Affordable Care Act (ACA) Marketplace Certification (FFM) — Questions and Answers

Question 1: Which population benefits most from Medicaid expansion under the ACA?

Only self-employed individuals
Low-income adults under age 65 (Correct answer)
High-income earners
Only individuals over age 65

Correct answer: Low-income adults under age 65

Medicaid expansion under the ACA extends coverage to low-income adults who previously did not qualify for Medicaid.

Question 2: Which tool or methodology is most appropriate for analyzing compliance & consumer protections outcomes?

Maintaining strict formality that inhibits collaboration
Adjusting boundaries based on individual situations without guidelines
Prioritizing relationships over professional standards
Maintaining professional boundaries while building collaborative relationships (Correct answer)

Correct answer: Maintaining professional boundaries while building collaborative relationships

Maintaining professional boundaries while building collaborative relationships is the correct approach because effective compliance & consumer protections in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 3: Under the ACA, which federal agency oversees Medicaid program administration and expansion implementation?

The Centers for Medicare & Medicaid Services (CMS) (Correct answer)
The Department of Health and Human Services Office of Civil Rights
The Department of Labor (DOL)
The Internal Revenue Service (IRS)

Correct answer: The Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS) within HHS administers Medicaid at the federal level and oversees state implementation of ACA expansion.

Question 4: What is a Section 1115 waiver in the context of ACA Medicaid programs?

A waiver exempting states from CHIP maintenance of effort requirements
An automatic waiver granted to all states that expand Medicaid
A waiver allowing states to reduce benefits below ACA minimums permanently
A demonstration waiver allowing states to test innovative Medicaid delivery or financing approaches with federal approval (Correct answer)

Correct answer: A demonstration waiver allowing states to test innovative Medicaid delivery or financing approaches with federal approval

Section 1115 waivers allow states to test and evaluate new Medicaid approaches—including work requirements, alternative benefit designs, and delivery reforms—subject to federal budget neutrality and CMS approval.

Question 5: What is a 'grandfathered' health plan under the ACA?

A plan covering only Medicare-eligible individuals
A plan offered exclusively to employees with 10+ years of service
A plan that existed before the ACA was enacted and has not made significant benefit or cost changes (Correct answer)
A plan providing coverage across multiple states

Correct answer: A plan that existed before the ACA was enacted and has not made significant benefit or cost changes

Grandfathered plans existed before March 23, 2010 (the ACA's enactment date), and are exempt from certain ACA requirements as long as they haven't made significant changes to coverage or cost-sharing.

Question 6: Under the ACA, which entity conducts external review of denied health insurance claims when an internal appeal is unsuccessful?

An independent review organization (IRO) (Correct answer)
The enrollee's employer HR department
The state insurance commissioner
A federal administrative law judge

Correct answer: An independent review organization (IRO)

The ACA mandates access to an IRO, a neutral third party, to conduct external review of adverse coverage decisions after internal appeals are exhausted.

Question 7: Which document must QHP issuers provide to enrollees that summarizes the key features of their health plan in plain language?

Summary of Benefits and Coverage (SBC) (Correct answer)
Evidence of Coverage (EOC)
Explanation of Benefits (EOB)
Certificate of Insurance (COI)

Correct answer: Summary of Benefits and Coverage (SBC)

The ACA requires issuers to provide a standardized SBC that clearly explains coverage, cost-sharing, and coverage limitations in plain language.

Question 8: Which plan type typically offers the MOST provider flexibility but usually has higher monthly premiums?

EPO
HMO
PPO (Correct answer)
HDHP

Correct answer: PPO

PPOs allow members to see any provider, including out-of-network providers, without a referral, offering the most flexibility at typically higher premium costs.

Question 9: Which of the following is NOT one of the 10 Essential Health Benefits under the ACA?

Mental health and substance use disorder services
Emergency services
Maternity and newborn care
Adult dental care (Correct answer)

Correct answer: Adult dental care

Adult dental care is not one of the 10 EHBs; pediatric oral care is required, but comprehensive adult dental coverage is not mandated.

Question 10: Under the ACA, which provision requires Medicaid programs to cover tobacco cessation counseling and medications for pregnant women at no cost sharing?

Section 2713
Section 1302
Section 2502
Section 4107 (Correct answer)

Correct answer: Section 4107

ACA Section 4107 requires Medicaid programs to cover tobacco cessation counseling and FDA-approved medications for pregnant women without cost sharing.

Question 11: Under the ACA, what is the Children's Health Insurance Program (CHIP) primarily designed to cover?

Uninsured children in families with incomes too high for Medicaid but who cannot afford private coverage (Correct answer)
Children of federal employees not covered by employer plans
Foster children in state custody regardless of income
Children in families earning below 100% FPL who qualify for Medicaid

Correct answer: Uninsured children in families with incomes too high for Medicaid but who cannot afford private coverage

CHIP covers uninsured children in low-to-moderate income families that earn too much to qualify for Medicaid but cannot afford private insurance.

Question 12: What ACA provision requires states to maintain Medicaid and CHIP eligibility for children at levels in effect on the date of enactment?

The state plan amendment process
The benchmark benefit requirement
The minimum essential coverage mandate
The maintenance of effort (MOE) requirement (Correct answer)

Correct answer: The maintenance of effort (MOE) requirement

The ACA's maintenance of effort (MOE) requirement prohibits states from restricting Medicaid and CHIP eligibility for children below levels in place on March 23, 2010.

Question 13: What is a catastrophic health plan under the ACA?

A plan with very high deductibles available to those under 30 or with qualifying hardship exemptions (Correct answer)
A plan that only covers emergency room visits
A plan with very low deductibles and high premiums
A plan covering all 10 EHBs with no cost-sharing requirements

Correct answer: A plan with very high deductibles available to those under 30 or with qualifying hardship exemptions

Catastrophic plans feature very high deductibles and are only available to individuals under age 30 or those with a qualifying hardship or affordability exemption.

