Mixed Deck — All CACS Topics Flashcards

What should a CAC do if they are unsure about how to assist a consumer?

Answer: Consult training resources or ask a supervisor

CACs are expected to provide accurate and reliable information. If a CAC is unsure, guessing or providing general advice can lead to misinformation and negative consequences for the consumer. Consulting official training materials or seeking guidance from a supervisor ensures that the consumer receives correct and compliant assistance, maintaining the integrity of the CAC program.

When explaining the Marketplace's network types to a consumer, which plan type generally requires referrals to see specialists but may offer lower premiums?

Answer: HMO (Health Maintenance Organization)

HMO plans typically require members to get referrals from a primary care physician before seeing specialists and generally have lower premiums.

A consumer receives APTC but then gains access to affordable employer-sponsored insurance (ESI). What should happen?

Answer: They likely become ineligible for APTC and should report the change to the Marketplace

Access to affordable employer-sponsored insurance generally disqualifies a consumer from APTC, and the change must be reported to avoid excess credit repayment.

Under Marketplace privacy rules, for how long are CAC organizations generally required to retain records of their consumer assistance activities?

Answer: 5 years

CMS generally requires certified entities like CAC programs to retain records related to their Navigator/CAC activities for a minimum of 5 years.

A consumer wants to know whether dental coverage is included in their Marketplace health plan. A CAC should explain that:

Answer: Dental coverage for adults is generally not included in health plans and must be purchased separately

Adult dental coverage is not an essential health benefit and is typically not included in Marketplace health plans; consumers must purchase a separate stand-alone dental plan.

Which of the following consumers is eligible to purchase a Qualified Health Plan (QHP) through the Marketplace?

Answer: A lawfully present immigrant with income at 200% FPL

Lawfully present immigrants who meet income requirements and are not incarcerated or enrolled in Medicare are eligible for Marketplace QHPs.

An individual is generally eligible for Medicare before the age of 65 under which of the following circumstances?

Answer: They have been receiving Social Security Disability Insurance (SSDI) benefits for 24 months.

Individuals under 65 can qualify for Medicare if they have a qualifying disability. Typically, this eligibility begins after they have received Social Security Disability Insurance (SSDI) benefits for 24 months. Other qualifying conditions include End-Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS).

When assisting consumers in a rural area, a CAC should be particularly mindful of which common barrier when helping them compare Qualified Health Plans?

Answer: Limited availability of in-network providers and facilities, which may require significant travel for care.

Rural areas often face challenges with healthcare provider shortages and limited infrastructure. A key role for a CAC is to help consumers verify that a plan's network includes a sufficient number of accessible doctors, hospitals, and specialists to meet their needs, as travel distance can be a significant barrier to care.

Which of the following is a qualifying life event for a Special Enrollment Period (SEP)?

Answer: Losing a job-based health plan

A Special Enrollment Period (SEP) allows individuals to enroll in or change a health plan outside of the annual Open Enrollment Period due to certain qualifying life events. Losing job-based health coverage is a common and significant qualifying event, as it means an individual has lost their Minimum Essential Coverage and needs new insurance.

During an enrollment, a client asks the CAC which political party supports the ACA. How should the CAC respond?

Answer: Explain that CACs do not engage in political discussions during enrollment assistance

CACs must remain politically neutral and redirect clients away from political discussions during enrollment assistance sessions.

A consumer wants their CAC to help them understand their Explanation of Benefits (EOB). Under what condition may the CAC view this document?

Answer: Only if the consumer is present and explicitly shares the document with the CAC

EOBs contain PHI, so a CAC may only review them when the consumer voluntarily shares the document and consents to assistance in the moment.

Which of the following is NOT considered a qualifying health plan (QHP) for ACA purposes?

Answer: Short-term limited duration health insurance

Short-term limited duration insurance (STLDI) is explicitly excluded from the definition of a QHP and does not provide minimum essential coverage.

When a consumer calls a CAC's office and wants to discuss their application over the phone, what should the CAC do first?

Answer: Verify the caller's identity using established authentication questions before discussing any PII

CACs must verify caller identity through security questions or other authentication methods before discussing any personally identifiable information over the phone.

Which document is essential to provide to consumers when assisting with coverage options?

Answer: The Summary of Benefits and Coverage (SBC)

The Summary of Benefits and Coverage (SBC) is a standardized document required by the Affordable Care Act (ACA) that provides a clear, concise summary of a health plan's benefits and coverage. It helps consumers compare different plans side-by-side by outlining costs, covered services, and limitations in an easy-to-understand format. Providing the SBC ensures transparency and empowers consumers to make informed decisions about their health insurance options.

A Certified Application Counselor Designated Organization (CDO) is creating a new radio advertisement. Which of the following phrases would be inappropriate and violate the principle of impartiality?

Answer: "We'll get you enrolled in the best, most affordable health plan, guaranteed!"

The phrase "We'll get you enrolled in the best, most affordable health plan, guaranteed!" is inappropriate because it makes a subjective promise ('best'), implies a bias towards a single factor ('most affordable'), and suggests the CDO, not the consumer, is making the choice. This violates the core principle of impartiality. All outreach materials must accurately reflect the fair and unbiased nature of the assistance provided.

Which income level determines eligibility for Medicaid in states that have adopted the ACA Medicaid expansion?

Answer: Up to 133% FPL (effectively 138% with the 5% income disregard)

Expansion states cover adults up to 133% FPL, but the standard 5% income disregard raises the effective threshold to 138% FPL.

Under CAC ethical standards, how should a CAC handle a situation where they are not able to answer a client's complex tax question related to the premium tax credit?

Answer: Acknowledge the limitation and refer the client to a tax professional or IRS resources

CACs must operate within their scope of expertise and refer clients to appropriate professionals when questions exceed that scope.

A 28-year-old single adult with an annual income of 130% of the Federal Poverty Level (FPL) lives in a state that has expanded Medicaid. Which program are they most likely eligible for?

Answer: Medicaid

The ACA allows states to expand Medicaid to cover most low-income adults under age 65 with household incomes up to 138% of the FPL. In a state that has adopted expansion, this individual's income would make them eligible for Medicaid.

For APTC purposes, what is considered 'affordable' employer-sponsored insurance under the ACA?

Answer: Employee-only premium does not exceed a set percentage of household income (9.02% for 2024)

Employer coverage is considered affordable if the employee-only premium does not exceed the IRS affordability threshold (9.02% in 2024) of household income.

A consumer enrolled in a Marketplace plan did not receive any APTC. Do they still need to file Form 8962?

Answer: Yes, if they were enrolled in a Marketplace plan and received a Form 1095-A

Anyone who enrolled in a Marketplace plan and received a Form 1095-A should file Form 8962, even if they did not receive advance payments.