How to Help Clients Navigate the Health Insurance Marketplace

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While the federal government intended the health insurance Marketplace to be intuitive, clients trying to navigate it may disagree. Many of your clients may be trying to enroll in the Marketplace for the first time. They will soon learn that the Marketplace functions differently from other health insurance plans they’ve had in the past. 

It’s critical for those who qualify for Marketplace insurance to understand how to find a plan and whether they can get a subsidy to help pay for it. The best way to do that is to create the perfect sales engagement strategy. Remember, a frustrating experience could take their focus off evaluating plans, causing you to lose a sale. 

Clients who understand the Marketplace rules and can navigate the system well can feel confident with their enrollment. With the help of your expertise, even the most non-technical person can purchase a plan effortlessly. In this post, we’ll break down the steps and best practices to set your clients up for success on the Marketplace. 

Shortcuts:

Terms Clients Need to Know When Enrolling in the Health Insurance Marketplace

Helping Clients Understand the Health Insurance Marketplace

A Step-by-Step Plan for Helping Clients Navigate the Marketplace

Reminders About Open Enrollment and Special Enrollment Periods

Providing Tips for Maintaining Health Coverage

Terms Clients Need to Know When Enrolling in the Health Insurance Marketplace

Your clients will have a frame of reference as you move forward when you start your presentation by defining unfamiliar health insurance terms. 

Here’s a list of terms to get you started:

  • Premiums: The amount they pay for their health plan
  • Deductibles: The amount they pay before their plan starts paying
  • Copayments and coinsurance: An amount they must pay to share in the costs
  • Network: A network of health providers their plan covers
  • Subsidies and tax credits: A tax credit based on their income that helps save on health plan premiums
  • Essential health benefits: Health services that are required under the Affordable Care Act (ACA) 

We recommend creating a slide showing the definitions and refer back to it as necessary for clarification when you are screensharing with your client. . 

Helping Clients Understand the Health Insurance Marketplace 

At the beginning of your sales presentation, clients may be interested to know a little about the background of the Marketplace. Sharing this information will make a good first impression and set the tone for the discussion.

It was established by the ACA in 2010 and was implemented in 2013. The Marketplace is also known as a Health Insurance Exchange and Obamacare.  

Clients also need to know that qualified applicants can only apply for health coverage during the open enrollment period. 

There are exceptions for those who need to enroll unexpectedly because of a qualifying life event.  

The Federal Health Insurance Marketplace

Clients will need to understand the differences between the federal and state health insurance marketplaces and the categories of plans.

The state and federal Marketplace websites break down health plans into four categories – Bronze, Silver, Gold, and Platinum. Each color has a different level of coverage.

When presenting this information, it helps to order the categories from the least to the greatest coverage as shown below. Point out that the Bronze plans are the least expensive and cover the least, and the Platinum plans are the most expensive and comprehensive:

  1. Bronze
  2. Silver
  3. Gold
  4. Platinum

State-Based Health Exchanges

The ACA The following 20 states offer state-based health exchanges.  

  • California
  • Colorado
  • Connecticut
  • District of Columbia
  • Georgia
  • Idaho
  • Kentucky
  • Maine
  • Maryland
  • Massachusetts
  • Minnesota
  • Nevada
  • New Jersey
  • New Mexico
  • New York
  • Pennsylvania
  • Rhode Island
  • Vermont
  • Virginia
  • Washington

Who Is Eligible for State and Federal Marketplaces?

A good resource to share with clients regarding Marketplace eligibility is A Quick Guide to the Health Insurance Marketplace®.  

Here are the eligibility criteria for state and federal exchanges:

  • Must reside in the United States
  • Must be a United States citizen or national, or be a lawfully present non-citizen in the United States
  • Must not be incarcerated
  • Must not be enrolled in Medicare
  • Must not have access to health insurance through an employer or government program

Inform clients that if they live in a state with a state-run plan, they cannot purchase a plan on the federal Marketplace. 

Benefits of Purchasing Through the Health Insurance Marketplace

Clients will primarily be concerned about two things – the coverage and costs. You can create a wow presentation by educating them about the Marketplace.

Here’s a good way to explain today’s health insurance market. 

Employers that offer health insurance to their employees often subsidize the high costs of health plans. In much the same way, the federal government, state government, or both may offer subsidies to individuals and families to help them afford healthcare. 

Here are some other things your clients should know:

  • Subsidies are also known as premium tax credits. 
  • To qualify for a subsidy, clients must file a federal tax return. If they’re married, they must file jointly. 
  • Clients’ income must be between 100% to 400% of the federal poverty level to qualify for the premium tax credit. 
  • Some people with larger incomes may also qualify for lower premium tax credits as a result of the American Rescue Plan. These tax credits are extended through 2025 through the Inflation Reduction Act. 
  • The government applies the credit in advance to lower premiums. This is called the advanced premium tax credit. The Marketplace sends the credit directly to their insurance provider. Alternatively, they can claim the full credit at tax time. 
  • Marketplace plans must cover pre-existing conditions and provide essential health benefits (e.g., prescription drugs, maternity and newborn care, lab costs, hospitalization, preventative healthcare).
  • Clients should be cognizant of how life changes can impact their subsidy amount, as the subsidy can change based on their income or household size. 

A Step-by-Step Plan for Helping Clients Navigate the Marketplace

Clients can find a link labeled Get Marketplace basics on the HealthCare.gov website for tips on how the Marketplace works.