Question 14: The ACA's risk adjustment model uses Hierarchical Condition Categories (HCCs) primarily to:

Predict relative medical costs based on enrollee diagnoses (Correct answer)
Set premium rates for individual enrollees
Determine Medicaid eligibility
Calculate subsidy amounts for marketplace plans

Correct answer: Predict relative medical costs based on enrollee diagnoses

HCCs group diagnosis codes to estimate each enrollee's expected medical costs, which feeds into the plan's overall risk score.

Question 15: What does the ACA require insurers to include in all health plans?

Essential health benefits such as preventive care and maternity services (Correct answer)
Only emergency room services
Only hospital visits and prescription drugs
Coverage is determined by each insurer with no regulations

Correct answer: Essential health benefits such as preventive care and maternity services

The ACA mandates that all health plans cover essential health benefits, including preventive care, maternity services, and mental health treatment.

Question 16: How does the ACA ensure consumer access to accurate health plan information?

By allowing insurers to provide vague coverage details
By requiring insurers to offer a standardized Summary of Benefits and Coverage (Correct answer)
By allowing insurers to change policies without notification
By limiting the information insurers must disclose

Correct answer: By requiring insurers to offer a standardized Summary of Benefits and Coverage

The ACA requires insurers to provide a Summary of Benefits and Coverage (SBC) that outlines plan details in a clear and understandable format.

Question 17: Which plan type is the basis for calculating Premium Tax Credits in the ACA marketplace?

Bronze plan
Silver plan (Correct answer)
Gold plan
Platinum plan

Correct answer: Silver plan

Premium Tax Credits are calculated based on the cost of the second-lowest-cost Silver plan (SLCSP) available in the applicant's geographic area.

Question 18: What is the most common mistake professionals make when implementing policies & regulations strategies?

Transferring all risk to external partners through contracts
Creating contingency plans for every possible scenario regardless of probability
Responding to problems only after they occur
Developing contingency plans for high-probability risk scenarios (Correct answer)

Correct answer: Developing contingency plans for high-probability risk scenarios

Developing contingency plans for high-probability risk scenarios is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 19: Under ACA quality compliance standards, what is the primary purpose of HEDIS (Healthcare Effectiveness Data and Information Set)?

To standardize prescription drug formularies across plans
To certify individual physicians for participation in QHPs
To set minimum staffing ratios for hospitals
To measure health plan performance on dimensions of care and service (Correct answer)

Correct answer: To measure health plan performance on dimensions of care and service

HEDIS is a widely used tool that allows consumers to compare health plan performance across standardized quality and service measures.

Question 20: Under the ACA Medicaid expansion, which income verification method is primarily used during the application process?

State agency interviews with case workers
Employer verification letters only
Real-time electronic data matches using federal data sources like SSA and IRS (Correct answer)
Paper tax returns submitted by mail

Correct answer: Real-time electronic data matches using federal data sources like SSA and IRS

The ACA requires states to use real-time electronic data matches with federal sources such as the SSA and IRS to verify income during the Medicaid application process.

Question 21: Which tool or methodology is most appropriate for analyzing policies & regulations outcomes?

Adjusting boundaries based on individual situations without guidelines
Maintaining strict formality that inhibits collaboration
Maintaining professional boundaries while building collaborative relationships (Correct answer)
Prioritizing relationships over professional standards

Correct answer: Maintaining professional boundaries while building collaborative relationships

Maintaining professional boundaries while building collaborative relationships is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 22: What best describes an Exclusive Provider Organization (EPO)?

A plan that only covers in-network care except in emergencies (Correct answer)
A plan that covers out-of-network care at any cost level
A plan requiring referrals for all specialist visits
A plan exclusively offered to large employer groups

Correct answer: A plan that only covers in-network care except in emergencies

EPOs restrict coverage to in-network providers except for emergency care, but unlike HMOs, they typically do not require specialist referrals.

Question 23: What is the actuarial value of a Silver plan in the ACA marketplace?

90%
60%
70% (Correct answer)
80%

Correct answer: 70%

Silver plans have an actuarial value of 70%, covering 70% of expected covered healthcare costs on average.

Question 24: How does the ACA improve preventive care?

By limiting access to wellness programs
By eliminating preventive services from coverage
By requiring plans to cover preventive services at no cost (Correct answer)
By increasing out-of-pocket costs for preventive care

Correct answer: By requiring plans to cover preventive services at no cost

The ACA mandates that health insurance plans cover preventive services without cost-sharing, making preventive care more accessible.

Question 25: Which population group was newly eligible for Medicaid under ACA expansion that was not previously covered in most states?

Seniors eligible for Medicare
Children under age 19
Low-income adults without dependent children (Correct answer)
Pregnant women above 138% FPL

Correct answer: Low-income adults without dependent children

Before ACA expansion, most states did not cover childless adults regardless of income; the ACA created a new eligibility category for low-income adults without dependent children.

Question 26: What happens if a person's income changes after receiving an ACA subsidy?

Subsidies can never be repaid
The individual loses coverage immediately
Subsidies may be adjusted based on income changes (Correct answer)
The subsidy amount remains unchanged

Correct answer: Subsidies may be adjusted based on income changes

If income increases or decreases, the subsidy amount may need to be adjusted, and excess subsidies may need to be repaid when filing taxes.

Question 27: Which ACA rule prevents insurers from using 'death spirals' — where only sick people enroll, causing premiums to rise, driving healthy people out — by stabilizing the risk pool?

