CEC Eligibility Determination Process 3 — Questions and Answers
Question 1: A consumer is incarcerated but pending disposition of charges. Are they eligible to enroll in a Marketplace plan?
- No, incarcerated individuals are never eligible for Marketplace coverage
- Yes, pending disposition of charges they are eligible to enroll (Correct answer)
- Only if they were enrolled prior to incarceration
- Only if the facility does not provide medical care
Correct answer: Yes, pending disposition of charges they are eligible to enroll
Individuals incarcerated pending disposition of charges are not excluded from Marketplace eligibility; only those incarcerated post-conviction are excluded.
Question 2: What is the upper income limit (as a percentage of FPL) for eligibility to receive Advance Premium Tax Credits under the ACA for 2024?
- 300% FPL
- 400% FPL
- No upper limit through 2025 under enhanced subsidies (Correct answer)
- 500% FPL
Correct answer: No upper limit through 2025 under enhanced subsidies
The American Rescue Plan Act eliminated the 400% FPL cliff through 2025 (extended by the Inflation Reduction Act), so there is no hard upper income limit for APTC.
Question 3: A Marketplace applicant's data-matching issue shows the SSA cannot verify their Social Security number. What is the standard timeline for the consumer to resolve this inconsistency?
- 15 days
- 30 days
- 90 days (Correct answer)
- 180 days
Correct answer: 90 days
Consumers typically have 90 days to resolve data-matching inconsistencies by submitting documentation to the Marketplace.
Question 4: Which of the following household sizes would place a family at exactly 100% of the 2024 Federal Poverty Level for the contiguous 48 states?
- Family of 4 earning $22,000/year
- Single individual earning $15,060/year (Correct answer)
- Family of 3 earning $20,120/year
- Family of 2 earning $25,000/year
Correct answer: Single individual earning $15,060/year
For 2024, 100% FPL for a single individual in the contiguous 48 states is $15,060.
Question 5: A consumer enrolled mid-year reports a change in income that drops them below 100% FPL. What happens to their APTC eligibility?
- APTC is immediately terminated
- APTC continues unchanged until the next Open Enrollment
- They may be transitioned to Medicaid if otherwise eligible (Correct answer)
- They receive a larger APTC to compensate for lower income
Correct answer: They may be transitioned to Medicaid if otherwise eligible
If a consumer's income drops below 100% FPL and they are Medicaid-eligible, they should be transitioned to Medicaid rather than continuing Marketplace coverage with APTC.
Question 6: An applicant states they are a lawfully present non-citizen. Which immigration status would make them eligible for Marketplace coverage but NOT for Medicaid/CHIP under the standard 5-year bar?
- Refugee
- Lawful Permanent Resident within their first 5 years in that status (Correct answer)
- Asylee
- Cuban/Haitian Entrant
Correct answer: Lawful Permanent Resident within their first 5 years in that status
Lawful Permanent Residents are subject to a 5-year waiting period before qualifying for federally funded Medicaid, but they are eligible for Marketplace coverage immediately.
Question 7: When an applicant is determined eligible for both APTC and cost-sharing reductions, what plan metal level must they select to access CSRs?
- Any metal level plan
- Bronze or Silver only
- Silver plans only (Correct answer)
- Gold or Platinum only
Correct answer: Silver plans only
Cost-sharing reductions are available only when a CSR-eligible consumer enrolls in a Silver-tier plan.
CEC Eligibility Determination Process 3
A consumer is incarcerated but pending disposition of charges.
Are they eligible to enroll in a Marketplace plan?