The FLC
Agent Field Guide

Health coverage decisions affect a family’s finances, access to care, and peace of mind. Your role is to turn a complicated process into a clear conversation, help consumers make informed choices, and leave a reliable record of their decisions.

Complete your readiness steps

• State authority: Maintain the appropriate health insurance license in every state where you actively assist consumers. Verify required issuer appointments.
• CMS participation: Complete the applicable annual registration, training, identity verification, and agreements. For PY2027, link the CMS Enterprise Portal account to a CMS-approved credential provider, ID.me or Login.gov, as instructed. New entrants must complete the required new-agent curriculum when registration is available.
• Your information: Keep your National Producer Number (NPN), contact details, and MLMS and NIPR profiles accurate. Verify your current registration status.
• FLC onboarding: Confirm your approved enrollment tools, secure record system, carrier access, and compliance contact before working with client information.

How to use this guide

Read the chapters in order for orientation, then use the quick reference when assisting clients. Examples are fictional. FLC practice tips suggest useful work habits. Follow the agency’s approved procedures when putting them into practice.

This guide supports agency orientation. It does not replace required CMS training, state licensing, issuer requirements, or execution of the applicable Marketplace and SHOP agreements. Its federal Marketplace guidance focuses on FFEs and State-based Exchanges using the federal platform; independently operated state exchanges may have different procedures.

A strong recommendation starts with the consumer’s priorities: doctors, prescriptions, expected treatment, preferred hospitals, and a realistic monthly budget. Translate plan features into what the consumer will pay and how they will obtain care.

Compare the complete cost of coverage

Review the premium after any eligible APTC, deductible, office visits, medication costs, and out-of-pocket maximum. Confirm network participation and prescription coverage for the specific plan and year. A familiar insurer’s name does not guarantee that every plan uses the same network or formulary.

Metal categories describe how covered costs are generally shared; they do not rank quality of care. Describe dental, vision, or supplemental products separately and explain their limits. A cash benefit policy does not replace comprehensive major medical coverage.

Financial assistance has narrower eligibility

Beginning in Plan Year 2027, APTC and income-based CSRs are limited to U.S. citizens, U.S. nationals, and eligible noncitizens: Lawful Permanent Residents, Cuban and Haitian Entrants, and Compact of Free Association migrants. Other eligibility conditions still apply. Prior-year assistance does not establish eligibility for the new year.

The former exception allowing certain lawfully present consumers below 100% of the federal poverty level (FPL), who were ineligible for Medicaid because of immigration status, to qualify for APTC has been removed. Treat eligibility to purchase coverage and eligibility for financial assistance as separate questions.

Read the reason for a Medicaid denial

Starting January 1, 2027 in applicable states, certain adults ages 19–64 must meet Medicaid community engagement requirements, subject to exceptions and exemptions. States granted a good-faith implementation delay may have later dates, no later than December 31, 2028. A consumer denied Medicaid solely for failure to demonstrate community engagement is treated as eligible for MEC and is ineligible for APTC/PTC. Do not assume every Medicaid denial creates subsidy eligibility.

2027 annual cost-sharing ceilings

These are federal ceilings, not every plan’s actual limit. The CSR rows apply to eligible reduced-cost-sharing variants. Verify the plan’s Summary of Benefits and Coverage. Special tribal cost-sharing rules require separate review.

Adult dental remains a separate consideration

Routine adult dental services cannot be included as an Essential Health Benefit (EHB). Insurers may still offer adult dental within a QHP as a non-EHB benefit or through a separate dental plan. Confirm how benefits, premiums, and limitations are structured.

Consumer consent authorizes assistance. Application review documents the consumer’s confirmation that the information being submitted is accurate. They serve different purposes.

Make the record clear

The documentation must establish the consumer’s actual action and the assistance authorized. Use the current compliant forms and procedures. Describe consent’s scope, purpose, duration, and revocation process; identify the consumer and agent or agency, and record the date. For application review, record the date, consumer and assisting agent names, and explanation of the applicable attestations. [8]

Does every action require fresh consent?

It depends on the existing consent. CMS does not prescribe one universal consent duration. Existing consent may support subsequent actions if it remains effective, has not been revoked, meets current requirements, and covers the action and person providing assistance. A longstanding relationship alone is not permission.

Even when the consent remains valid, an agent actively submitting an application or update must separately document the required review and accuracy confirmation. Knowing that nothing has changed does not replace the consumer’s confirmation.

Retain evidence that can be produced

Keep consent and application-review documentation for at least 10 years and produce it when CMS requests it. Use a secure, retrievable process. An unsupported internal note is not a substitute for evidence of the consumer’s required action.

Marketplace financial assistance depends on expected annual household income for the coverage year. Use current earnings and known changes to build a reasonable projection. Last year’s tax return is a reference; it may not reflect a new job, reduced hours, or a growing business.

