The assister's standard operating procedures manual

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

• As of December 19, 2024, this SOP is no longer accessible.

Consumer Protections: Privacy and Security Guidelines  – updated November 2022 

• As of December 19, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources. Requirements and Best Practices for Handling Personally Identifiable Information (PDF) and Obtaining Consumer Authorization and Handling Consumers' Personally Identifiable Information (PII) in the Federally-facilitated Marketplace (FFM) (PDF)

Consumer Protections: Fraud Prevention Guidelines  – updated November 2022 (PDF)

• As of October 3, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resource: Assister Certification Training Course: Privacy, Security, and Fraud Prevention Standards (PDF)

SOP-1. Receive Consent Before Accessing Consumer PII  – updated March 2020 

• As of December 19, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources. Requirements and Best Practices for Handling Personally Identifiable Information (PDF) and Obtaining Consumer Authorization and Handling Consumers' Personally Identifiable Information (PII) in the Federally-facilitated Marketplace (FFM) (PDF) 

SOP-2. Assess Consumers’ Knowledge & Needs  – updated November 2020 (PDF)

• As of October 3, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resource: Assister Certification Training Course: Health Coverage Basics (PDF)

SOP-3. Create an Account  – updated July 2020

• As of June 20, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources: Microlearning: Application Walkthrough: Helping Consumers Apply for Marketplace Coverage and Microlearning: Account Creation: Identity Verification and Screening Questions.

SOP-4. Verify Identity and Resolve Potential Data Matching Issues  – updated March 2022

• As of December 19, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources.  Data Matching Inconsistencies (DMIs) (PDF), How to Resolve Income Data Matching Inconsistencies (DMIs) (PDF), Microlearning: Application Walkthrough: Helping Consumers Apply for Marketplace Coverage, Microlearning: Account Creation: Identity Verification and Screening Questions, and Microlearning: Post-Enrollment Assistance: Locating Information About and Resolving Potential Data Matching Issues

SOP-5. Apply for Health Coverage  – updated April 2023 

• As of June 20, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources: Microlearning: Application Walkthrough: Helping Consumers Apply for Marketplace Coverage, Microlearning: Income: Household Size and Types of Income to Include on a Marketplace Application, Microlearning: Income: Reporting Income on a Marketplace Application, and Microlearning: Income: Resolving an Income Data Issue.

SOP-6. Review Eligibility Results  – updated March 2021 

• As of June 20, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources: Microlearning Application Walkthrough: Helping Consumers Understand the Eligibility Notice and Microlearning: Application Walkthrough: Helping Consumers Apply for Marketplace Coverage.

SOP-7. Lower Costs of Coverage  – updated December 2022 (PDF)

• As of October 3, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources: Advance Payments of the Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR) Basics (PDF) and Microlearning: Application Walkthrough: Helping Consumers Enroll in Marketplace Coverage.

SOP-8. Compare, Save, & Select Health Plans  – updated December 2020 

• As of June 20, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resource: Microlearning Application Walkthrough: Helping Consumers Enroll in Marketplace Coverage.

SOP-9. Pay Health Plan Premium  – updated November 2020

• As of June 20, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources: Microlearning: Post-Enrollment Issues: Making Health Plan Premium Payments and Microlearning: Application Walkthrough: Helping Consumers Enroll in Marketplace Coverage.

SOP-10. Request a Marketplace Eligibility Appeal  – updated May 2021

• As of December 19, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources. Marketplace Appeals (PDF) and Marketplace Eligibility Appeals: Eligibility Appeals Process Overview (PDF)

SOP-11. Exemptions  – updated November 2022 (PDF)

• As of October 3, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resource: Taxes, Exemptions, Reconciling Advance Payments of the Premium Tax Credit, and Failure to File and Reconcile (PDF).

SOP-12. Understanding Form 1095-A and Reconciling Advance Payments of the Premium Tax Credit  – updated October 2022 (PDF)

• As of October 3, 2024, the SOP is no longer accessible. Information on this topic can be found in the following resources: Taxes, Exemptions, Reconciling Advance Payments of the Premium Tax Credit, and Failure to File and Reconcile (PDF); Microlearning: Application Walkthrough: Helping Consumers Enroll in Marketplace Coverage; and Microlearning: Post Enrollment Assistance: Locating Form 1095-A and Determining the Second Lowest Cost Silver Plan (SLCSP) Premium.

SOP-13. Update a Federally-facilitated Marketplace Account  – April 2023

• As of December 19, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources. Microlearning: Reporting Life Changes: Types of Qualifying Life Events, Microlearning: Reporting Life Changes: Making Changes to a Marketplace Application, Microlearning: Reporting Life Changes: Changing Marketplace Plans, and Microlearning: Post-Enrollment Assistance: Terminating a Marketplace Plan

SOP-14. Renew Health Coverage  – updated December 2022

• As of December 19, 2024, this SOP is no longer accessible. Information on this topic can be found in the following resources. Microlearning: Post-Enrollment Assistance: Locating and Understanding the Marketplace Open Enrollment Notice (MOEN) and Re-enrollment, Microlearning: Application Walkthrough: Helping Consumers Enroll in Marketplace Coverage, Microlearning: Reporting Life Changes: Reporting a Change in Income, and Microlearning: Reporting Life Changes: Reporting a Change in Household Size and Changing Marketplace Plans

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.