs you will likely need to upload follow-up documents to verify information on the application.
Household members who are not applying do not need to provide their SSN. However, it is recommended to do so to prevent or resolve income DMIs.
What counts as income?
HealthSherpa has the list of what to include and exclude when considering income built into the subsidy application for your ease of reference. You can also view the full breakdown of what’s included as income here.
If my consumer just lost their job, do I count that income?
Yes, you’ll want to include any income a consumer may have already earned during the year. Should their anticipated income change later in the year (perhaps they get a new job, etc.), they may simply update their income information at that time.
What does the “Renewal of eligibility” agreement question mean?
This question refers to the subsidy application itself. Per Healthcare.gov “Agreeing to this statement allows the Marketplace to use available income information from the IRS for up to 5 years for renewing your [subsidy] application. If you enroll in coverage through the Marketplace, we want to help you keep your coverage. One way to do that is to allow us to check electronically available income data to make sure you’re still [subsidy] eligible, instead of asking you to prove that your income still qualifies…Selecting this option may impact your ability to get help paying for coverage at renewal or require you to provide more information.”
You can learn more about other agreement questions here
How do I explain that the consumer may need to pay APTC dollars back?
Consumers may need to pay back the difference between the amount of advanced premium tax credits used and the final amount a consumer is found to have been eligible to receive during a given tax year. Healthcare.gov elaborates on this here.
One thing to keep in mind is that, depending on current legislation, there could also be dollar caps on the amount of repayment dollars potentially owed. Here is some information on those repayment limits for tax year 2024.
It’s critical that consumers ensure their subsidy application always reflects the most accurate information possible throughout a plan year. Consumers can update their subsidy application any time by contacting you, their agent, or by logging into their subsidy application directly to report changes.
Part of an Agency? Agency downline FAQs:
What do the ‘agency’, ‘shared’, and ‘mine’ toggles mean?
Keeping the toggle set to “Mine” will allow you to view clients and leads under your HealthSherpa account.
Sliding the toggle to “Shared” or “Agency” will allow you to see additional clients and leads that may belong to other agents in your agency.
If you see filters on your clients and leads tabs that allow you to toggle between “Mine” & “Agency” or “Mine” & “Shared,” then your agency administrator has enabled these intentionally.
Post-enrollment:
Consumer dashboard: empower your consumer’s to self-service
Every client that's enrolled through HealthSherpa receives an invitation to log in to their very own consumer dashboard. From the consumer dashboard, client’s can view their plan details, upload their own follow-up documents, view notices from the Marketplace (like 1095-A forms), and even report changes to their application. Full details can be found here.
How does my consumer cancel their coverage if they later get coverage through a job?
Consumers can cancel their plan during the year for various reasons. View step-by-step instructions here to ensure the correct path is followed for their unique circumstance.
Renewals:
What are active vs passive renewals?
CMS covers these in depth on page 26 here.
A passive enrollment takes place when a consumer does not make an active re-submission and plan selection prior to the December 15th deadline. In a passive enrollment, CMS will automatically re-enroll that individual in either the same plan or an alternate plan selected by the FFM effective 1/1.
An active enrollment takes place when a consumer actively participates in re-submitting their application and plan selection for the upcoming plan year.
Other:
Do I have to wait until open enrollment to help consumers?
No. You can help consumers throughout the year as long as they have a Qualifying Life Event. Learn more about Qualified Life Events (QLEs) here.
Special Enrollment Periods (SEPs) & Qualified Life Events (QLEs):
What are SEPs and QLEs?
SEPs are certain timeframes outside of OEP when a client can enroll in an ACA plan. This timeframe is triggered by a QLE. Learn more about Qualified Life Events (QLEs) here.
How are effective dates determined?
Effective dates for consumers with SEPs are determined by the specific QLE that has taken place. For most SEPs, coverage starts on the first of the month after plan selection. Other SEPs have an effective date of coverage that retros back to the date of the QLE.
How long do customers have to apply?
The enrollment window for customers to apply for coverage outside of open enrollment is determined by the specific QLE that has taken place. Learn more about Qualified Life Events (QLEs) here.
Medicaid:
Do customer’s need an actual denial letter from Medicaid/CHIP to qualify for an SEP?
Not necessarily, but customers will typically need to be able to provide alternative documentation in those instances. The full list of documentation is available here.
Customers may be eligible for an SEP if they or others in their household had Medicaid/CHIP, but recently lost it; have Medicaid/CHIP, but will lose it soon; applied for Medicaid/CHIP recently, but were denied; and possibly other scenarios. Full details on the scenarios can be found here.
Does ‘Medicaid Eligible’ on the quoter or on an eligibility notice mean that the customer is automatically enrolled in Medicaid?
‘Medicaid eligible’ on the quoter does not necessarily mean the parties on the quote will be found Medicaid eligible.
‘Medicaid eligible’ on the subsidy eligibility notice typically indicates that someone on the application may be eligible for Medicaid. If a person is found eligible for Medicaid/CHIP on an eligibility notice, the marketplace will automatically send the customer’s information to the respective state agency who will contact the consumer about potential enrollment. Customers can also apply directly through their state Medicaid agency as outlined here.
Does the potential Medicaid eligibility go to Medicaid for evaluation or does the customer still have to do something for Medicaid to review the notice?
‘Medicaid eligible’ on the subsidy eligibility notice typically indicates that someone on the application may be eligible for Medicaid. If a person is found eligible for Medicaid/CHIP on an eligibility notice, the marketplace will automatically send the customer’s information to the respective state agency who will contact the consumer about potential enrollment. Customers can also apply directly through their state Medicaid agency as outlined here.
Will the effective date for ACA coverage be backdated if the customer is denied for Medicaid?
CMS explains this in depth here. In short, they will receive an effective date on the first of the following month. However, they may conduct a three-way call with the Marketplace Call Center to ask for a retroactive effective date. This is usually granted when a customer has already completed a Marketplace application but was initially determined to be Medicaid eligible at the time of application.
Training Videos
Here is a video that walks you through steps you can take to get started.