Affordable Care Act (ACA) Marketplace Certification (FFM) — Questions and Answers

Question 1: What is the actuarial value of a Gold plan under the ACA?

80% (Correct answer)
60%
70%
90%

Correct answer: 80%

Gold plans have an actuarial value of 80%, meaning the plan pays 80% of covered healthcare costs on average for a standard population.

Question 2: What is the primary objective of professional ethics & standards within the ACA professional framework?

Analyzing data systematically using validated assessment tools (Correct answer)
Copying approaches used by competitors without adaptation
Relying on informal observations and anecdotal reports
Making assumptions based on previous experience alone

Correct answer: Analyzing data systematically using validated assessment tools

Analyzing data systematically using validated assessment tools is the correct approach because effective professional ethics & standards in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 3: Under the ACA, Medicaid expansion extended eligibility to adults with incomes up to what percentage of the federal poverty level (FPL)?

150% FPL
100% FPL
138% FPL (Correct answer)
133% FPL

Correct answer: 138% FPL

The ACA's Medicaid expansion covers adults with household incomes up to 138% of the FPL (133% plus a 5% income disregard).

Question 4: Which tool or methodology is most appropriate for analyzing policies & regulations outcomes?

Maintaining professional boundaries while building collaborative relationships (Correct answer)
Prioritizing relationships over professional standards
Maintaining strict formality that inhibits collaboration
Adjusting boundaries based on individual situations without guidelines

Correct answer: Maintaining professional boundaries while building collaborative relationships

Maintaining professional boundaries while building collaborative relationships is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 5: Which of the following correctly describes 'scope of practice' for a trained navigator?

Navigators are licensed to sell insurance and may earn commissions
Navigators may advise clients on which plan is medically best for their diagnoses
Navigators facilitate enrollment and provide education but may not recommend specific plans or provide legal/tax advice (Correct answer)
Navigators may complete the application without client participation to save time

Correct answer: Navigators facilitate enrollment and provide education but may not recommend specific plans or provide legal/tax advice

Navigators are trained to educate and facilitate, not to recommend specific plans or provide advice that falls within licensed professions.

Question 6: A health plan with a risk score BELOW the market average under the ACA risk adjustment program will most likely:

Receive funds from the risk adjustment pool
Pay into the risk adjustment pool (Correct answer)
File for reinsurance reimbursement
Be exempt from risk adjustment transfers

Correct answer: Pay into the risk adjustment pool

Plans with below-average risk scores (healthier enrollees) pay transfers to compensate plans with higher-risk enrollees.

Question 7: Which of the following is a key performance indicator for evaluating communication & stakeholder engagement effectiveness?

Treating all tasks with equal urgency regardless of impact
Prioritizing based on risk assessment and potential impact (Correct answer)
Addressing the most recent issue first regardless of severity
Focusing only on tasks with immediate financial implications

Correct answer: Prioritizing based on risk assessment and potential impact

Prioritizing based on risk assessment and potential impact is the correct approach because effective communication & stakeholder engagement in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 8: Which population benefits most from Medicaid expansion under the ACA?

High-income earners
Only self-employed individuals
Only individuals over age 65
Low-income adults under age 65 (Correct answer)

Correct answer: Low-income adults under age 65

Medicaid expansion under the ACA extends coverage to low-income adults who previously did not qualify for Medicaid.

Question 9: Under the ACA, which section addresses wellness programs offered through employer-sponsored group health plans?

Section 1201
Section 1402
Section 2705 (Correct answer)
Section 1311

Correct answer: Section 2705

ACA Section 2705 governs nondiscrimination and wellness programs in group health plans, including incentive limits and reasonable alternative standards.

Question 10: What distinguishes an advanced affordable care act certified practitioner's approach to communication & stakeholder engagement from that of a novice?

Rotating responsibilities randomly to promote flexibility
Establishing cross-functional teams with clearly defined roles (Correct answer)
Creating competition between teams to drive performance
Assigning all responsibilities to a single department

Correct answer: Establishing cross-functional teams with clearly defined roles

Establishing cross-functional teams with clearly defined roles is the correct approach because effective communication & stakeholder engagement in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 11: Under the ACA, which federal agency oversees Medicaid program administration and expansion implementation?

The Department of Health and Human Services Office of Civil Rights
The Centers for Medicare & Medicaid Services (CMS) (Correct answer)
The Department of Labor (DOL)
The Internal Revenue Service (IRS)

Correct answer: The Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS) within HHS administers Medicaid at the federal level and oversees state implementation of ACA expansion.

Question 12: Which of the following best describes 'cost-sharing reductions' (CSRs) under the ACA?

Tax deductions for health insurance premiums paid by self-employed individuals
Employer contributions toward employee health insurance premiums
Reductions in premium costs available to all marketplace enrollees
Subsidies that lower deductibles and copays for Silver plan enrollees with qualifying incomes (Correct answer)

Correct answer: Subsidies that lower deductibles and copays for Silver plan enrollees with qualifying incomes

CSRs reduce out-of-pocket costs such as deductibles, copays, and coinsurance for Silver plan enrollees with household incomes between 100% and 250% of the Federal Poverty Level.

Question 13: What is the most common mistake professionals make when implementing policies & regulations strategies?

Transferring all risk to external partners through contracts
Developing contingency plans for high-probability risk scenarios (Correct answer)
Creating contingency plans for every possible scenario regardless of probability
Responding to problems only after they occur

Correct answer: Developing contingency plans for high-probability risk scenarios

Developing contingency plans for high-probability risk scenarios is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 14: Which scenario would require a affordable care act certified professional to escalate a tax credits & subsidies concern?

