Market place Individual
Indian Health Service (IHS)
American Indians and Alaska Natives can get medical care through the IHS. The IHS mostly serves people who live on or near reservations or in rural areas. IHS program benefits are not considered minimum essential coverage. However, persons who receive services from the IHS are eligible for an exemption from the requirement to maintain minimum essential coverage.
In which of the following ways must non-grandfathered health plans limit cost sharing for enrolled individuals?
Annual cost-sharing limits cannot exceed specified amounts.
The security controls described in the Privacy and Security Agreement with the Centers for Medicare & Medicaid Services require agents and brokers to ensure that personally identifiable information is protected against which of the following?
Any reasonably anticipated threats or hazards to the confidentiality, integrity, and availability of such information
To effectively help consumers understand and participate in the annual redetermination and re-enrollment process, agents and brokers should:
Assist consumers in updating their eligibility information and making a plan selection by the specified deadline for coverage effective January 1 of the following year.
Which of the following are roles of agents and brokers in the Individual Marketplace and the SHOP?
Assist individuals with enrolling in QHPs through the Marketplace and employers with selecting and enrolling in SHOP coverage Assist qualified individuals in the Individual Marketplace in applying for APTC and CSRs for eligible plans
Which of the following are elements to protecting information?
Availability: Defending information systems and resources from malicious, unauthorized users to ensure accessibility by authorized users Confidentiality: Protecting information from unauthorized disclosure to people or processes Integrity: Assuring the reliability and accuracy of information and information technology resources
Which of the following are eligibility criteria for individuals enrolling in a QHP?
Be a resident of the state in which he/she applies for coverage and enrolls in a QHP Be a United States citizen or national, or a lawfully present non-citizen, and expect to remain so for the entire period coverage is sought Not be incarcerated, other than incarceration pending disposition of charges
To become certified, a QHP must meet which of the following criteria?
Benefit design standards, including non-discrimination requirements and limits on cost sharing Coverage, at a minimum, of a comprehensive package of benefits, known as EHB Network adequacy standards Available for enrollment through the Marketplace for the full plan year for which the plan was certified
For which of the following purposes can an agent or broker share PII about an individual?
Help an individual obtain an assessment of his/her Medicaid eligibility Assist an individual in obtaining a determination as to whether he/she qualifies for the premium tax credit through his/her state's Marketplace Select a QHP
Your client is eligible for a maximum of $500 per month of APTC and he selects a QHP that costs $600 per month. He chooses to receive the full amount of APTC. How much is the monthly premium payment for which your client is responsible?
His monthly premium payment is $100 per month.
Which of the following are examples of practices that an agent or broker must follow with respect to PII in the Marketplace?
Informing consumers of the collection and use of their PII Providing consumers with the opportunity to review and correct their PII Taking appropriate steps to safeguard the confidentiality of PII Reporting privacy breaches to the CMS IT Service Desk
Health insurance issuers are NOT allowed to charge an older adult:
More than three times the rate of a 21-year old
For plan year 2018, the Open Enrollment period falls between which of the following dates?
November 1, 2017 and December 15, 2017
When the Marketplace receives a QHP selection from a qualified individual, it promptly notifies the applicable QHP issuer of the requested enrollment and transmits the needed eligibility and enrollment information. The QHP issuer then...
Provides the enrollee with an enrollment information package (after the enrollee makes the first month's premium payment)
Which of the following is an allowable use and disclosure of personally identifiable information (PII) specified in Appendix A in both Privacy and Security Agreements: the "Agreement Between Agent or Broker and the Centers for Medicare & Medicaid Services for the Individual Market Federally-facilitated Exchanges and the State-based Exchanges on the Federal Platform" and the "Agreement Between Agent or Broker and CMS for the Small Business Health Options Programs of the Federally-facilitated Exchanges and State-based Exchanges on the Federal Platform?"
