CEC Application Assistance & Enrollment Procedures 4

Question 1

What is the primary difference between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) plan?

Accepted Answer

HMOs typically require referrals and restrict coverage to in-network providers, while PPOs offer more flexibility with out-of-network coverage

Answer

HMOs always have lower deductibles than PPOs

Answer

PPOs require a primary care physician designation; HMOs do not

Answer

HMOs cover more services than PPOs under federal law

Question 2

A consumer who missed open enrollment claims they qualify for an SEP because they recently got married. What documentation might be needed to verify this SEP?

Accepted Answer

Marriage certificate

Answer

Birth certificate

Answer

Proof of prior coverage termination

Answer

Employer letter

Question 3

Under the ACA, what is the maximum percentage of household income that a consumer at 300% FPL is generally expected to pay for a benchmark Silver plan premium after applying APTC?

Accepted Answer

A fixed percentage set by the ACA's affordability schedule for their income level

Answer

0%

Answer

50% of the premium

Answer

The full premium with no subsidy

Question 4

A consumer asks about enrolling their newborn in Marketplace coverage. What rule applies to newborns born to an enrolled parent?

Accepted Answer

Newborns are automatically enrolled under the parent's plan and have a 60-day SEP to be formally added or switched

Answer

Newborns must wait until the next open enrollment period to be added

Answer

Newborns are ineligible for Marketplace coverage until age 1

Answer

Newborns require a separate application and premium payment immediately

Question 5

When an enrollment counselor assists a consumer in selecting a plan, which of the following is the MOST appropriate guidance regarding network adequacy?

Accepted Answer

Advise the consumer to verify that their preferred doctors and hospitals are in the plan's network before enrolling

Answer

Choose the plan with the lowest premium regardless of network

Answer

All Marketplace plans have identical provider networks

Answer

Network differences only apply to dental plans

Question 6

A consumer who received APTC during the year reports a significant income increase when filing taxes. What is the likely outcome?

Accepted Answer

The consumer may need to repay some or all of the excess APTC received, subject to repayment caps for lower incomes

Answer

The consumer receives a larger refund for the excess subsidies

Answer

There is no financial consequence for income changes

Answer

The IRS automatically adjusts the APTC without any consumer action

Question 7

Which of the following scenarios would NOT qualify as a Special Enrollment Period trigger?

Accepted Answer

Voluntarily canceling a current Marketplace plan because premiums seem high

Answer

Losing job-based health coverage

Answer

Moving to a new ZIP code or county that offers different Marketplace plans

Answer

Having a baby