Collecting feedback only during formal review periods
Discouraging critical feedback to maintain team morale
Creating feedback mechanisms that encourage continuous improvement (Correct answer)
Using feedback solely for personnel evaluations

Correct answer: Creating feedback mechanisms that encourage continuous improvement

Creating feedback mechanisms that encourage continuous improvement is the correct approach because effective tax credits & subsidies in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 15: Which metal tier has the HIGHEST actuarial value under the ACA?

Gold
Silver
Bronze
Platinum (Correct answer)

Correct answer: Platinum

Platinum plans have the highest actuarial value of 90%, meaning insurers cover 90% of covered healthcare costs for a standard population.

Question 16: Which of the following is an Essential Health Benefit mandated by the ACA?

Vision care for adults
Prescription drug coverage (Correct answer)
Acupuncture and alternative medicine
Long-term care services

Correct answer: Prescription drug coverage

Prescription drugs are one of the 10 mandated EHBs; alternative medicine, long-term care, and adult vision care are not required EHBs.

Question 17: Under the ACA, what is 'presumptive eligibility' in the context of Medicaid?

Automatic Medicaid enrollment for all individuals below the poverty line
A waiver program for states to expand eligibility beyond ACA limits
A process allowing qualified entities to temporarily enroll individuals in Medicaid pending full eligibility determination (Correct answer)
The practice of denying coverage based on presumed income

Correct answer: A process allowing qualified entities to temporarily enroll individuals in Medicaid pending full eligibility determination

Presumptive eligibility allows qualified entities (such as hospitals) to make a temporary Medicaid eligibility determination so individuals can receive immediate coverage while the full application is processed.

Question 18: What is the recommended frequency for reviewing and updating tax credits & subsidies protocols?

Tracking activity volume without measuring quality
Reviewing results only at year-end
Relying on periodic external audits as the sole evaluation method
Monitoring outcomes through regular data collection and trend analysis (Correct answer)

Correct answer: Monitoring outcomes through regular data collection and trend analysis

Monitoring outcomes through regular data collection and trend analysis is the correct approach because effective tax credits & subsidies in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 19: Which plan type typically offers the MOST provider flexibility but usually has higher monthly premiums?

HMO
EPO
PPO (Correct answer)
HDHP

Correct answer: PPO

PPOs allow members to see any provider, including out-of-network providers, without a referral, offering the most flexibility at typically higher premium costs.

Question 20: Which of the following is one of the 10 Essential Health Benefits mandated by the ACA?

Pediatric services, including oral and vision care (Correct answer)
Long-term nursing home care
Cosmetic surgery
Dental care for adults

Correct answer: Pediatric services, including oral and vision care

Pediatric services including oral and vision care is one of the 10 mandated EHBs; adult dental, long-term care, and cosmetic surgery are not included.

Question 21: Which of the following is NOT one of the 10 Essential Health Benefits under the ACA?

Emergency services
Adult dental care (Correct answer)
Maternity and newborn care
Mental health and substance use disorder services

Correct answer: Adult dental care

Adult dental care is not one of the 10 EHBs; pediatric oral care is required, but comprehensive adult dental coverage is not mandated.

Question 22: Under the ACA Medicaid expansion, which income verification method is primarily used during the application process?

Paper tax returns submitted by mail
Employer verification letters only
State agency interviews with case workers
Real-time electronic data matches using federal data sources like SSA and IRS (Correct answer)

Correct answer: Real-time electronic data matches using federal data sources like SSA and IRS

The ACA requires states to use real-time electronic data matches with federal sources such as the SSA and IRS to verify income during the Medicaid application process.

Question 23: When a client's Special Enrollment Period (SEP) eligibility is questionable, what is the ethical approach?

Skip the SEP question and submit a standard application
Advise the client to wait for Open Enrollment to avoid risk
Enroll the client under any available SEP to ensure they get coverage
Explain the qualifying events, let the client self-attest accurately, and document the basis for the SEP claim (Correct answer)

Correct answer: Explain the qualifying events, let the client self-attest accurately, and document the basis for the SEP claim

Assisters must explain SEP rules accurately, ensure the client attests truthfully, and document the qualifying event rather than gaming the system.

Question 24: Which population group was newly eligible for Medicaid under ACA expansion that was not previously covered in most states?

Low-income adults without dependent children (Correct answer)
Children under age 19
Seniors eligible for Medicare
Pregnant women above 138% FPL

Correct answer: Low-income adults without dependent children

Before ACA expansion, most states did not cover childless adults regardless of income; the ACA created a new eligibility category for low-income adults without dependent children.

Question 25: Under the ACA, how long must health insurers retain records related to MLR calculations and rebate payments?

Ten years (Correct answer)
Seven years
Five years
Three years

Correct answer: Ten years

CMS regulations require issuers to retain all records supporting MLR calculations and rebate determinations for at least ten years.

Question 26: Under ACA ethics standards, what is the correct response when an assister realizes they lack the expertise to answer a client's complex tax question about premium tax credits?

Provide a best-guess answer to avoid delaying the client
Advise the client to file taxes without addressing the credit
Skip the tax discussion and complete enrollment without mentioning it
Acknowledge the limitation and refer the client to a tax professional or IRS resources (Correct answer)

Correct answer: Acknowledge the limitation and refer the client to a tax professional or IRS resources

Assisters must recognize and disclose the limits of their knowledge and refer clients to qualified professionals for matters outside their scope.

Question 27: What is the Open Enrollment Period under the ACA?

