Marketplace and Medicaid enrollment help: rules

Patients ask the front desk about coverage all year: whether they can still get a plan, whether their Medicaid is about to end, or which plan includes the practice. A practice that answers those questions well keeps patients in care and keeps claims payable. A practice that answers them carelessly can end up recommending insurance it is not licensed to sell, handing out gifts tied to enrollment, or printing a deadline that turns out to be wrong.

This guide is for owners, office managers and front desk leads at independent practices, dental offices, chiropractic and integrative clinics who want to help patients get and keep coverage through the Health Insurance Marketplace and Medicaid. It covers the official helper roles (certified application counselors and Navigators), what Medicaid rules say about help with applications and renewals, how to handle enrollment dates, plan recommendations, gifts, and reminder messages. For Medicare Advantage and Part D plans, which follow a separate set of CMS rules, see our guide to Medicare Advantage marketing in your office. For the wider rules on gifts and outreach to Medicaid patients, see marketing to Medicaid patients, and for the Medicare inducement rules, marketing to Medicare patients.

This is general information, not legal advice. Sources cited were checked on October 30, 2026: federal Marketplace rules 45 CFR 155.20, 155.210, 155.225 and 155.410, the HealthCare.gov dates and deadlines page and glossary, Medicaid rules 42 CFR 435.907, 435.908, 435.916 and 435.923, the Medicare Advantage election period rule 42 CFR 422.62, the beneficiary inducement law 42 U.S.C. 1320a-7a and its regulation 42 CFR 1003.110, the HIPAA marketing definition in 45 CFR 164.501 and authorization rule 164.508, and Florida Statutes 626.112. State rules on insurance licensing, Medicaid assisters and State Exchanges differ, so check yours, and have a health care attorney review any enrollment help program before you launch it.

The short version

Pointing patients to official help is the safe starting point. Telling patients where to apply and where to find free, trained help in person does not require a license or a special program.
Doing the application work for patients is a defined role. Marketplace application help is done by certified application counselors, Navigators, and licensed agents and brokers, each with its own rules. Medicaid agencies can certify application assisters and must let applicants choose who helps them.
Certified helpers must be fair and impartial. A certified application counselor must give fair, impartial and accurate information, act in the applicant’s best interest, and disclose relationships with plans.
No gifts tied to enrollment. Certified application counselors and Navigators may not give gifts of any value as an inducement for enrollment, and the federal beneficiary inducement law limits what a practice can offer Medicare and Medicaid patients.
Check dates on the day you publish. On October 30, 2026, the federal rule text and the HealthCare.gov dates page did not show the same end date for 2027 open enrollment. Link to the official page instead of printing a date from memory.
A plan paying you changes the HIPAA analysis. If a health plan or insurer pays the practice to send a message about its coverage, the HIPAA exceptions for treatment and operations messages no longer apply, and the message is marketing that needs patient authorization.

Who helps people enroll, and under what rules

Federal Marketplace rules recognize three kinds of outside helpers. Each is defined by regulation, and a practice should know which one it is, or whether it is none of them, before it describes its help to patients.

Navigators are entities or individuals that receive a Navigator grant from the Exchange. Under 45 CFR 155.210, they must carry out public education, give fair, accurate and impartial information, facilitate plan selection, refer people with complaints to consumer assistance offices, and serve people with limited English and people with disabilities. A Navigator may not be a health insurer or an insurer’s subsidiary, and may not receive consideration from an insurer in connection with enrollment.
Certified application counselors are staff members or volunteers of organizations designated by the Exchange, or certified directly by the Exchange, under 45 CFR 155.225. Each Exchange must have a certified application counselor program. Counselors provide information about plans and insurance affordability programs, help people apply, and help them enroll.
Agents and brokers are, under 45 CFR 155.20, people or entities licensed by the state as an agent, broker or insurance producer. They are paid through the insurance system and are governed by state insurance law as well as federal Exchange rules.

A practice’s own front desk staff who answer coverage questions without any of these designations are none of the three. That is not a problem as long as what they do stays within general information and referral. The trouble starts when staff begin choosing plans for patients, filling out applications with patients’ personal information, or describing the practice as an official enrollment site without the designation behind it.

Can a medical practice become a certified application counselor organization?

The rule leaves room for it. Under 45 CFR 155.225(b), an Exchange may designate an organization to certify its staff or volunteers as certified application counselors if the organization signs an agreement with the Exchange to follow the section’s standards, keeps a registration process and a way to track counselor performance, and provides data to the Exchange on request. In a Federally-facilitated Exchange, designated organizations must submit quarterly reports. The rule also says that, in a Federally-facilitated Exchange, no health care provider is ineligible to be a certified application counselor or a designated organization solely because it receives payment from an insurer for health care services it provides.