A practical estimation conversation

1. Confirm the tax household. Identify the expected tax filer, spouse, and dependents. Use the Marketplace rules for whose income is counted, including required-to-file dependent income.
2. Review current earnings. Discuss pay frequency, hours, seasonal work, and net self-employment income. Use the application’s income instructions; gross business receipts are not the same as net business income.
3. Add known changes. Consider a job starting or ending, variable hours, expected bonuses, household changes, and relevant permitted adjustments.
4. Explain and document the estimate. Record the assumptions, supporting information, and consumer confirmation before submission.

Explain the tax consequence plainly

APTC is reconciled against the final allowable credit when the consumer files their federal tax return. For tax years after 2025, repayment caps no longer limit repayment of excess APTC. A consumer may owe the entire excess, including through a reduced refund or added tax balance. Overestimating income may reduce assistance during the year. Refer individual tax questions to a qualified tax professional.

Resolve income data matching issues

A data matching issue (DMI) means submitted information needs verification. The CMS PY2027 training describes income differences exceeding 50% or $12,000, whichever is less, as a potential trigger. Follow the actual eligibility notice for the issue and deadline.

Match evidence to the current estimate: recent pay statements for a new job, a self-employment ledger, tax records when representative, or benefit statements. An outdated W-2 may not support this year’s projection. Unresolved issues may reduce financial assistance to zero.

The CMS training identifies Enhanced Direct Enrollment (EDE) as the primary agent-assisted pathway for Plan Year 2027. An approved EDE platform connects to the Marketplace so the application, eligibility, and plan selection process can occur through that platform.

Follow the verification sequence

1. Document consent. Do this before searching or accessing consumer information.
2. Complete consumer authorization. The consumer may receive a one-time confirmation link or passcode by text, email, or phone to authorize the agent.
3. Complete identity proofing when prompted. Some consumers must use an EDE identity-verification link. Do not submit until required verification and authorization are complete.
4. Confirm application identifiers. Agent-assisted applications require a verified SSN or immigration document number for each non-newborn applicant. This safeguard applies across EDE, HealthCare.gov, and Call Center pathways.
5. Review, confirm, and submit. Document the consumer’s accuracy confirmation before submission; use the authorized NPN and verify the resulting application status.

HealthCare.gov assistance has boundaries

Consumers manage their own accounts. Do not create a consumer account, sign in as the consumer, submit through the consumer pathway as though you were the consumer, or retain their account or associated email login credentials.

Limited side-by-side assistance and Call Center support may be available. Under the CMS PY2027 training, a consumer cannot add or change an NPN through HealthCare.gov or an EDE consumer pathway. An existing NPN remains unless the consumer removes it. Use the current authorized agent-association process.

Protect your own access

Never share individual CMS credentials with a manager, assistant, or colleague. The Individual Marketplace General Agreement permits one Enterprise Portal account, one login session for the covered activities, and one person search at a time. Scripting or automation requires advance written CMS approval.

Federal Marketplace Open Enrollment for 2027

Confirm the applicable exchange calendar and any announced changes. Independently operated State-based Exchanges may use different dates. Medicaid and CHIP applications can be made throughout the year.

Outside Open Enrollment, establish SEP eligibility

A Special Enrollment Period (SEP) may be available after a qualifying event such as loss of qualifying coverage, marriage, a qualifying move, or birth or adoption. Requirements and enrollment windows vary by event. Ask for the event, dates, prior coverage when relevant, and the notice or evidence supporting it.

The monthly SEP for consumers at or below 150% FPL has been removed beyond Plan Year 2026. Low income alone does not create that SEP. Loss of coverage because premiums were not paid also does not create a loss-of-MEC SEP.

Handle SEP verification promptly

Loss of minimum essential coverage may trigger an SEP verification issue (SVI). CMS has also expanded federal pre-enrollment verification beyond this category. Follow the application’s notice rather than assuming only one SEP type can be reviewed.

Use the notice’s exact deadline, acceptable documents, and submission instructions. Do not confuse a qualifying-event enrollment window with the deadline for verifying an already selected plan.

Confirm what the consumer chose

Before enrollment, review the specific plan name, coverage year, effective date, premium after eligible assistance, network, medications, deductible, and other major costs. Explain prior authorization and referral requirements when relevant. Give the consumer an opportunity to ask questions and confirm their selection.

Help the consumer activate coverage

Premiums are paid to the insurance company, not to the Marketplace. Explain how and when to pay the first premium, using the issuer’s instructions. Check for unresolved verification requirements. Preserve confirmation details and distinguish “plan selected,” “pending,” and “active coverage.”

Encourage the consumer to obtain the member ID, register with the insurer using their own credentials, and review how to access care. Confirm activation with the issuer or approved status tool before telling a consumer they can use coverage.

