Questions to Ask Clients Shopping for an ACA Plan

When working with a client who is shopping for an Affordable Care Act (ACA) insurance plan from the federal marketplace or their state marketplace, there are a series of questions you should ask to better serve them.

Ask these questions in your meeting to understand your client’s needs and what they might be looking for in their health insurance plan.

How often do you typically need health care each year?

Asking how often your client visits the doctor each year can help you determine if they’d be better suited for a plan in a higher metal tier to have more costs covered, as long as they’re comfortable with a higher premium. Maybe your client only visits the doctor once a year for their annual physical, or maybe they have conditions they manage with more frequent visits to providers. They may feel as though the lower deductible and lower copays are worth the higher premium.

What is your estimated annual household income?

Cost-sharing reductions, or subsidies, are one of the most significant ways to save money and make marketplace coverage more affordable. Your client’s annual household income is one important element of estimating their subsidies that could be used to greatly reduce their health care costs. Use this calculator from to estimate their subsidies before deciding on a plan.

Remind your client that, if they qualify for cost-sharing reductions, they must select a silver plan to apply those savings. Silver plans can be the most affordable options for clients who are eligible for subsidies.

Remind your client that, if they qualify for cost-sharing reductions, they must select a silver plan to apply those savings.

More individuals are eligible for subsidies through 2025, thanks to the Inflation Reduction Act! This is also a great time to remind your clients to reconcile their premium tax credits.

How much are you comfortable spending each month for health insurance?

Some clients may feel influenced by budget concerns. Subsidies can drastically reduce the amount of monthly premiums they’ll pay; however, if they’re not eligible for subsidies, clients may feel more comfortable choosing a lower metal tier of coverage to reduce their monthly spending.

Catastrophic plans can be an option for clients who are looking for enough coverage to act as a safety net but don’t use health services often and aren’t willing to spend more than what’s necessary for health insurance. These plans are only ideal for clients who want protection from worst-case scenarios, such as getting very sick or injured.

Are your doctors in a particular network that you’d like to remain in?

When evaluating your client’s current health status and medications, consider if there are doctors or specialists they’d like to continue to see. This can help you decide on a plan with a particular network if your client feels that’s valuable to them.

HMO & EPO plans limit coverage to a local network of physicians and facilities and typically will not cover out-of-network care, except for emergency medical services. These plans can be more affordable options for clients with chronic conditions.

HMO plans require a referral from a primary care physician to see a specialist, while EPOs do not. Because of this, some individuals may choose an EPO or PPO plan for added flexibility. However, these more flexible plans are also more expensive. Consider in-network flexibility, coverage, and affordability when your client is choosing a plan.

Do you take any prescription medications?

Those with chronic conditions or those who take prescription drugs may want to decide between an HMO or EPO plan that has better coverage for their condition. Typically, these plans have more coverage for prescriptions than PPO plans.

Have you had a significant life event recently?

If your client recently got married, had a child, lost other health coverage, or has moved, they’re eligible for a Special Enrollment Period (SEP). Your client will have 60 days to select new coverage through the marketplace with this SEP. If they have not experienced any of these events, they will have to wait until the ACA Open Enrollment Period (OEP) to enroll in a plan.

Is dental coverage important to you?

Dental services for adults are typically not covered as part of marketplace plans. Some carriers do offer dental benefits as part of their plan, but this isn’t common and may not be available in all areas. We recommend asking if your client is interested in receiving dental coverage. A supplemental dental, vision, and hearing plan or stand-alone dental insurance plan may be a great choice for these clients.

Dental benefits will be essential coverage under the ACA in 2027! Read more about upcoming changes to the marketplace in our annual State of the ACA Market 2024 report.

Do you have life insurance?

Think about the other products in your insurance portfolio. Are there any products your client could benefit from, such as life insurance? Life insurance can provide peace of mind and protection in case of an accident. Consider this your opportunity to offer your other services to your marketplace clients.

Don’t offer supplemental products in your portfolio? Contact your sales specialist to discuss opportunities for adding new products and growing your sales!

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Asking your client these important questions will help you be a better agent and make even more sales. Use this list in your next client meeting to better understand your client’s needs.

You don’t have to have the answers to the tough questions all on your own. With Ritter, you have access to sales support, on-demand training, and resources to help you succeed with one free registration!

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