Under 155.225(d), a staff member can be certified only after they:

complete Exchange-approved training and pass the certification exams before they start;
disclose to the organization and to potential applicants any relationships the counselor or sponsoring organization has with plans or insurance affordability programs, and other potential conflicts of interest;
follow the Exchange’s privacy and security standards;
agree to act in the best interest of the applicants they help;
provide information accessibly to people with disabilities, directly or through referral;
sign an agreement with the organization; and
are recertified at least once a year after recertification training.

Under 155.225(f), applicants must be told before they get help what counselors do, including that counselors are not acting as tax advisers or attorneys. Applicants must give authorization before a counselor gets access to their personally identifiable information, the authorization must be kept on record (in a Federally-facilitated Exchange, for at least six years unless another federal law requires longer), and applicants can revoke it at any time.

Section 155.225(g) lists what designated organizations and counselors must not do. They must not charge applicants for help with the Exchange, receive consideration from an insurer in connection with enrolling anyone in a plan, pay individual counselors per application, per person helped or per enrollment in a Federally-facilitated Exchange, give gifts of any value as an inducement for enrollment, or make autodialed or prerecorded calls to consumers they have no relationship with. For a practice, the payment rule is the one to read closely: the provider exception covers payment for health care services, not payment connected to enrollment.

Medicaid: help with applications and renewals

Medicaid has its own rules on application help, and they apply all year. HealthCare.gov’s glossary states that people can apply and enroll in Medicaid or the Children’s Health Insurance Program at any time of year.

The state agency must provide help. Under 42 CFR 435.908(a), the Medicaid agency must help anyone who asks with the application or renewal process, in person, by phone and online, in a way that is accessible to people with disabilities and people with limited English.
Patients choose who helps them. Under 435.908(b), the agency must allow people of the applicant’s or beneficiary’s choice to help with the application or renewal.
States may certify application assisters. Under 435.908(c), a state may certify staff and volunteers of state-designated organizations as application assisters. Certified assisters must be registered with the agency, trained in eligibility rules for the Marketplace and all insurance affordability programs in the state, and trained in confidentiality and conflict of interest rules, including the rule against reassignment of provider claims. They may not accept payment from applicants for their help.
Authorized representatives act on the patient’s behalf. Under 435.923, applicants can designate a person or organization to sign applications, submit renewal forms, receive notices and act for them with the agency. A provider or staff member acting as an authorized representative must affirm that they will follow Medicaid confidentiality rules and the rule against reassignment of provider claims.

Renewals are where practices can help without any special role. Under 42 CFR 435.916, the agency must renew eligibility for people whose income is measured under the modified adjusted gross income rules once in 12 months, and must first try to renew using information it already has. If it cannot, it must send a renewal form that already contains the information it has and give the person at least 30 days to respond. If a person loses coverage for not returning the form and then returns it within 90 days (or a longer period the state chooses), the agency must reconsider eligibility without a new application. A reminder from the practice to open mail from the state Medicaid agency and return the renewal form on time is a simple, helpful message. Your text reminder rules still apply to how you send it.

Enrollment dates: check them on the day you publish

Open enrollment dates are the detail practices want on a flyer, and the detail that goes out of date first. On October 30, 2026, we found that two official sources did not match:

The federal regulation. 45 CFR 155.410(e)(5), as published in the electronic Code of Federal Regulations, says that for benefit years beginning on or after January 1, 2027, the annual open enrollment period for all Exchanges must begin no later than November 1, must end no later than December 31 of the year before the benefit year, and must not exceed 9 weeks. Under 155.410(f)(4), coverage must start January 1 for plan selections received by December 31.
HealthCare.gov. The dates and deadlines page stated that open enrollment for 2027 starts November 1 and listed December 15 as the last day to enroll for coverage starting January 1 and January 15 as the day open enrollment ends. The glossary also described the open enrollment period as November 1 to January 15.

We could not resolve the difference from these sources, and we are not going to guess. The safe approach for practice materials is the same either way: say that open enrollment for 2027 coverage starts November 1, and send patients to HealthCare.gov or their state’s Exchange for the deadline that applies to them. States that run their own Exchange can set different dates within the federal limits. If you do print a deadline, check the official page the day the material goes out and put a date-checked note on internal copies.