Medical Loss Ratio floors
Out-of-pocket maximum limits
Pre-existing condition underwriting
Community rating with age bands limited to 3:1 (Correct answer)

Correct answer: Community rating with age bands limited to 3:1

Community rating prevents insurers from charging sick enrollees more, while age bands (3:1 ratio) limit but don't eliminate age-based pricing variation.

Question 28: What is the primary objective of professional ethics & standards within the ACA professional framework?

Making assumptions based on previous experience alone
Relying on informal observations and anecdotal reports
Copying approaches used by competitors without adaptation
Analyzing data systematically using validated assessment tools (Correct answer)

Correct answer: Analyzing data systematically using validated assessment tools

Analyzing data systematically using validated assessment tools is the correct approach because effective professional ethics & standards in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 29: Which metal tier has the HIGHEST actuarial value under the ACA?

Gold
Silver
Platinum (Correct answer)
Bronze

Correct answer: Platinum

Platinum plans have the highest actuarial value of 90%, meaning insurers cover 90% of covered healthcare costs for a standard population.

Question 30: What is the primary purpose of a 'conflict of interest' policy in an ACA navigator organization?

To prevent navigators from assisting clients with competing insurance needs
To limit the number of plans an assister can present to clients
To require navigators to disclose their personal health insurance plan
To ensure that personal, financial, or organizational interests do not improperly influence assistance provided to clients (Correct answer)

Correct answer: To ensure that personal, financial, or organizational interests do not improperly influence assistance provided to clients

Conflict of interest policies protect clients by ensuring that assistance is based solely on client needs rather than external incentives or relationships.

Question 31: What is the primary purpose of the Affordable Care Act (ACA)?

To expand healthcare access and reduce costs (Correct answer)
To make all healthcare services free
To replace Medicare and Medicaid
To eliminate employer-provided insurance

Correct answer: To expand healthcare access and reduce costs

The ACA was designed to expand healthcare coverage, improve quality, and reduce costs for individuals and businesses.

Question 32: What is the recommended frequency for reviewing and updating policies & regulations protocols?

Monitoring outcomes through regular data collection and trend analysis (Correct answer)
Tracking activity volume without measuring quality
Reviewing results only at year-end
Relying on periodic external audits as the sole evaluation method

Correct answer: Monitoring outcomes through regular data collection and trend analysis

Monitoring outcomes through regular data collection and trend analysis is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 33: Which ACA program financially penalizes hospitals with excess readmissions within 30 days of discharge?

Value-Based Purchasing Program
Hospital Readmissions Reduction Program (HRRP) (Correct answer)
Hospital-Acquired Condition Reduction Program
Meaningful Use Incentive Program

Correct answer: Hospital Readmissions Reduction Program (HRRP)

The HRRP reduces Medicare payments to hospitals with higher-than-expected 30-day readmission rates for specified conditions.

Question 34: Under the ACA, what is the minimum value standard that employer-sponsored health plans must meet?

The plan must cover at least 50% of the total allowed costs
The plan must cover at least 60% of the total allowed costs (Correct answer)
The plan must cover at least 80% of the total allowed costs
The plan must cover at least 70% of the total allowed costs

Correct answer: The plan must cover at least 60% of the total allowed costs

ACA minimum value requires that an employer-sponsored plan pay at least 60% of total allowed costs for a standard population.

Question 35: A new regulation impacts policies & regulations procedures. What should a ACA professional do first?

Ensuring compliance with current regulatory requirements and standards (Correct answer)
Delegating compliance oversight to administrative staff
Interpreting regulations loosely to allow maximum flexibility
Complying only with regulations that have enforcement mechanisms

Correct answer: Ensuring compliance with current regulatory requirements and standards

Ensuring compliance with current regulatory requirements and standards is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 36: What is the 'no wrong door' policy under the ACA as it applies to Medicaid and Marketplace enrollment?

Individuals can apply for coverage through any channel—Marketplace, state Medicaid agency, or other entry points—and be connected to the right program (Correct answer)
All health plans must accept any applicant regardless of health status
States cannot deny Medicaid applications submitted outside office hours
Individuals can switch between Medicaid and Marketplace plans at any time

Correct answer: Individuals can apply for coverage through any channel—Marketplace, state Medicaid agency, or other entry points—and be connected to the right program

The 'no wrong door' policy ensures that regardless of where a person applies for health coverage, they will be screened and connected to the appropriate program, whether Medicaid, CHIP, or a Marketplace plan.

Question 37: Under the ACA, which employees are NOT counted when calculating an ALE's full-time equivalent workforce for the 50-employee threshold?

Employees enrolled in a government health plan
Employees on FMLA leave
Seasonal employees working fewer than 120 days per year (Correct answer)
All part-time employees regardless of hours

Correct answer: Seasonal employees working fewer than 120 days per year

Seasonal employees who work fewer than 120 days in a calendar year are excluded from the ALE calculation for determining the 50 FTE threshold.

Question 38: Under ACA regulations, which statement about Navigator confidentiality obligations is correct?

Navigators must protect consumer information and cannot share it without the consumer's consent except as required by law (Correct answer)
Navigators must report all consumer health information to the state exchange automatically
Navigators are exempt from privacy requirements since they are not covered entities under HIPAA
Navigators may share consumer data with insurance carriers to help find the best plan

Correct answer: Navigators must protect consumer information and cannot share it without the consumer's consent except as required by law

Navigator program rules require strict confidentiality of consumer information, and sharing without consent (outside legal exceptions) is prohibited.

Question 39: In the context of affordable care act certified, which principle most directly governs policies & regulations practices?

Using trial-and-error without systematic documentation
Following popular trends without evaluating their applicability
Applying evidence-based methodologies with peer-reviewed support (Correct answer)
Relying exclusively on vendor-provided solutions

Correct answer: Applying evidence-based methodologies with peer-reviewed support

Applying evidence-based methodologies with peer-reviewed support is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 40: What is a key requirement for employers under the ACA?