A set time each year to enroll in or change health plans (Correct answer)
A time when pre-existing conditions can be denied coverage
A mandatory enrollment period for government employees only
A period where only employers can enroll in health plans

Correct answer: A set time each year to enroll in or change health plans

The Open Enrollment Period is the annual window during which individuals can sign up for or change their health insurance plans.

Question 28: A health insurer that significantly over-priced premiums relative to actual claims in the individual market will MOST likely face which ACA consequence?

Risk adjustment payments from the pool
Obligation to pay MLR rebates to policyholders (Correct answer)
ESRP penalties from CMS
Increased reinsurance contributions

Correct answer: Obligation to pay MLR rebates to policyholders

If an insurer spends less than 80% of individual market premiums on claims and quality, it must rebate the excess to enrollees under the MLR requirement.

Question 29: Which provision of the ACA prohibits insurance companies from denying coverage based on pre-existing conditions?

Medicaid Expansion
Individual Mandate
Guaranteed Issue Provision (Correct answer)
Employer Mandate

Correct answer: Guaranteed Issue Provision

The ACA includes a provision that ensures individuals with pre-existing conditions cannot be denied health coverage.

Question 30: What does the ACA require insurers to include in all health plans?

Only emergency room services
Coverage is determined by each insurer with no regulations
Essential health benefits such as preventive care and maternity services (Correct answer)
Only hospital visits and prescription drugs

Correct answer: Essential health benefits such as preventive care and maternity services

The ACA mandates that all health plans cover essential health benefits, including preventive care, maternity services, and mental health treatment.

Question 31: A new regulation impacts health insurance coverage & enrollment procedures. What should a ACA professional do first?

Complying only with regulations that have enforcement mechanisms
Delegating compliance oversight to administrative staff
Ensuring compliance with current regulatory requirements and standards (Correct answer)
Interpreting regulations loosely to allow maximum flexibility

Correct answer: Ensuring compliance with current regulatory requirements and standards

Ensuring compliance with current regulatory requirements and standards is the correct approach because effective health insurance coverage & enrollment in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 32: A health insurance marketplace is launching a special enrollment period (SEP) communications campaign. Which qualifying life event should be prominently featured in messaging to renters?

Loss of other health coverage (Correct answer)
Starting a college savings plan
Purchase of a new home
Receiving an inheritance

Correct answer: Loss of other health coverage

Loss of health coverage is the most common qualifying life event and most relevant to renters who may lose employer-based coverage.

Question 33: What ACA provision requires states to maintain Medicaid and CHIP eligibility for children at levels in effect on the date of enactment?

The benchmark benefit requirement
The minimum essential coverage mandate
The state plan amendment process
The maintenance of effort (MOE) requirement (Correct answer)

Correct answer: The maintenance of effort (MOE) requirement

The ACA's maintenance of effort (MOE) requirement prohibits states from restricting Medicaid and CHIP eligibility for children below levels in place on March 23, 2010.

Question 34: What is the purpose of the Individual Mandate under the ACA?

To increase insurance premiums
To eliminate the need for Medicaid
To penalize only high-income individuals
To encourage universal health insurance coverage (Correct answer)

Correct answer: To encourage universal health insurance coverage

The Individual Mandate required most Americans to have health insurance or pay a penalty to encourage broader participation and reduce costs.

Question 35: What distinguishes an advanced affordable care act certified practitioner's approach to risk management & mitigation from that of a novice?

Establishing cross-functional teams with clearly defined roles (Correct answer)
Assigning all responsibilities to a single department
Rotating responsibilities randomly to promote flexibility
Creating competition between teams to drive performance

Correct answer: Establishing cross-functional teams with clearly defined roles

Establishing cross-functional teams with clearly defined roles is the correct approach because effective risk management & mitigation in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 36: What is a catastrophic health plan under the ACA?

A plan with very high deductibles available to those under 30 or with qualifying hardship exemptions (Correct answer)
A plan that only covers emergency room visits
A plan with very low deductibles and high premiums
A plan covering all 10 EHBs with no cost-sharing requirements

Correct answer: A plan with very high deductibles available to those under 30 or with qualifying hardship exemptions

Catastrophic plans feature very high deductibles and are only available to individuals under age 30 or those with a qualifying hardship or affordability exemption.

Question 37: When a QHP issuer fails to meet ACA MLR requirements, what must they do?

Suspend enrollment until the ratio is corrected
Pay a federal excise tax equal to the shortfall
Provide rebates to enrollees, employers, or both (Correct answer)
Reduce premiums by the shortfall percentage

Correct answer: Provide rebates to enrollees, employers, or both

Issuers who fail to meet MLR thresholds must issue rebates to policyholders or employers based on the excess amount spent on administrative costs.

Question 38: Which of the following is covered under the 'preventive and wellness services' Essential Health Benefit?

Elective cosmetic procedures
All prescription medications
Vaccinations recommended by the ACIP (Correct answer)
Experimental treatments approved by the FDA

Correct answer: Vaccinations recommended by the ACIP

Preventive and wellness services include ACIP-recommended vaccinations, preventive screenings, and counseling, all provided at no cost-sharing under ACA marketplace plans.

Question 39: Which scenario would require a affordable care act certified professional to escalate a health insurance coverage & enrollment concern?

Creating feedback mechanisms that encourage continuous improvement (Correct answer)
Collecting feedback only during formal review periods
Using feedback solely for personnel evaluations
Discouraging critical feedback to maintain team morale

Correct answer: Creating feedback mechanisms that encourage continuous improvement

Creating feedback mechanisms that encourage continuous improvement is the correct approach because effective health insurance coverage & enrollment in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 40: Under the ACA, what is the Modified Adjusted Gross Income (MAGI) methodology used for in Medicaid eligibility?

