ACA / Marketplace Basics
Affordable Care Act plans sold on the federal or state Marketplace. The only health plans that qualify for government subsidies.
ACA plans are the ONLY plans that qualify for APTC subsidies. Always check subsidy eligibility before recommending a non-ACA product.
📋 How ACA Plans Work
- Sold through the federal Marketplace (healthcare.gov) or state-based exchanges — HealthSherpa works for federal marketplace states; state exchange states (CA, CO, CT, DC, ID, KY, MA, MD, ME, MN, NJ, NM, NV, NY, PA, RI, VA, VT, WA) must be enrolled through that state's own exchange portal
- Guaranteed issue — cannot be denied for pre-existing conditions
- Must cover 10 Essential Health Benefits including preventive care, mental health, maternity
- Premium is based on age, location, household size, and income — not health status
- APTC subsidies are applied as advance tax credits that reduce the monthly premium
- Plans run January 1 – December 31 — coverage is annual
✅ Who Qualifies for ACA Plans
- US citizens or lawfully present immigrants
- Not incarcerated
- Not eligible for Medicare (under 65, or 65+ without Medicare eligibility)
- Not offered affordable employer coverage (affordability = less than 9.96% of household income for employee-only coverage)
- Medicaid-eligible clients do NOT qualify for Marketplace subsidies — they go to Medicaid instead
- DACA recipients are not eligible for Marketplace coverage
⚠️ Employer Coverage Check
- If employer offers coverage, client can still get Marketplace plan — but only qualifies for subsidy if employer plan is "unaffordable" or doesn't meet minimum value standard
- Always ask: "Does your employer offer health insurance? Do you know what it costs for just you?"
- Family members CAN still get subsidized Marketplace plans even if the employee is covered at work (family glitch fixed in 2023)
✅ 10 Essential Health Benefits (all ACA plans must cover)
- 1. Ambulatory (outpatient) services
- 2. Emergency services
- 3. Hospitalization
- 4. Maternity and newborn care
- 5. Mental health and substance use disorder services
- 6. Prescription drugs
- 7. Rehabilitative and habilitative services
- 8. Laboratory services
- 9. Preventive and wellness services (many free)
- 10. Pediatric services including dental and vision for children
Subsidies (APTC & CSR)
The most powerful selling tool in ACA. Many clients pay $0–$50/month after subsidies. Always calculate before quoting a price.
Enhanced subsidies from the American Rescue Plan (ARP) are still active — many clients pay $0/month. Always run the subsidy calculation first.
💰 How APTC Works
- APTC = Advanced Premium Tax Credit — reduces the monthly premium the client pays
- Based on MAGI (Modified Adjusted Gross Income) as a % of the Federal Poverty Level (FPL) — for W-2 employees this is usually line 9 or 11 on their tax return; for self-employed it's income after deductible business expenses; always recommend clients consult a tax professional if unsure
- Always enter ANNUAL household income — all earners in the household, not just the applicant
- Income is estimated for the upcoming year — client reports actual income at tax time
- Reconciliation warning: If actual income is higher than estimated, client may owe back some credit at tax time. Even if they update their income mid-year, the subsidy already received in the first part of the year was based on their original estimate — the IRS reconciles on the full annual income, not monthly. Clients should update their Marketplace application immediately when income changes, but warn them they may still owe a small portion back for the months before the update.
- If actual income is lower: client gets additional credit as a tax refund
- ARP enhanced subsidies: no income cap — even above 400% FPL can qualify
📊 2025 Federal Poverty Level — Key Thresholds
| Household Size | 100% FPL | 138% FPL (Medicaid) | 250% FPL (CSR cutoff) | 400% FPL |
|---|---|---|---|---|
| 1 person | $15,650 | $21,597 | $39,125 | $62,600 |
| 2 people | $21,150 | $29,187 | $52,875 | $84,600 |
| 3 people | $26,650 | $36,777 | $66,625 | $106,600 |
| 4 people | $32,150 | $44,367 | $80,375 | $128,600 |
| 5 people | $37,650 | $51,957 | $94,125 | $150,600 |
| 6 people | $43,150 | $59,547 | $107,875 | $172,600 |
| 7 people | $48,650 | $67,137 | $121,625 | $194,600 |
| 8 people | $54,150 | $74,727 | $135,375 | $216,600 |
+$5,500 per additional person beyond 8. Alaska and Hawaii have higher FPL thresholds.
Key rules: Below 100% FPL in non-expansion states = no subsidy, no Medicaid (coverage gap). Below 138% FPL in Medicaid expansion states = Medicaid, not Marketplace. Always check which state the client is in.
Always use HealthSherpa to calculate exact subsidy amounts — a $1,000 income difference can change the subsidy significantly.
💵 Cost Sharing Reductions (CSR)
- CSR = extra savings on deductibles, copays, and out-of-pocket max for lower-income clients
- Only available on Silver plans — client must select Silver to receive CSR
- 100–150% FPL: most generous CSR — deductibles as low as $0, OOP max very low
- 150–200% FPL: strong CSR — significantly reduced cost sharing
- 200–250% FPL: moderate CSR — some reduction in cost sharing
- If client picks Gold or Bronze when they qualify for CSR Silver, they lose those cost-sharing savings
- Always point out CSR Silver to eligible clients — it's one of the best values in ACA
💡 Agent Tips on Subsidies
- Run HealthSherpa first — always show the client what they'll pay AFTER subsidy, not the full premium
- "Before I tell you the price, I need to check what subsidies you qualify for — most of my clients end up paying far less than they expect."
- Small income changes = big subsidy swings. If client is close to a threshold, discuss with them carefully.
- Self-employed clients: use NET income (after business deductions) for the subsidy calculation
- Reconciliation warning: if client gets a raise, changes jobs, or gains a household member mid-year — they need to update their Marketplace application immediately to avoid owing money at tax time
- Always document the income figure used in The Atlas contact notes
Enrollment Periods
OEP runs Nov 1 – Dec 15. Outside of that, clients need a qualifying event for a SEP. Know the triggers cold.
📅 Open Enrollment Period (OEP)
- Dates: November 1 – December 15 each year
- Enroll by Dec 15 for January 1 effective date
- Enroll Dec 16 – Jan 15 for February 1 effective date
- OEP is your biggest ACA season — start prospecting in October
- Existing clients auto-renew if you don't actively enroll them — always do a review to make sure they're on the best plan for the new year
- Outside of OEP and SEP: no enrollment allowed — set client expectations immediately
⚡ Common SEP Qualifying Events
- Lost job-based coverage — most common. Client has 60 days from loss of coverage.
- Got married — 60 days from marriage date
- Had a baby / adopted a child — 60 days from birth/adoption
- Moved to a new state or zip code — 60 days from move
- Gained citizenship or lawful status
- Released from incarceration
- Voluntarily dropping coverage does NOT qualify for SEP — client must wait for OEP
- SEP window is 60 days from the event — document the qualifying event date carefully in HealthSherpa and The Atlas
🎓 FFM Certification
- FFM (Federally Facilitated Marketplace) certification is REQUIRED to enroll clients in ACA Marketplace plans
- Must complete the annual FFM training through CMS before each plan year
- Training is available at cms.gov — typically opens in September for the following plan year
- Without FFM cert: you can still help clients but cannot enroll them directly — they would need to self-enroll
- Keep your FFM cert current — it's required and it's the foundation of your ACA business
ACA Plan Metal Tiers
Bronze, Silver, Gold, Platinum — each represents a different cost-sharing split between client and insurer. Silver is usually the sweet spot with subsidies.
📊 Metal Tier Comparison
- Bronze (60/40): Insurer pays 60%, you pay 40%. Lowest premium, highest deductible ($5,000–$9,000+). Best for healthy clients who rarely use care.
- Silver (70/30): Insurer pays 70%, you pay 30%. Mid-range premium and deductible. ONLY tier that qualifies for CSR savings. Usually the best value for subsidy-eligible clients.
- Gold (80/20): Insurer pays 80%, you pay 20%. Higher premium, lower deductible. Good for clients with chronic conditions or high healthcare use.
- Platinum (90/10): Insurer pays 90%, you pay 10%. Highest premium, lowest deductible. Rarely the best value — usually only for very high healthcare users.
