Predictika · ACA individual marketplace plans: enrollment windows, premium tax credit, cost-sharing reductions and age-rated premiums

An AI sales agent's ACA marketplace quote, checked before it goes out

An AI sales agent prepares an individual marketplace plan quote for a fictional applicant. Before it goes out, the agent sends it to Predictika’s validator, which checks it against the enrollment, tax credit, cost-sharing and pricing rules, compares the monthly premium the agent states with the one it computes, and returns a verdict with every reason.

Scope: ACA individual marketplace plan quotes for the Ambetter product line, 2026 plan year. See everything this validator covers

This validator models individual marketplace quotes in the style of Centene Ambetter plans: enrollment eligibility, premium tax credit and cost-sharing reduction rules, and age-rated pricing for the 2026 plan year. It handles any quote made of these plans and rules, not just the scenarios shown below.

  • Enrollment windows — Open enrollment, the 60-day special enrollment window after a qualifying life event, document verification, and the metal-level lock for current enrollees.
  • Premium tax credit eligibility — Income as a share of the federal poverty level, Medicaid expansion and coverage-gap rules, the 400 percent income cap, and the bar on credits when an affordable employer plan is offered.
  • Plans and cost-sharing reductions — Plans sold by rating area, catastrophic-plan age and hardship rules, cost-sharing reduction variants on silver plans, and acknowledgement when the reductions are given up on another metal level.
  • Pricing and the stated premium — The federal default age curve, up to three rated children, a tobacco surcharge, the benchmark-based advance tax credit, and a check that the monthly premium the agent states matches the premium the validator computes.

It does not cover other carriers or products, real rates and benchmark premiums, small-group or Medicare plans, or state-specific rules beyond the five rating areas modeled.

The AI sales agentBuilds the quote from the conversation and says it is ready.
Predictika validatorChecks the quote against the product and contract rules and returns every finding it has.

8 scenarios in 4 groups · each group runs from the agent’s first attempt to the outcome · click one to switch

What the agent proposes

The AI sales agent says

Illustrative agent statement. The validator receives the structured request below.

Proposing agent: AI sales agent (scripted)

Before sending, the agent must call Recorded run

Predictika validator


      

        
        
        
      

      
Waiting for the call.

      
    

  

  
    

    
Where rules-based CPQ gets it wrong
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Our assessment of what a typical rules-based CPQ (product rules, price rules and validation rules, as in Salesforce CPQ or Revenue Cloud) does with the same cases. It is a judgment about effort and reliability, not a claim that nothing can be built.

    
What the validator catchesTypical rules-based CPQPredictika
Tax credit eligibilityOnly with workarounds
Income band, Medicaid expansion, employer offer and plan level interlock, so a rules-based CPQ needs separate rules for each combination.		All of them are evaluated together on every call.
A credit based on another planOnly with workarounds
The credit depends on the benchmark silver plan in the area, not the plan sold, which a price rule has to look up separately.		The benchmark premium is part of the same calculation.
Cost-sharing variant by income bandOnly with care
The variant must match the income band and exists only on silver plans, which usually becomes one rule per band.		The expected variant is computed from income and compared with the one chosen.
Enrollment window and metal lockOnly with workarounds
The 60-day window and the metal-level lock depend on the event date and current coverage, which quote rules rarely see.		Both are checked from the dates and coverage in the request.
The premium the agent statesOnly with workarounds
Comparing a stated premium with a computed one means a separate rule per quote layout, and price rules rarely run on stated figures.		The stated premium is a field in the request and is checked against the computed premium.
Every problem returned in one answerOnly with workarounds
Rules tend to fire as the application is saved, so a rep often fixes one error and meets the next.		All findings come back together, whatever order the choices arrived in.

  

  

    
What this validator catches
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Every rule is checked on every call, in whatever order the choices arrive, and one problem never hides another. Blocking findings stop the quote; approval findings need a person to sign off; everything else is computed.

    
RuleEffectWhat it checks
Plan sold in the areablockA plan is sold only in rating areas of its own state
Enrollment windowblockOutside open enrollment and without a qualifying life event there is no enrollment window
60-day special enrollment windowblockA qualifying life event must be within the last 60 days
Metal-level lockblockA current enrollee using a special enrollment period stays in the same metal level
Household sizeblockThe household must be at least as large as the people on the application
Catastrophic plan eligibilityblockCatastrophic plans are for applicants under 30 or with a hardship exemption
No credit on catastrophic plansblockAdvance premium tax credits cannot be applied to a catastrophic plan
Medicaid expansion statesblockIncome under 138 percent of the poverty level in an expansion state goes to Medicaid, not the tax credit
Coverage gapblockIncome under 100 percent of the poverty level in a non-expansion state has no tax credit
400 percent income capblockNo premium tax credit above 400 percent of the poverty level
Affordable employer coverageblockAn affordable employer plan offer bars the tax credit
Cost-sharing reduction levelblockThe cost-sharing variant must match the income band, and exists only on silver plans
Cost-sharing reductions given upneeds approvalA household that qualifies for the reductions must acknowledge giving them up on a non-silver plan
Special enrollment documentsneeds approvalSpecial enrollment needs documents proving the qualifying event before coverage starts
Stated member premiumblockThe monthly premium the agent states differs from the computed premium by more than USD 1

  

  

    
Scenarios and results
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The recorded result of the validator for each scenario on this page: the request the AI agent sent, the verdict, and every finding, in the order they appear above.