To determine if an individual qualifies for Medicare Part D low-income subsidies
To assess asset tests for long-term care Medicaid eligibility
To standardize income counting rules across Medicaid, CHIP, and the Marketplace (Correct answer)
To calculate the amount of premium tax credits for employer plans

Correct answer: To standardize income counting rules across Medicaid, CHIP, and the Marketplace

MAGI-based income rules were introduced by the ACA to create a uniform income-counting methodology across Medicaid, CHIP, and Marketplace subsidies, replacing varied state methodologies.

Question 41: Which plan type is the basis for calculating Premium Tax Credits in the ACA marketplace?

Silver plan (Correct answer)
Gold plan
Bronze plan
Platinum plan

Correct answer: Silver plan

Premium Tax Credits are calculated based on the cost of the second-lowest-cost Silver plan (SLCSP) available in the applicant's geographic area.

Question 42: What is the recommended frequency for reviewing and updating policies & regulations protocols?

Relying on periodic external audits as the sole evaluation method
Tracking activity volume without measuring quality
Monitoring outcomes through regular data collection and trend analysis (Correct answer)
Reviewing results only at year-end

Correct answer: Monitoring outcomes through regular data collection and trend analysis

Monitoring outcomes through regular data collection and trend analysis is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 43: Under the ACA, what is the federal government's matching rate (FMAP) for newly eligible Medicaid expansion enrollees?

50% federal match
100% federal match through 2020, then 90% (Correct answer)
90% federal match
75% federal match

Correct answer: 100% federal match through 2020, then 90%

The federal government paid 100% of Medicaid expansion costs through 2016, phasing down to a permanent 90% federal match starting in 2020.

Question 44: Which federal agency is primarily responsible for overseeing ACA communications to the public through Healthcare.gov?

Department of Labor (DOL)
Internal Revenue Service (IRS)
Social Security Administration (SSA)
Centers for Medicare & Medicaid Services (CMS) (Correct answer)

Correct answer: Centers for Medicare & Medicaid Services (CMS)

CMS administers Healthcare.gov and leads federal ACA consumer communications and outreach.

Question 45: Which of the following plans are required to cover all 10 Essential Health Benefits?

Short-term health insurance plans
Supplemental insurance plans
ACA Marketplace individual and small group plans (Correct answer)
Grandfathered plans

Correct answer: ACA Marketplace individual and small group plans

ACA Marketplace plans in the individual and small group markets must cover all 10 Essential Health Benefits as a condition of marketplace participation.

Question 46: Which scenario would require a affordable care act certified professional to escalate a policies & regulations concern?

Collecting feedback only during formal review periods
Using feedback solely for personnel evaluations
Discouraging critical feedback to maintain team morale
Creating feedback mechanisms that encourage continuous improvement (Correct answer)

Correct answer: Creating feedback mechanisms that encourage continuous improvement

Creating feedback mechanisms that encourage continuous improvement is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 47: In the context of affordable care act certified, which principle most directly governs tax credits & subsidies practices?

Following popular trends without evaluating their applicability
Relying exclusively on vendor-provided solutions
Applying evidence-based methodologies with peer-reviewed support (Correct answer)
Using trial-and-error without systematic documentation

Correct answer: Applying evidence-based methodologies with peer-reviewed support

Applying evidence-based methodologies with peer-reviewed support is the correct approach because effective tax credits & subsidies in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 48: Which data source do ACA risk adjustment models primarily rely on to calculate enrollee risk scores?

Prior year premium payment history
Pharmacy claims data only
Enrollee diagnosis codes from medical claims and encounter data (Correct answer)
Enrollee self-reported health status surveys

Correct answer: Enrollee diagnosis codes from medical claims and encounter data

HHS risk adjustment models use diagnosis codes submitted in medical claims and encounter data to map enrollees to Hierarchical Condition Categories.

Question 49: What is a 'grandfathered' health plan under the ACA?

A plan providing coverage across multiple states
A plan covering only Medicare-eligible individuals
A plan that existed before the ACA was enacted and has not made significant benefit or cost changes (Correct answer)
A plan offered exclusively to employees with 10+ years of service

Correct answer: A plan that existed before the ACA was enacted and has not made significant benefit or cost changes

Grandfathered plans existed before March 23, 2010 (the ACA's enactment date), and are exempt from certain ACA requirements as long as they haven't made significant changes to coverage or cost-sharing.

Question 50: Which tool or methodology is most appropriate for analyzing compliance & consumer protections outcomes?

Maintaining strict formality that inhibits collaboration
Prioritizing relationships over professional standards
Maintaining professional boundaries while building collaborative relationships (Correct answer)
Adjusting boundaries based on individual situations without guidelines

Correct answer: Maintaining professional boundaries while building collaborative relationships

Maintaining professional boundaries while building collaborative relationships is the correct approach because effective compliance & consumer protections in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 51: A client shares that they are undocumented but has a citizen child who needs coverage. What is the ethically correct course of action?

Report the parent's status to immigration authorities
Enroll the child in CHIP or Marketplace coverage without disclosing the parent's status unnecessarily (Correct answer)
Decline to assist because the parent is ineligible
Require proof of citizenship before any assistance

Correct answer: Enroll the child in CHIP or Marketplace coverage without disclosing the parent's status unnecessarily

Eligible children may receive coverage regardless of their parents' status, and assisters must protect client confidentiality and serve all eligible individuals.

