CEC - Certified Enrollment Counselor Post-Enrollment and Renewals Questions and Answers

Question 1

A consumer who is enrolled in a Marketplace plan with APTC experiences a significant, permanent increase in household income mid-year. What is their primary responsibility regarding this change?

Accepted Answer

Report the change to the Marketplace within 30 days.

Answer

Consumers are required to report changes in circumstances, such as income or household size, to the Marketplace within 30 days of the event. Reporting the change promptly allows the Marketplace to adjust the consumer's Advance Premium Tax Credit (APTC) amount. This helps the consumer avoid having to pay back a large amount of excess APTC when they file their federal income taxes.

Question 2

During the annual renewal period, a consumer who takes no action is automatically re-enrolled. However, their specific 2025 plan is being discontinued by the insurer. What is the most likely action the Marketplace will take?

Accepted Answer

Automatically enroll the consumer into a similar plan from the same insurer, or a different insurer if a similar plan is not available from the original one.

Answer

If a consumer's plan is discontinued, the Marketplace will automatically re-enroll them in a new plan that is as similar as possible to their previous one, a process often called a "crosswalk." The priority is to find a similar plan from the same insurance company first. If that's not possible, it will look for a similar plan from a different insurer. This prevents a gap in coverage for the consumer.

Question 3

A consumer who receives Advance Premium Tax Credits (APTC) has paid their premium for January, February, and March but fails to pay their April premium on time. Under the ACA, what is the required grace period an insurer must provide before terminating coverage?

Accepted Answer

90 days, during which the insurer must pay claims for the first month but may pend claims for the second and third months.

Answer

For enrollees receiving APTC who have paid at least one full month's premium, federal regulations (45 CFR § 156.270) mandate a 90-day (three-month) grace period. During the first month of the grace period, the insurer must continue to pay claims. For the second and third months, the insurer can pend claims, meaning they can hold off on paying them until the overdue premiums are paid.

Question 4

A consumer with existing Marketplace coverage wants to change their plan mid-year. Which of the following qualifying life events will most likely allow them to select a new plan from a different insurance company and potentially a different metal level?

Accepted Answer

A permanent move to a new ZIP code where their current plan is not offered.

Answer

A permanent move to a new service area where new Qualified Health Plans (QHPs) are available is a qualifying life event that necessitates selecting a new plan, allowing the consumer to choose from any available plan/insurer in the new area. While other events like a birth or marriage trigger a Special Enrollment Period (SEP), they often restrict the consumer to adding the new member to their current plan or choosing another plan at the same metal level. A change in income making someone newly CSR-eligible allows a switch to a Silver plan, but not necessarily to any other metal level or carrier.

Question 5

When assisting a consumer with their annual renewal during Open Enrollment, what is the most important best practice for a Certified Enrollment Counselor to follow?

Accepted Answer

Encourage the consumer to actively review and update their application and compare all available plan options.

Answer

The best practice is to always encourage active renewal. This ensures the consumer's household and income information is accurate, leading to the correct amount of financial assistance and avoiding tax penalties. It also provides an opportunity to compare new plans, as premiums, provider networks, and drug formularies can change each year, and the consumer's current plan may no longer be the best fit.

(CEC) Certified Enrollment Counselor Practice Test

(CEC) Certified Enrollment Counselor Practice Test

CEC - Certified Enrollment Counselor Post-Enrollment and Renewals Questions and Answers