Employers can only offer coverage to part-time workers
Large employers must offer health insurance to full-time employees (Correct answer)
Small businesses must provide coverage to all employees
There are no employer requirements under the ACA

Correct answer: Large employers must offer health insurance to full-time employees

The ACA’s Employer Mandate requires large employers to provide health insurance to full-time employees or face penalties.

Question 41: Which of the following is a key performance indicator for evaluating professional ethics & standards effectiveness?

Treating all tasks with equal urgency regardless of impact
Focusing only on tasks with immediate financial implications
Prioritizing based on risk assessment and potential impact (Correct answer)
Addressing the most recent issue first regardless of severity

Correct answer: Prioritizing based on risk assessment and potential impact

Prioritizing based on risk assessment and potential impact is the correct approach because effective professional ethics & standards in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 42: What is the actuarial value of a Gold plan under the ACA?

70%
90%
80% (Correct answer)
60%

Correct answer: 80%

Gold plans have an actuarial value of 80%, meaning the plan pays 80% of covered healthcare costs on average for a standard population.

Question 43: Which of the following is one of the 10 Essential Health Benefits mandated by the ACA?

Long-term nursing home care
Cosmetic surgery
Pediatric services, including oral and vision care (Correct answer)
Dental care for adults

Correct answer: Pediatric services, including oral and vision care

Pediatric services including oral and vision care is one of the 10 mandated EHBs; adult dental, long-term care, and cosmetic surgery are not included.

Question 44: What distinguishes an advanced affordable care act certified practitioner's approach to quality assurance & compliance from that of a novice?

Assigning all responsibilities to a single department
Establishing cross-functional teams with clearly defined roles (Correct answer)
Creating competition between teams to drive performance
Rotating responsibilities randomly to promote flexibility

Correct answer: Establishing cross-functional teams with clearly defined roles

Establishing cross-functional teams with clearly defined roles is the correct approach because effective quality assurance & compliance in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 45: Which ACA provision allowed states to extend Medicaid coverage to former foster youth up to age 26 regardless of income?

Section 2004 of the ACA (Correct answer)
Section 2715 of the ACA
Section 1401 of the ACA
Section 1311 of the ACA

Correct answer: Section 2004 of the ACA

ACA Section 2004 requires states to provide Medicaid coverage to former foster care youth up to age 26 regardless of income level.

Question 46: Under the ACA, what is the Modified Adjusted Gross Income (MAGI) methodology used for in Medicaid eligibility?

To standardize income counting rules across Medicaid, CHIP, and the Marketplace (Correct answer)
To calculate the amount of premium tax credits for employer plans
To assess asset tests for long-term care Medicaid eligibility
To determine if an individual qualifies for Medicare Part D low-income subsidies

Correct answer: To standardize income counting rules across Medicaid, CHIP, and the Marketplace

MAGI-based income rules were introduced by the ACA to create a uniform income-counting methodology across Medicaid, CHIP, and Marketplace subsidies, replacing varied state methodologies.

Question 47: What is the most common mistake professionals make when implementing health insurance coverage & enrollment strategies?

Responding to problems only after they occur
Developing contingency plans for high-probability risk scenarios (Correct answer)
Transferring all risk to external partners through contracts
Creating contingency plans for every possible scenario regardless of probability

Correct answer: Developing contingency plans for high-probability risk scenarios

Developing contingency plans for high-probability risk scenarios is the correct approach because effective health insurance coverage & enrollment in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 48: Which ACA section established the Basic Health Program (BHP), an optional coverage alternative for states serving low-income residents?

Section 2001
Section 1311
Section 1331 (Correct answer)
Section 1402

Correct answer: Section 1331

ACA Section 1331 established the Basic Health Program, which allows states to create a state-administered coverage program for residents earning between 133–200% FPL instead of enrolling them in Marketplace plans.

Question 49: A risk manager at an insurance company wants to quantify the impact of high-cost claimants on plan financials. Which metric is MOST relevant?

Concentration of claims among top 1–5% of enrollees (Correct answer)
Total enrollment in special enrollment periods
Number of plans offered in the marketplace
Average premium across all metal tiers

Correct answer: Concentration of claims among top 1–5% of enrollees

A small percentage of enrollees typically generate the majority of medical costs, so analyzing claims concentration helps quantify catastrophic risk exposure.

Question 50: Which communication approach is most appropriate when discussing a sensitive health topic with a client during ACA enrollment assistance?

Use plain language, ensure privacy, and follow the client's lead (Correct answer)
Ask the client detailed medical questions to determine the best plan
Share the client's information with community partners to provide better help
Avoid the topic entirely to prevent discomfort

Correct answer: Use plain language, ensure privacy, and follow the client's lead

Privacy, plain language, and client-centered communication are core ethical standards for enrollment assisters.

Question 51: Which employer size is exempt from the ACA's employer shared responsibility provisions (employer mandate)?

All non-profit employers
Employers with fewer than 100 employees
Employers with fewer than 25 employees
Employers with fewer than 50 full-time equivalent employees (Correct answer)

Correct answer: Employers with fewer than 50 full-time equivalent employees

Employers with fewer than 50 full-time equivalent employees are not subject to the ACA employer shared responsibility provisions and face no penalties.

Question 52: Under the ACA, what is 'presumptive eligibility' in the context of Medicaid?

A waiver program for states to expand eligibility beyond ACA limits
A process allowing qualified entities to temporarily enroll individuals in Medicaid pending full eligibility determination (Correct answer)
The practice of denying coverage based on presumed income
Automatic Medicaid enrollment for all individuals below the poverty line

Correct answer: A process allowing qualified entities to temporarily enroll individuals in Medicaid pending full eligibility determination

Presumptive eligibility allows qualified entities (such as hospitals) to make a temporary Medicaid eligibility determination so individuals can receive immediate coverage while the full application is processed.