Question 52: A client who signed a consent form later revokes permission for their data to be shared with a research partner. What must the assister do?

Immediately stop sharing the client's data and notify the research partner of the revocation (Correct answer)
Honor the original consent form since it was signed voluntarily
Explain that data already shared cannot be retrieved but stop future sharing
Inform the client that revocation is not possible after enrollment

Correct answer: Immediately stop sharing the client's data and notify the research partner of the revocation

Clients have the right to revoke consent at any time, and the assister must act promptly to halt further data sharing upon revocation.

Question 53: What best describes an Exclusive Provider Organization (EPO)?

A plan requiring referrals for all specialist visits
A plan that only covers in-network care except in emergencies (Correct answer)
A plan that covers out-of-network care at any cost level
A plan exclusively offered to large employer groups

Correct answer: A plan that only covers in-network care except in emergencies

EPOs restrict coverage to in-network providers except for emergency care, but unlike HMOs, they typically do not require specialist referrals.

Question 54: A affordable care act certified professional discovers a discrepancy during communication & stakeholder engagement review. What is the most appropriate immediate action?

Engaging stakeholders collaboratively to align goals and expectations (Correct answer)
Limiting communication to written reports only
Accepting all stakeholder requests without prioritization
Working independently to avoid conflicting opinions

Correct answer: Engaging stakeholders collaboratively to align goals and expectations

Engaging stakeholders collaboratively to align goals and expectations is the correct approach because effective communication & stakeholder engagement in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 55: Under ACA quality compliance standards, what is the primary purpose of HEDIS (Healthcare Effectiveness Data and Information Set)?

To certify individual physicians for participation in QHPs
To standardize prescription drug formularies across plans
To set minimum staffing ratios for hospitals
To measure health plan performance on dimensions of care and service (Correct answer)

Correct answer: To measure health plan performance on dimensions of care and service

HEDIS is a widely used tool that allows consumers to compare health plan performance across standardized quality and service measures.

Question 56: Under the ACA, which provision requires Medicaid programs to cover tobacco cessation counseling and medications for pregnant women at no cost sharing?

Section 2502
Section 2713
Section 4107 (Correct answer)
Section 1302

Correct answer: Section 4107

ACA Section 4107 requires Medicaid programs to cover tobacco cessation counseling and FDA-approved medications for pregnant women without cost sharing.

Question 57: What happens if a person's income changes after receiving an ACA subsidy?

Subsidies may be adjusted based on income changes (Correct answer)
The subsidy amount remains unchanged
The individual loses coverage immediately
Subsidies can never be repaid

Correct answer: Subsidies may be adjusted based on income changes

If income increases or decreases, the subsidy amount may need to be adjusted, and excess subsidies may need to be repaid when filing taxes.

Question 58: A Health Savings Account (HSA) can be used in conjunction with which type of ACA health plan?

Any HMO plan
Any Bronze plan
An HSA-qualified High-Deductible Health Plan (HDHP) (Correct answer)
A Platinum plan

Correct answer: An HSA-qualified High-Deductible Health Plan (HDHP)

HSAs are only available to individuals enrolled in IRS-qualified HDHPs that meet the minimum deductible and maximum out-of-pocket thresholds set by the IRS.

Question 59: Under the ACA's risk adjustment program, which entity collects and distributes payments among insurers in the individual and small group markets?

The Federal Reserve
CMS on behalf of each state (Correct answer)
The U.S. Treasury
State insurance commissioners directly

Correct answer: CMS on behalf of each state

CMS operates the permanent risk adjustment program and transfers funds from lower-risk to higher-risk plans in the individual and small group markets.

Question 60: What is the actuarial value of a Silver plan in the ACA marketplace?

70% (Correct answer)
80%
90%
60%

Correct answer: 70%

Silver plans have an actuarial value of 70%, covering 70% of expected covered healthcare costs on average.

Question 61: Which ACA provision allowed states to extend Medicaid coverage to former foster youth up to age 26 regardless of income?

Section 2715 of the ACA
Section 1311 of the ACA
Section 2004 of the ACA (Correct answer)
Section 1401 of the ACA

Correct answer: Section 2004 of the ACA

ACA Section 2004 requires states to provide Medicaid coverage to former foster care youth up to age 26 regardless of income level.

Question 62: What does an HMO (Health Maintenance Organization) typically require of its members?

Seeing any provider without referrals
Choosing a primary care physician and obtaining referrals for specialists (Correct answer)
Equal coverage for out-of-network and in-network providers
Paying higher premiums for broader network access

Correct answer: Choosing a primary care physician and obtaining referrals for specialists

HMOs require members to select a primary care physician (PCP) who coordinates care and must provide referrals for specialist visits to be covered.

Question 63: A new regulation impacts policies & regulations procedures. What should a ACA professional do first?

Ensuring compliance with current regulatory requirements and standards (Correct answer)
Delegating compliance oversight to administrative staff
Complying only with regulations that have enforcement mechanisms
Interpreting regulations loosely to allow maximum flexibility

Correct answer: Ensuring compliance with current regulatory requirements and standards

Ensuring compliance with current regulatory requirements and standards is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 64: An insurer notices that its risk score is being dragged down by a large number of enrollees with no claims during the year. The risk manager should recognize this as:

A sign that healthy enrollees with no diagnoses are being undercounted in the risk score (Correct answer)
A positive indicator of effective preventive care programs
Evidence that the plan should exit the individual market
Grounds for disputing the risk adjustment transfer

Correct answer: A sign that healthy enrollees with no diagnoses are being undercounted in the risk score

Enrollees with no claims generate no diagnosis codes, which lowers the plan's average risk score even if those enrollees have underlying conditions that were simply not captured.

