CEC Health Coverage Options & Program Eligibility 4 — Questions and Answers
Question 1: A consumer loses job-based coverage on March 15. How long do they have to enroll in a Marketplace plan using their SEP?
- 30 days from the loss
- 60 days from the loss (Correct answer)
- 90 days from the loss
- Until the next Open Enrollment
Correct answer: 60 days from the loss
Consumers who lose qualifying coverage have a 60-day SEP window to enroll in a Marketplace plan before or after the qualifying event.
Question 2: Which of the following best describes the 'Medicaid gap' problem in non-expansion states?
- Adults earn too much for Marketplace subsidies but too little to qualify (Correct answer)
- Children are excluded from Medicaid in those states
- Medicare doesn't cover residents of those states
- Employers are exempt from the employer mandate
Correct answer: Adults earn too much for Marketplace subsidies but too little to qualify
In non-expansion states, adults with income below 100% FPL don't qualify for Marketplace APTCs (which start at 100% FPL) and may not qualify for Medicaid, leaving them in a 'coverage gap.'
Question 3: Which Medicare part covers outpatient services, including doctor visits and preventive care?
- Part A
- Part B (Correct answer)
- Part C
- Part D
Correct answer: Part B
Medicare Part B covers medically necessary outpatient services, preventive services, and durable medical equipment.
Question 4: Under the ACA, children may remain on a parent's health plan until what age?
- 21
- 23
- 25
- 26 (Correct answer)
Correct answer: 26
The ACA requires health plans that offer dependent coverage to allow adult children to remain on a parent's plan until age 26, regardless of marital or student status.
Question 5: Which of the following is a characteristic of a Preferred Provider Organization (PPO)?
- Requires a referral to see specialists
- Only covers in-network providers
- Allows out-of-network coverage at a higher cost (Correct answer)
- Assigns a primary care physician to coordinate all care
Correct answer: Allows out-of-network coverage at a higher cost
PPOs allow members to see out-of-network providers at a higher cost-sharing level without needing a referral, offering greater flexibility than HMOs.
Question 6: What income threshold generally determines CHIP eligibility for children in most states?
- Below 100% FPL
- Between 100%–200% FPL only
- Up to 200%–300% FPL (varies by state) (Correct answer)
- Above 400% FPL
Correct answer: Up to 200%–300% FPL (varies by state)
CHIP eligibility for children typically covers households earning too much for Medicaid but generally up to 200–300% FPL, with variation by state.
Question 7: A consumer enrolls in a Marketplace plan and later receives a higher-paying job mid-year. What should they do?
- Wait until Open Enrollment to report the change
- Report the income change to the Marketplace promptly to adjust APTC (Correct answer)
- Drop coverage immediately
- Switch to Medicaid regardless of income
Correct answer: Report the income change to the Marketplace promptly to adjust APTC
Consumers must report income changes promptly so the Marketplace can adjust their APTC; failure to do so may result in repayment of excess credits at tax time.
CEC Health Coverage Options & Program Eligibility 4
A consumer loses job-based coverage on March 15.
How long do they have to enroll in a Marketplace plan using their SEP?