CEC - Certified Enrollment Counselor Post-Enrollment and Renewals Questions and Answers — Questions and Answers
Question 1: A consumer who is enrolled in a Marketplace plan with APTC experiences a significant, permanent increase in household income mid-year. What is their primary responsibility regarding this change?
- Report the change to the Marketplace within 30 days. (Correct answer)
- Wait until the next Open Enrollment Period to update their information.
- Notify their insurance company directly of the income change.
- Wait to reconcile the difference when they file their federal income taxes.
Correct answer: Report the change to the Marketplace within 30 days.
Consumers are required to report changes in circumstances, such as income or household size, to the Marketplace within 30 days of the event. Reporting the change promptly allows the Marketplace to adjust the consumer's Advance Premium Tax Credit (APTC) amount. This helps the consumer avoid having to pay back a large amount of excess APTC when they file their federal income taxes.
Question 2: During the annual renewal period, a consumer who takes no action is automatically re-enrolled. However, their specific 2025 plan is being discontinued by the insurer. What is the most likely action the Marketplace will take?
- Terminate the consumer's coverage and financial assistance.
- Automatically enroll the consumer into the lowest-cost Bronze plan available.
- Automatically enroll the consumer into a similar plan from the same insurer, or a different insurer if a similar plan is not available from the original one. (Correct answer)
- Send a notice that the consumer must select a new plan within 30 days or they will have a gap in coverage.
Correct answer: Automatically enroll the consumer into a similar plan from the same insurer, or a different insurer if a similar plan is not available from the original one.
If a consumer's plan is discontinued, the Marketplace will automatically re-enroll them in a new plan that is as similar as possible to their previous one, a process often called a "crosswalk." The priority is to find a similar plan from the same insurance company first. If that's not possible, it will look for a similar plan from a different insurer. This prevents a gap in coverage for the consumer.
Question 3: A consumer who receives Advance Premium Tax Credits (APTC) has paid their premium for January, February, and March but fails to pay their April premium on time. Under the ACA, what is the required grace period an insurer must provide before terminating coverage?
- 30 days, during which all claims must be paid.
- 60 days, with the insurer having the option to pend claims for the entire period.
- A period ending on the last day of the month for which the premium was due.
- 90 days, during which the insurer must pay claims for the first month but may pend claims for the second and third months. (Correct answer)
Correct answer: 90 days, during which the insurer must pay claims for the first month but may pend claims for the second and third months.
For enrollees receiving APTC who have paid at least one full month's premium, federal regulations (45 CFR § 156.270) mandate a 90-day (three-month) grace period. During the first month of the grace period, the insurer must continue to pay claims. For the second and third months, the insurer can pend claims, meaning they can hold off on paying them until the overdue premiums are paid.
Question 4: A consumer with existing Marketplace coverage wants to change their plan mid-year. Which of the following qualifying life events will most likely allow them to select a new plan from a different insurance company and potentially a different metal level?
- A change in income that makes them newly eligible for cost-sharing reductions (CSRs).
- A permanent move to a new ZIP code where their current plan is not offered. (Correct answer)
- The birth of a child, adding a new dependent to the household.
- Getting married, which changes their household size and tax filing status.
Correct answer: A permanent move to a new ZIP code where their current plan is not offered.
A permanent move to a new service area where new Qualified Health Plans (QHPs) are available is a qualifying life event that necessitates selecting a new plan, allowing the consumer to choose from any available plan/insurer in the new area. While other events like a birth or marriage trigger a Special Enrollment Period (SEP), they often restrict the consumer to adding the new member to their current plan or choosing another plan at the same metal level. A change in income making someone newly CSR-eligible allows a switch to a Silver plan, but not necessarily to any other metal level or carrier.
Question 5: When assisting a consumer with their annual renewal during Open Enrollment, what is the most important best practice for a Certified Enrollment Counselor to follow?
- Encourage the consumer to actively review and update their application and compare all available plan options. (Correct answer)
- Advise the consumer to allow passive (automatic) re-enrollment to ensure there is no gap in coverage.
- Recommend the plan with the lowest premium, as that is the most common consumer priority.
- Focus only on updating the income section, as it is the most critical for financial assistance.
Correct answer: Encourage the consumer to actively review and update their application and compare all available plan options.
The best practice is to always encourage active renewal. This ensures the consumer's household and income information is accurate, leading to the correct amount of financial assistance and avoiding tax penalties. It also provides an opportunity to compare new plans, as premiums, provider networks, and drug formularies can change each year, and the consumer's current plan may no longer be the best fit.
Question 6: A consumer receives a Data Matching Issue (DMI) notice regarding their immigration status. The notice states they have 95 days to submit valid documentation. If the consumer fails to respond and resolve the issue within the specified timeframe, what is the most likely consequence?
- Their financial assistance will be removed, but they can keep the plan by paying the full premium.
- They will be assessed a penalty during the next tax filing season.
- Their eligibility for Marketplace coverage will be terminated, resulting in a loss of their health plan. (Correct answer)
- Their enrollment will be automatically switched to a state Medicaid plan.
Correct answer: Their eligibility for Marketplace coverage will be terminated, resulting in a loss of their health plan.
Failure to resolve a Data Matching Issue related to a core eligibility requirement like citizenship or immigration status within the allowed timeframe (typically 90 or 95 days) will result in the termination of the consumer's eligibility for Marketplace coverage. This means both their health plan and any associated financial assistance will be ended.
CEC - Certified Enrollment Counselor Post-Enrollment and Renewals Questions and Answers
A consumer who is enrolled in a Marketplace plan with APTC experiences a significant, permanent increase in household income mid-year.
What is their primary responsibility regarding this change?