Question 65: What does 'actuarial value' represent in an ACA health plan?

The percentage of total covered healthcare costs the plan pays on average (Correct answer)
The standard copay amount for primary care visits
The annual deductible a member must satisfy before coverage begins
The maximum premium an insurer can charge

Correct answer: The percentage of total covered healthcare costs the plan pays on average

Actuarial value is the percentage of total covered healthcare expenses that the plan pays for a standard population of enrollees.

Question 66: Under ACA Medicaid expansion rules, how often must states conduct eligibility renewals for expansion enrollees?

Annually (Correct answer)
Every six months
Every two years
Only when the enrollee reports an income change

Correct answer: Annually

States must renew Medicaid eligibility for expansion enrollees at least annually using electronic data matches before sending renewal forms to the beneficiary.

Question 67: What is the purpose of Cost-Sharing Reductions (CSRs) under the ACA?

To provide subsidies only to high-income earners
To eliminate all healthcare costs
To reduce out-of-pocket expenses for lower-income enrollees (Correct answer)
To replace Medicaid for all enrollees

Correct answer: To reduce out-of-pocket expenses for lower-income enrollees

CSRs lower out-of-pocket costs like deductibles and co-payments for eligible individuals enrolled in Silver-tier marketplace plans.

Question 68: What is the primary advantage of a Bronze plan for a relatively healthy individual?

Lower out-of-pocket maximums
Access to a wider provider network
Lower monthly premiums (Correct answer)
Lower deductibles than other metal tiers

Correct answer: Lower monthly premiums

Bronze plans offer the lowest monthly premiums of all metal tiers, making them cost-effective for individuals who rarely use healthcare services.

Question 69: In the context of affordable care act certified, which principle most directly governs policies & regulations practices?

Applying evidence-based methodologies with peer-reviewed support (Correct answer)
Using trial-and-error without systematic documentation
Relying exclusively on vendor-provided solutions
Following popular trends without evaluating their applicability

Correct answer: Applying evidence-based methodologies with peer-reviewed support

Applying evidence-based methodologies with peer-reviewed support is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 70: What is the 'coverage gap' that exists in non-expansion states under the ACA?

Adults who earn too much for traditional Medicaid but too little for Marketplace subsidies (Correct answer)
Part-time workers excluded from employer plans
Children between ages 19 and 26 dropped from parental coverage
People earning above 400% FPL who can't afford Marketplace plans

Correct answer: Adults who earn too much for traditional Medicaid but too little for Marketplace subsidies

In non-expansion states, adults above the state's traditional Medicaid income limit but below 100% FPL fall into a coverage gap: ineligible for Medicaid and ineligible for Marketplace premium tax credits.

Question 71: Which communication channel is most effective for reaching elderly populations during ACA open enrollment?

Instagram and TikTok social media campaigns
Online chatbots on Healthcare.gov
Text message SMS blasts
Direct mail and in-person community events (Correct answer)

Correct answer: Direct mail and in-person community events

Older adults are more reliably reached through direct mail and trusted in-person settings than digital-first channels.

Question 72: What is the actuarial value of a Bronze plan in the ACA marketplace?

70%
60% (Correct answer)
80%
50%

Correct answer: 60%

Bronze plans have an actuarial value of 60%, providing the lowest coverage level but typically the lowest monthly premiums.

Question 73: Which ACA section established the Basic Health Program (BHP), an optional coverage alternative for states serving low-income residents?

Section 1402
Section 1331 (Correct answer)
Section 1311
Section 2001

Correct answer: Section 1331

ACA Section 1331 established the Basic Health Program, which allows states to create a state-administered coverage program for residents earning between 133–200% FPL instead of enrolling them in Marketplace plans.

Question 74: A risk manager at an insurance company wants to quantify the impact of high-cost claimants on plan financials. Which metric is MOST relevant?

Average premium across all metal tiers
Concentration of claims among top 1–5% of enrollees (Correct answer)
Total enrollment in special enrollment periods
Number of plans offered in the marketplace

Correct answer: Concentration of claims among top 1–5% of enrollees

A small percentage of enrollees typically generate the majority of medical costs, so analyzing claims concentration helps quantify catastrophic risk exposure.

Question 75: Which of the following best describes 'culturally competent' ACA outreach?

Focusing outreach exclusively on communities with the highest uninsured rates regardless of cultural context
Translating English materials word-for-word into another language without adaptation
Using the same messaging for all demographic groups to ensure consistency
Tailoring communication to reflect the values, language, and health beliefs of a specific community (Correct answer)

Correct answer: Tailoring communication to reflect the values, language, and health beliefs of a specific community

Cultural competence requires adapting content, tone, and format to reflect the specific cultural context of the target community.

Question 76: Under the ACA, the Essential Health Benefits benchmark for each state is typically based on:

The largest small group health plan by enrollment in the state (Correct answer)
The most affordable Bronze plan available in the state
The second-lowest Silver plan in the state marketplace
A federally standardized plan applied uniformly to all states

Correct answer: The largest small group health plan by enrollment in the state

States select their EHB benchmark from approved options, most commonly the largest small group health plan by enrollment in that state, giving states some flexibility in defining EHBs.

Question 77: Under ACA ethics guidelines, when is it acceptable for a navigator to accept a tip from a grateful client?

Never; navigators may not accept compensation from clients (Correct answer)
When the client insists and the navigator documents it
When the tip is under $20
Only after the open enrollment period ends

Correct answer: Never; navigators may not accept compensation from clients

Navigators funded by federal grants are prohibited from accepting any payment, gifts, or tips from the clients they assist.

