If you want to expand into the under-65 health insurance market, where do you start? We’re covering the ins and outs of the Affordable Care Act and selling under-65 health plans!
The American Rescue Plan Act of 2021 expanded the Affordable Care Act, improving health insurance affordability to those younger than 65. The Inflation Reduction Act (IRA) increased subsidies and added to the strength of the ACA. There’s no better time to enter the under-65 individual health market than now, so we’re giving all the info you need to know to get started!
What Is the Affordable Care Act (ACA)?
The Affordable Care Act (ACA) is a federal law, signed in 2010, that reformed America’s health care and insurance landscape. Formally known as the “Patient Protection and Affordable Care Act” and colloquially called “Obamacare,” the ACA includes several key provisions that gave 20 million Americans access to affordable health insurance coverage.
Key provisions:
- The creation of health insurance marketplaces, or exchanges
- The individual mandate — which required every American to have health insurance or pay a tax penalty
- People with pre-existing conditions cannot be denied coverage or charged more for it
- Children can stay on a parent’s plan until they turn 26 years old
- Preventative care at no additional cost
- Subsidies, or tax credits, for qualifying individuals/families purchasing through the marketplace
- The expansion of Medicaid for low-income adults up to 138 percent of the Federal Poverty Level
The individual mandate penalty was repealed at the federal level in 2019. A select number of states have since implemented their own health insurance individual mandates and penalties. These include California, the District of Columbia, Massachusetts, New Jersey, and Rhode Island. Vermont has their own individual mandate, but they do not have a penalty associated with it.
Why Is Selling Under-65 Health Plans Suddenly a Great Opportunity?
A few years ago, things were looking a little bleak in the ACA market. Several carriers left the marketplace or state exchanges, and the ones who stayed cut commissions for agents and brokers selling these plans. But, a lot has changed since then. Now, the future of this market is looking exceptionally bright for everyone: carriers, agents, brokers, and consumers!
ACA Commissions Are Back, and They’re High!
Carriers are once again offering commissions, and they’re pretty great. Just like with Medicare Advantage, Medicare Supplement, and prescription drug plan sales, agents can earn new/initial commissions (first year) and renewal commissions (second year and beyond). Unlike in Medicare sales, ACA commissions are typically paid per member, per month!
Unlike in Medicare sales, these commissions are typically paid per member, per month!
For example, one carrier offers $19 initial and $16 renewal commissions in several states. Let’s say you help enroll four family members in this plan. You’d earn an initial commission of $76 per month for the first year, which is a total of $912! In year two and beyond, you’d receive $64 in renewal commission each month, which brings your yearly total to $768. And, these amounts are just what you could earn for writing one household!
More People Are Eligible for ACA Subsidies
The American Rescue Plan Act of 2021 expanded federal health insurance subsidy access for millions of Americans. Before, households just above 400 percent of the Federal Poverty line (the limit for subsidy eligibility) made too much to qualify for an ACA health subsidy. The income cap is now at 8.39 percent, instead of 9.12 percent, allowing more households to qualify for financial assistance!
In August 2022, the Inflation Reduction Act of 2022 (IRA) extended subsidies for an additional three years, through the end of 2025. Individuals will be able to be evaluated for subsidy eligibility each year, and if they qualify, can receive subsidies to apply to a marketplace plan.
Remember: Clients who choose to accept subsidies, must report them at tax time to capitalize on savings for the upcoming year.
May Only Require One Certification (at No Cost!)
If you sell Medicare Advantage and Part D prescription drug plans, you’ll be familiar with AHIP (a federal requirement) and carrier certifications. In order to sell under-65 health plans, insurance agents must also complete a federal certification — the Federally Facilitated Marketplace (FFM) certification or a state-based certification in states that have their own exchange. Carrier certifications aren’t required. FFM certification is also completely free, unlike AHIP!
Agents and brokers new to the ACA marketplace must complete the full individual marketplace training. Those who are returning to the marketplace are eligible to take a shorter training with optional review modules. Anyone wishing to proceed with FFM training requirements can find and complete them on the Centers for Medicare & Medicaid Services’ Marketplace Learning Management System (MLMS).
Steps for Completing the FFM Certification:
- Create an account on the CMS Enterprise Portal. (Returning agents/brokers can log in to their current account and proceed to step 4.)
- Navigate to the FFM Training for Agents/Brokers/Assisters.
- Confirm your identity.
