CACs Affordable Care Act Basics 2 — Questions and Answers
Question 1: Under the ACA, what is the maximum out-of-pocket limit for an individual in a Marketplace plan for plan year 2024?
- $5,000
- $7,000
- $9,450 (Correct answer)
- $12,000
Correct answer: $9,450
For 2024, the ACA out-of-pocket maximum for individual coverage is $9,450; once reached, the plan pays 100% of covered in-network costs.
Question 2: Which federal agency administers the Health Insurance Marketplace (Healthcare.gov)?
- Social Security Administration
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- Department of Labor
- Office of Personnel Management
Correct answer: Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS), within HHS, operates the federally facilitated Marketplace at Healthcare.gov.
Question 3: A consumer's ACA plan covers an emergency visit at an out-of-network hospital. Under the ACA's essential health benefit rules, which statement is TRUE?
- Emergency services can be denied for out-of-network use
- Plans must cover emergency services without prior authorization (Correct answer)
- Cost-sharing for emergencies can be unlimited
- Emergency services are only covered at in-network facilities
Correct answer: Plans must cover emergency services without prior authorization
The ACA requires all non-grandfathered plans to cover emergency services without prior authorization, even from out-of-network providers.
Question 4: What does 'creditable coverage' mean in the context of the ACA and Special Enrollment Periods?
- Coverage that is free of charge
- Prior health insurance that counts toward satisfying waiting periods (Correct answer)
- Coverage that includes dental and vision
- A plan with a credit score requirement
Correct answer: Prior health insurance that counts toward satisfying waiting periods
Creditable coverage refers to prior qualifying health coverage that may be used to satisfy enrollment requirements and avoid gaps triggering penalties.
Question 5: Under the ACA, which of the following is NOT considered a minimum essential coverage (MEC) type?
- Medicare Part A
- Medicaid
- A short-term limited-duration health plan (Correct answer)
- CHIP
Correct answer: A short-term limited-duration health plan
Short-term limited-duration plans are explicitly excluded from the definition of minimum essential coverage under the ACA.
Question 6: What is the income threshold (as a percentage of the Federal Poverty Level) above which individuals are NOT eligible for Medicaid under standard ACA expansion rules for adults?
- 100% FPL
- 133% FPL (effectively 138% with 5% disregard) (Correct answer)
- 150% FPL
- 200% FPL
Correct answer: 133% FPL (effectively 138% with 5% disregard)
ACA Medicaid expansion covers adults up to 133% FPL; with the standard 5% income disregard, the effective threshold is 138% FPL.
Question 7: A consumer wants to know if a specific drug is covered before enrolling in a Marketplace plan. Which plan document should the CAC direct them to review?
- Summary of Benefits and Coverage (SBC)
- Plan Formulary (Correct answer)
- Certificate of Coverage
- Explanation of Benefits (EOB)
Correct answer: Plan Formulary
The plan formulary lists all covered prescription drugs and their tier-based cost-sharing, making it the correct resource for checking drug coverage.
CACs Affordable Care Act Basics 2
Under the ACA, what is the maximum out-of-pocket limit for an individual in a Marketplace plan for plan year 2024?