To make your work easier, we’ve outlined a step-by-step guide below to add to your slide presentation. 

Step 1: Gather Their Personal Information

Besides their basic contact information, the site will also ask about your clients’ income, so they’ll need their pay stubs and last year’s tax return. 

They’ll also need to provide information about any current health coverage that’s available to them. 

Immigrants will have to submit documents to prove their status. Here are examples of documents they may need to provide:

  • Permanent resident card (green card)
  • Reentry permit
  • Refugee travel document
  • Employment authorization document
  • Immigrant visa

Undocumented immigrants don’t qualify for health plans on the Marketplace, Medicare, Medicaid, or CHIP. 

Once your clients have everything together, they’re ready to proceed to the Marketplace website. 

Step 2: Visit the Marketplace Website

Pull up HealthCare.gov or their state exchange site on any electronic device. They cannot apply on the federal site if their state offers a state exchange. 

Create an account. 

Next, select their state in the dropdown menu, then click on the box marked “start application”. State exchanges may have a slightly different format. 

Now, they’re ready to start comparing health plans. 

Step 3: Compare Available Plans

The site will display the available health plans based on their zip code. Note that this is just a preview of the plan coverages, deductibles, out-of-pocket costs, and premiums. They’ll get exact prices once they fill out the application. 

They can pull up plans according to levels (Bronze, Silver, Gold, and Platinum) to make it easier to compare plans. 

Compare plans including deductibles, copays, coverage, and premiums. They can check the plans they like the best. Another screen will pop up, and they will be able to see the plans side by side. 

After choosing their preferred plan, advise them to ensure their health providers are in-network on the plan. 

Once they’ve chosen a plan, they can factor in the applicable tax credits if eligible. 

Step 4: Check for Subsidies or Tax Credits

In the best-case scenario, they will be eligible for a subsidy to reduce the amount of their plan. The government considers their household income and the number of family members needing insurance when determining how much they’ll pay. 

A quick way to estimate how much they can expect in a subsidy is to use the KFF Health Insurance Marketplace Calculator. This is just a ballpark figure. They’ll get the exact figures after completing their application. 

Step 5: Enroll in a Plan

The final step is to review all facets of their plan.

Here are some bases to cover:

  • Coverage
  • Network providers
  • Deductibles
  • Out-of-pocket limits
  • Copays and coinsurance amounts

Once they’re very sure they’ve selected the best plan, click to enroll. 

Shortly after, they’ll receive details about their plan.

The Marketplace website is intuitive and user-friendly in its design. With our step-by-step process, they should not have trouble exploring their options, choosing a health plan, and enrolling. 

Reminders About Open Enrollment and Special Enrollment Periods

Let clients know that once they’ve enrolled in a Marketplace health plan, they won’t have to worry about it until the next open enrollment period. 

Your clients will also need to learn a bit more about the various enrollment periods. 

Open Enrollment

The open enrollment period for the federal Marketplace runs from November 1st to January 15th. 

As we stated earlier, the open enrollment period differs depending on where clients live, so be sure to check the applicable timeframe. The Centers for Medicare and Medicaid Services (CMS) generally puts out a publication that lists the open enrollment dates for state-based Marketplaces. 

Inform clients that if they don’t make a choice in subsequent years, the Marketplace will automatically re-enroll them in the same plan or choose a similar one for them. The reason for this is to ensure their health coverage doesn’t lapse. 

Special Enrollment Periods

If clients miss the open enrollment window, they’ll have to wait until the next enrollment period to purchase a plan. 

The government set up a special enrollment period for those who have major changes in their lives that impact their healthcare plans. 

Here is a list of some qualifying life events that allow individuals to enroll outside the open enrollment period:

  • Got married
  • Got divorced
  • Had a baby, adopted a child, or placed a child in foster care
  • Experienced a death in the family that caused them to lose their current health plan
  • Lost a job that provided health insurance
  • Became a United States citizen
  • Qualified for Medicare, Medicaid, or CHIP
  • Got out of prison
  • Moved to a different geographical area
  • Been affected by a natural disaster (e.g., earthquake, hurricane, wildfire)

As an added resource, send them to HealthCare.gov for other circumstances that may allow clients to take advantage of a special enrollment period. Tell them they may have to submit documentation to support their qualifying life event. 

To enroll, they can log into their account and request to enroll in the special enrollment period. They can also call the Marketplace Call Center at (800) 318-2596 to enroll.

Options When a Client Misses Open Enrollment

It’s in their best interest not to miss the open enrollment period, but if they do, they may still have options for obtaining a health plan. 

Here are some potential avenues for getting coverage:

  • Their spouse’s plan: If their spouse has employer-sponsored coverage, check if their enrollment period is still open, and add the spouse.
  • Medicaid or CHIP: They may qualify for a government plan. 
  • Short-term health insurance: They can get coverage for up to four months in a 12-month period.
  • Faith-based health sharing plan: Members pay premiums that go into a pool to cover medical bills for all members of the plan.

While these options may not be ideal, they’re better than not having health insurance at all. Medical costs are high, and one injury or illness can put their financial health at risk. 

Providing Tips for Maintaining Health Coverage

It’s essential for clients to understand how the Marketplace works. The choices they make may impact their costs or coverage. A thoughtfully created sales presentation will increase your conversions.

Health plans can change significantly from one year to the next, so encourage clients to review their plans every year and decide if they want to make changes. 

Finally, remind clients on a Marketplace plan to report any changes to their income or household so they know of any increases or decreases in their subsidy amount. 

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