Medicare is separate. Under 42 CFR 422.62(a)(2), the annual coordinated election period for Medicare Advantage runs October 15 through December 7 for the following calendar year. Practices that see both Medicare and Marketplace patients in the fall should not mix the two sets of dates on one sign.

Recommending plans: steering and insurance licensing

Patients may want the practice to tell them which plan to pick, especially which plans include the practice. Two different sets of rules bear on that conversation.

First, certified application counselors and Navigators must give fair, impartial and accurate information about the full range of options. A counselor who works for a practice can say truthfully which plans the practice is in network with, since that is information the patient needs, but should not push a patient toward a plan because it pays the practice better, and must have disclosed the practice’s plan relationships before helping.

Second, state insurance law decides who may sell, solicit or negotiate insurance. Florida Statutes 626.112 is one example: no person may act as, advertise or hold themselves out to be an insurance agent unless licensed and appointed, and a license is required to engage in the solicitation of insurance. Federal rules define an agent or broker by reference to state licensing, so the state’s definition of solicitation is what matters. Staff who are not licensed should stay with factual network information and referral to official help, and should not recommend one plan over another.

A related point for your website: a page that lists the plans you accept should be current. Our guide to insurance accepted pages and provider directories covers keeping that list accurate.

Gifts and inducements around enrollment

Enrollment drives at health fairs and community events can come with giveaways. Two separate rules limit them.

The Exchange assister rules. Certified application counselors (155.225(g)(4)) and Navigators (155.210(d)(6)) may not give applicants or potential enrollees gifts of any value as an inducement for enrollment. Gifts for other purposes must not exceed nominal value, individually or in total, in a single encounter. Gifts include gift items, gift cards, cash cards, cash, and promotional items that market a third party’s products or services. Reimbursing a consumer’s legitimate expenses to get application help, such as travel or postage, is not a gift under these rules.
The beneficiary inducement law. Under 42 U.S.C. 1320a-7a(a)(5), a person who offers remuneration to a Medicare or Medicaid beneficiary that they know or should know is likely to influence the beneficiary to choose a particular provider for items or services paid by Medicare or Medicaid can face civil money penalties. The regulation at 42 CFR 1003.110 lists exceptions, including items or services that improve a beneficiary’s ability to get Medicare or Medicaid items and services and pose a low risk of harm (not likely to skew clinical decisions, increase costs through overuse, or raise safety or quality concerns), and free items for people in financial need that are not offered as part of an advertisement or solicitation.

Help with an application is itself something of value. Whether a free enrollment help program run by a practice fits an exception depends on how it is offered and to whom, which is why a health care attorney should look at the program before it is advertised. Offering help to anyone who asks, whether or not they are or become a patient, and not tying the help to booking a visit, keeps the program further from the inducement concern.

Messages to your patients about coverage

Practices can reach their own patients about enrollment and renewal through signs, website pages, portal messages and reminders. The HIPAA question is whether a message is marketing.

Under 45 CFR 164.501, marketing means a communication about a product or service that encourages recipients to purchase or use it. The definition excludes communications for treatment, care coordination and certain health care operations purposes, such as describing the plans the practice participates in, but only where the practice receives no financial remuneration for making the communication. Financial remuneration means direct or indirect payment from or on behalf of a third party whose product or service is being described.

Put plainly: a reminder that the practice sends on its own to tell patients that their Medicaid renewal may be coming, or which plans the practice accepts, sits differently from a message a health plan or insurer pays the practice to send. If a plan or insurer pays for the message, the exceptions do not apply, and under 45 CFR 164.508(a)(3) the practice needs the patient’s written authorization, which must state that payment is involved. Turn down offers from plans to fund patient mailings unless your attorney has reviewed the arrangement.

Questions to ask before you offer enrollment help

Will our staff only point patients to official help, or will they help fill out applications?
If they will help with applications, are we a designated certified application counselor organization or a state-certified Medicaid assister organization, and is each helper currently certified?
Have we written down each relationship the practice has with plans and insurers, so helpers can disclose it?
Does any plan or insurer pay us anything connected to enrollment, outreach or patient mailings?
Is any giveaway tied to enrolling, to choosing a plan, or to booking a visit?
Who checks enrollment dates against HealthCare.gov or our State Exchange before signs and posts go out?
Is anyone on staff licensed to sell insurance, and if so, is their insurance work kept separate from their practice role?