    
1. Cost-sharing reductions: Silver plan, no variant

    
The agent's request. Ambetter Balanced Care 11 Silver for a single 40-year-old applicant in Dallas, household income $28,000, with the advance premium tax credit applied. Member premium USD 117.50 per month. Ready to send.

    
Verdict: Blocked.

    
    
      
  • Cost-sharing reduction level. Cost-sharing variant NoCSR does not match eligibility (CSR87) for a Silver plan; CSR variants exist only on silver plans for APTC-eligible households up to 250 percent FPL.
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2. Cost-sharing reductions: Silver plan with the variant

    
The agent's request. Ambetter Balanced Care 11 Silver for a single 40-year-old applicant in Dallas, household income $28,000, with the advance premium tax credit and the 87 percent cost-sharing reduction variant. Member premium USD 117.50 per month. Ready to send.

    
Verdict: Allowed.

    
3. Premium tax credit: Family over the income cap

    
The agent's request. Ambetter Balanced Care 11 Silver for a Dallas family of four (two adults aged 35 and 33 and two children), household income $150,000. Member premium USD 1,619.50 per month. Ready to send.

    
Verdict: Blocked.

    
    
      
  • Tax credit income limit. Income is 466.6 percent of FPL, above the 400 percent cap for premium tax credits.
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4. Premium tax credit: Family without the credit

    
The agent's request. Ambetter Balanced Care 11 Silver for a Dallas family of four (two adults aged 35 and 33 and two children), household income $150,000, paying the full premium. Member premium USD 1,619.50 per month. Ready to send.

    
Verdict: Allowed.

    
5. Special enrollment: Event 75 days ago

    
The agent's request. Ambetter Balanced Care Silver NC for a Charlotte family of three (aged 34 and 32 and one child), household income $55,000, enrolling through a special enrollment period after a move, with the premium tax credit and the 73 percent cost-sharing reduction variant. Member premium USD 408.12 per month. Ready to send.

    
Verdict: Blocked.

    
    
      
  • Special enrollment window. The qualifying life event was 75 days ago; the special enrollment window is 60 days.
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  • Special enrollment documents. Special enrollment needs documents proving the qualifying life event before coverage starts.
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6. Special enrollment: Event 30 days ago

    
The agent's request. Ambetter Balanced Care Silver NC for a Charlotte family of three (aged 34 and 32 and one child), household income $55,000, enrolling through a special enrollment period after a move 30 days ago, with the premium tax credit and the 73 percent cost-sharing reduction variant. Member premium USD 408.12 per month. Ready to send.

    
Verdict: Needs approval.

    
    
      
  • Special enrollment documents. Special enrollment needs documents proving the qualifying life event before coverage starts.
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7. The premium the agent states: Stated premium below computed

    
The agent's request. Ambetter Balanced Care Silver FL for a Miami couple aged 60 and 62, household income $60,000, with the advance premium tax credit applied. Member premium USD 486.23 per month. Ready to send.

    
Verdict: Blocked.

    
    
      
  • Monthly premium the agent stated. The quoted member premium of $486.23 per month does not match the $540.26 the validator computed.
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8. The premium the agent states: Stated premium corrected

    
The agent's request. Ambetter Balanced Care Silver FL for a Miami couple aged 60 and 62, household income $60,000, with the advance premium tax credit applied. Member premium USD 540.26 per month. Ready to send.

    
Verdict: Allowed.

  

  

    
Narration transcript
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The text of the narrated walkthrough, step by step.

    
    
      
  1. Welcome to a demo of Predictika's Validator. An AI sales agent prepares an individual marketplace plan quote for a fictional applicant. Before it goes out, the agent sends it to Predictika’s validator, which checks it against the enrollment, tax credit, cost-sharing and pricing rules, compares the monthly premium the agent states with the one it computes, and returns a verdict with every reason.
    2. 
      
  2. I will start with the first request by the agent.
    3. 
      
  3. The agent says. Ambetter Balanced Care 11 Silver for a single 40-year-old applicant in Dallas, household income $28,000, with the advance premium tax credit applied. Member premium USD 117.50 per month. The rest of the request is on screen.
    4. 
      
  4. Before it goes out, the agent calls the validator.
    5. 
      
  5. Blocked, with one finding, all in one answer. Cost-sharing variant NoCSR does not match eligibility (CSR87) for a Silver plan; CSR variants exist only on silver plans for APTC-eligible households up to 250 percent FPL.
    6. 
      
  6. The validator returned one blocking finding in one answer. A check that reads one field at a time would pass most of this; it shows only when the choices in the quote are checked against each other.
    7. 
      
  7. What this shows: for cost-sharing variant by income band, a rules-based CPQ is error-prone for this.
    8. 
      
  8. Now the agent resubmits.
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  9. The corrected request. It sets the CSR Variant to CSR87.
    10. 
      
  10. It calls the validator again.
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  11. This time the validator clears it.
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  12. The validator also returns the line-item quote, on screen.
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  13. The earlier finding is cleared, and the validator's total, USD 117.50, matches the quote.
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  14. One problem caught in one call, fixed in one pass, and a clean quote. That is the value of Predictika's validator: catching mistakes before they reach the customer. Now you can try the other scenarios yourself.
    15.