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 require members to use in-network providers and get referrals for specialists, whereas PPOs allow out-of-network care at a higher cost-sharing level.

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

Marriage is a qualifying life event triggering an SEP, and a marriage certificate is the standard documentation used to verify this event.

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

The ACA establishes an affordability schedule where consumers pay a capped percentage of income for the benchmark plan, with the APTC covering the remainder.

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

A birth triggers a 60-day SEP, and newborns are generally covered under the parent's plan during this window until formally enrolled.

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

Consumers should confirm that their preferred providers are in-network before enrolling to avoid unexpected out-of-network costs.

(CEC) Certified Enrollment Counselor Practice Test

(CEC) Certified Enrollment Counselor Practice Test

CEC Application Assistance & Enrollment Procedures 4