CEC Eligibility Determination Process 5 — Questions and Answers
Question 1: An applicant says they are enrolled in a health care sharing ministry. Does this constitute minimum essential coverage that would disqualify them from APTC?
- Yes, all health coverage counts as MEC
- No, health care sharing ministries are not MEC (Correct answer)
- Yes, but only if the ministry is federally recognized
- Only if they have been enrolled for more than 12 months
Correct answer: No, health care sharing ministries are not MEC
Health care sharing ministries do not qualify as minimum essential coverage, so members may still be eligible for Marketplace plans and APTC.
Question 2: A Marketplace consumer notifies the exchange of a new baby born during the plan year. What is the effective date of coverage for the newborn?
- The first of the month following the birth
- The date of birth (Correct answer)
- 60 days after the birth is reported
- The start of the next plan year
Correct answer: The date of birth
Newborns are covered from their date of birth when added to an existing Marketplace plan within the SEP window.
Question 3: A consumer's annual household income is 250% FPL. They qualify for which level of cost-sharing reductions if they enroll in a Silver plan?
- CSR variant with actuarial value of approximately 94%
- CSR variant with actuarial value of approximately 87% (Correct answer)
- CSR variant with actuarial value of approximately 73%
- No CSR; standard Silver plan at 70% AV only
Correct answer: CSR variant with actuarial value of approximately 87%
At 200–250% FPL, a Silver CSR plan has an enhanced actuarial value of approximately 87%.
Question 4: Which of the following is a qualifying life event that would open a Special Enrollment Period for an individual who currently has no health coverage?
- Voluntarily canceling a prior plan
- Gaining a dependent through adoption (Correct answer)
- Aging off a parent's plan at age 27
- Moving within the same service area
Correct answer: Gaining a dependent through adoption
Gaining a dependent through adoption, birth, or placement in foster care is a qualifying life event that triggers a SEP.
Question 5: A consumer is determined eligible for Medicaid by the Marketplace and sent to their state Medicaid agency. The state agency later denies eligibility. What option does the consumer have for Marketplace coverage?
- They must reapply during the next Open Enrollment Period only
- They receive a SEP to enroll in a Marketplace plan (Correct answer)
- They are permanently ineligible because the Marketplace referred them
- They can only enroll if the state denial was made in error
Correct answer: They receive a SEP to enroll in a Marketplace plan
A denial of Medicaid or CHIP eligibility triggers a Special Enrollment Period allowing the consumer to enroll in a Marketplace plan.
Question 6: For Marketplace APTC purposes, which of the following individuals would be included in the applicant's 'tax household' even if they do not need coverage?
- A roommate who shares living expenses
- A spouse filing a joint return (Correct answer)
- A domestic partner not legally married
- An elderly parent who lives in the home but files separately
Correct answer: A spouse filing a joint return
A spouse who files a joint federal tax return is included in the applicant's tax household regardless of whether they need coverage.
Question 7: An enrollment counselor discovers that an applicant received APTC but did not file a tax return to reconcile it. What consequence may the applicant face in subsequent years?
- Their APTC is automatically forgiven after 3 years
- They may be barred from receiving APTC in future years until they file and reconcile (Correct answer)
- The Marketplace will recalculate and increase their future APTC to compensate
- No consequence; reconciliation is voluntary
Correct answer: They may be barred from receiving APTC in future years until they file and reconcile
Failure to file and reconcile APTC can result in a consumer being ineligible to receive advance payments of the premium tax credit in future coverage years.
CEC Eligibility Determination Process 5
An applicant says they are enrolled in a health care sharing ministry.
Does this constitute minimum essential coverage that would disqualify them from APTC?