ACA Certification Exam Questions and
Answers
Young Adult Coverage - Answer-Under the Affordable Care Act, health plans that cover children must
make coverage available to children up to age 26. Young adults can join or remain on a parent's plan
even if they are:
Married (coverage does not extend to married child's spouse)
Not living with a parent
Not attending school
Not financially dependent on a parent
Eligible to enroll in their employer's plan (starting in 2014)
Guaranteed Issue - Answer-The Affordable Care Act requires health insurance issuers to offer all of their
individual market and group market plans to any applicant in the state. It also requires health insurance
issuers to accept any individual who applies for those policies, as long as the applicant agrees to the
terms and conditions of the policy, including the payment of premiums. This provision is called
"guaranteed issue."
Guaranteed Renewability - Answer-Additionally, the Affordable Care Act requires health insurance
issuers to offer to renew or continue in force coverage at the option of the policyholder. This is called
"guaranteed renewability."
,Pre-existing Conditions - Answer-Effective for all health plans with plan years beginning on or after
January 1, 2014, the Affordable Care Act prohibits health insurance issuers from limiting or excluding
coverage related to pre-existing health conditions, regardless of the age of the covered individual. For
persons under age 19, this provision became effective for policy years beginning on or after September
23, 2010.
Generally, a pre-existing condition is any health condition or illness that was present before the
coverage effective date, regardless of whether medical advice or treatment was actually received or
recommended.
Clinical Trials - Answer-The Affordable Care Act prohibits health insurance issuers from:
Precluding participation of qualified individuals in an approved clinical trial
Denying, limiting, or placing additional conditions on the coverage of routine patient costs for items and
services furnished in connection with participation in an approved clinical trial
Discriminating against qualified individuals on the basis of their participation in an approved clinical trial
Medical Loss Ratio - Answer-Is a basic financial measurement that shows how much of the premium
dollars a health insurance issuer spends on health care expenses, as opposed to profits or administrative
costs. As of 2012, a health insurance issuer that does not spend enough of its premium dollars on health
care services must provide rebates to insured individuals or policyholders.
Two Types of Martketplaces (exchanges) - Answer-The Individual Marketplaces for individual
consumers and their families such as Kate, the self-employed interior decorator
The SHOP Marketplaces for small business owners such as Tony, the owner of the small Italian
restaurant
Functions of Marketplace - Answer-Certifying health plans to participate in a Marketplace as QHPs
Determining individuals' eligibility for enrollment in a QHP
, Determining individuals' eligibility for premium tax credits and cost-sharing reductions
Determining or assessing individuals' eligibility for enrollment in Medicaid and/or the Children's Health
Insurance Program (CHIP)
Facilitating individuals' enrollment in a QHP
Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing
compliance with certification requirements
Facilitating employers' applications and employee enrollments in coverage through SHOP
Some states will establish their own Marketplaces; however, if a state does not choose to establish its
own Marketplace, HHS will establish a Federally-facilitated Marketplace.
Qualified Health Plan - Answer-Coverage, at a minimum, of a comprehensive package of benefits,
known as essential health benefits, or EHB
Benefit design standards, including non-discrimination requirements and limits on cost-sharing
Network adequacy standards
Essential Health Benefits - Answer-Reflect appropriate balance among the 10 EHB categories
Do not discriminate based on age, disability or expected length of life
Take into account the health care needs of diverse segments of the population
10 EHB Categories - Answer-Ambulatory patient services(dr. visits)
Mental health and substance abuse, including behavioral health
Rehabilitative and habilative services and devices
Laboratory services
Emergency services
maternity and newborn care
Prescription drugs
Pediatric services, including oral (pkg or stand alone)
Answers
Young Adult Coverage - Answer-Under the Affordable Care Act, health plans that cover children must
make coverage available to children up to age 26. Young adults can join or remain on a parent's plan
even if they are:
Married (coverage does not extend to married child's spouse)
Not living with a parent
Not attending school
Not financially dependent on a parent
Eligible to enroll in their employer's plan (starting in 2014)
Guaranteed Issue - Answer-The Affordable Care Act requires health insurance issuers to offer all of their
individual market and group market plans to any applicant in the state. It also requires health insurance
issuers to accept any individual who applies for those policies, as long as the applicant agrees to the
terms and conditions of the policy, including the payment of premiums. This provision is called
"guaranteed issue."
Guaranteed Renewability - Answer-Additionally, the Affordable Care Act requires health insurance
issuers to offer to renew or continue in force coverage at the option of the policyholder. This is called
"guaranteed renewability."
,Pre-existing Conditions - Answer-Effective for all health plans with plan years beginning on or after
January 1, 2014, the Affordable Care Act prohibits health insurance issuers from limiting or excluding
coverage related to pre-existing health conditions, regardless of the age of the covered individual. For
persons under age 19, this provision became effective for policy years beginning on or after September
23, 2010.
Generally, a pre-existing condition is any health condition or illness that was present before the
coverage effective date, regardless of whether medical advice or treatment was actually received or
recommended.
Clinical Trials - Answer-The Affordable Care Act prohibits health insurance issuers from:
Precluding participation of qualified individuals in an approved clinical trial
Denying, limiting, or placing additional conditions on the coverage of routine patient costs for items and
services furnished in connection with participation in an approved clinical trial
Discriminating against qualified individuals on the basis of their participation in an approved clinical trial
Medical Loss Ratio - Answer-Is a basic financial measurement that shows how much of the premium
dollars a health insurance issuer spends on health care expenses, as opposed to profits or administrative
costs. As of 2012, a health insurance issuer that does not spend enough of its premium dollars on health
care services must provide rebates to insured individuals or policyholders.
Two Types of Martketplaces (exchanges) - Answer-The Individual Marketplaces for individual
consumers and their families such as Kate, the self-employed interior decorator
The SHOP Marketplaces for small business owners such as Tony, the owner of the small Italian
restaurant
Functions of Marketplace - Answer-Certifying health plans to participate in a Marketplace as QHPs
Determining individuals' eligibility for enrollment in a QHP
, Determining individuals' eligibility for premium tax credits and cost-sharing reductions
Determining or assessing individuals' eligibility for enrollment in Medicaid and/or the Children's Health
Insurance Program (CHIP)
Facilitating individuals' enrollment in a QHP
Carrying out certain plan oversight functions, including monitoring QHP issuers for continuing
compliance with certification requirements
Facilitating employers' applications and employee enrollments in coverage through SHOP
Some states will establish their own Marketplaces; however, if a state does not choose to establish its
own Marketplace, HHS will establish a Federally-facilitated Marketplace.
Qualified Health Plan - Answer-Coverage, at a minimum, of a comprehensive package of benefits,
known as essential health benefits, or EHB
Benefit design standards, including non-discrimination requirements and limits on cost-sharing
Network adequacy standards
Essential Health Benefits - Answer-Reflect appropriate balance among the 10 EHB categories
Do not discriminate based on age, disability or expected length of life
Take into account the health care needs of diverse segments of the population
10 EHB Categories - Answer-Ambulatory patient services(dr. visits)
Mental health and substance abuse, including behavioral health
Rehabilitative and habilative services and devices
Laboratory services
Emergency services
maternity and newborn care
Prescription drugs
Pediatric services, including oral (pkg or stand alone)
