Mixed Deck — All CES Topics Flashcards

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

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.

A Navigator is a federally funded, certified professional who may:

Answer: Provide unbiased enrollment assistance at no cost to consumers

Navigators are federally funded, trained, and certified to provide free, unbiased help with Marketplace applications, enrollment, and plan comparison without selling plans.

Which of the following must an applicant provide to apply for Marketplace coverage?

Answer: Household size and estimated annual income

Marketplace applications require household information including size, income estimate, citizenship or immigration status, and Social Security numbers to determine eligibility for plans and financial assistance.

An employer must notify the plan administrator of a qualifying COBRA event within how many days?

Answer: 30 days

Employers must notify the plan administrator within 30 days of a qualifying event such as termination of employment or reduction in hours.

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

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.

Which document is commonly required for income verification?

Answer: Pay stub

A pay stub is a widely accepted and reliable document for verifying a client's current income. It provides detailed information on gross wages, deductions, and net pay for a specific period, allowing enrollment specialists to accurately assess if the client's income falls within the program's eligibility limits. This ensures fair and accurate determination of financial need.

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.

What is the purpose of verifying residency?

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.

What should an Enrollment Specialist do if key documents are missing?

Answer: Notify the client to resubmit with full documents

If key documents are missing, the enrollment specialist cannot fully verify eligibility or process the application accurately. The correct procedure is to promptly inform the client about the missing items and instruct them to resubmit a complete application. This ensures that all necessary information is gathered for a proper assessment and prevents delays or rejections due to incomplete submissions.

Who should be contacted if enrollment policy is unclear?

Answer: A supervisor

When enrollment policy is unclear, contacting a supervisor is the correct action. Supervisors possess the authority and expertise to provide accurate clarification and guidance, ensuring that policies are applied correctly and consistently, which is vital for compliance and client protection.

Under the ACA, which metal tier plan covers approximately 80% of expected healthcare costs on average?

Answer: Gold

Gold plans have an actuarial value of about 80%, meaning the plan pays 80% of covered costs on average, leaving the member to pay 20%.

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

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.

What is the income threshold at or below which an individual would typically be directed to Medicaid instead of Marketplace subsidies?

Answer: 138% FPL in Medicaid expansion states

In states that expanded Medicaid, individuals with income at or below 138% FPL are eligible for Medicaid and not eligible for Marketplace premium tax credits.

Which program allows states to use eligibility findings from other programs (like SNAP or TANF) to fast-track Medicaid/CHIP enrollment?

Answer: Express Lane Eligibility (ELE)

Express Lane Eligibility lets states use findings from other benefit programs to streamline and accelerate Medicaid and CHIP enrollment determinations.

What is a Health Reimbursement Arrangement (HRA)?

Answer: An employer-funded account that reimburses qualified medical expenses

An HRA is an employer-funded account that reimburses employees for qualified out-of-pocket medical expenses and is not portable if the employee leaves.

Which plan type has NO deductible but restricts members entirely to in-network providers?

Answer: HMO

Many HMO plans have no deductible and use copayments for services, but members must stay strictly within the HMO network for covered care.

For employer-sponsored coverage to be considered 'affordable' under the ACA in 2025, the employee's share of self-only premium must not exceed what percentage of household income?

Answer: 9.12%

For plan years beginning in 2025, employer coverage is considered affordable if the employee's self-only premium does not exceed 9.02% of household income.

What does PPO stand for in health insurance?

Answer: Preferred Provider Organization

PPO stands for Preferred Provider Organization, offering flexibility to see in-network or out-of-network providers without referrals.

Medicaid is jointly funded by which two entities?

Answer: Federal government and state governments

Medicaid is jointly financed by the federal government and each state, with the federal share determined by the FMAP formula.

What is the key element of excellent customer service?

Answer: Effective communication

Effective communication is the cornerstone of excellent customer service because it ensures clarity, understanding, and builds trust between the specialist and the client. It involves actively listening, providing clear and concise information, and addressing concerns promptly and respectfully to create a positive experience.