ACA 101: Selling Health Insurance for the Under-65 Market

Interested in growing your business by tapping into the under-65 health insurance space?

This guide breaks down the essentials of the Affordable Care Act (ACA) and what it takes to successfully sell health plans in this market. Here’s a quick overview of what you should know before getting started!

What Is the Affordable Care Act (ACA)?

The Affordable Care Act (ACA)—formally the Patient Protection and Affordable Care Act and commonly called Obamacare—was signed into law in 2010. This landmark legislation reshaped the U.S. health care system by expanding access to affordable coverage.

During the 2025 Marketplace Open Enrollment Period (OEP), more than 24.2 million Americans enrolled in health plans made available through the ACA.

Key Provisions of the ACA:

Creation of health insurance marketplaces (exchanges)
The original individual mandate, which required health coverage or a tax penalty (repealed at the federal level in 2019)
Guaranteed coverage for people with pre-existing conditions at no extra cost
Coverage for dependents up to age 26 under a parent’s plan
Preventive care services at no additional cost
Premium tax credits and subsidies to lower monthly costs for eligible individuals and families
Medicaid expansion for low-income adults earning up to 138% of the Federal Poverty Level

State-Level Mandates

Although the federal individual mandate penalty ended in 2019, some states now enforce their own requirements, including:

California
The District of Columbia
Massachusetts
New Jersey
Rhode Island
Vermont (mandate in place, but without penalties)

Certification Requirements for Selling ACA Plans

Selling ACA plans is much simpler than Medicare certifications:

To sell under-65 health plans on HealthCare.gov, agents only need to complete the Federally Facilitated Marketplace (FFM) certification.
Unlike Medicare Advantage and Part D, there are no carrier-specific certifications required.
Best of all, FFM certification is free.
For states operating a State-Based Marketplace (SBM), agents may only need to complete that state’s ACA certification process.

ACA Plans as a Complement to Your Insurance Portfolio

If you’re already selling products like Medicare plans, adding under-65 ACA health plans is a natural next step. Many of your existing clients may have spouses, children, or other family members under 65 who need coverage—and you’ll be in the perfect position to help.

By offering ACA plans, you can:

Better serve your current clients
Capture referral opportunities
Expand your book of business
Increase your commissions

Build a Medicare Sales Pipeline

Selling ACA plans doesn’t just provide immediate growth—it also helps you create a future Medicare pipeline.

Your under-65 clients today may eventually age into Medicare eligibility. As their trusted advisor, they’ll likely turn to you when that time comes. By guiding them through ACA coverage now, you’re building long-term relationships that can naturally transition into Medicare sales—or even other products you offer.

In short: ACA sales open doors for stronger client loyalty today and Medicare opportunities tomorrow.

Understanding the ACA Marketplace & Exchanges

If you’re planning to sell under-65 health insurance, it’s essential to understand how the ACA marketplace and exchanges work.

What Is the ACA Marketplace?

The ACA marketplace—also called the federal health insurance marketplace or exchange—is the platform where Americans can shop for and enroll in under-65 health insurance plans. The federal marketplace is hosted at HealthCare.gov and is used by most states.

Some states operate their own state-based marketplaces (SBMs). These exchanges perform the same functions as HealthCare.gov but are managed independently by the state.

On-Exchange vs. Off-Exchange Plans

ACA-compliant health insurance plans are available on the exchange or off the exchange:

On-Exchange Plans
- Purchased through HealthCare.gov, a state exchange website, or an approved enrollment partner such as HealthSherpa
- Must include all essential health benefits outlined by the ACA
- Eligible for subsidies (premium tax credits) to help lower monthly costs
Off-Exchange Plans
- Purchased directly from an insurance carrier
- Typically cover most, if not all, of the same essential health benefits as on-exchange plans
- Not eligible for ACA subsidies—individuals cannot use tax credits to pay for these plans

Key takeaway: Clients who qualify for subsidies must enroll in an on-exchange plan to receive financial assistance.

Open Enrollment Period (OEP) & Special Enrollment Periods (SEPs)

Each year, individuals can shop for and enroll in new under-65 health plans during the Open Enrollment Period (OEP). In most states, OEP runs from November 1 through January 15.

Outside of OEP, clients may still qualify to enroll through a Special Enrollment Period (SEP) if they’ve experienced a qualifying life event.

Common Qualifying Life Events for SEPs:

Loss of job-based coverage, Medicaid, Medicare, or coverage through a family member
Moving to a new ZIP code or county
Marriage or divorce
Birth or adoption of a child, or death in the family
Change in citizenship or immigration status
Change in subsidy eligibility
Government error or another federally recognized qualifying reason

SEP Enrollment Window

To use a Special Enrollment Period, clients (and their agents) must act quickly. Enrollment must be completed within 60 days of the qualifying life event.

Tip for agents: Always ask your clients about recent life changes. You might uncover SEP eligibility that allows them to get coverage outside of OEP.

ACA Subsidies & Eligibility

You’ve probably heard a lot about ACA subsidies—but what exactly are they, and who qualifies?

ACA subsidies, formally called Advanced Premium Tax Credits (APTCs), are designed to make health insurance more affordable for individuals and families with low to middle incomes.

Who Qualifies for ACA Subsidies?

