ACA TERMS
This is the calculation the Marketplace uses to determine subsidy eligibility, it’s based on the household's projected annual income and family size
This must be stated at the very beginning of every call with a new or prospective customer.
A Member says “I can’t afford health insurance.”
Highlight that most people qualify for premium tax credits or cost-sharing reductions, which can make coverage much more affordable than they expect.
These two metal tiers typically have the highest deductibles and lowest premiums, making them best suited for young and healthy individuals.
If a consumer’s reported income cannot be verified, the Marketplace will issue this type of request.
What is an Income verification?
These are the only plans that qualify for cost-sharing reductions (CSRs), even though all metal levels can receive a premium subsidy.
This is the number of days a consumer has to cancel a newly issued health or life insurance policy and receive a full refund.
A Member says, “I’m healthy, I don’t need insurance.”
Remind them that coverage protects against unexpected accidents or medical emergencies, which can cost thousands without insurance.
This tier is the only one that qualifies for cost-sharing reductions (CSRs), even though all tiers qualify for subsidies.
What are Silver plans?
When a Special Enrollment Period (SEP) is triggered, this type of verification issue may require documentation of a qualifying life event.
What is an SVI (SEP Verification Issue)
These are the 3 factors (excluding tobacco use) that can legally affect your premium pricing under the ACA.
This unethical sales tactic involves misleading a customer into canceling a policy and replacing it with another for the agent’s benefit.
A member says, “I already have coverage through work.”
Confirm whether their employer plan is affordable and provides minimum essential coverage. Ask when the coverage goes into effect, and then compare it with Marketplace options to see where they can find the best coverage and savings.
This metal tier typically covers about 80% of medical costs on average, leaving consumers with about 20% cost-sharing.
What is the Gold tier?
Consumers generally have this many days to submit documentation to resolve (SEP).
What are 30 days ?
This tax form has information about Marketplace plans any member of your household had in 2024, including:
All ACA-compliant plans must cover these 10 categories of essential health benefits from maternity to mental health.
A member says " I didn't sign up for this , this is a lie this is fraud"
Reassure them the day of the enrollment, Agent spoken to, and what policy they signed up for. I will also send over the consent form and then begin initiating the save by probing and highlighting the benefits.
This metal tier has the highest monthly premiums but the lowest out-of-pocket costs, often chosen by people with ongoing medical needs.
What is the Platinum tier?
If a consumer fails to resolve an income verification documentation, what happens to their coverage?
They may lose their subsidy and be billed for the full premium amount.
Any insurance plan that meets the Affordable Care Act requirement for having health coverage. To avoid the penalty for not having insurance for plans 2018 and earlier, you must enroll in a plan that qualifies as this type of coverage.
Suggesting an income outside of a $5,000 range of what the consumer reports or coaching them to inflate/deflate it is considered this type of violation.
A member says " I don't think I need this right now "
I get it! What I can do is send you the benefits so you can review them at your own pace. That way, you’re covered just in case something happens and won’t have to worry about paying out of pocket for insurance.
This type of ACA plan is available to people under 30 or those with a hardship exemption, offering very low premiums but high deductibles.
What is a Catastrophic plan?
A consumer must provide this type of document to verify citizenship or lawful presence.
What are identity and immigration documents (e.g., passport, green card, naturalization certificate)?