CACs Consumer Education and Assistance 3 — Questions and Answers
Question 1: A consumer who enrolled in a Marketplace plan wants to add their newborn to their coverage. A CAC should advise them that a birth triggers a SEP and the consumer must report the birth within:
- 30 days of the birth
- 60 days of the birth (Correct answer)
- 90 days of the birth
- 120 days of the birth
Correct answer: 60 days of the birth
A newborn must be added to Marketplace coverage within 60 days of the birth, which is the standard SEP window for birth, adoption, or placement.
Question 2: When explaining the Marketplace's network types to a consumer, which plan type generally requires referrals to see specialists but may offer lower premiums?
- PPO (Preferred Provider Organization)
- EPO (Exclusive Provider Organization)
- HMO (Health Maintenance Organization) (Correct answer)
- POS (Point of Service)
Correct answer: HMO (Health Maintenance Organization)
HMO plans typically require members to get referrals from a primary care physician before seeing specialists and generally have lower premiums.
Question 3: A consumer asks a CAC whether they can keep their doctor after enrolling in a Marketplace plan. The BEST advice the CAC can provide is to:
- Assure them all Marketplace plans cover any licensed physician in the US
- Tell them to call their doctor to confirm participation in the specific plan's network before enrolling (Correct answer)
- Advise them to pick a Gold plan since it always covers more providers
- Explain that provider networks are standardized across all plans in each state
Correct answer: Tell them to call their doctor to confirm participation in the specific plan's network before enrolling
Consumers should verify their preferred doctors and facilities are in-network for a specific plan before enrolling, as networks vary by plan.
Question 4: During Open Enrollment, a consumer who received advance premium tax credits (APTC) last year wants to re-enroll. A CAC must remind them to:
- Pay back all APTC received before they can re-enroll
- Update their household income and family size information each year (Correct answer)
- Choose the same plan they had previously to maintain APTC eligibility
- Submit a new eligibility application every month throughout the year
Correct answer: Update their household income and family size information each year
Consumers receiving APTC must update their income and household information annually during Open Enrollment to ensure their tax credit amount is accurate.
Question 5: A CAC is assisting a consumer who speaks limited English. Under federal civil rights requirements, the CAC or their organization must:
- Provide language assistance services free of charge to individuals with limited English proficiency (Correct answer)
- Advise the consumer to return with a family member who speaks English
- Charge a reasonable fee for interpreter services provided during the application
- Only provide written translations, not verbal interpretation
Correct answer: Provide language assistance services free of charge to individuals with limited English proficiency
Federal civil rights law (Title VI) requires covered entities to provide meaningful access, including free language assistance, to individuals with limited English proficiency.
Question 6: A consumer enrolled in a Bronze plan asks why their bills are so high even though they pay premiums every month. A CAC should explain that Bronze plans:
- Have no deductible but charge higher copays for every service
- Have the highest actuarial value (90%) among metal tiers
- Have lower premiums but higher deductibles and out-of-pocket costs (Correct answer)
- Do not cover preventive care, which accounts for most of their bills
Correct answer: Have lower premiums but higher deductibles and out-of-pocket costs
Bronze plans have the lowest premiums but the highest cost-sharing, meaning consumers pay more out-of-pocket before the plan covers most services.
Question 7: Which of the following is a key responsibility of a CAC under the CMS Standards for Navigators, In-Person Assisters, and CACs?
- Selling Marketplace plans and earning commissions on enrollments
- Providing information in an impartial manner to help consumers make their own decisions (Correct answer)
- Determining eligibility for consumers based on personal knowledge rather than system determinations
- Advising consumers on tax preparation related to health coverage
Correct answer: Providing information in an impartial manner to help consumers make their own decisions
CACs are required to provide impartial, accurate information to help consumers understand their options and make their own coverage decisions.
CACs Consumer Education and Assistance 3
A consumer who enrolled in a Marketplace plan wants to add their newborn to their coverage.
A CAC should advise them that a birth triggers a SEP and the consumer must report the birth within: