This article covers best practices for completing Marketplace applications accurately, including how to handle Social Security Numbers on EDE applications, how to avoid creating duplicate applications, and how income below 100% of the federal poverty level affects eligibility.
Key Terms
Key Terms
Enhanced Direct Enrollment (EDE): A CMS-approved process that allows agents, brokers, and web-brokers to complete Marketplace applications and enrollments directly through a partner website without sending consumers to HealthCare.gov.
Data Matching Issue (DMI): A discrepancy between the information a consumer provides on their Marketplace application and information in federal data sources. Unresolved DMIs can result in the consumer losing coverage or financial assistance.
Modified Adjusted Gross Income (MAGI): The income calculation method the Marketplace uses to determine eligibility for APTC, cost-sharing reductions, and Medicaid/CHIP.
Federal Poverty Level (FPL): A measure of income issued annually by the federal government and used to determine eligibility for Marketplace financial assistance.
Person search: A lookup function on EDE partner websites that allows agents and brokers to check whether a consumer already has an existing Marketplace application for the current coverage year.
What is different about entering a Social Security Number on an EDE application?
If an applicant has a Social Security Number (SSN), it must be entered on the Marketplace application. EDE websites are required to display additional language clarifying that the "doesn't have an SSN" box may only be selected if the applicant attests they have never been issued an SSN.
If an applicant's SSN is not included on the application, the consumer will receive a Data Matching Issue (DMI) and will need to submit additional documentation. An unresolved DMI puts the consumer at risk of losing coverage or financial assistance, and puts you at risk of losing compensation. You or the consumer can update the application to include the SSN to resolve the DMI instead of submitting documents.
What can I do to avoid creating a duplicate application for a consumer who already has a Marketplace application?
Before taking any other action, obtain consent from the consumer and perform a person search to check whether the consumer already has a Marketplace application for the current coverage year. If one search input does not return an existing application, try another — such as the SSN or variations of the consumer's name. Always confirm the consumer's first name, last name, middle initials, and date of birth are spelled and entered correctly.
If an existing application is found, update it — do not create a new application. A duplicate application can cause all members of the existing policy to lose coverage and tax credits.
How is eligibility determined for a consumer whose annual income is below 100% of the FPL but whose monthly income is too high for Medicaid?
The Marketplace calculates household income using MAGI methodology and converts it to a percentage of the FPL to determine eligibility for APTC, cost-sharing reductions, and Medicaid/CHIP. In cases where a consumer's annual income is below 100% FPL but their current monthly income is too high for Medicaid, state Medicaid/CHIP agencies are required to use projected annual income to determine eligibility. If the state determines the consumer is not eligible for Medicaid, the consumer may then be eligible to enroll in a Marketplace qualified health plan with financial assistance.
Additional Resources
For additional help, please contact Producer Support, which is available by chat directly from your account, by phone at (866) 568-9649, or by email at [email protected].