- Click on the “Complete Agent Broker Training” link on the Agent Broker Registration Status page in the portal.
- Complete the training and exams (vendor or CMS training through MLMS).
- Sign the CMS Privacy and Security Agreements.
You can learn more about these steps here. Once you have completed this training, you should be good to start selling ACA health plans!
If you’re selling ACA plans in a state that operates in a state-based marketplace, follow the certification requirements on that exchange.
Note: Select states may require additional certification training. To learn more about these requirements, keep reading here.
ACA Plans Will Work Nicely with Your Current Insurance Portfolio
If you’re already selling other insurance products, like Medicare plans, why not add under-65 health plans to your portfolio? You likely work with clients who are under 65 or who have spouses or kids who are under 65 who need health insurance help. When you add ACA health plans to offerings, you can better serve your current clients and any referrals that come your way while growing your commissions! Plus, your under-65 clients will eventually become leads for your Medicare business or the other products you sell!
We recommend that agents grow their businesses and foster lifelong relationships with their clients by developing a Medicare pipeline. When it becomes time for your clients who have an ACA policy to turn age 65, as their trusted agent of record, you are able to find a great Medicare policy that fits their health care needs.
Understanding the ACA Marketplace & Exchanges
If you’re going to start selling under-65 health plans, you need to know about the ACA marketplace and exchanges. Keep reading for the details!
What Is the ACA Marketplace?
The ACA marketplace, also known as the federal health insurance marketplace or exchange, is a website where Americans can go to buy under-65 health insurance plans. This website is HealthCare.gov. Every state that participates in the federal marketplace will conduct ACA sales and other marketplace functions through this platform.
Some states have their own marketplace websites, or exchanges. These are independently operated marketplaces that conduct the same functions as the federal marketplace separately.
On-Exchange vs. Off-Exchange Plans
ACA health plans are available on the exchange (on-exchange) or off the exchange (off-exchange). Plans available on the exchange include those bought through HealthCare.gov (the federal marketplace), those bought on a state’s exchange website, or those bought through an approved exchange enrollment platform, like HealthSherpa. Off-exchange plans are those bought directly from the carrier.
On-exchange plans must provide essential health benefits and follow specific guidelines set by the ACA. Only on-exchange plans can accept ACA subsidies! Off-exchange plans usually offer most, if not all, the essential health benefits as their on-exchange counterparts. However, individuals cannot use an ACA subsidy to buy an off-exchange plan.
Read more about on-exchange and off-exchange marketplace plans in our article answering all your FAQs.
The Open Enrollment Period & New SEPs
Every year, people can shop for and enroll in new under-65 health plans on the marketplace during the Open Enrollment Period (OEP), which runs from November 1 to December 15 in most states, or during a Special Enrollment Period (SEP).
Your client may have an SEP if they’ve recently experienced any of the following:
- Job loss
- Moving to a new zip code
- New child or death in the family
- Coverage loss
- Marriage/divorce
- Citizenship status change
- Government error
- Change in subsidy eligibility
- Qualifying federal reason
- Losing job-based coverage, Medicaid, eligibility for Medicare, or coverage through a family member
To take advantage of an SEP, you and your clients must act within 60 days of the qualifying life event.
ACA Subsidies & Their Eligibility Requirements
Today, more Americans are eligible for ACA subsidies than ever before, thanks to the ARPA and IRA. What are ACA subsidies and how do people qualify for them?
ACA subsidies are an Advanced Premium Tax Credit designed to help lower-income and middle-income individuals and families afford health insurance. To qualify, someone must meet the following criteria:
- Income is between 100 percent to 400 percent of the Federal Poverty Level
- Buying health plan through the marketplace or exchange
- Does not have “affordable” employer-sponsored coverage available to select*
*Starting in 2023, family members can access subsidized ACA coverage if an employee’s cost for their coverage exceeds 9.12 percent of the household’s income. This is thanks to the closing of the family glitch. All family members will now be taken into consideration in the eligibility calculations, not just the employee.
To estimate 2024 subsidies, use the 2023 income levels to calculate savings.