Question 53: When explaining cost-sharing reductions (CSRs) to a client, which statement is accurate?

CSRs apply to all metallic tier plans purchased on or off the marketplace
CSRs are only available on Silver plans purchased through the marketplace (Correct answer)
CSRs are automatically applied to Bronze plans for low-income enrollees
CSRs reduce monthly premiums for all income levels

Correct answer: CSRs are only available on Silver plans purchased through the marketplace

Cost-sharing reductions are only available to eligible individuals who enroll in Silver plans through the marketplace.

Question 54: A state exchange is experiencing low enrollment among Hispanic communities. Which stakeholder partnership would most effectively address this gap?

State department of motor vehicles offices
Federal immigration enforcement agencies
National insurance carrier marketing departments
Federally Qualified Health Centers (FQHCs) and Hispanic-serving community organizations (Correct answer)

Correct answer: Federally Qualified Health Centers (FQHCs) and Hispanic-serving community organizations

FQHCs and community-based organizations serving Hispanic populations have existing trust and infrastructure for effective outreach.

Question 55: A stakeholder questions the value of quality assurance & compliance initiatives. Which response best demonstrates ROI?

Centralizing accountability with a single individual
Avoiding accountability discussions to prevent conflict
Distributing accountability so widely that no one is responsible
Building a culture of accountability with transparent reporting (Correct answer)

Correct answer: Building a culture of accountability with transparent reporting

Building a culture of accountability with transparent reporting is the correct approach because effective quality assurance & compliance in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 56: An ALE's 4980H(b) penalty is assessed per month per full-time employee who does what?

Receives a premium tax credit through the Marketplace (Correct answer)
Earns above 400% of the federal poverty level
Works fewer than 30 hours per week
Declines employer coverage and enrolls in Medicare

Correct answer: Receives a premium tax credit through the Marketplace

The 4980H(b) 'B' penalty is triggered for each full-time employee who receives a premium tax credit through the Marketplace because the employer's coverage was unaffordable or failed minimum value.

Question 57: Under ACA Medicaid expansion rules, how often must states conduct eligibility renewals for expansion enrollees?

Only when the enrollee reports an income change
Every six months
Annually (Correct answer)
Every two years

Correct answer: Annually

States must renew Medicaid eligibility for expansion enrollees at least annually using electronic data matches before sending renewal forms to the beneficiary.

Question 58: What is the purpose of the Individual Mandate under the ACA?

To increase insurance premiums
To eliminate the need for Medicaid
To penalize only high-income individuals
To encourage universal health insurance coverage (Correct answer)

Correct answer: To encourage universal health insurance coverage

The Individual Mandate required most Americans to have health insurance or pay a penalty to encourage broader participation and reduce costs.

Question 59: What does 'actuarial value' represent in an ACA health plan?

The maximum premium an insurer can charge
The standard copay amount for primary care visits
The percentage of total covered healthcare costs the plan pays on average (Correct answer)
The annual deductible a member must satisfy before coverage begins

Correct answer: The percentage of total covered healthcare costs the plan pays on average

Actuarial value is the percentage of total covered healthcare expenses that the plan pays for a standard population of enrollees.

Question 60: Which of the following is a permissible safe harbor an employer can use to demonstrate affordability of coverage under the ACA?

The state wage index safe harbor
The employer's total revenue safe harbor
The W-2 wages safe harbor (Correct answer)
The employer size safe harbor

Correct answer: The W-2 wages safe harbor

The W-2 wages safe harbor allows employers to determine affordability by ensuring the employee's contribution does not exceed the affordability percentage of W-2 box 1 wages.

Question 61: An assister notices a colleague is recommending plans based on which insurer offers the best referral gifts. What is the assister's ethical duty?

Ignore it since it is not their responsibility
Advise clients to choose any plan except those recommended by the colleague
Join the colleague to earn the same gifts
Report the conduct to their supervisor or compliance officer (Correct answer)

Correct answer: Report the conduct to their supervisor or compliance officer

Ethical standards require that assisters report conflicts of interest or improper conduct that harm clients or violate program integrity.

Question 62: A client shares that they are undocumented but has a citizen child who needs coverage. What is the ethically correct course of action?

Enroll the child in CHIP or Marketplace coverage without disclosing the parent's status unnecessarily (Correct answer)
Require proof of citizenship before any assistance
Report the parent's status to immigration authorities
Decline to assist because the parent is ineligible

Correct answer: Enroll the child in CHIP or Marketplace coverage without disclosing the parent's status unnecessarily

Eligible children may receive coverage regardless of their parents' status, and assisters must protect client confidentiality and serve all eligible individuals.

Question 63: What ACA requirement specifically addresses maternal and newborn hospital stays?

Insurers must cover home birth as an alternative to hospital delivery
Plans cannot restrict coverage for a hospital stay to less than 48 hours following a vaginal delivery (Correct answer)
Hospitals must provide a dedicated maternal quality nurse for each birth
Plans must cover all newborn care for 90 days at no cost

Correct answer: Plans cannot restrict coverage for a hospital stay to less than 48 hours following a vaginal delivery

Building on NMHPA, ACA plans may not restrict a hospital stay following vaginal delivery to less than 48 hours or a cesarean section to less than 96 hours.

Question 64: Under the ACA, which section addresses wellness programs offered through employer-sponsored group health plans?

Section 2705 (Correct answer)
Section 1402
Section 1311
Section 1201

Correct answer: Section 2705

ACA Section 2705 governs nondiscrimination and wellness programs in group health plans, including incentive limits and reasonable alternative standards.

Question 65: What is the recommended frequency for reviewing and updating tax credits & subsidies protocols?

Reviewing results only at year-end
Relying on periodic external audits as the sole evaluation method
Tracking activity volume without measuring quality
Monitoring outcomes through regular data collection and trend analysis (Correct answer)

Correct answer: Monitoring outcomes through regular data collection and trend analysis

Monitoring outcomes through regular data collection and trend analysis is the correct approach because effective tax credits & subsidies in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 66: A client is visibly upset and pressuring an assister to enroll them in a plan immediately without reviewing options. What is the ethical response?

Ask the client to reschedule when they are calmer
Quickly enroll the client in any plan to de-escalate the situation
Enroll in the cheapest plan to give the client immediate relief
Remain calm, explain the importance of reviewing options, and proceed at a pace that ensures informed decision-making (Correct answer)

Correct answer: Remain calm, explain the importance of reviewing options, and proceed at a pace that ensures informed decision-making

Even under pressure, assisters must ensure the client understands their options; rushing enrollment without informed consent is an ethical violation.

Question 67: What was the Supreme Court ruling in NFIB v. Sebelius (2012) regarding ACA Medicaid expansion?

States are required to expand Medicaid or lose all federal Medicaid funding
All states must expand Medicaid within 2 years
States may choose whether to expand Medicaid without losing existing federal Medicaid funding (Correct answer)
Medicaid expansion was ruled unconstitutional

Correct answer: States may choose whether to expand Medicaid without losing existing federal Medicaid funding

In NFIB v. Sebelius, the Supreme Court ruled that states could opt out of Medicaid expansion without losing their existing federal Medicaid funding, making expansion voluntary.

Question 68: Under the ACA, Medicaid expansion extended eligibility to adults with incomes up to what percentage of the federal poverty level (FPL)?

133% FPL
138% FPL (Correct answer)
100% FPL
150% FPL

Correct answer: 138% FPL

The ACA's Medicaid expansion covers adults with household incomes up to 138% of the FPL (133% plus a 5% income disregard).

Question 69: What is the actuarial value of a Bronze plan in the ACA marketplace?

60% (Correct answer)
70%
80%
50%

Correct answer: 60%

Bronze plans have an actuarial value of 60%, providing the lowest coverage level but typically the lowest monthly premiums.

Question 70: A affordable care act certified professional discovers a discrepancy during quality assurance & compliance review. What is the most appropriate immediate action?

Limiting communication to written reports only
Engaging stakeholders collaboratively to align goals and expectations (Correct answer)
Accepting all stakeholder requests without prioritization
Working independently to avoid conflicting opinions

Correct answer: Engaging stakeholders collaboratively to align goals and expectations

Engaging stakeholders collaboratively to align goals and expectations is the correct approach because effective quality assurance & compliance in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 71: During a quality assurance & compliance audit, which documentation is most critical to have readily available?

Blaming individual team members for process failures
Addressing symptoms without investigating deeper causes
Accepting recurring problems as unavoidable
Conducting root cause analysis to identify underlying systemic issues (Correct answer)

Correct answer: Conducting root cause analysis to identify underlying systemic issues

Conducting root cause analysis to identify underlying systemic issues is the correct approach because effective quality assurance & compliance in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 72: Which of the following is a key performance indicator for evaluating communication & stakeholder engagement effectiveness?

Prioritizing based on risk assessment and potential impact (Correct answer)
Addressing the most recent issue first regardless of severity
Treating all tasks with equal urgency regardless of impact
Focusing only on tasks with immediate financial implications

Correct answer: Prioritizing based on risk assessment and potential impact

Prioritizing based on risk assessment and potential impact is the correct approach because effective communication & stakeholder engagement in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 73: What does an HMO (Health Maintenance Organization) typically require of its members?

Choosing a primary care physician and obtaining referrals for specialists (Correct answer)
Paying higher premiums for broader network access
Equal coverage for out-of-network and in-network providers
Seeing any provider without referrals

Correct answer: Choosing a primary care physician and obtaining referrals for specialists

HMOs require members to select a primary care physician (PCP) who coordinates care and must provide referrals for specialist visits to be covered.

Question 74: What is the most common mistake professionals make when implementing compliance & consumer protections strategies?

Transferring all risk to external partners through contracts
Responding to problems only after they occur
Developing contingency plans for high-probability risk scenarios (Correct answer)
Creating contingency plans for every possible scenario regardless of probability

Correct answer: Developing contingency plans for high-probability risk scenarios

Developing contingency plans for high-probability risk scenarios is the correct approach because effective compliance & consumer protections in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 75: What is the purpose of the ACA's quality improvement strategy requirement for qualified health plans (QHPs)?

To mandate electronic health records for all enrollees
To set premium rate caps for all plans
To require plans to offer only preventive services
To ensure plans implement activities that improve health outcomes and patient safety (Correct answer)

Correct answer: To ensure plans implement activities that improve health outcomes and patient safety

QHP quality improvement strategies must address clinical quality, patient safety, health outcomes, and reducing health disparities.

Question 76: An insurer concerned about risk selection from a short-term health plan market operating alongside its ACA-compliant plans should be MOST worried about:

Sick enrollees leaving for short-term plans due to lower premiums
Healthy individuals leaving the ACA pool for cheaper non-compliant plans (Correct answer)
Regulators mandating risk adjustment inclusion of short-term plans
Short-term plans filing MLR rebates

Correct answer: Healthy individuals leaving the ACA pool for cheaper non-compliant plans

Short-term plans attract healthy people who can pass underwriting, leaving the ACA pool with sicker, higher-cost enrollees — classic adverse selection.

Question 77: What is the primary purpose of Medicaid managed care organizations (MCOs) under ACA-expanded Medicaid programs?