The metal tier does NOT affect the quality of care — all ACA plans cover the same 10 essential benefits. The tier only affects how costs are split between client and insurer.
💡 Which Tier to Recommend
- CSR-eligible (100–250% FPL): Always Silver first — CSR makes Silver behave like Gold or Platinum at lower premiums
- Healthy, low income, no CSR: Bronze — lowest premium, rarely uses coverage
- Moderate healthcare use, above 250% FPL: Compare Silver vs Gold — run total estimated annual cost
- Chronic conditions, frequent care: Gold — lower out-of-pocket when they use it
- Never recommend Platinum without a compelling specific reason — Gold almost always offers better overall value
- When in doubt: run the math — add annual premium + estimated out-of-pocket cost for each tier in HealthSherpa
HealthSherpa — Quoting & Enrollment
Our exclusive ACA quoting and enrollment platform. Agency join code: d3bb. All ACA enrollments go through HealthSherpa.
HealthSherpa
📋 What HealthSherpa Does
- Calculates exact subsidy (APTC) based on household income and size
- Shows all available ACA plans in client's zip code with after-subsidy premiums
- Filters plans by doctor network, drug formulary, deductible, premium
- Enrolls clients directly — applications go straight to the Marketplace
- Tracks your book of ACA clients — renewals, changes, cancellations
- All enrollments through HealthSherpa credit to your agency when clients use join code d3bb
📋 Standard ACA Enrollment Workflow
- Step 1: Get client info — name, DOB, SSN, household members, annual income estimate
- Step 2: Open HealthSherpa — enter zip code, household size, estimated income
- Step 3: Review subsidy amount — show client their AFTER-subsidy premium options
- Step 4: Filter by current doctors and prescriptions if needed
- Step 5: Present 2–3 plan options — explain bronze vs silver vs gold trade-offs
- Step 6: If CSR-eligible (Silver), highlight the CSR Silver option specifically
- Step 7: Complete application in HealthSherpa — verify all household members and income
- Step 8: Submit — client will receive confirmation from Marketplace
- Step 9: Log enrollment in The Atlas — note plan, premium, effective date, income used
- Step 10: Remind client to pay first premium directly to carrier to activate coverage
Coverage is NOT active until the client pays their first premium to the carrier. Always remind them — many clients assume enrollment = coverage.
💡 Tips & Common Pitfalls
- Always use household income, not just the applicant's income — includes all earners in the home
- Self-employed income: use net income after business deductions, not gross revenue
- Do NOT round income up to avoid Medicaid — this is fraud. Use the client's best estimate.
- If client is Medicaid-eligible, they go to Medicaid — cannot get Marketplace subsidy
- Warn clients about mid-year income changes — they MUST update their Marketplace application immediately. Important: even after updating, the IRS reconciles on annual income, not monthly — so they may still owe back a portion of the subsidy received before the update. Set this expectation upfront so tax time isn't a surprise.
- Clients who get an SEP must document the qualifying event — HealthSherpa will prompt for this
- First premium must go directly to the carrier — HealthSherpa does not collect premiums
- ACA does NOT cover dental or vision for adults — always offer a standalone dental/vision plan
State-Based Exchanges
These states run their own exchanges — do NOT use HealthSherpa for enrollment here. Go directly to the state portal. Subsidy eligibility rules are the same as federal marketplace.
⚠️ HealthSherpa only works for federal marketplace states (healthcare.gov). If your client lives in one of the states below, you must enroll through that state's portal directly.
