This online Manual contains standard operating procedures (SOPs) for Navigators and certified application counselors (CACs) who assist consumers within a Federally-facilitated Marketplace for the individual market (also referred to as an “Individual Federally-facilitated Marketplace,” “Individual FFM,” or “Individual Marketplace”). The SOPs reflect requirements, policies, and best practices under the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010, and as further amended (referred to collectively as the Affordable Care Act), Centers for Medicare & Medicaid Services (CMS) regulations, and CMS guidance.
The CMS Center for Consumer Information & Insurance Oversight (CCIIO) maintains this Manual as an online catalog of topic-specific assister SOPs and will periodically update individual portions of the Manual as relevant regulations, guidance, or policies are released. In the future, CCIIO may alter, delete, suspend, or discontinue the procedures detailed in various portions of this Manual.
Introduction and Instructions for Use – updated September 2022
Consumer Protections: Privacy and Security Guidelines – updated November 2022
Consumer Protections: Fraud Prevention Guidelines – updated November 2022
SOP-1. Receive Consent Before Accessing Consumer PII – updated March 2020
SOP-2. Assess Consumers’ Knowledge & Needs – updated November 2020
SOP-3. Create an Account – updated July 2020
SOP-4. Verify Identity and Resolve Potential Data Matching Issues – updated March 2022
SOP-5. Apply for Health Coverage – updated April 2023
SOP-6. Review Eligibility Results – updated March 2021
SOP-7. Lower Costs of Coverage – updated December 2022
SOP-8. Compare, Save, & Select Health Plans – updated December 2020
SOP-9. Pay Health Plan Premium – updated November 2020
SOP-10. Request a Marketplace Eligibility Appeal – updated May 2021
SOP-11. Exemptions – updated November 2022
SOP-12. Understanding Form 1095-A and Reconciling Advance Payments of the Premium Tax Credit – updated October 2022
SOP-13. Update a Federally-facilitated Marketplace Account – April 2023
SOP-14. Renew Health Coverage – updated December 2022
This Manual is not intended to take the place of the statutes, regulations, and formal policy guidance it is based upon. It summarizes current policy and operations as of the date it was published. We encourage assisters to refer to these statutes, regulations, and interpretive guidance for complete and current information about the requirements that apply to them.
Certain portions of the Manual contain screenshots from HealthCare.gov that are intended only as an example of what you and/or the consumer may see when the consumer is completing an application at HealthCare.gov. All names and contact information used in the screenshots are fictional. The use of health insurer names and/or health plan names are for demonstration purposes only and should not be construed as an endorsement by CMS of any specific health insurer or health plan.