CEC Health Coverage Options & Program Eligibility 5 — Questions and Answers
Question 1: Which of the following coverage scenarios triggers a 'minimum essential coverage' standard under the ACA?
- Short-term health plans lasting 3 months
- Marketplace Qualified Health Plans (Correct answer)
- Fixed indemnity insurance only
- Discount health cards
Correct answer: Marketplace Qualified Health Plans
Marketplace Qualified Health Plans meet the ACA's minimum essential coverage (MEC) standard; short-term plans and discount cards generally do not.
Question 2: An applicant is a U.S. citizen living abroad permanently. Are they eligible for Marketplace coverage?
- Yes, if they pay U.S. taxes
- No, they must reside in the United States to enroll (Correct answer)
- Yes, if their income is below 400% FPL
- Only if they are over 65
Correct answer: No, they must reside in the United States to enroll
Marketplace eligibility requires residing in the United States; U.S. citizens living abroad are not eligible to enroll in Marketplace plans.
Question 3: What is the primary difference between an HMO and an EPO health plan?
- EPOs require a primary care physician referral; HMOs do not
- HMOs require referrals for specialists; EPOs generally do not but restrict to network (Correct answer)
- EPOs cover out-of-network services; HMOs do not
- HMOs cover dental; EPOs do not
Correct answer: HMOs require referrals for specialists; EPOs generally do not but restrict to network
HMOs typically require PCP referrals for specialist visits, while EPOs allow direct specialist access but still restrict coverage to in-network providers.
Question 4: A person is incarcerated awaiting trial (pre-trial detention). Are they eligible for Marketplace coverage?
- No, all incarcerated persons are excluded
- Yes, people in pre-trial detention may be eligible (Correct answer)
- Only if they are on Medicaid
- Only if the facility does not provide care
Correct answer: Yes, people in pre-trial detention may be eligible
The ACA excludes individuals 'incarcerated' after conviction from Marketplace plans, but individuals in pre-trial detention are generally considered eligible.
Question 5: Which term describes the amount a consumer must pay out-of-pocket before their insurance begins to cover most services?
- Premium
- Copayment
- Deductible (Correct answer)
- Out-of-pocket maximum
Correct answer: Deductible
The deductible is the amount a consumer pays before the insurer begins sharing costs; once met, cost-sharing (copays/coinsurance) applies for most services.
Question 6: Under the ACA's employer mandate, which employers are required to offer minimum essential coverage to full-time employees?
- Employers with 10 or more full-time employees
- Employers with 25 or more full-time employees
- Employers with 50 or more full-time equivalent employees (Correct answer)
- All employers regardless of size
Correct answer: Employers with 50 or more full-time equivalent employees
Applicable Large Employers (ALEs) with 50 or more full-time equivalent employees must offer MEC to full-time employees or face potential employer shared responsibility payments.
Question 7: Which of the following populations qualifies for Medicare based on age alone?
- Adults 62 and older
- Adults 64 and older
- Adults 65 and older (Correct answer)
- Adults 67 and older
Correct answer: Adults 65 and older
Medicare eligibility based on age begins at 65 for U.S. citizens and qualifying permanent residents who have worked and paid Medicare taxes for at least 10 years.
CEC Health Coverage Options & Program Eligibility 5
Which of the following coverage scenarios triggers a 'minimum essential coverage' standard under the ACA?