Certified Enrollment Specialist (CES) — Questions and Answers

Question 1: Which action shows active listening?

Giving handouts
Asking follow-up questions (Correct answer)
Interrupting for clarity
Typing while speaking

Correct answer: Asking follow-up questions

Asking follow-up questions is a clear indicator of active listening, as it demonstrates engagement, critical thinking, and a genuine desire to fully understand the client's needs or concerns. This practice helps clarify details, ensures accuracy in information gathering, and makes the client feel heard and valued.

Question 2: A catastrophic health plan is available primarily to which group?

Medicare-eligible individuals
Small business employees only
Adults under age 30 or those with hardship exemptions (Correct answer)
All ACA Marketplace enrollees

Correct answer: Adults under age 30 or those with hardship exemptions

Catastrophic plans are available to people under 30 or those who qualify for a hardship or affordability exemption, featuring low premiums and very high deductibles.

Question 3: When reconciling APTC at tax time, what happens if an enrollee's actual income was higher than estimated?

They must repay some or all excess advance credits received (Correct answer)
There is no impact if income changed by less than 25%
The IRS automatically adjusts the amount with no repayment
They receive a larger refund

Correct answer: They must repay some or all excess advance credits received

If actual annual income exceeds the estimate, the enrollee must repay excess APTC when filing taxes, subject to annual repayment caps based on income.

Question 4: What is the purpose of verifying residency?

To record vaccination dates
To ensure the applicant lives within the service area (Correct answer)
To validate education history
To confirm age

Correct answer: To ensure the applicant lives within the service area

Verifying residency is crucial for many programs to confirm that an applicant resides within the geographical boundaries of the service area. This ensures that resources are allocated to the intended population and that the program can legally and logistically provide services to the eligible individuals. Proof of residency prevents ineligible individuals from accessing benefits.

Question 5: At 150% FPL, a CSR-eligible enrollee in a Silver plan would have an actuarial value of approximately:

70%
73%
94% (Correct answer)
87%

Correct answer: 94%

Enrollees with incomes between 100–150% FPL in a CSR Silver plan receive the highest level of CSR, boosting the actuarial value to approximately 94%.

Question 6: Which event does NOT qualify as a COBRA-triggering event for a covered dependent child?

Employee's Medicare entitlement
Dependent reaching age 26 (Correct answer)
Ceasing to be a dependent under plan terms
Employee's reduction in hours

Correct answer: Dependent reaching age 26

While aging off a parent's plan at 26 is a qualifying event for COBRA, aging off is specifically listed as a qualifying event for dependent children who lose coverage.

Question 7: What is the 'family glitch' that was fixed by IRS rules effective 2023?

Dependents could not be added mid-year to employer plans
Affordability of employer coverage was measured only against the employee's premium, not the family cost (Correct answer)
Children over 18 could not remain on parents' plans
Spouses were excluded from premium tax credit calculations

Correct answer: Affordability of employer coverage was measured only against the employee's premium, not the family cost

The family glitch referred to the rule that employer coverage was deemed 'affordable' based only on the employee-only premium, leaving dependent family members ineligible for Marketplace subsidies.

Question 8: If an applicant's income changes significantly during the plan year, the recommended action is to:

Contact the insurer directly to adjust premium payments
Report the income change to the Marketplace promptly to adjust APTC (Correct answer)
Wait until the next open enrollment to make changes
Immediately cancel the plan and re-enroll

Correct answer: Report the income change to the Marketplace promptly to adjust APTC

Reporting income changes to the Marketplace promptly allows APTC to be adjusted in real time, preventing a large tax repayment at year-end.

Question 9: A dependent child who ages off a parent's employer plan at age 26 has how long to enroll in a Marketplace plan?

90 days from the date coverage ends
30 days from the date coverage ends
Until the next open enrollment period only
60 days from the date coverage ends (Correct answer)

Correct answer: 60 days from the date coverage ends

Aging off a parent's plan at 26 is a qualifying event that triggers a 60-day SEP for Marketplace enrollment starting from the date coverage ends.

Question 10: What is one of the responsibilities under FERPA?

Provide access to vendors
Delete records quickly
Protect student educational information (Correct answer)
Share files with parents

Correct answer: Protect student educational information

FERPA (Family Educational Rights and Privacy Act) is a federal law that protects the privacy of student education records. Under FERPA, educational institutions must ensure the confidentiality of student information and grant parents and eligible students certain rights regarding access to and control over these records.

Question 11: An employee who is newly eligible for employer-sponsored coverage has how many days to enroll?