Question 78: What is the primary purpose of the Affordable Care Act (ACA)?

To expand healthcare access and reduce costs (Correct answer)
To replace Medicare and Medicaid
To make all healthcare services free
To eliminate employer-provided insurance

Correct answer: To expand healthcare access and reduce costs

The ACA was designed to expand healthcare coverage, improve quality, and reduce costs for individuals and businesses.

Question 79: What is the minimum actuarial value for an employer-sponsored plan to meet the ACA's 'minimum value' standard?

50%
60% (Correct answer)
70%
80%

Correct answer: 60%

An employer plan must have an actuarial value of at least 60% to satisfy the minimum value requirement and protect employers from applicable ACA penalties.

Question 80: A stakeholder questions the value of quality assurance & compliance initiatives. Which response best demonstrates ROI?

Centralizing accountability with a single individual
Avoiding accountability discussions to prevent conflict
Building a culture of accountability with transparent reporting (Correct answer)
Distributing accountability so widely that no one is responsible

Correct answer: Building a culture of accountability with transparent reporting

Building a culture of accountability with transparent reporting is the correct approach because effective quality assurance & compliance in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 81: What is the most common mistake professionals make when implementing compliance & consumer protections strategies?

Transferring all risk to external partners through contracts
Creating contingency plans for every possible scenario regardless of probability
Developing contingency plans for high-probability risk scenarios (Correct answer)
Responding to problems only after they occur

Correct answer: Developing contingency plans for high-probability risk scenarios

Developing contingency plans for high-probability risk scenarios is the correct approach because effective compliance & consumer protections in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 82: Which behavior by an assister would most directly violate the ACA's program integrity standards?

Explaining the difference between HMO and PPO plans
Explaining cost-sharing reductions to a client
Steering clients toward a plan because the assister's family member is a provider in that network (Correct answer)
Discussing premium tax credit calculation methods

Correct answer: Steering clients toward a plan because the assister's family member is a provider in that network

Using personal relationships to steer clients toward specific plans is a conflict of interest that violates ACA program integrity and ethical standards.

Question 83: Which income level generally qualifies for ACA subsidies?

Between 100% and 400% of the federal poverty level (Correct answer)
Only those earning minimum wage qualify
Above 500% of the federal poverty level
Below 50% of the federal poverty level

Correct answer: Between 100% and 400% of the federal poverty level

Households earning between 100% and 400% of the federal poverty level typically qualify for ACA subsidies to lower premium costs.

Question 84: Which ACA provision established the National Strategy for Quality Improvement in Health Care?

Section 2718
Section 3011 (Correct answer)
Section 4002
Section 1332

Correct answer: Section 3011

ACA Section 3011 required HHS to develop and publish a National Quality Strategy to guide quality improvement across the health care system.

Question 85: Which factor determines eligibility for ACA premium subsidies?

Employment status only
The type of pre-existing condition
Household income and federal poverty level (Correct answer)
Age and marital status

Correct answer: Household income and federal poverty level

ACA premium subsidies are based on household income and are designed to make health coverage more affordable.

Question 86: What is the ACA affordability threshold for employer-sponsored coverage based on in 2024?

Coverage must cost no more than 10% of the employee's household income
Coverage must cost no more than 8.39% of the employee's household income (Correct answer)
Coverage must cost no more than 9.02% of the employee's household income
Coverage must cost no more than 7.5% of the employee's household income

Correct answer: Coverage must cost no more than 8.39% of the employee's household income

For 2024, employer-sponsored self-only coverage is considered affordable if the employee's required contribution does not exceed 8.39% of household income.

Question 87: What is a Section 1115 waiver in the context of ACA Medicaid programs?

A waiver exempting states from CHIP maintenance of effort requirements
A waiver allowing states to reduce benefits below ACA minimums permanently
An automatic waiver granted to all states that expand Medicaid
A demonstration waiver allowing states to test innovative Medicaid delivery or financing approaches with federal approval (Correct answer)

Correct answer: A demonstration waiver allowing states to test innovative Medicaid delivery or financing approaches with federal approval

Section 1115 waivers allow states to test and evaluate new Medicaid approaches—including work requirements, alternative benefit designs, and delivery reforms—subject to federal budget neutrality and CMS approval.

Question 88: When explaining cost-sharing reductions (CSRs) to a client, which statement is accurate?

CSRs are automatically applied to Bronze plans for low-income enrollees
CSRs apply to all metallic tier plans purchased on or off the marketplace
CSRs reduce monthly premiums for all income levels
CSRs are only available on Silver plans purchased through the marketplace (Correct answer)

Correct answer: CSRs are only available on Silver plans purchased through the marketplace

Cost-sharing reductions are only available to eligible individuals who enroll in Silver plans through the marketplace.

Question 89: Under the ACA, what is the minimum value standard that employer-sponsored health plans must meet?

The plan must cover at least 60% of the total allowed costs (Correct answer)
The plan must cover at least 50% of the total allowed costs
The plan must cover at least 80% of the total allowed costs
The plan must cover at least 70% of the total allowed costs

Correct answer: The plan must cover at least 60% of the total allowed costs

ACA minimum value requires that an employer-sponsored plan pay at least 60% of total allowed costs for a standard population.

Question 90: Under the ACA, what is the Children's Health Insurance Program (CHIP) primarily designed to cover?

