This article covers how agents and brokers can assist clients who are transitioning between ACA Marketplace coverage and Medicare, including how to terminate Marketplace coverage, how to handle household members who are continuing their Marketplace coverage, and when to call the Marketplace Call Center instead of making changes online.
Key Terms
Key Terms
Initial Enrollment Period (IEP): A 7-month window during which a consumer can first sign up for Medicare. For most consumers, the IEP begins 3 months before their 65th birthday, includes the month of their birthday, and ends 3 months after their birthday month.
Special Enrollment Period (SEP): A time outside of Open Enrollment when a consumer can enroll in or change their Marketplace coverage due to a qualifying life event or other specific circumstance.
Advance Payments of the Premium Tax Credit (APTC): Federal financial assistance paid directly to a consumer's insurance carrier to reduce their monthly Marketplace premium. APTC amounts may change when a household member with Medicare is removed from a Marketplace plan.
Accumulators: Tracking totals for cost-sharing amounts a consumer has paid toward their deductible, out-of-pocket maximum, or other plan limits during a coverage year. Accumulators may reset when a consumer selects a new Marketplace plan.
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.
Can a client keep their Marketplace plan while waiting for Medicare to start?
Yes. A consumer can keep their Marketplace plan without penalty until their Medicare coverage starts. Alternatively, a consumer can choose to terminate their Marketplace plan when they enroll in Medicare. The decision depends on the consumer's coverage needs and the timing of their Medicare start date.
Once Medicare eligibility begins, consumers have a 7-month Initial Enrollment Period (IEP) to sign up. For most consumers, the IEP begins 3 months before their 65th birthday, includes the month of their birthday, and ends 3 months after their birthday month.
How do I help a client terminate their Marketplace plan when they enroll in Medicare?
You can assist a client with terminating their Marketplace plan in any of the following ways:
Help them end their coverage through an Enhanced Direct Enrollment (EDE) website.
Direct them to HealthCare.gov to manage the termination themselves.
Call the Marketplace Agent/Broker Partner Line at 1-855-788-6275 on their behalf.
If the consumer is managing the termination themselves through their HealthCare.gov account, they should navigate to "My plans & programs" and select "End (Terminate) All Coverage."
How do I help a client keep their Marketplace plan until their Medicare start date?
Consumers who want Marketplace coverage until their Medicare begins should update their Marketplace application online or by phone through the Marketplace Call Center, with or without your assistance. On the application — either on HealthCare.gov or on an EDE website — the consumer will be asked whether they are starting Medicare within the next three months. The consumer can provide their Medicare start date, enroll in a Marketplace plan, and the Marketplace will automatically end their Marketplace coverage at the appropriate time.
What happens to other household members on the same Marketplace plan when a consumer transitions to Medicare?
If other household members are continuing their Marketplace coverage after the Medicare enrollee is removed from the plan, their APTC amount and premium responsibility may be updated. Those continuing enrollees may be eligible to shop for a new Marketplace plan if they qualify for a Special Enrollment Period (SEP).
If the person transitioning to Medicare is the subscriber on the Marketplace policy, the remaining household members will need to select the same plan or a new plan. When they do, their accumulators — such as their deductible progress or annual out-of-pocket limit — may reset. For clients transitioning from an ACA Family Plan to Medicare Advantage due to aging into MA eligibility, agents must contact CMS to remove the individual from the family plan.
Are there situations where I should not make changes online and must call the Marketplace Call Center instead?
Yes. There is one specific scenario where the consumer must call the Marketplace Call Center at 1-800-318-2596 rather than making changes online: when a Marketplace enrollee started Medicare in the past or is starting Medicare in the next month, and someone on the same application also needs to add a newborn born in the last 60 days or report an adoption that occurred in the last 60 days.
In these cases, making changes online risks a gap in coverage for the consumer transitioning to Medicare. The consumer should call the Marketplace Call Center to report these changes and avoid that gap.
Additional Resources
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