CMS FFM Agent cheat sheet

FFM agents must complete Marketplace registration with the Federally-facilitated Marketplace before assisting consumers, including identity proofing and signing the applicable agent/broker agreement.

Registration flows through the CMS Enterprise Portal and the Marketplace Learning Management System (MLMS); both the portal account and the MLMS training path must be completed.

Required annual training must be completed before the start of each plan year's Open Enrollment; the curriculum is refreshed yearly, so prior-year completion does not carry forward.

The MLMS curriculum covers the FFM registration pathway plus a SHOP-specific module for agents who intend to assist small employers.

Training completion is reported to CMS and must be attested; the attestation confirms the agent completed required training and will comply with Marketplace requirements.

The Marketplace-registered agent receives an FFM User ID, which must be used when assisting consumers through the Marketplace eligibility and enrollment systems.

Continuing education is separate from Marketplace registration: state CE/licensing requirements are administered by state insurance departments, not CMS.

If an agent's license lapses or is disciplined, Marketplace registration may be terminated; CMS can suspend or terminate an agent's ability to transact Marketplace business.

Agents must complete privacy and security training as part of registration because they handle personally identifiable information (PII) and protected health information (PHI).

Marketplace eligibility generally requires lawful presence, U.S. residency, and lack of eligibility for minimum essential coverage through Medicare, Medicaid, CHIP, or an affordable employer plan.

Premium tax credit eligibility requires household income between 100% and 400% of the federal poverty level (FPL) for the applicable family size, with no affordable employer-sponsored coverage offered.

Affordability of employer coverage is measured against the employee's required contribution for self-only coverage as a percentage of household income, indexed annually.

Special enrollment periods (SEPs) are triggered by qualifying life events such as marriage, birth, adoption, loss of minimum essential coverage, or a permanent move; most require enrollment within 60 days of the event.

Open Enrollment for the individual Marketplace runs annually, typically November 1 through January 15 for the FFM; coverage effective dates depend on the enrollment date within that window.

Consumers may be eligible for cost-sharing reductions (CSRs) if they enroll in a Silver plan and have household income at or below 250% FPL.

Enrollment transactions occur through the Marketplace eligibility system; agents must use the consumer's attested information and cannot alter income or household data without consumer confirmation.

SHOP enrollment allows small employers (generally 1-50 employees, state-dependent) to offer qualified health plans to employees through the Small Business Health Options Program.

Consumers denied Medicaid/CHIP are referred to the Marketplace; the eligibility determination is made by the Marketplace using the single streamlined application.

Qualified Health Plans (QHPs) are certified by the Marketplace and must cover the 10 essential health benefits (EHBs), including hospitalization, prescription drugs, maternity care, and mental health/substance use disorder services.

Metal tiers reflect actuarial value: Bronze ~60%, Silver ~70%, Gold ~80%, Platinum ~90%; catastrophic plans are available only to consumers under 30 or with a hardship exemption.

The Summary of Benefits and Coverage (SBC) is a standardized document that must be provided to consumers and describes covered benefits, cost sharing, and coverage examples.

Cost sharing includes deductibles, copayments, and coinsurance; out-of-pocket maximums are capped annually and apply to in-network EHB coverage.

Network types (HMO, PPO, EPO, POS) determine whether referrals are required and whether out-of-network services are covered; agents must verify network status for providers.

Formulary information identifies covered prescription drugs and tier placement; consumers should verify specific medications against the plan's drug list before enrolling.

Pediatric dental and vision benefits are among the EHBs; adult dental and vision are generally not required EHBs and are often offered as separate or supplemental coverage.

Premium tax credits are applied to the benchmark Silver plan premium; consumers may choose to apply the credit in advance (APTC) or claim it at tax filing.

Agents must not discriminate against consumers on the basis of race, color, national origin, sex, age, disability, or other protected characteristics in Marketplace transactions.

Section 1557 of the Affordable Care Act prohibits discrimination in health programs receiving federal financial assistance and requires language access and auxiliary aids.

Agents must protect PII and PHI, following HIPAA and Marketplace privacy standards; unauthorized disclosure or misuse can result in termination and civil penalties.

Marketing and sales activities are governed by Marketplace regulations; agents may not misrepresent plan benefits, cost sharing, or provider networks.

Agents must not enroll consumers without consent or use deceptive tactics such as switching plans without authorization; such acts can constitute fraud.

Consumer complaints and appeals processes exist: consumers may appeal eligibility determinations and may file complaints against agents with CMS or state regulators.

Agents must disclose their role and compensation structure and must not accept payments from consumers for Marketplace enrollment assistance where prohibited.

Recordkeeping requirements apply; agents must retain documentation of consumer consent and enrollment transactions for the period required by CMS and state law.

State licensing and appointment requirements apply in addition to Marketplace registration; agents must hold an active license in the state where they assist consumers.