Many agents and insurers know to direct their efforts towards the senior market, but did you know that seniors aren’t the only people covered under Medicare?
The under 65 market accounts for more than eight million Medicare recipients!
The recent expansion of the Affordable Care Act through the American Rescues Plan Act of 2021 has improved health insurance affordability to those younger than 65. Now is the time to enter this market, and below we’ve listed all you need to know to get started.
What is the Affordable Care Act (ACA)?
In 2010, the Affordable Care Act was signed into law, reforming American health care and insurance. This ended up giving 20 million Americans access to affordable health insurance coverage with its creation of several key provisions. Those provisions are:
- The creation of health insurance marketplaces, or exchanges
- People with pre-existing conditions are not to be denied coverage or charged more because of it
- Children can stay on their parent’s health plan until they turn 26
- Preventative care comes at no additional cost
- The individual mandate – requiring every American to have some type of health insurance or pay a tax penalty
- Subsidies, or tax credits, are available for qualifying individuals/families buying through the marketplace
- Medicaid expansion to cover low-income adults up to 138% of the Federal Poverty Level
In 2019, the individual mandate was repealed, but since then, several states have implemented their own similar mandates and penalties. (Including California, the District of Columbia, Massachusetts, New Jersey, and Rhode Island.)
Why is the Under 65 Market Suddenly Such a Big Opportunity?
- Commission Rates are High
A few years ago, this wasn’t the case, many carriers were leaving the marketplace or state exchanges, and those who stayed were cutting commissions for agents and brokers on such plans. But now we are seeing changes for the better. Carriers are offering high commission rates. Just like with Medicare Advantage and prescription drug plans, agents earn an initial commission for the first year and then a renewal commission on the second year and beyond. And the best part: these commissions are per member, per month, so the earning potential is incredibly high.
- More People Than Ever are Eligible for ACA Subsidies
As stated above, the American Rescue Plan Act of 2021 has expanded federal health insurance subsidies to millions of Americans. Previously, households slightly above 400% of the Federal Poverty line made too much in order to qualify for ACA health coverage. The cap is now 8.5% rather than 9.5%, letting more households qualify for financial assistance. More people eligible means more opportunities!
- You May Only Need One Certification to Start Selling
If you are already selling MAPD plans, you are probably already familiar with AHIP and carrier certifications. For someone to sell under 65 health plans, they also must complete a federal certification called the Federally Facilitated Marketplace (FFM) certification. There is no carrier certification, and the FFM certification is completely free to acquire.
New to the ACA marketplace, agents and brokers must complete a full marketplace training, and those returning are offered a shorter training with optional reviews. The FFM training requirements can be found in the Centers for Medicare & Medicaid Services’ Marketplace Learning Management System (MLMS)
The Steps to Complete the FFM certification are as follows:
- Register an account on the CMS Enterprise Portal (or log in and proceed to step 4)
- Go to the FFM training for Agents/Brokers/Assisters.
- Confirm your identity
- Click on “Complete Agent Broker Training” on the Agent Broker Registration Status page
- Complete the training and exams, either the vendor or CMS training through MLMS
- Agree to the CMS privacy and Security Agreements
Select states may require additional training. For more information, please reach out to Agent Pipeline at 800.962.4693
- Offering ACA Plans Will Strengthen Your Portfolio
If you already sell other insurance products, adding ACA plans to your offerings will only work to your advantage. You likely already are working with clients that are under 65 or who have close family under 65. Adding ACA plans allows you to tap into the potential, thereby better serving your current clients and any referrals they bring you while also growing your commissions. If you also sell Medicare, under 65 health offerings can be a precursor to Medicare or any other products you sell.
- CMS is Adopting Rules that Lower Costs for ACA Plans
CMS has made an announcement that they will be adopting rules that work to lower out-of-pocket costs, increase competition, and improve the shopper experience when purchasing an ACA health plan. In 2022, you can expect the maximum out-of-pocket costs to be $400 lower than what CMS proposed in November of 2020.
The ACA Marketplace and Exchanges
In order to step into the under 65 space, you’ll need to understand their marketplace and exchanges.
The ACA Marketplace
The ACA Marketplace, or federal health insurance marketplace or exchange, is a website that lets Americans buy under 65 health insurance plans. Some states have developed their own marketplaces or exchange websites, but otherwise, this website is HealthCare.gov.
What is the Difference Between an On-Exchange and Off-Exchange Plans
ACA plans are available either on the exchange or off the exchange. On-exchange plans account for those bought through HealthCare.gov, a state’s exchange website, or plans bought through an approved exchange enrollment platform. An off-exchange plan would be one bought directly from a carrier.
On-exchange plans are required to provide essential health benefits and follow the guidelines set by the ACA. Off-exchange plans don’t accept ACA subsidies and usually offer most, if not all, essential health benefits.
Open Enrollment and Special Enrollment Periods
The Open Enrollment Period runs from November 1 to December 15 and is a time when people can shop for and potentially enroll in a new under 65 health plan. They may also do this during a special enrollment period.
Eligibility for a special enrollment period can be gained if the client experiences any of the following:
- They’ve lost their job
- Moved to a new zip code
- There is a new child or death in the family
- They have experienced a coverage loss
- Marriage or divorce
- A change in citizenship status
- There has been a government error
- A change in subsidy eligibility
- A qualifying federal reason
In 2022, there will be additional special enrollment period opportunities available.
- If the client did not receive timely notice about a qualifying event
- If the client loses their employer contributions or government subsidies for continued employer health coverage through COBRA
In order to take advantage of a SEP, you and your client must act within 60 days of the qualifying life event.
ACA Subsidies and Eligibility Requirements
There are more people eligible for ACA subsidies than ever before in the United States due to the American Rescue Plan Act of 2021. So, what are they, and how can people qualify?
ACA subsidies are a form of Advanced Premium Tax Credit that has been targeted toward the lower-income and middle-income population in order for them to be able to afford health insurance. In order to qualify, one must:
- Have income between 100% and 400% of the Federal Poverty Level
- Be buying a health plan through the marketplace or exchange
- Does not have affordable employer-sponsored coverage available
For something to be considered affordable, the plan must be able to cover at least 60% of covered benefits or have premiums that cost no more than 8.5% of the individual’s annual household income after tax. When working with a client to determine if they are eligible for these subsidies, make as accurate an estimate as possible. When filing their taxes at the end of the year, your client might be required to pay back the subsidy if they earned more than the estimate. If they make less, they may get a refund for any additional subsidy qualification.
The under 65 marketplace is organized into four different tiers. These are referred to as metal tiers and are named as follows: Bronze, Silver, Gold, and Platinum. They are a quick way to tell both you and your client how medical costs are shared between the policy and policyholder. This does not refer to the level of care or covered services of the plans.
The higher the metal tier is, the lower the coinsurance responsibility for the member. The silver level plan is where the most cost reduction is found based on income. It is the most aggressive plan if your client qualifies for a subsidy.
Your job as an agent is to help your clients best understand their options based on their needs. But, unlike a navigator, an agent or broker can recommend one plan over another. The Under 65 market can increase your overall income and build out your book of business. With the American Rescue Plan Act, the under 65 market is more profitable than ever.
If you have any further questions or would like to know more about entering the under 65 market, contact the professionals at Agent Pipeline at 800.962.4693.