ACA STUDY EXAMS GUIDE ANSWERS AND
QUESTIONS SET A+
✔✔Calculating Premium Tax Credit - ✔✔The amount of the premium tax credit depends
on the plan that the individual or family selects. If the premium for the selected plan is
greater than the maximum premium tax credit, the individual or family may elect to
receive the maximum premium tax credit in advance, and pay the difference in a
monthly premium cost. If the premium for the selected plan is less than the maximum
payment, the individual or family may elect to receive the maximum premium tax credit
in advance, and have no additional premium cost.
✔✔Cost-sharing Reductions - ✔✔Meet the eligibility requirements for enrollment in a
QHP
Meet the criteria for eligibility for a premium tax credit
Have annual household income at or below 250% of FPL, except for members of
federally-recognized Indian tribes, who have special standards
Be enrolled in a silver-level QHP, except for members of federally-recognized Indian
tribes who have special standards
✔✔Single Streamlined Application - ✔✔By mail
Online
In-Person
Via call center
Agents and brokers are expected to assist consumers in submitting online applications.
✔✔Eligibility Determinations - ✔✔Application filers may request an eligibility
determination enrollment in a QHP and for insurance affordability programs, which
include Medicaid, CHIP, advance payment of the premium tax credit, and cost-sharing
reductions.
Depending on the state, the Marketplace may make an "assessment" of eligibility for
Medicaid and CHIP instead of a determination. In this case, an applicant who is
assessed as potentially eligible for Medicaid or CHIP by the Marketplace will be
transferred to the State Medicaid or CHIP agency for a final determination.
, ✔✔Verification: Assurance of Correct Data - ✔✔Marketplace data verification for
individuals seeking coverage through the Marketplace:
Social Security Number (if applicant has SSN)
Citizenship or lawful presence
Incarceration status
American Indian/Alaskan-Native status (if applicable)
Verification for individuals seeking eligibility for insurance affordability programs:
Current monthly household income (Medicaid/CHIP); annual household income
(advance payment of the premium tax credit/cost-sharing reduction)
Access to minimum essential coverage (premium tax credit/cost-sharing reduction)
✔✔Marketplace Notification Requirements: - ✔✔The Marketplace must provide
applicant timely written notice of eligibility determination. Notification occurs immediately
if the application was submitted electronically, and will indicate if additional information
is needed.
Notices will include information regarding the right to appeal eligibility findings.
The Marketplace must transfer any applicant assessed or determined eligible for
Medicaid or CHIP to the applicable State Medicaid or CHIP agency, which will follow up
for plan/delivery system selection.
✔✔Medicaid and CHIP Eligibility - ✔✔Medicaid and CHIP provide free or low-cost
health insurance coverage.
Medicaid is administered by states to provide health coverage for low-income people,
families and children, the elderly and people with disabilities. Beginning in 2014,
individuals with incomes of about $15,000 or less will qualify for Medicaid in about half
of all states. The Medicaid program is designed to be very affordable for every
participant and cost sharing is extremely limited.
CHIP is administered by states to provide no-cost or low-cost health insurance
coverage for children in families who earn too much to qualify for Medicaid coverage but
cannot afford to purchase private health insurance. CHIP also covers pregnant women
in some states.
✔✔SHOP Program Features - ✔✔Be located in a SHOP's service area (generally a
state)
Offer coverage to all full-time employees (those working an average of 30 or more
hours per week)
Have at least one eligible employee on payroll
Have 50 or fewer full-time equivalent (FTE) employees on payroll in 2014
This methodology includes part-time employees, but not seasonal employees (those
working fewer than 120 days per year)
While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the
definitions above, State-based SHOP Marketplaces have flexibility in their counting
approaches in 2014
QUESTIONS SET A+
✔✔Calculating Premium Tax Credit - ✔✔The amount of the premium tax credit depends
on the plan that the individual or family selects. If the premium for the selected plan is
greater than the maximum premium tax credit, the individual or family may elect to
receive the maximum premium tax credit in advance, and pay the difference in a
monthly premium cost. If the premium for the selected plan is less than the maximum
payment, the individual or family may elect to receive the maximum premium tax credit
in advance, and have no additional premium cost.
✔✔Cost-sharing Reductions - ✔✔Meet the eligibility requirements for enrollment in a
QHP
Meet the criteria for eligibility for a premium tax credit
Have annual household income at or below 250% of FPL, except for members of
federally-recognized Indian tribes, who have special standards
Be enrolled in a silver-level QHP, except for members of federally-recognized Indian
tribes who have special standards
✔✔Single Streamlined Application - ✔✔By mail
Online
In-Person
Via call center
Agents and brokers are expected to assist consumers in submitting online applications.
✔✔Eligibility Determinations - ✔✔Application filers may request an eligibility
determination enrollment in a QHP and for insurance affordability programs, which
include Medicaid, CHIP, advance payment of the premium tax credit, and cost-sharing
reductions.
Depending on the state, the Marketplace may make an "assessment" of eligibility for
Medicaid and CHIP instead of a determination. In this case, an applicant who is
assessed as potentially eligible for Medicaid or CHIP by the Marketplace will be
transferred to the State Medicaid or CHIP agency for a final determination.
, ✔✔Verification: Assurance of Correct Data - ✔✔Marketplace data verification for
individuals seeking coverage through the Marketplace:
Social Security Number (if applicant has SSN)
Citizenship or lawful presence
Incarceration status
American Indian/Alaskan-Native status (if applicable)
Verification for individuals seeking eligibility for insurance affordability programs:
Current monthly household income (Medicaid/CHIP); annual household income
(advance payment of the premium tax credit/cost-sharing reduction)
Access to minimum essential coverage (premium tax credit/cost-sharing reduction)
✔✔Marketplace Notification Requirements: - ✔✔The Marketplace must provide
applicant timely written notice of eligibility determination. Notification occurs immediately
if the application was submitted electronically, and will indicate if additional information
is needed.
Notices will include information regarding the right to appeal eligibility findings.
The Marketplace must transfer any applicant assessed or determined eligible for
Medicaid or CHIP to the applicable State Medicaid or CHIP agency, which will follow up
for plan/delivery system selection.
✔✔Medicaid and CHIP Eligibility - ✔✔Medicaid and CHIP provide free or low-cost
health insurance coverage.
Medicaid is administered by states to provide health coverage for low-income people,
families and children, the elderly and people with disabilities. Beginning in 2014,
individuals with incomes of about $15,000 or less will qualify for Medicaid in about half
of all states. The Medicaid program is designed to be very affordable for every
participant and cost sharing is extremely limited.
CHIP is administered by states to provide no-cost or low-cost health insurance
coverage for children in families who earn too much to qualify for Medicaid coverage but
cannot afford to purchase private health insurance. CHIP also covers pregnant women
in some states.
✔✔SHOP Program Features - ✔✔Be located in a SHOP's service area (generally a
state)
Offer coverage to all full-time employees (those working an average of 30 or more
hours per week)
Have at least one eligible employee on payroll
Have 50 or fewer full-time equivalent (FTE) employees on payroll in 2014
This methodology includes part-time employees, but not seasonal employees (those
working fewer than 120 days per year)
While the Federally-facilitated SHOPs (FF-SHOP) must determine eligibility using the
definitions above, State-based SHOP Marketplaces have flexibility in their counting
approaches in 2014