Explain the premium grace period

A consumer receiving APTC who has paid at least one full month’s premium during the benefit year generally has a three-consecutive-month grace period. It starts with the first missed payment month. Claims may be pended in the second and third months. The consumer must pay outstanding premiums to avoid termination; state rules govern grace periods when APTC does not apply.

Termination for nonpayment does not itself create a loss-of-coverage SEP. Encourage early contact with the issuer about payment status and amounts due.

Make renewal an active review

Eligible consumers who do not act by December 15 may be automatically re-enrolled for January 1. Automatic renewal is not guaranteed for every consumer, and it does not guarantee the same plan, network, premium, or financial assistance.

Read the Marketplace and issuer renewal notices. Recheck expected income, household, eligibility, and 2027 verification requirements, then compare plans. When you actively submit an application or update, obtain the required accuracy confirmation even if existing consent is still valid.

Health Savings Accounts: explain the essentials

An HSA is a tax-advantaged account for eligible individuals to pay qualified medical expenses. Unused funds carry forward. HSAs are opened through a bank or other qualified financial institution, not through the Marketplace. Ordinary Marketplace premiums generally cannot be paid tax-free from an HSA.

Beginning in 2026, Exchange Bronze and Catastrophic plans are treated as HSA-compatible; the course also identifies identical off-Exchange versions. Other IRS-qualified high-deductible health plans may qualify. Plan eligibility alone does not establish that an individual may contribute: other coverage, Medicare enrollment, and additional IRS rules matter. Catastrophic enrollment restrictions and tax-credit limitations still apply.

Eligible individuals age 55 or older may have an additional $1,000 catch-up contribution. Eligibility periods, combined employer/individual contributions, and other IRS restrictions can affect the amount permitted.

Permitted deductible HSA contributions may affect Marketplace income. Review expected contributions and income updates with the consumer; refer tax treatment and contribution questions to a qualified tax professional. Avoid recommending a specific HSA provider unless authorized and qualified to do so.

Individual Coverage HRAs: an employer-funded option

An Individual Coverage Health Reimbursement Arrangement (ICHRA) allows an employer to reimburse eligible medical expenses, including individual coverage premiums, under the arrangement’s rules. Employers gain a defined contribution budget; employees can select individual coverage that meets their needs.

Obtain the employer’s notice and offer details. An affordable ICHRA offer generally blocks the premium tax credit, even if the employee declines the offer. If it is unaffordable, the employee generally must opt out and satisfy other eligibility requirements to receive a Marketplace credit. A consumer cannot receive ICHRA reimbursement and a PTC for the same coverage period.

Every advertisement sets an expectation. Plan Year 2027 standards apply to agent, broker, and web-broker marketing, including materials produced or distributed by third parties. Review the entire consumer experience: the ad, landing page, lead form, call script, and follow-up.

Practices CMS expressly prohibits

• Cash, monetary rebates, gift cards, travel vouchers, or cash equivalents as enrollment-related inducements.
• Gifts that do not satisfy the conditions for nominal value, availability to all similarly situated consumers regardless of enrollment, and a noncash form.
• Statements implying consumers will always qualify for zero-dollar insurance or premiums.
• Identical or facsimile government or other official logos and notations.
• Inaccurate deadlines, enrollment timelines, or SEP eligibility claims.
• False or misleading descriptions or citations of legislation, regulations, or Executive Orders.
• Untruthful endorsements using a notable person’s image, likeness, or quotation.

Third-party leads remain your responsibility

Agents can be held accountable for misleading marketing used by a lead generator or other third party working with them. A vendor’s assurances do not replace review of the materials and practices generating the leads.

CMS may request marketing materials for monitoring, audit, or enforcement. Be able to produce the relevant digital content, scripts, flyers, and social posts.

The clearer example illustrates tone and accuracy; it is not a preapproved advertisement. Include applicable state and product disclosures, and obtain any required internal review.

Personally identifiable information (PII) identifies someone directly or in combination with other information. Protect identity, income, application, and payment records using approved secure systems.

Use information only for authorized purposes

Provide the required privacy notice before collecting PII. Obtain consent and limit access to the authorized work. Unrelated uses of Marketplace PII require appropriate informed consent. Store separately collected non-Marketplace information separately from covered Marketplace PII.

Do not request citizenship or immigration status from someone not seeking coverage. Do not require their SSN except where permitted to verify relevant tax-filer household income and family size. Required applicant identifiers and nonapplicant privacy rules address different situations.

Access location and technology matter

Covered Exchange and supporting access systems may be accessed only from the United States, its territories, embassies, or military installations. VPNs must not route Exchange traffic through excluded locations. The course also prohibits offshore or foreign-hosted services for covered activities. Verify vendor arrangements and travel access with compliance.