🔗 State Exchange Links
| State | Exchange Name | Agent/Broker Portal |
|---|---|---|
| California | Covered California | coveredca.com/agent ↗ |
| Colorado | Connect for Health Colorado | connectforhealthco.com ↗ |
| Connecticut | Access Health CT | accesshealthct.com ↗ |
| Washington DC | DC Health Link | dchealthlink.com ↗ |
| Idaho | Your Health Idaho | yourhealthidaho.org ↗ |
| Kentucky | kynect | kynect.ky.gov ↗ |
| Maine | CoverME.gov | coverme.gov ↗ |
| Maryland | Maryland Health Connection | marylandhealthconnection.gov ↗ |
| Massachusetts | Massachusetts Health Connector | mahealthconnector.org ↗ |
| Minnesota | MNsure | mnsure.org ↗ |
| Nevada | Nevada Health Link | nevadahealthlink.com ↗ |
| New Jersey | Get Covered NJ | getcoverednj.com ↗ |
| New Mexico | beWellnm | bewellnm.com ↗ |
| New York | NY State of Health | nystateofhealth.ny.gov ↗ |
| Pennsylvania | Pennie | pennie.com ↗ |
| Rhode Island | HealthSource RI | healthsourceri.com ↗ |
| Virginia | Marketplace Virginia | marketplace.virginia.gov ↗ |
| Vermont | Vermont Health Connect | healthconnect.vermont.gov ↗ |
| Washington | Washington Healthplanfinder | wahealthplanfinder.org ↗ |
💡 All Other States
All other states use the federal Marketplace at healthcare.gov — enroll through HealthSherpa (agency code: d3bb) for those clients.
FFM Certification — Annual Requirement
You must complete FFM certification every year before selling ACA Marketplace plans. It's a 2-part process through CMS.
⚠️ Creating a CMS account alone is NOT enough
You must also add the FFM Agent Broker role and complete identity proofing. Both steps are required to satisfy Part II.
📋 Have these ready before you start: Your NPN (National Producer Number) · Your MLN User ID (from Part I training below)
Part I — Complete FFM Training
Complete the Agent/Broker web-based training on the Marketplace Learning Network (MLN). You'll get your MLN User ID here.
📚 MLN Training Site →
Group / agency code: WFG
Part II — CMS Portal Registration
Log into the CMS Enterprise Portal, add the FFM Agent Broker role, and complete Experian identity proofing.
🏛️ CMS Enterprise Portal →
Use your NPN + MLN User ID to validate
Step-by-Step: CMS Portal (Part II)
⚠️ MLN training results take up to 2 business days to sync with CMS. Complete Part I first, then wait before attempting Part II. If validation fails, email FFMProducer-AssisterHelpDesk@cms.hhs.gov with your name, NPN, and MLN User ID.
ACA Scripts & Objections
Word-for-word openers, subsidy reveals, and objection handlers for ACA conversations.
🎙️ Opening Script
- "Before I quote you anything, I need to run your information through the subsidy calculator — most of my clients end up paying way less than they expected."
- "ACA plans are the only plans where the government helps pay your premium — and right now the credits are better than they've ever been."
- "Do you know what your estimated household income will be this year? That's the key number I need to find out what you qualify for."
📞 Needs Analysis Questions
- "How many people are in your household?"
- "What's your estimated annual household income for this year?"
- "Do you have any doctors you want to make sure are covered?"
- "Do you take any prescription medications regularly?"
- "Are you currently uninsured or transitioning off another plan?"
- "What's more important to you — lower monthly premium or lower out-of-pocket when you use it?"
💰 Revealing the Subsidy
- "Based on your income and household size, you qualify for $X per month in government subsidies. That brings your premium down from $X to $X."
- "I'm showing you a Silver plan here — it's the one that qualifies for extra savings on your deductible and copays on top of the premium reduction."
- "This plan covers the same thing a $500/month plan covers — you're just getting help paying for it."
🛡️ Common Objections
- "I make too much to qualify" → "Since the American Rescue Plan, there's no income cap on subsidies. Let me run your numbers — you might be surprised."
- "I'm healthy, I don't need insurance" → "ACA plans cover preventive care at $0 — annual checkups, screenings, vaccines. You're paying for peace of mind and the unexpected, not just doctor visits."
- "My employer offers insurance" → "Let me check if your employer plan is considered 'affordable' by the ACA — if it costs more than 9.96% of your household income, you may still qualify for Marketplace coverage here."
- "I'll just wait until I get sick" → "You can't enroll outside of open enrollment unless you have a qualifying life event. If you get sick in March and OEP ended in December, you're out of options until next November."
- "The deductible is too high" → "Let's look at a Silver plan with CSR — if your income qualifies, the deductible can be as low as $0–$500, which is better than most employer plans."