Requesting an individual's PII to obtain an assessment of his or her Medicaid eligibility
Which of the following are prohibited according to the specifications for prohibited uses and disclosure of PII?
Requesting information regarding the citizenship of an individual who is not seeking coverage for himself or herself on any application Requesting an SSN of an individual who is not seeking coverage for himself or herself on any application Requesting any individual's PII to discriminate or discourage the enrollment of individuals with significant health needs in QHPs
Which of the following are controls that agents and brokers can apply to manage risk and protect consumer information?
Security awareness training Restricting access to systems that contain sensitive information
A 60-year-old military veteran seeking health insurance coverage:
Should first apply directly to the Veterans Health Administration (VHA) to determine eligibility for VHA benefits
Your client, a U.S. citizen who is not incarcerated, lost her employer-sponsored coverage through her job last month, and just relocated to your state, where she intends to reside. Does she meet the eligibility criteria for obtaining health insurance through the Marketplace and enrolling in a QHP in your state?
Yes, she meets the criteria to enroll in a QHP because she intends to reside in your state, she is a U.S. citizen, and she is not incarcerated.
A 34-year-old woman is looking for health insurance coverage that is more affordable than the coverage offered by her employer. She does not qualify for a hardship or affordability exemption, but is eligible for catastrophic coverage.
false
Agents and brokers can refuse to amend, correct, substitute, or delete personally identifiable information (PII) maintained and/or stored by the agent or broker unless an individual offers evidence that the PII is not accurate, timely, complete, relevant, or necessary to accomplish a function related to the Marketplace.
false
Agents or brokers must decide to grant or deny an individual access to personally identifiable information pertaining to the individual within 30 days of receipt of the access request.
false
An agent or broker can create a Marketplace user account at HealthCare.gov for a consumer.
false
An individual is not eligible to purchase a QHP through the Marketplace if that individual receives employer-sponsored coverage.
false
If an agent or broker has a business partner that assists in performing Marketplace functions involving personally identifiable information, the business partner is not legally obligated to meet or exceed the same set of standards.
false
If an individual applies for Marketplace coverage and help paying for it, and finds that he or she is eligible for Medicaid, that individual is not eligible to enroll in Marketplace coverage.
false
Kate qualifies for and enrolls in Marketplace coverage with APTC and CSRs. If Kate's daughter, Rose, is determined eligible for CHIP, Rose can also enroll in a Marketplace plan with APTC and CSRs.
false
Marta and Henry are not lawfully present in the United States. They have a son, Raul, who was born in the United States. Marta and Henry should provide you with the information about their immigration status so that you can help them apply for health coverage for Raul.
false
The individual shared responsibility requirement under the Affordable Care Act requires all individuals to have minimum essential coverage for themselves (and/or their spouse or dependents) or make a payment through the tax filing process.
false
When assisting consumers using the Marketplace Pathway, agents and brokers may log in as the consumer, using the consumer's username and password.
false
Your colleague Hank hands you a list with email addresses of potential clients who expressed interest in enrolling in a QHP through the Marketplace, and asks you to contact each of them to set up appointments. Since the list does not contain individual names, you can store and share this list as you wish because it does not contain the clients' PII.
false
Agents, brokers, and web-brokers must be appropriately licensed in each state where they sell qualified health plans through the Marketplace.
true
An agent or broker may only collect, use, or disclose PII to the extent necessary to carry out the functions authorized in the Individual Marketplace Privacy and Security Agreement and the SHOP Privacy and Security Agreement.
true
An agent or broker must account for all disclosures of an individual's personally identifiable information (PII), except for disclosures made to members of the agent's or broker's workforce who have a need for the PII to perform their duties and disclosures needed to carry out the required functions of the agent or broker.
true
An agent's or broker's National Producer Number (NPN) must be entered on a Marketplace application in order to record it on the Marketplace enrollment transaction health insurance issuers use to issue compensation for assisting a consumer with that application.