To replace fee-for-service for only mental health services
To process Medicaid applications on behalf of states
To administer Medicare Advantage plans for dual eligibles
To coordinate and deliver Medicaid covered services under capitated payment contracts with states (Correct answer)

Correct answer: To coordinate and deliver Medicaid covered services under capitated payment contracts with states

Medicaid MCOs contract with states to provide Medicaid-covered services to enrollees under capitated (per-member per-month) payment arrangements, coordinating care and managing costs.

Question 78: Which ACA provision most directly mitigates the risk that large employers will drop coverage and shift employees to the marketplace?

Individual mandate penalty
Employer Shared Responsibility Payment (ESRP) (Correct answer)
Medical Loss Ratio rule
Essential Health Benefits requirement

Correct answer: Employer Shared Responsibility Payment (ESRP)

The ESRP (employer mandate) requires applicable large employers to offer affordable minimum-value coverage or pay a penalty, discouraging them from dropping coverage.

Question 79: Which provision of the ACA prohibits insurance companies from denying coverage based on pre-existing conditions?

Employer Mandate
Medicaid Expansion
Individual Mandate
Guaranteed Issue Provision (Correct answer)

Correct answer: Guaranteed Issue Provision

The ACA includes a provision that ensures individuals with pre-existing conditions cannot be denied health coverage.

Question 80: A Certified Application Counselor (CAC) is ethically prohibited from doing which of the following during client communications?

Recommending a specific plan based on personal commission incentives (Correct answer)
Explaining the difference between metallic tier levels
Providing information about special enrollment periods
Helping a client compare out-of-pocket costs

Correct answer: Recommending a specific plan based on personal commission incentives

CACs must provide unbiased assistance and cannot recommend plans based on personal financial incentives.

Question 81: Which of the following best describes 'cost-sharing reductions' (CSRs) under the ACA?

Employer contributions toward employee health insurance premiums
Tax deductions for health insurance premiums paid by self-employed individuals
Reductions in premium costs available to all marketplace enrollees
Subsidies that lower deductibles and copays for Silver plan enrollees with qualifying incomes (Correct answer)

Correct answer: Subsidies that lower deductibles and copays for Silver plan enrollees with qualifying incomes

CSRs reduce out-of-pocket costs such as deductibles, copays, and coinsurance for Silver plan enrollees with household incomes between 100% and 250% of the Federal Poverty Level.

Question 82: What is the primary advantage of a Bronze plan for a relatively healthy individual?

Access to a wider provider network
Lower out-of-pocket maximums
Lower deductibles than other metal tiers
Lower monthly premiums (Correct answer)

Correct answer: Lower monthly premiums

Bronze plans offer the lowest monthly premiums of all metal tiers, making them cost-effective for individuals who rarely use healthcare services.

Question 83: During a risk management & mitigation audit, which documentation is most critical to have readily available?

Conducting root cause analysis to identify underlying systemic issues (Correct answer)
Blaming individual team members for process failures
Accepting recurring problems as unavoidable
Addressing symptoms without investigating deeper causes

Correct answer: Conducting root cause analysis to identify underlying systemic issues

Conducting root cause analysis to identify underlying systemic issues is the correct approach because effective risk management & mitigation in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 84: Which of the following plans are required to cover all 10 Essential Health Benefits?

Grandfathered plans
ACA Marketplace individual and small group plans (Correct answer)
Supplemental insurance plans
Short-term health insurance plans

Correct answer: ACA Marketplace individual and small group plans

ACA Marketplace plans in the individual and small group markets must cover all 10 Essential Health Benefits as a condition of marketplace participation.

Question 85: Which of the following is a best practice for following up with clients after ACA enrollment assistance?

Share the client's contact information with insurance carriers for follow-up sales calls
Avoid all post-enrollment contact to protect client privacy
Contact clients weekly throughout the year to discuss plan alternatives
Send a confirmation of enrollment details and remind clients of key dates like first premium payment deadlines (Correct answer)

Correct answer: Send a confirmation of enrollment details and remind clients of key dates like first premium payment deadlines

A timely follow-up confirming enrollment details and first payment deadlines reduces lapses in coverage due to missed initial premiums.

Question 86: Under ACA Section 2719, what must health plans provide when they deny coverage or rescind a claim?

A referral to a state ombudsman only
A full refund of premiums paid during the denial period
Only a written explanation with no further recourse
An internal and external appeals process with written notice (Correct answer)

Correct answer: An internal and external appeals process with written notice

ACA Section 2719 requires non-grandfathered plans to maintain internal and external appeals processes and provide timely written notices of adverse decisions.

Question 87: Which of the following is covered under the 'preventive and wellness services' Essential Health Benefit?

Vaccinations recommended by the ACIP (Correct answer)
All prescription medications
Elective cosmetic procedures
Experimental treatments approved by the FDA

Correct answer: Vaccinations recommended by the ACIP

Preventive and wellness services include ACIP-recommended vaccinations, preventive screenings, and counseling, all provided at no cost-sharing under ACA marketplace plans.

Question 88: Under the ACA, the Essential Health Benefits benchmark for each state is typically based on:

The largest small group health plan by enrollment in the state (Correct answer)
A federally standardized plan applied uniformly to all states
The most affordable Bronze plan available in the state
The second-lowest Silver plan in the state marketplace

Correct answer: The largest small group health plan by enrollment in the state

States select their EHB benchmark from approved options, most commonly the largest small group health plan by enrollment in that state, giving states some flexibility in defining EHBs.

Question 89: Under the ACA's temporary reinsurance program (2014–2016), which enrollees' claims primarily triggered reinsurance payments to insurers?