Preserve evidence, take authorized containment steps, and provide the facts known: discovery time, incident type, systems, accounts, affected data, actions taken, and next steps. Send follow-up reports and root-cause information as CMS directs.

Keep these obligations visible

Verify identity for consumer requests. Retention and lawful destruction rules continue after agreements end. Do not delete records to answer a consumer request without checking applicable retention duties.

The Small Business Health Options Program (SHOP) helps eligible small employers offer health and dental coverage to employees. It is group coverage arranged by an employer. Individual Marketplace coverage, including coverage purchased with an ICHRA, follows a different process.

Confirm the employer’s eligibility

• SHOP generally serves businesses with 1–50 full-time equivalent employees. Some states allow businesses with up to 100 employees.
• The employer generally needs at least one employee who is not an owner, partner, spouse, or family member. Confirm the applicable employee-counting rules.
• Coverage must be offered to all full-time employees, generally those working 30 or more hours weekly.
• The business must have an office or employee work site in the state whose SHOP is used.
• In most states, at least 70% of employees offered coverage must enroll or have other qualifying coverage. State participation rates vary.

Minimum participation requirements are waived during the November 15–December 15 enrollment window. Use the current SHOP participation calculator and state requirements rather than assuming every business uses the same percentage.

How enrollment works

Eligible employers can generally start SHOP coverage throughout the year. Confirm local SHOP-certified plan availability, the effective date, and carrier submission requirements. For federally facilitated SHOP coverage, plans are purchased through a participating insurer or a registered agent or broker; employers do not select and enroll in SHOP plans through a HealthCare.gov consumer application.

Obtain the employer’s SHOP eligibility determination when required, then review plan choices, premiums, employer contributions, employee enrollment, payment, and ongoing administration with the issuer.

Register for the SHOP role

Maintain the appropriate state license and appointments. Use your existing CMS Enterprise Portal account if you have one, complete the applicable identity and MLMS profile steps, and execute the SHOP Privacy and Security Agreement. Individual Marketplace training and agreements do not replace the SHOP agreement. CMS SHOP training is recommended rather than a federal prerequisite; follow any additional agency, state, or carrier requirements.

This chapter is an introductory SHOP overview based on official resources. The agreement references in this guide cover the Individual Marketplace. Review the current SHOP agreement for obligations specific to that role.

Start with the employer’s goals

Ask how the employer wants to support employees, how much it can reliably contribute, where employees work, and which provider networks matter. Distinguish the employer’s funding decision from the employees’ plan enrollment decisions.

Discuss the Small Business Health Care Tax Credit carefully

SHOP may offer access to a tax credit for qualifying employers. Basic conditions generally include fewer than 25 FTEs, average wages below the current inflation-adjusted threshold, and payment of at least 50% of employee-only premiums. SHOP coverage is generally required, subject to limited exceptions.

The maximum credit is generally 50% of eligible employer premiums, or 35% for eligible tax-exempt employers, for two consecutive taxable years. The actual credit depends on the employer’s circumstances and phaseouts. The tax-credit FTE calculation differs from some other employee-counting rules.

Explain the potential benefit without guaranteeing eligibility or savings. Refer calculations, wage thresholds, exceptions, and filing questions to the employer’s tax professional.

When an ICHRA enters the discussion

An employer may want predictable contributions while allowing employees to select individual coverage. An ICHRA can support that goal, but it requires proper arrangement design, notices, coverage substantiation, and an affordability review. Coordinate with qualified benefits and tax professionals. Do not label an ICHRA as a SHOP plan.

Before accessing a client’s information

• Verify current registration, state license, required appointment, and approved access.
• Provide the required privacy notice and document effective consent covering the intended work.
• Confirm the consumer or authorized representative and complete required authorization and identity steps.

Before submitting an application or update

• Confirm the tax household, expected income, coverage offers, citizenship or eligible immigration category, and enrollment opportunity.
• Resolve required identity and identifier checks; track all outstanding document requests.
• Explain the relevant application attestations and tax reconciliation responsibilities.
• Document the consumer’s review and accuracy confirmation, and the plan decision when enrolling.
• Use an authorized NPN. An agency NPN is not a workaround for missing license, appointment, registration, or state-law requirements.

After plan selection

• Explain the first premium, issuer payment instructions, verification tasks, and coverage effective date.
• Record the actual status and confirmations. Arrange follow-up for pending items.
• Explain how to report income and household changes and prepare for the next renewal.

Know when to stop and obtain help

If a consumer requests false income, an unauthorized change, a fabricated SEP, or account credential sharing, explain the permitted process. If an appointment or NPN rule is unclear, check state law and carrier requirements before acting. Another agent’s or an agency’s NPN may be permitted only under the applicable rules; never assume.