CEC Application Assistance & Enrollment Procedures 3 — Questions and Answers
Question 1: What does the term 'minimum essential coverage' (MEC) mean in the context of health insurance enrollment?
- Coverage that only includes emergency services
- Health coverage that meets the ACA's basic requirements, such as employer-sponsored plans, Medicaid, Medicare, and Marketplace plans (Correct answer)
- A plan with the lowest possible premium
- Coverage limited to preventive care only
Correct answer: Health coverage that meets the ACA's basic requirements, such as employer-sponsored plans, Medicaid, Medicare, and Marketplace plans
Minimum essential coverage includes a range of plan types—employer, government, and individual market—that satisfy the ACA's coverage standards.
Question 2: A consumer's annual income is estimated at 250% of the Federal Poverty Level (FPL). Which cost-sharing reduction (CSR) tier would they most likely qualify for if enrolled in a Silver plan?
- No CSR because they earn too much
- CSR plan variant with the highest level of cost sharing reductions (for incomes 100–150% FPL)
- CSR plan variant available for incomes 201–250% FPL (Correct answer)
- CSR plan variant for incomes 151–200% FPL
Correct answer: CSR plan variant available for incomes 201–250% FPL
Consumers with incomes between 201–250% FPL qualify for a Silver plan CSR variant that provides moderate reductions in deductibles and out-of-pocket costs.
Question 3: When completing a Marketplace application, which household members' income must be included in the household income calculation for subsidy eligibility?
- Only the primary applicant's income
- All people who file taxes together and their dependents, including those not enrolling in coverage (Correct answer)
- Only household members who are enrolling in coverage
- Income from children under 18 is never included
Correct answer: All people who file taxes together and their dependents, including those not enrolling in coverage
Household income for ACA subsidy calculations includes the income of all tax filers and their dependents, even if some members are not applying for Marketplace coverage.
Question 4: An enrollment counselor discovers that a consumer has already enrolled in a plan for the upcoming year but wants to switch. What is the correct guidance?
- The consumer cannot switch once enrolled under any circumstances
- The consumer may switch plans during open enrollment before the deadline without penalty (Correct answer)
- The consumer must pay a fee to switch plans
- A new SEP must be triggered to switch plans during open enrollment
Correct answer: The consumer may switch plans during open enrollment before the deadline without penalty
During open enrollment, consumers can change their plan selection as many times as needed before the enrollment deadline; the last selection is the active enrollment.
Question 5: What is the significance of a plan's 'out-of-pocket maximum' for a consumer choosing coverage?
- It is the maximum amount the plan will pay for covered services
- It is the maximum amount the consumer will pay out of pocket for covered services in a plan year before the plan pays 100% (Correct answer)
- It sets the limit on annual premium increases
- It determines the deductible amount
Correct answer: It is the maximum amount the consumer will pay out of pocket for covered services in a plan year before the plan pays 100%
Once a consumer reaches the out-of-pocket maximum, the insurance plan covers 100% of covered in-network costs for the remainder of the plan year.
Question 6: A consumer is switching from COBRA continuation coverage to a Marketplace plan. Which enrollment scenario is correct?
- Loss of COBRA triggers a Special Enrollment Period but electing COBRA does not (Correct answer)
- Voluntarily dropping COBRA immediately triggers an SEP
- COBRA enrollment status has no effect on Marketplace eligibility
- Consumers on COBRA are ineligible for Marketplace plans
Correct answer: Loss of COBRA triggers a Special Enrollment Period but electing COBRA does not
Losing COBRA coverage (due to exhaustion or non-payment) triggers an SEP, but voluntarily dropping COBRA does not create a qualifying event.
Question 7: An enrollment counselor notices a consumer has entered an income amount that seems inconsistent with their stated occupation. What is the appropriate action?
- Change the income to a more plausible amount without telling the consumer
- Enroll the consumer and ignore the discrepancy
- Ask clarifying questions to ensure the reported income is accurate and explain the consequences of misreporting (Correct answer)
- Report the consumer to the IRS immediately
Correct answer: Ask clarifying questions to ensure the reported income is accurate and explain the consequences of misreporting
Enrollment counselors should help consumers report accurate income by asking clarifying questions and explaining that misreporting can result in repayment of excess subsidies.
CEC Application Assistance & Enrollment Procedures 3
What does the term 'minimum essential coverage' (MEC) mean in the context of health insurance enrollment?