Marketplace Plan Selection Guide
Help users explain the major individual market plan-selection concepts that affect ICHRA participant support.
Purpose
Help users explain the major individual market plan-selection concepts that affect ICHRA participant support.
When to use
Use before or during participant education, plan-shopping support, enrollment reminders, or human support routing.
Who should use this
Employee support owner, HR, advisor, broker, marketplace support partner, or HRB designee.
Review boundary
This guide supports education and routing. It does not provide individualized plan recommendations unless delivered by a properly licensed and assigned advisor.
Resource sections
On-exchange vs. off-exchange coverage
- Explain that coverage path can affect subsidy and reimbursement handling.
- Route subsidy, tax, and reimbursement questions to the appropriate reviewer.
- Retain the path note if the workflow requires it.
Plan availability is local
- Plan options vary by ZIP code, county, carrier, and service area.
- Use current source data and note the lookup date.
- Do not assume another employee's plan options apply.
Metal tiers and cost-sharing
- Explain premium and cost-sharing tradeoffs in plain language.
- Note deductible, copay, coinsurance, and out-of-pocket maximum concepts.
- Avoid individualized plan advice outside the assigned role.
Provider networks and service areas
- Encourage provider and facility verification before enrollment.
- Flag service-area and travel questions for review.
- Retain verification notes only under the approved evidence process.
Plan types
- Explain common plan types such as HMO, PPO, EPO, and POS.
- Flag referral, primary-care, and out-of-network limits.
- Route confusing plan-type questions to licensed support.
Prescription drug/formulary review
- Remind participants to verify prescriptions and formularies.
- Note prior authorization, step therapy, pharmacy, and tier questions.
- Retain source/date notes if allowed by workflow.
Premium, deductible, and out-of-pocket tradeoffs
- Help users distinguish premium from total potential cost.
- Flag high-cost care, drug, family, or specialist needs for support.
- Do not guarantee coverage or payment.
Enrollment and payment reminders
- Confirm enrollment deadline and first-premium payment responsibility.
- Identify where confirmation evidence should live.
- Escalate payment-risk issues.
When to route
- Route plan recommendation, subsidy, Medicare, COBRA, tax, provider, drug, and coverage-dispute questions as appropriate.
- Identify the support or advisor lane.
- Retain routing notes.
Evidence to retain
- Plan comparison notes, if retained under approved process - Retain with the audit file, evidence map, or review record as applicable.
- Exchange/off-exchange path note - Retain with the audit file, evidence map, or review record as applicable.
- Provider/drug verification notes - Retain with the audit file, evidence map, or review record as applicable.
- Enrollment/payment confirmation location - Retain with the audit file, evidence map, or review record as applicable.
- Participant decision support note - Retain with the audit file, evidence map, or review record as applicable.
- Source/version note for plan data - Retain with the audit file, evidence map, or review record as applicable.
Evidence is not saved in this static version. Assign an owner, repeat the process consistently, review exceptions, explain the rationale, and retain copies in the employer file or local project record.
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This guide supports education and routing. It does not provide individualized plan recommendations unless delivered by a properly licensed and assigned advisor.