CACs - Certified Application Counselor Marketplace Plan Options Questions and Answers 1 — Questions and Answers
Question 1: A 28-year-old single individual is in good health and wants a Marketplace plan with the lowest possible monthly premium. They understand that this means they will have a high deductible and will pay more for care when they need it. Which 'metal level' plan would be the most appropriate recommendation?
- Gold
- Silver
- Bronze (Correct answer)
- Platinum
Correct answer: Bronze
Bronze plans are designed to have the lowest monthly premiums but the highest out-of-pocket costs, such as deductibles and copayments, when care is needed. This structure is suitable for healthy individuals who primarily want coverage for major accidents or illnesses.
Question 2: An applicant with a household income at 180% of the Federal Poverty Level (FPL) wants to receive financial assistance to lower their deductibles, copayments, and coinsurance. To receive these specific 'extra savings,' which type of Marketplace plan MUST they enroll in?
- Any plan offered on the Marketplace
- A Silver plan (Correct answer)
- A Gold or Platinum plan
- A Bronze plan
Correct answer: A Silver plan
Cost-Sharing Reductions (CSRs), often called 'extra savings,' are only available to eligible individuals who enroll in a Silver plan. These savings lower out-of-pocket costs like deductibles and copays for consumers with household incomes between 100% and 250% of the FPL.
Question 3: Which of the following is NOT considered one of the 10 Essential Health Benefits that all Marketplace plans are required to cover?
- Maternity and newborn care
- Prescription drugs
- Cosmetic surgery (Correct answer)
- Mental health and substance use disorder services
Correct answer: Cosmetic surgery
The Affordable Care Act (ACA) requires that all individual and small group plans, including those on the Marketplace, cover 10 Essential Health Benefits. These include categories like maternity care, prescription drugs, and mental health services. Cosmetic surgery that is not medically necessary is not an essential health benefit.
Question 4: A consumer loses their job-based health coverage on June 15th. They want to enroll in a Marketplace plan. This situation is known as a Qualifying Life Event (QLE), which triggers what opportunity for the consumer?
- A discount on their first month's premium
- An automatic enrollment into a Gold plan
- A Special Enrollment Period (SEP) (Correct answer)
- An exemption from all out-of-pocket costs
Correct answer: A Special Enrollment Period (SEP)
Losing other health coverage, such as from a job, is a Qualifying Life Event (QLE) that allows an individual to enroll in a new health plan outside of the regular Open Enrollment Period. This window of opportunity is called a Special Enrollment Period (SEP).
Question 5: A 35-year-old individual wants to purchase a Catastrophic health plan because of its very low premium. They do not qualify for a hardship or affordability exemption. As a Certified Application Counselor, what should you advise them?
- They can enroll in a Catastrophic plan without any restrictions.
- They are not eligible for a Catastrophic plan due to their age. (Correct answer)
- They can only enroll if they also sign up for a dental plan.
- They must first enroll in a Bronze plan for one year.
Correct answer: They are not eligible for a Catastrophic plan due to their age.
Catastrophic plans are generally only available to individuals under the age of 30 or those who qualify for a hardship or affordability exemption. Since the individual is 35 and does not have an exemption, they are not eligible for this type of plan.
Question 6: A family is comparing a Health Maintenance Organization (HMO) plan and a Preferred Provider Organization (PPO) plan on the Marketplace. What is a key difference a CAC should explain to them?
- HMO plans have higher premiums than PPO plans.
- PPO plans generally require referrals to see specialists, while HMOs do not.
- HMOs only cover services from in-network providers (except in emergencies), while PPOs offer some coverage for out-of-network care. (Correct answer)
- Only PPO plans cover the 10 Essential Health Benefits.
Correct answer: HMOs only cover services from in-network providers (except in emergencies), while PPOs offer some coverage for out-of-network care.
A primary distinction between HMOs and PPOs is the provider network. HMOs typically limit coverage to care from in-network doctors and hospitals, except in emergencies. PPO plans provide more flexibility by offering coverage for both in-network and out-of-network providers, though out-of-pocket costs are higher for out-of-network care.
CACs - Certified Application Counselor Marketplace Plan Options Questions and Answers 1
A 28-year-old single individual is in good health and wants a Marketplace plan with the lowest possible monthly premium.
They understand that this means they will have a high deductible and will pay more for care when they need it.
Which 'metal level' plan would be the most appropriate recommendation?