Medicaid expansion enrollees
High-cost enrollees whose claims exceeded the attachment point (Correct answer)
All enrollees with chronic conditions
Enrollees who switched plans mid-year

Correct answer: High-cost enrollees whose claims exceeded the attachment point

Reinsurance payments were triggered when an individual's claims exceeded a set attachment point, helping plans cover catastrophic costs.

Question 90: Under the ACA, what is the federal government's matching rate (FMAP) for newly eligible Medicaid expansion enrollees?

100% federal match through 2020, then 90% (Correct answer)
90% federal match
75% federal match
50% federal match

Correct answer: 100% federal match through 2020, then 90%

The federal government paid 100% of Medicaid expansion costs through 2016, phasing down to a permanent 90% federal match starting in 2020.

Question 91: What is the 'coverage gap' that exists in non-expansion states under the ACA?

Part-time workers excluded from employer plans
Adults who earn too much for traditional Medicaid but too little for Marketplace subsidies (Correct answer)
People earning above 400% FPL who can't afford Marketplace plans
Children between ages 19 and 26 dropped from parental coverage

Correct answer: Adults who earn too much for traditional Medicaid but too little for Marketplace subsidies

In non-expansion states, adults above the state's traditional Medicaid income limit but below 100% FPL fall into a coverage gap: ineligible for Medicaid and ineligible for Marketplace premium tax credits.

Question 92: A Navigator is approached by a local TV station wanting to interview them about ACA enrollment. What is the best course of action?

Agree immediately and share client success stories with names and details
Consult with their organization's leadership and follow media engagement protocols before agreeing (Correct answer)
Decline all media requests as prohibited by ACA regulations
Refer the reporter directly to individual clients for interviews

Correct answer: Consult with their organization's leadership and follow media engagement protocols before agreeing

Navigators should follow their organization's media protocols and never share client information without explicit consent.

Question 93: Under the ACA, what does the term 'minimum essential coverage' (MEC) include for employer-sponsored plans?

Only HMO plans approved by the state
Plans covering only preventive services
Plans with no cost-sharing for any service
Any eligible employer-sponsored plan that covers basic medical care (Correct answer)

Correct answer: Any eligible employer-sponsored plan that covers basic medical care

Minimum essential coverage for employers includes any eligible employer-sponsored plan that provides at least basic medical benefits, regardless of cost-sharing amounts.

Question 94: Which of the following is a key performance indicator for evaluating quality assurance & compliance effectiveness?

Addressing the most recent issue first regardless of severity
Prioritizing based on risk assessment and potential impact (Correct answer)
Treating all tasks with equal urgency regardless of impact
Focusing only on tasks with immediate financial implications

Correct answer: Prioritizing based on risk assessment and potential impact

Prioritizing based on risk assessment and potential impact is the correct approach because effective quality assurance & compliance in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 95: Which of the following is an Essential Health Benefit mandated by the ACA?

Vision care for adults
Prescription drug coverage (Correct answer)
Long-term care services
Acupuncture and alternative medicine

Correct answer: Prescription drug coverage

Prescription drugs are one of the 10 mandated EHBs; alternative medicine, long-term care, and adult vision care are not required EHBs.

Question 96: What is the minimum actuarial value for an employer-sponsored plan to meet the ACA's 'minimum value' standard?

80%
50%
60% (Correct answer)
70%

Correct answer: 60%

An employer plan must have an actuarial value of at least 60% to satisfy the minimum value requirement and protect employers from applicable ACA penalties.

Question 97: An enrollment assister discovers that a client submitted inaccurate income information on their application. What is the appropriate action?

Leave the error in place since correcting it could reduce the client's subsidy
Help the client correct the application by reporting accurate income to the marketplace (Correct answer)
Report the client to the IRS for fraud without informing them
Complete the enrollment without disclosing the error to avoid delays

Correct answer: Help the client correct the application by reporting accurate income to the marketplace

Assisters are obligated to help clients provide accurate information; leaving known errors uncorrected is an ethical and legal violation.

Question 98: Which scenario would require a affordable care act certified professional to escalate a policies & regulations concern?

Using feedback solely for personnel evaluations
Creating feedback mechanisms that encourage continuous improvement (Correct answer)
Discouraging critical feedback to maintain team morale
Collecting feedback only during formal review periods

Correct answer: Creating feedback mechanisms that encourage continuous improvement

Creating feedback mechanisms that encourage continuous improvement is the correct approach because effective policies & regulations in the affordable care act certified field requires adherence to professional standards, evidence-based practices, and systematic methodology. This approach ensures consistent, high-quality outcomes while maintaining professional accountability.

Question 99: A Health Savings Account (HSA) can be used in conjunction with which type of ACA health plan?

A Platinum plan
An HSA-qualified High-Deductible Health Plan (HDHP) (Correct answer)
Any HMO plan
Any Bronze plan

Correct answer: An HSA-qualified High-Deductible Health Plan (HDHP)

HSAs are only available to individuals enrolled in IRS-qualified HDHPs that meet the minimum deductible and maximum out-of-pocket thresholds set by the IRS.

Question 100: What happens if an individual does not enroll in a health insurance plan during Open Enrollment?

They will automatically be enrolled in Medicaid
They must wait until the next Open Enrollment (Correct answer)
They will receive an automatic subsidy
They can enroll at any time without restrictions

Correct answer: They must wait until the next Open Enrollment

Unless they qualify for a Special Enrollment Period, individuals must wait until the next Open Enrollment Period to apply for coverage.

Affordable Care Act (ACA) Marketplace Certification (FFM)

The CMS Federally Facilitated Marketplace (FFM) certification validates that health insurance agents and brokers have the knowledge to assist consumers with ACA Marketplace enrollment, eligibility, plan selection, and compliance. Passing requires 70% or higher on each of four module-based exams.

100

Questions

90 min

Time Limit

70%

To Pass

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