15 days
60 days
90 days
30 days (Correct answer)

Correct answer: 30 days

Under HIPAA portability rules, newly eligible employees have at least 30 days to enroll in an employer-sponsored plan when they first become eligible.

Question 12: What should you do if you suspect a compliance violation?

Inform a supervisor or compliance officer (Correct answer)
Post to social media
Ignore the situation
Confront the client

Correct answer: Inform a supervisor or compliance officer

If you suspect a compliance violation, the correct protocol is to immediately inform a supervisor or compliance officer. This ensures that the issue can be properly investigated and addressed by the appropriate personnel, mitigating potential risks and ensuring adherence to legal and ethical standards.

Question 13: When an enrollment assister helps a consumer, which action is outside the scope of a Navigator's role?

Explaining the difference between plan metal tiers
Recommending a specific plan and accepting compensation from the insurer (Correct answer)
Explaining eligibility for premium tax credits
Helping complete a Marketplace application

Correct answer: Recommending a specific plan and accepting compensation from the insurer

Navigators are prohibited from accepting compensation from insurers and are not permitted to recommend specific plans; they must remain impartial and consumer-focused.

Question 14: In a family health plan, an embedded deductible means:

Dependents share a single copayment pool
Each family member has their own individual deductible within the family deductible (Correct answer)
The deductible is automatically waived for children
The entire family must meet one combined deductible before anyone has coverage

Correct answer: Each family member has their own individual deductible within the family deductible

An embedded deductible means each family member has an individual deductible limit so that one person's costs can trigger coverage before the family aggregate is met.

Question 15: An individual who loses employer-sponsored coverage due to job loss may use a Marketplace SEP. The SEP is triggered:

Only after COBRA coverage expires
When employer coverage is lost regardless of COBRA eligibility (Correct answer)
Only if COBRA is declined within 60 days
Six months before the anticipated job loss

Correct answer: When employer coverage is lost regardless of COBRA eligibility

Loss of employer coverage—whether or not the person elects COBRA—is a qualifying event that triggers a 60-day Marketplace SEP immediately.

Question 16: An EPO plan differs from a PPO primarily because an EPO:

Requires a PCP referral
Covers out-of-network care at higher costs
Has no deductible
Does not cover out-of-network care except emergencies (Correct answer)

Correct answer: Does not cover out-of-network care except emergencies

An EPO (Exclusive Provider Organization) restricts coverage to in-network providers, with no out-of-network benefits except for true emergencies.

Question 17: What is the Federal Medical Assistance Percentage (FMAP) used to determine?

The share of Medicaid costs the federal government reimburses to each state (Correct answer)
The share of CHIP costs paid by beneficiaries as premiums
The maximum income limit for Medicaid in each state
The percentage of beneficiaries enrolled in managed care

Correct answer: The share of Medicaid costs the federal government reimburses to each state

FMAP is the formula-driven percentage of state Medicaid expenditures that the federal government matches, varying by state based on per capita income.

Question 18: A broker or agent helping with Marketplace enrollment must be:

Employed by a nonprofit organization
State-licensed and registered with the Marketplace (Correct answer)
Federally certified as a CAC
Approved by the state Medicaid office

Correct answer: State-licensed and registered with the Marketplace

Agents and brokers must hold a state insurance license and register with the federal or state Marketplace to assist clients with Marketplace plan enrollment.

Question 19: What is a common tool for monitoring compliance?

Flyers
Vacation logs
Internal audits (Correct answer)
Holiday calendar

Correct answer: Internal audits

Internal audits are a common and effective tool for monitoring compliance within an organization. They involve a systematic, independent review of operations and records to ensure adherence to policies, procedures, and external regulations, identifying areas for improvement before external issues arise.

Question 20: When is the annual Open Enrollment Period (OEP) for ACA Marketplace individual and family plans?

October 1 – December 15
September 15 – November 30
December 1 – February 28
November 1 – January 15 (Correct answer)

Correct answer: November 1 – January 15

The ACA Marketplace Open Enrollment Period runs November 1 through January 15, with coverage starting January 1 for enrollments completed by December 15.

Question 21: A formulary in a health insurance plan refers to:

The schedule of copayments
The network of approved hospitals
The plan's deductible structure
The list of covered prescription drugs (Correct answer)

Correct answer: The list of covered prescription drugs

A formulary is the plan's list of covered prescription drugs, typically organized into tiers with different cost-sharing amounts.

Question 22: Which Medicaid waiver authority allows states to test innovative service delivery and financing models that deviate from standard Medicaid rules?