Foster children in state custody regardless of income
Uninsured children in families with incomes too high for Medicaid but who cannot afford private coverage (Correct answer)
Children of federal employees not covered by employer plans
Children in families earning below 100% FPL who qualify for Medicaid

Correct answer: Uninsured children in families with incomes too high for Medicaid but who cannot afford private coverage

CHIP covers uninsured children in low-to-moderate income families that earn too much to qualify for Medicaid but cannot afford private insurance.

Question 91: How does the ACA improve preventive care?

By limiting access to wellness programs
By requiring plans to cover preventive services at no cost (Correct answer)
By eliminating preventive services from coverage
By increasing out-of-pocket costs for preventive care

Correct answer: By requiring plans to cover preventive services at no cost

The ACA mandates that health insurance plans cover preventive services without cost-sharing, making preventive care more accessible.

Question 92: What is the ACA's requirement for health plans regarding coverage of preventive services rated 'A' or 'B' by the U.S. Preventive Services Task Force?

Plans may cover them with a standard copay
Plans must cover them only for high-risk enrollees
Plans must cover them without cost-sharing (Correct answer)
Plans may exclude them if they increase premiums

Correct answer: Plans must cover them without cost-sharing

Non-grandfathered plans must cover USPSTF Grade A and B preventive services with no cost-sharing for the enrollee.

Question 93: In the context of affordable care act certified, which principle most directly governs compliance & consumer protections practices?

Relying exclusively on vendor-provided solutions
Following popular trends without evaluating their applicability
Applying evidence-based methodologies with peer-reviewed support (Correct answer)
Using trial-and-error without systematic documentation

Correct answer: Applying evidence-based methodologies with peer-reviewed support

Applying evidence-based methodologies with peer-reviewed support is the correct approach because effective compliance & consumer protections in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 94: For ACA purposes, a full-time employee is defined as one who works an average of how many hours per month?

130 hours per month (Correct answer)
100 hours per month
160 hours per month
120 hours per month

Correct answer: 130 hours per month

The ACA defines a full-time employee as one who works on average at least 130 hours of service per calendar month.

Question 95: What is a key requirement for employers under the ACA?

Employers can only offer coverage to part-time workers
There are no employer requirements under the ACA
Large employers must offer health insurance to full-time employees (Correct answer)
Small businesses must provide coverage to all employees

Correct answer: Large employers must offer health insurance to full-time employees

The ACA’s Employer Mandate requires large employers to provide health insurance to full-time employees or face penalties.

Question 96: What is the primary purpose of Medicaid managed care organizations (MCOs) under ACA-expanded Medicaid programs?

To process Medicaid applications on behalf of states
To coordinate and deliver Medicaid covered services under capitated payment contracts with states (Correct answer)
To replace fee-for-service for only mental health services
To administer Medicare Advantage plans for dual eligibles

Correct answer: To coordinate and deliver Medicaid covered services under capitated payment contracts with states

Medicaid MCOs contract with states to provide Medicaid-covered services to enrollees under capitated (per-member per-month) payment arrangements, coordinating care and managing costs.

Question 97: Under ACA rules, the maximum out-of-pocket limit mitigates financial risk for enrollees primarily by:

Requiring insurers to cover all claims once the deductible is met
Preventing insurers from charging copayments for preventive care
Capping total annual cost-sharing for covered in-network services (Correct answer)
Limiting premium increases to a fixed percentage per year

Correct answer: Capping total annual cost-sharing for covered in-network services

The annual out-of-pocket maximum stops enrollees from paying unlimited cost-sharing, protecting against catastrophic financial exposure for in-network covered services.

Question 98: What was the Supreme Court ruling in NFIB v. Sebelius (2012) regarding ACA Medicaid expansion?

States are required to expand Medicaid or lose all federal Medicaid funding
States may choose whether to expand Medicaid without losing existing federal Medicaid funding (Correct answer)
All states must expand Medicaid within 2 years
Medicaid expansion was ruled unconstitutional

Correct answer: States may choose whether to expand Medicaid without losing existing federal Medicaid funding

In NFIB v. Sebelius, the Supreme Court ruled that states could opt out of Medicaid expansion without losing their existing federal Medicaid funding, making expansion voluntary.

Question 99: Which IRS code section governs the employer shared responsibility (pay-or-play) provisions under the ACA?

IRC Section 36B
IRC Section 5000A
IRC Section 6056
IRC Section 4980H (Correct answer)

Correct answer: IRC Section 4980H

IRC Section 4980H contains the ACA's employer shared responsibility provisions, establishing the 'A' and 'B' penalty frameworks for ALEs.

Question 100: What is the 'no wrong door' policy under the ACA as it applies to Medicaid and Marketplace enrollment?

Individuals can switch between Medicaid and Marketplace plans at any time
Individuals can apply for coverage through any channel—Marketplace, state Medicaid agency, or other entry points—and be connected to the right program (Correct answer)
States cannot deny Medicaid applications submitted outside office hours
All health plans must accept any applicant regardless of health status

Correct answer: Individuals can apply for coverage through any channel—Marketplace, state Medicaid agency, or other entry points—and be connected to the right program

The 'no wrong door' policy ensures that regardless of where a person applies for health coverage, they will be screened and connected to the appropriate program, whether Medicaid, CHIP, or a Marketplace plan.

Affordable Care Act (ACA) Marketplace Certification (FFM)

The CMS Federally Facilitated Marketplace (FFM) certification validates that health insurance agents and brokers have the knowledge to assist consumers with ACA Marketplace enrollment, eligibility, plan selection, and compliance. Passing requires 70% or higher on each of four module-based exams.

100

Questions

90 min

Time Limit

70%

To Pass

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