CES Marketplace and Exchange Navigation 2 — Questions and Answers
Question 1: What is the income threshold at or below which an individual would typically be directed to Medicaid instead of Marketplace subsidies?
- 100% FPL in all states
- 138% FPL in Medicaid expansion states (Correct answer)
- 200% FPL regardless of state
- 250% FPL in all states
Correct 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.
Question 2: Which individuals are NOT eligible to purchase coverage through the ACA Marketplace?
- Self-employed individuals
- Part-time workers without employer coverage
- Undocumented immigrants (Correct answer)
- People over age 65 not enrolled in Medicare
Correct answer: Undocumented immigrants
Undocumented immigrants are not eligible to purchase Marketplace coverage or receive financial assistance, though they may qualify for emergency Medicaid.
Question 3: What is a 'qualified health plan' (QHP) in the context of the ACA Marketplace?
- Any health plan approved by a state insurance commissioner
- A plan certified by the Marketplace as meeting ACA requirements and offering essential health benefits (Correct answer)
- A plan that covers only preventive and primary care services
- An employer-sponsored plan that meets minimum value standards
Correct answer: A plan certified by the Marketplace as meeting ACA requirements and offering essential health benefits
A QHP is a health insurance plan certified by the Marketplace, meeting ACA standards including coverage of essential health benefits, minimum actuarial value, and other requirements.
Question 4: When comparing Marketplace plans, the Summary of Benefits and Coverage (SBC) is a standardized document that:
- Provides a detailed list of all covered medications
- Gives a plain-language summary of plan benefits and costs to facilitate comparison (Correct answer)
- Lists all in-network providers
- 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 5: If an applicant's income changes significantly during the plan year, the recommended action is to:
- Wait until the next open enrollment to make changes
- Report the income change to the Marketplace promptly to adjust APTC (Correct answer)
- Immediately cancel the plan and re-enroll
- Contact the insurer directly to adjust premium payments
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 6: The Basic Health Program (BHP) is an optional state program that serves individuals with incomes between:
- 100–138% FPL
- 138–200% FPL
- 100–200% FPL (Correct answer)
- 200–300% FPL
Correct answer: 100–200% FPL
The BHP allows states to offer more stable, lower-cost coverage to residents with incomes between 100–200% FPL who would otherwise be in the Marketplace.
CES Marketplace and Exchange Navigation 2
What is the income threshold at or below which an individual would typically be directed to Medicaid instead of Marketplace subsidies?