CES Premium and Cost-Sharing 2

Question 1

Cost-sharing reductions (CSR) improve coverage for eligible individuals by:

Accepted Answer

Lowering deductibles, copayments, and out-of-pocket maximums within a Silver plan

Answer

CSRs reduce the cost-sharing features within a Silver plan—including deductibles, copays, coinsurance, and the out-of-pocket maximum—for eligible low-income enrollees.

Question 2

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

Accepted Answer

94%

Answer

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 3

What is the minimum value standard for employer-sponsored health insurance under the ACA?

Accepted Answer

60% actuarial value

Answer

An employer-sponsored plan meets 'minimum value' if it covers at least 60% of the total allowed cost of benefits, equivalent to a Bronze plan's actuarial value.

Question 4

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?

Accepted Answer

9.12%

Answer

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.

Question 5

A member has a $2,000 deductible and 20% coinsurance with a $6,000 out-of-pocket maximum. After paying the deductible, they incur $20,000 in additional covered charges. What is their total out-of-pocket cost?

Accepted Answer

$6,000 (capped at OOP max)

Answer

Once the out-of-pocket maximum of $6,000 is reached (deductible + coinsurance), the plan covers 100% of additional costs, so total cost is capped at $6,000.

CES - Certified Enrollment Specialist Practice Test

CES - Certified Enrollment Specialist Practice Test

CES Premium and Cost-Sharing 2