When assisting clients who are exploring Affordable Care Act (ACA) coverage through the federal or state marketplace, it’s important to ask the right questions to uncover their needs and priorities.
Use these questions during your conversations to gain a clear understanding of what matters most to them and to help guide them toward the health insurance plan that best fits their situation.
How Often Do You Use Health Care Each Year?
Asking your client how frequently they visit doctors or providers can help determine the most suitable plan tier. For example, a client who only schedules an annual physical may prefer a lower-premium option, while someone managing ongoing conditions with regular visits might benefit from a plan in a higher metal tier. These plans often come with lower deductibles and copays, which may make the higher monthly premium worthwhile.
What Is Your Estimated Annual Household Income?
Your client’s annual household income is a key factor in determining their eligibility for Premium Tax Credits and Cost-Sharing Reductions (CSRs)—two programs that can significantly lower the cost of marketplace coverage. Use the subsidy calculator on HealthCare.gov to estimate potential savings before recommending a plan.
Be sure to remind clients that:
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Cost-Sharing Reductions are only applied when enrolling in a Silver plan.
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Premium Tax Credits can be used on plans at any metal level.
Thanks to the Inflation Reduction Act, more individuals remain eligible for subsidies through 2025, making ACA coverage even more accessible. It’s also an ideal opportunity to remind clients about the importance of reconciling their Premium Tax Credits to avoid tax issues later.
How Much Can You Comfortably Spend Each Month on Health Insurance?
For many clients, budget plays a major role in choosing the right plan. Subsidies can significantly lower monthly premium costs, but if a client doesn’t qualify, they may prefer a lower metal tier to keep expenses manageable.
For clients who rarely use health services and simply want protection against worst-case scenarios, Catastrophic plans may be an option. These plans provide a financial safety net in case of serious illness or injury but are not designed for those who need regular care or broad coverage.
Do You Have Doctors or Specialists You Want to Keep Seeing?
When discussing your client’s health needs and medications, ask if there are doctors or specialists they’d like to continue seeing. This can help narrow down plan options that include their preferred providers within the network.
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HMO & EPO plans: These limit coverage to a local network of providers and typically don’t cover out-of-network care (except for emergencies). They can be cost-effective choices, especially for clients with chronic conditions.
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HMO plans require a referral from a primary care physician to see a specialist.
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EPO plans don’t require referrals but still restrict care to in-network providers.
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PPO plans offer the most flexibility for out-of-network care and specialist access without referrals, but they usually come with higher premiums.
Encourage clients to balance network access, coverage flexibility, and affordability when choosing the plan that fits their needs best.
Do You Take Any Prescription Medications?
Clients who manage chronic conditions or regularly take prescription drugs should carefully review how different plans cover their medications. In many cases, HMO or EPO plans provide stronger prescription coverage compared to PPO options, making them a more cost-effective choice for those who rely on ongoing medications.
Have You Experienced a Major Life Event Recently?
Certain life changes—such as getting married, having a baby, losing other health coverage, or moving—make your client eligible for a Special Enrollment Period (SEP). With an SEP, they have 60 days to choose a new plan through the Marketplace.
If none of these events apply, your client will need to wait until the ACA Open Enrollment Period (OEP) to sign up for coverage.
Is Dental Coverage Important to You?
Most marketplace health plans do not include adult dental services. While a few carriers may offer dental benefits within their plans, this is uncommon and availability varies by location. Be sure to ask your client if dental coverage is a priority for them. In many cases, a stand-alone dental plan or a supplemental dental, vision, and hearing policy can be a great solution.
Looking ahead, dental benefits will become an essential health benefit under the ACA starting in 2027. For more details on upcoming marketplace changes, see our State of the ACA Market 2025 report.
By asking your clients these key questions, you’ll gain deeper insight into their needs—helping you provide stronger guidance and ultimately close more sales. Keep this list handy for your next client meeting to make the most of every conversation.
And remember, you don’t have to tackle the tough questions alone. As an Essential Care agent, you’ll have access to dedicated sales support, on-demand training, and a full library of resources—all available with a free registration to help you succeed.
Not affiliated with or endorsed by Medicare or any government agency.
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