CES Premium and Cost-Sharing 2 â Questions and Answers
Question 1: Cost-sharing reductions (CSR) improve coverage for eligible individuals by:
- Reducing monthly premiums to zero
- Lowering deductibles, copayments, and out-of-pocket maximums within a Silver plan (Correct answer)
- Eliminating the need for prior authorizations
- Providing free dental and vision coverage
Correct answer: Lowering deductibles, copayments, and out-of-pocket maximums within a Silver plan
CSRs reduce the cost-sharing features within a Silver planâincluding deductibles, copays, coinsurance, and the out-of-pocket maximumâfor eligible low-income enrollees.
Question 2: At 150% FPL, a CSR-eligible enrollee in a Silver plan would have an actuarial value of approximately:
- 70%
- 73%
- 87%
- 94% (Correct answer)
Correct answer: 94%
Enrollees with incomes between 100â150% 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?
- 50% actuarial value
- 60% actuarial value (Correct answer)
- 70% actuarial value
- 80% actuarial value
Correct answer: 60% actuarial value
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?
- 8.39%
- 9.12% (Correct answer)
- 9.83%
- 10.50%
Correct 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.
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?
- $2,000 + $4,000 = $6,000
- $2,000 + $20,000 = $22,000
- $6,000 (capped at OOP max) (Correct answer)
- $4,000 (20% of $20,000)
Correct answer: $6,000 (capped at OOP max)
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.
Question 6: Under the ACA, cost-sharing for recommended preventive services must be waived for which plan types?
- All health plans including grandfathered plans
- Non-grandfathered individual and employer group plans (Correct answer)
- Only Marketplace plans
- Only fully insured plans, not self-funded plans
Correct answer: Non-grandfathered individual and employer group plans
The ACA's preventive services mandate applies to non-grandfathered group health plans and individual health insurance coverage, including self-funded employer plans.
CES Premium and Cost-Sharing 2
Cost-sharing reductions (CSR) improve coverage for eligible individuals by: