CEC Health Coverage Options & Program Eligibility 2 — Questions and Answers
Question 1: A 35-year-old single adult with no dependents has income at 140% FPL. Which program is most appropriate?
- Marketplace plan with premium tax credit
- Medicaid (in expansion states) (Correct answer)
- CHIP
- Medicare Part A
Correct answer: Medicaid (in expansion states)
In states that expanded Medicaid, adults with income up to 138% FPL qualify, but 140% FPL falls just above the threshold, so a Marketplace plan with APTC is correct.
Question 2: Which of the following is NOT a qualifying life event that triggers a Special Enrollment Period?
- Getting married
- Losing job-based coverage
- Voluntarily dropping coverage (Correct answer)
- Having a baby
Correct answer: Voluntarily dropping coverage
Voluntarily dropping coverage is not a qualifying life event; SEPs are triggered by involuntary loss of coverage or life changes like marriage or birth.
Question 3: Under the ACA, which metal tier plan has the highest actuarial value?
- Bronze
- Silver
- Gold
- Platinum (Correct answer)
Correct answer: Platinum
Platinum plans have the highest actuarial value at approximately 90%, meaning the plan pays 90% of covered costs on average.
Question 4: A consumer's employer offers coverage that costs 12% of their household income. How does this affect Marketplace eligibility?
- They are eligible for Marketplace APTC because the offer is unaffordable (Correct answer)
- They are ineligible for Marketplace APTC
- They must take the employer plan
- They qualify for Medicaid instead
Correct answer: They are eligible for Marketplace APTC because the offer is unaffordable
Employer-sponsored coverage is considered unaffordable if the employee-only premium exceeds 9.02% (2023 threshold) of household income, making the consumer eligible for Marketplace subsidies.
Question 5: Which federal program provides health coverage specifically to low-income pregnant women who do not otherwise qualify for Medicaid?
- CHIP Unborn Child option
- CHIP Perinatal (Correct answer)
- Marketplace SEP for pregnancy
- Medicare Maternal Care
Correct answer: CHIP Perinatal
CHIP Perinatal (or unborn child option) allows states to extend CHIP coverage to unborn children of low-income women who don't qualify for Medicaid.
Question 6: What is the income range for premium tax credit eligibility on the Marketplace (after the ARP 2021 expansions made permanent)?
- 100%–250% FPL
- 100%–300% FPL
- 100%–400% FPL
- 100% FPL and above with no upper cap (Correct answer)
Correct answer: 100% FPL and above with no upper cap
Under the Inflation Reduction Act, the upper income cap on APTC was eliminated; anyone above 100% FPL (400%+ FPL) may qualify if premiums exceed the benchmark percentage of income.
Question 7: A consumer who is lawfully present in the US but has been here fewer than 5 years on a qualified immigration status is applying for Medicaid. What is the general rule?
- They must wait 5 years before qualifying for full Medicaid (Correct answer)
- They qualify immediately in all states
- They are barred from all public coverage
- They qualify only for Medicare
Correct answer: They must wait 5 years before qualifying for full Medicaid
Most lawfully present immigrants must satisfy a 5-year waiting period before being eligible for federally funded Medicaid, though some exceptions apply (e.g., refugees, pregnant women in some states).
CEC Health Coverage Options & Program Eligibility 2
A 35-year-old single adult with no dependents has income at 140% FPL.
Which program is most appropriate?