Use and avoid

Use: “Need health coverage? Free, trained local help is available. Ask our front desk where to find it.” Avoid: “Enroll here today” when the practice is not a designated enrollment site.
Use: “Open enrollment for 2027 coverage starts November 1. Check HealthCare.gov or your state’s Exchange for your deadline.” Avoid: a printed end date that nobody checked against the official page.
Use: “We are in network with these plans: [Plan list]. Our certified counselor can explain all of your options.” Avoid: “Pick [Plan name], it is the best plan for our patients.”
Use: “Your Medicaid renewal form may arrive by mail. Return it by the date on the form to keep your coverage.” Avoid: “Renew now and get a free gift card.”
Use: “Application help is free.” Avoid: charging any fee for Exchange application help, or folding it into a visit fee.

An illustration

This example is invented. [Practice name], a family practice, sees patients whose Medicaid renewals are coming due and others who are uninsured. The office manager wants a fall campaign.

They start with what needs no special role: a page on the practice website and a waiting room sign that say free local enrollment help is available, link to HealthCare.gov’s local help search and the state Medicaid agency’s site, and state that open enrollment for 2027 coverage starts November 1, with the deadline to be checked on the official site. A portal message to existing Medicaid patients reminds them to watch for a renewal form and return it on time. No plan or insurer pays for any of it, and the message does not promote any plan.

A health plan then offers to pay for a mailing to the practice’s patients about its new coverage. The office manager declines, because a paid message about the plan’s product would be marketing that needs each patient’s written authorization. The practice also considers having two front desk staff certified as application counselors. Before applying, the office manager lists the practice’s plan contracts so that they can be disclosed, confirms with the practice’s attorney how the program would be offered, and drops a planned gift card raffle for people who enroll.

Checklist

Decide whether staff will refer only, or apply to become certified application counselors or Medicaid assisters.
If certifying staff, complete Exchange-approved training and exams before anyone helps, and track annual recertification.
Write a plan relationship disclosure that helpers give before they help.
Get and keep the applicant’s authorization before a helper accesses personal information, and keep the records for the required period.
Charge nothing for Exchange application help.
Remove gifts tied to enrollment, and keep any other giveaway at nominal value.
Link to HealthCare.gov or your State Exchange for deadlines, and check any printed date on the day it goes out.
Keep Medicare Advantage dates and materials separate from Marketplace materials.
Refuse plan or insurer payment for patient messages unless your attorney has reviewed it and patients have authorized it.
Have a health care attorney review the program and the wording before launch.

How we help

We build practice websites, local SEO, Google Ads and lead generation and an AI front desk for independent practices. For coverage and enrollment, we can write a clear coverage help page that points patients to official help, keeps dates linked to the official source, and lists your accepted plans accurately, and we can set up front desk scripts that keep coverage questions to facts and referrals. Our tools are built with HIPAA in mind. We confirm in writing what a BAA covers before any patient information flows through a tool, and if it is not covered, we do not route patient information through it. We are not a healthcare provider and we do not give legal or medical advice. For the wider rules on healthcare advertising, see our healthcare marketing rules guide.

Can a medical office help patients sign up for marketplace insurance?

Yes, within limits. Any office can point patients to free official help and to HealthCare.gov or the state’s Exchange. Hands-on application help is the work of certified application counselors, Navigators and licensed agents and brokers. Under 45 CFR 155.225, an Exchange can designate an organization to certify its staff as counselors, and in a Federally-facilitated Exchange, a provider is not ineligible solely because it receives insurer payments for health care services.

Can our front desk tell patients which plan to choose?

Staff can say truthfully which plans the practice is in network with. Recommending one plan over another can raise state insurance licensing questions: Florida, for example, requires a license to engage in the solicitation of insurance. Certified counselors must give fair and impartial information and disclose the practice’s plan relationships.

When is open enrollment for 2027 coverage?

Open enrollment for 2027 coverage starts November 1, 2026. On October 30, 2026, the federal regulation and the HealthCare.gov dates page did not show the same end date, so check HealthCare.gov or your state’s Exchange for the deadline that applies. Medicaid and CHIP applications are accepted at any time of year.

Can we give a gift card to patients who enroll or renew?

No for certified application counselors and Navigators, who may not give gifts of any value as an inducement for enrollment. For Medicare and Medicaid patients, the beneficiary inducement law at 42 U.S.C. 1320a-7a(a)(5) also limits gifts likely to influence their choice of provider. Have an attorney review any giveaway.

Can a health plan pay us to send our patients information about its coverage?

Not without patient authorization. Under 45 CFR 164.501, a communication that would otherwise fall under the treatment or operations exceptions becomes marketing when the practice receives payment from the third party whose product is described, and 45 CFR 164.508(a)(3) then requires the patient’s written authorization stating that payment is involved.

Helping patients with marketplace and Medicaid enrollment: what a medical practice can say and do