To be eligible, applicants must meet the following criteria:

Income level: Between 100% and 400% of the Federal Poverty Level (FPL)
Enrollment: Must purchase a plan through the Marketplace or state exchange
Employer coverage: Cannot have access to “affordable” employer-sponsored insurance*

*Thanks to the closure of the family glitch, family members can now qualify for subsidies if the employee’s share of their own employer coverage costs more than 8.39% of household income. Previously, only the employee’s cost was considered, but now the entire family’s eligibility is factored into the calculation.

Estimating Subsidies

When estimating 2026 subsidy amounts, agents should use 2025 income levels as the baseline for calculating potential savings.

2025 Income Levels for Federal Poverty Levels

Family Size	100% FPL	150% FPL	200% FPL	250% FPL	400% FPL
1	$15,650	$23,475	$31,300	$39,125	$62,600
2	$21,150	$31,725	$42,300	$52,875	$84,600
3	$26,650	$39,975	$53,300	$66,625	$106,600
4	$32,150	$48,225	$64,300	$80,375	$128,600
Each additional	$5,500	$8,250	$11,00	$13,750	$22,000

Source

Individuals with incomes below 138% of the Federal Poverty Level (FPL)—or below their state’s designated threshold—may qualify for free or low-cost health coverage through Medicaid.

For residents of Hawaii and Alaska, poverty guidelines differ from the rest of the U.S. Agents should refer to the most up-to-date income standards available on HHS.gov to confirm eligibility in those states.

When applying for a Marketplace plan, you and your client will work together to estimate their household income for the upcoming year. Their subsidy amount is calculated using this estimate, along with other eligibility factors.

At tax time, the IRS will compare the client’s actual income with the estimate they provided:

If they earned more than expected: They may need to repay part or all of the subsidy they received.
If they earned less than expected: They could receive a refund for additional subsidy dollars they qualified for but didn’t initially receive. This process is called subsidy reconciliation, and it’s an important point to explain to clients so they understand how their year-end taxes may be affected.

ACA Metal Levels: Bronze, Silver, Gold & Platinum

Marketplace plans for individuals under 65 are grouped into four “metal tiers”: Bronze, Silver, Gold, and Platinum.

These levels don’t reflect the quality of care or the types of services covered—all ACA-compliant plans must include essential health benefits. Instead, the tiers show how medical costs are split between the insurance company and the policyholder.

In short, the metal level tells you and your clients what percentage of health care costs the plan will pay versus what the client will pay out of pocket.

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

Metal Tiers & Client Recommendations

As you move up through the ACA metal tiers, the plan covers a greater share of costs while the member’s out-of-pocket responsibility decreases.

The most popular option in the Marketplace is the Silver tier, largely because it allows clients to apply subsidies. For clients who qualify, recommending a Silver plan is often the best fit.

That said, not every client’s situation is the same. Some may prefer a Bronze plan combined with a supplemental option (like a hospital indemnity plan). This combination can provide affordable premiums while still protecting against major expenses.

Catastrophic Health Plans

Beyond the metal tiers, clients may also qualify for catastrophic health plans. These plans are designed to provide low monthly premiums with very high deductibles, making them a budget-friendly way to protect against serious or unexpected medical events.

To be eligible, clients must meet certain criteria:

Be under age 30, or
Qualify for a hardship or affordability exemption (such as Marketplace or job-based insurance being deemed unaffordable)

Catastrophic plans cover the same 10 essential health benefits as other ACA plans, including preventive care at no cost. They also provide at least three primary care visits per year before the deductible applies.

Recent Policy Updates

On September 4, 2025, CMS released new guidance regarding hardship exemptions for Plan Year 2026. This update was designed to address rising premiums by expanding access to catastrophic plans.

Under the new rules, hardship exemptions are now also available to individuals who do not qualify for premium subsidies or cost-sharing reductions, giving them an affordable coverage alternative.

Requirements for Selling ACA Plans

Before you can begin selling ACA Marketplace plans, you’ll need to meet several key requirements:

Licensing – Hold an active state health insurance license in the states where you plan to sell.
Certification – Complete the required FFM (or SBM) certification to sell ACA plans.
Carrier Appointments – Get appointed with carriers whose ACA products you want to offer.

Compliance When Working With Clients

Once you’re certified and ready to sell, you must also follow federal compliance rules when assisting consumers:

Obtain consumer authorization before helping with enrollment.
Collect eligibility attestations to confirm that the client meets the requirements for ACA coverage and subsidies.

The 2025 Marketplace Integrity and Affordability Final Rule introduces new safeguards to protect consumers from improper enrollments and unauthorized changes to their health coverage. It also sets updated standards to strengthen the overall integrity and accountability of ACA exchanges.

Your Advantage

You may already know that navigators are available to assist people enrolling in ACA Marketplace plans. But here’s the key difference: navigators cannot recommend one plan over another.

As an agent or broker, you can.

That means you’re uniquely positioned to:

Guide clients toward the plans that truly fit their needs
Compare options and explain the pros and cons
Provide ongoing support beyond just enrollment

By entering the under-65 health insurance market, you’re not only protecting the best interests of your clients—you’re also strengthening your own business. ACA sales can diversify your portfolio, grow your commissions, and keep your book of business thriving for years to come.

A Growing Opportunity

The ACA health market has gone through many changes in recent years, but one thing remains clear: the opportunity is strong. At Essential Care, we see the ACA marketplace as a powerful way to grow alongside our agents—and we’re excited to help you build lasting success in under-65 sales.

Not affiliated with or endorsed by Medicare or any government agency.

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