CEC ACA & Marketplace Fundamentals 4 — Questions and Answers
Question 1: Under the ACA, what is the maximum annual out-of-pocket limit for a self-only Marketplace plan in 2024?
- $5,500
- $7,500
- $9,450 (Correct answer)
- $12,200
Correct answer: $9,450
For 2024, the ACA out-of-pocket maximum for self-only coverage is $9,450, limiting total cost-sharing exposure for in-network essential health benefits.
Question 2: What are the 10 Essential Health Benefits (EHBs) required to be covered in all Marketplace plans?
- Includes dental, vision, and long-term care services
- Includes ambulatory services, emergency care, mental health, prescription drugs, and 6 others (Correct answer)
- Covers only hospital and physician services plus prescriptions
- Determined individually by each state with no federal requirements
Correct answer: Includes ambulatory services, emergency care, mental health, prescription drugs, and 6 others
The 10 EHBs include ambulatory services, emergency care, hospitalization, maternity, mental health/substance use, prescription drugs, rehabilitative services, lab services, preventive care, and pediatric services.
Question 3: A Navigator is different from a licensed insurance agent/broker in that Navigators:
- Can sell plans and receive commissions
- Provide unbiased education and assistance but cannot recommend specific plans or receive compensation tied to enrollment (Correct answer)
- Are only authorized to assist Medicaid applicants
- Must be employed by a health insurance company
Correct answer: Provide unbiased education and assistance but cannot recommend specific plans or receive compensation tied to enrollment
Navigators provide free, unbiased enrollment assistance and education but are prohibited from recommending specific plans or accepting compensation from insurers.
Question 4: Which state runs its own fully state-based Marketplace (SBM) and does NOT use HealthCare.gov for enrollment?
- Texas
- Florida
- California (Correct answer)
- Georgia
Correct answer: California
California operates Covered California, a fully state-based Marketplace with its own enrollment platform separate from HealthCare.gov.
Question 5: What is the minimum actuarial value for a Silver plan under ACA metal tier standards?
- 60%
- 70% (Correct answer)
- 80%
- 90%
Correct answer: 70%
Silver plans must have an actuarial value of approximately 70%, meaning the plan pays 70% of average costs for a standard population.
Question 6: An enrollee who is offered affordable employer coverage but wants to enroll in a Marketplace plan instead will generally:
- Qualify for full APTC subsidy on the Marketplace
- Not be eligible for APTC if the employer plan meets ACA affordability and minimum value standards (Correct answer)
- Be required to take the employer plan by law
- Qualify for CSRs but not APTC
Correct answer: Not be eligible for APTC if the employer plan meets ACA affordability and minimum value standards
If an employer plan is affordable and meets minimum value standards, the employee is not eligible for Marketplace premium tax credits (APTC).
Question 7: Which form does an insurer use to report Marketplace coverage to the IRS and send to enrollees for tax filing purposes?
- Form 1095-A (Correct answer)
- Form 1095-B
- Form 1095-C
- Form W-2
Correct answer: Form 1095-A
Form 1095-A (Health Insurance Marketplace Statement) is issued by the Marketplace to enrollees and is required to complete Form 8962 for APTC reconciliation.
CEC ACA & Marketplace Fundamentals 4
Under the ACA, what is the maximum annual out-of-pocket limit for a self-only Marketplace plan in 2024?