2023 Income Levels for Federal Poverty Levels
| Family Size | 100% FPL | 150% FPL | 200% FPL | 250% FPL | 400% FPL |
|---|---|---|---|---|---|
| 1 | $14,580 | $21,870 | $29,160 | $36,450 | $58,320 |
| 2 | $19,720 | $29,580 | $39,440 | $49,300 | $78,880 |
| 3 | $24,860 | $37,290 | $49,720 | $62,150 | $99,440 |
| 4 | $30,000 | $45,000 | $60,000 | $75,000 | $120,000 |
| Each additional | $5,140 | $7,710 | $10,280 | $12,850 | $20,560 |
Note: Individuals who fall below 138 percent of the FPL (or their state’s designated limit) should qualify for free-or-low-cost health insurance through Medicaid. If your client lives in Hawaii or Alaska, please be aware that poverty guidelines differ. You can review those states’ guidelines on HHS.gov.
When helping your client apply for a plan, you’ll work together to estimate how much income they think they’ll have for the following year. Then, they’ll receive a subsidy based on that income estimate, as well as additional factors. When your client files their taxes at the end of the year, they may have to pay back some or all of the subsidy if they earned over their estimated income for the year. Alternatively, if they made less than their original estimate, they should get a refund of any additional portion of the subsidy they may qualify for.
Check out our Ritter blog article debunking some of the myths that surround the ACA, including income requirements!
Bronze, Silver, Gold, Platinum ACA Metal Levels Explained
Under-65 marketplace plans are categorized into four metal tiers: Bronze, Silver, Gold, and Platinum. Basically, these tiers can tell you and your clients how covered medical costs are shared between the policy and the policyholder (but not the level of care or the plan’s covered services).
These tiers can tell you and your clients how covered medical costs are shared between the policy and the policyholder.
The Metal Tiers for ACA Health Plans
| Tiers | Bronze | Silver | Gold | Platinum |
|---|---|---|---|---|
| % Covered Medical Costs Paid by the Policy | 60% | 70% | 80% | 90% |
| % of Covered Medical Costs Paid by the Policyholder | 40% | 30% | 20% | 10% |
| Monthly Premium Comparative Cost | Lowest | Moderate | High | Highest |
| Unsubsidized Annual Deductible Comparative Cost | Highest | Moderate | Low | Lowest |
| Eligible to Apply a Cost-Sharing Reduction? | No | Yes | No | No |
| Eligible to Apply a Premium Tax Credit? | Yes | Yes | Yes | Yes |
As you can see from the table, as the metal tiers go up, the member’s coinsurance responsibility goes down while the plan’s coinsurance responsibility goes up. The most prevalent tier in the marketplace is the Silver tier due to the ability to apply subsidies. We reccomend suggesting a Silver plan to a client that qualifies for subsidies.
Consider your client’s budget and what makes sense for them. Some clients may find a Bronze plan paired with another plan such as a hospital indemnity plan to be more affordable and offer the coverage they are looking for.
New Requirements for Agents Selling ACA Plans
The 2024 Marketplace Final Rule dictates that, effective June 18, 2023, agents must document a client’s authorization to receive assistance with their ACA coverage decisions. Agents must obtain this consent before assisting a client with enrolling in a plan. We’ve created a form to document client consent and eligibility attestations and call scripts to go with the Consumer Authorization form and Eligibility Attestation form to make it easier to compliantly collect client authorization and eligibility attestations. Staying compliant in your business practices doesn’t need to be stressful. As an agent, you have the unique ability to help individuals find affordable health care coverage!
The Agent Advantage
You may know that navigators are also available to help individuals find and enroll in on-exchange plans. However, there’s a big difference between navigators and agents or brokers like you: Navigators cannot recommend one plan over another.
Health insurance marketplace navigators cannot recommend one plan over another — but you can!
You can help your clients understand the best plans for them based on their needs. By getting involved in this market, you’re looking out for the best interest of your clients, and yours as well! Under-65 sales can increase your bottom line and keep your book of business booming for years to come as the market is stronger than ever!
Still feeling uneasy about selling ACA Marketplace products? Check out our comprehensive agent eBook, The Complete Guide to Selling Affordable Care Act Insurance Plans to boost your confidence and get started!
The ACA health market has seen a lot of changes within the past few years. Here at Ritter, we’re embracing the amazing sales opportunities that the ACA presents. We’ve jumped back into the marketplace, and we hope you’ll join us in selling under-65 plans!
Interested in learning more about Ritter’s under-65 health contracting opportunities? Send us a message.
Editor’s Note: A special thanks to our friends at Quick Insured Brokerage, one of the Ritter Insurance Marketing Family of Companies, for their assistance with this informational post! This article has been updated to include information relevant to 2024.
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