Section 1915(b) Managed Care Waiver
Section 1115 Demonstration Waiver (Correct answer)
Section 1905 Mandatory Services Waiver
Section 1902 State Plan Amendment

Correct answer: Section 1115 Demonstration Waiver

Section 1115 Research and Demonstration Waivers give states broad flexibility to pilot approaches that deviate from standard Medicaid requirements, subject to HHS approval.

Question 23: American Indians and Alaska Natives who are members of a federally recognized tribe have a special Marketplace enrollment right that allows them to enroll:

Only during the annual Open Enrollment Period
Only when losing Indian Health Service coverage
Any month of the year (Correct answer)
Once per year only

Correct answer: Any month of the year

Federally recognized American Indians and Alaska Natives can enroll in or change Marketplace plans once per month throughout the year.

Question 24: What documentation is typically required when claiming a SEP based on loss of prior coverage?

Proof of income only
A termination letter or letter from prior insurer confirming coverage end date (Correct answer)
A signed affidavit with no additional documentation
A letter from a doctor confirming medical need

Correct answer: A termination letter or letter from prior insurer confirming coverage end date

Applicants claiming a loss-of-coverage SEP are typically required to submit a termination-of-coverage letter from their prior insurer or employer.

Question 25: What is the Children's Health Insurance Program (CHIP) primarily designed to cover?

Children of federal employees only
Children with disabilities who qualify for SSI
All children under age 18 regardless of income
Children in families with incomes too high for Medicaid but who cannot afford private insurance (Correct answer)

Correct answer: Children in families with incomes too high for Medicaid but who cannot afford private insurance

CHIP targets children in families whose incomes are above the Medicaid limit but who still cannot afford private health insurance coverage.

Question 26: The SHOP (Small Business Health Options Program) Marketplace is designed for:

Large employers seeking alternative coverage options
Small employers with generally 1–50 employees (Correct answer)
Nonprofit organizations with any number of employees
Self-employed individuals without employees

Correct answer: Small employers with generally 1–50 employees

SHOP is the ACA Marketplace for small businesses, generally those with 1–50 full-time equivalent employees, allowing them to offer employees a choice of QHPs.

Question 27: What is the primary role of the Health Insurance Marketplace created by the ACA?

To regulate insurance premiums directly
To provide free health insurance to all Americans
To replace Medicaid and Medicare with private coverage
To offer a platform where individuals can compare and purchase qualified health plans (Correct answer)

Correct answer: To offer a platform where individuals can compare and purchase qualified health plans

The Health Insurance Marketplace is a structured platform where consumers can shop, compare, and enroll in ACA-compliant qualified health plans and apply for financial assistance.

Question 28: When comparing Marketplace plans, the Summary of Benefits and Coverage (SBC) is a standardized document that:

Lists all in-network providers
Provides a detailed list of all covered medications
Gives a plain-language summary of plan benefits and costs to facilitate comparison (Correct answer)
Certifies the plan as a QHP

Correct answer: Gives a plain-language summary of plan benefits and costs to facilitate comparison

The SBC is a standardized, easy-to-read four-page document required by the ACA that summarizes a plan's benefits, cost-sharing, and coverage limits for comparison shopping.

Question 29: If an enrollee chooses a plan other than the benchmark Silver plan, the APTC amount:

Is reduced by 10% for non-Silver plans
Increases to match the chosen plan's premium
Is only applicable to Silver plans
Stays the same regardless of which plan is selected (Correct answer)

Correct answer: Stays the same regardless of which plan is selected

The APTC amount is fixed based on the benchmark Silver plan and applied to whichever plan the enrollee selects, covering more of a less expensive plan or less of a more expensive one.

Question 30: When an employer changes the annual open enrollment period, employees who didn't previously elect coverage may:

Enroll only if they qualify for a SEP
Wait until the following plan year
Enroll at any time during the year
Enroll during the new enrollment period even without a life event (Correct answer)

Correct answer: Enroll during the new enrollment period even without a life event

Employer plan changes that create a new or extended open enrollment window give all employees the opportunity to elect coverage during that new window.

Question 31: For 2025, the ACA out-of-pocket maximum for an individual in a non-grandfathered plan is approximately:

$7,000
$5,000
$9,200 (Correct answer)
$12,000

Correct answer: $9,200

The ACA sets annual out-of-pocket maximum limits that are adjusted each year; for 2025, the individual limit is $9,200 and family limit is $18,400.

Certified Enrollment Specialist (CES)

The CES designation validates a professional's knowledge of employee benefit enrollment, including voluntary benefit plans, COBRA continuation coverage, ACA marketplace navigation, special enrollment periods, and premium and cost-sharing structures.

Questions

90 min

Time Limit

70%

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