Premium and Cost-Sharing Flashcards
6 cards from real CES practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Premium and Cost-Sharing flashcards as text
When reconciling APTC at tax time, what happens if an enrollee's actual income was higher than estimated?
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.
Which of the following is NOT included in the ACA definition of a 'cost-sharing' reduction?
Answer: Monthly premium
Cost-sharing refers to the enrollee's share of covered service costs including deductibles, copayments, and coinsurance; monthly premiums are a separate category.
For self-funded (self-insured) employer plans, which ACA cost-sharing provisions still apply?
Answer: Out-of-pocket maximums and preventive care no-cost-sharing apply
Non-grandfathered self-funded plans must comply with ACA requirements including the out-of-pocket maximum limit and no cost-sharing for preventive services.
The 'cliff' in the ACA subsidy structure historically referred to the situation where income just above 400% FPL resulted in:
Answer: Complete loss of all premium tax credits
Prior to 2021, the ACA subsidy cliff meant that household income just above 400% FPL caused complete loss of premium tax credits, sometimes resulting in thousands of dollars more in premiums.
Embedded versus aggregate deductibles primarily affect families because with an aggregate deductible:
Answer: The entire family deductible must be met collectively before any one member receives coverage beyond cost-sharing
An aggregate deductible means the family must collectively reach the full family deductible amount before any member receives the plan's coverage for non-preventive services.
A plan's 'allowed amount' (also called 'negotiated rate') is important for cost-sharing because:
Answer: Coinsurance is calculated as a percentage of the allowed amount, not the billed charge
Cost-sharing amounts like coinsurance are calculated on the allowed amount—the rate negotiated between the plan and provider—not the provider's full billed charge.