true
Consumer Operated and Oriented Plans are private, nonprofit, member-run health insurers.
true
Consumers who are notified of a Marketplace inconsistency have 90 days to resolve the issue or they may lose eligibility for health care coverage and/or financial assistance through the Marketplace.
true
Eligibility for Medicaid and CHIP is primarily based on current monthly income, while eligibility for APTC and income-based CSRs is based on projected annual household income, projected family size, and other eligibility criteria for the coverage year.
true
If Mary is determined eligible for Medicaid, she is generally NOT eligible for a Marketplace plan with APTC or income-based CSRs.
true
Individuals under age 30 and individuals who qualify for a hardship or affordability exemption may purchase a catastrophic plan.
true
Medicaid and the Children's Health Insurance Program eligibility is primarily based on current monthly income, while eligibility for the premium tax credit and cost-sharing reductions is based on projected annual household income.
true
Security refers to the mechanisms in place to protect the confidentiality and privacy of personal information.
true
Some individuals who are eligible for the premium tax credit are also eligible for cost-sharing reductions, as determined by their modified adjusted gross income.
true
The Affordable Care Act requires qualified non-grandfathered health plans to provide certain recommended preventive health services without cost-sharing or deductible requirements.
true
The Department of Health & Human Services may impose a civil money penalty of not more than $25,000 per person or entity, per use or disclosure against any person who knowingly and willfully uses or discloses personally identifiable information in violation of section 1411(g) of the Affordable Care Act.
true
The annual individual shared responsibility payment is the greater of 2.5% of the taxpayer's household income that is above the tax return filing threshold for the taxpayer's filing status; or the taxpayer's flat dollar amount, which is adjusted annually based on the cost-of-living adjustment and other factors.
true
The total family premium generally includes per-member rates for all members, but limits per-member premiums for covered children to up to three dependent children under the age of 21.
true
To become certified as a QHP, a plan that has a provider network must have an adequate provider network, which includes substance abuse disorder and mental health providers, and a sufficient number and geographic distribution of essential community providers to ensure reasonable and timely access to a broad range of such providers for low-income and medically underserved populations in the QHP's service area.
true
Which of the following is NOT a role of agents, brokers, and web-brokers within the Marketplace?
Assisting employers in applying for the premium tax credit
A risk is the likelihood that a vulnerability will exploit a threat.
false
How many years must informed consent documents be appropriately secured and retained?
10 years
Which of the following are steps you can take as an agent or broker to help promote information security?
Change your password often Use a different password for each system or application Change your password immediately if you suspect it has been compromised
What are EHB?
Essential health benefits, a comprehensive package of 10 benefit categories that all non-grandfathered individual and small group health plans must offer
Which of the following are components of the Affordable Care Act?
Extension of dependent coverage of children up to age 26 Prohibition on charging consumers a higher premium based on health status or gender Prohibition on coverage limitations or exclusions based on pre-existing conditions
Any incident involving the loss or suspected loss of PII must be reported in accordance with health insurance issuer requirements.
FALSE Correct! The agent's or broker's designated Policy Official, if applicable, and/or other personnel authorized to access PII and responsible for reporting and managing incidents or breaches, must report any incident involving the loss or suspected loss of PII consistent with CMS' Incident and Breach Notification Procedures. Any incident involving the loss or suspected loss of PII must be reported to the CMS IT Service Desk by telephone at (410) 786-2580 or 1-800-562-1963 or via email notification at [email protected] within required time frames.
Which of the following would be considered a vulnerability to a system's security?
Failing to install and regularly run an anti-virus program on a computer system
Which of the following is NOT an example of personally identifiable information?
Family composition
Which of the following statements is true regarding family premiums?
Family premiums are based on the premiums for each family member, including each family member's age and tobacco use (subject to state law).
Which of the following is NOT true regarding effective dates for special enrollment period enrollments through the Marketplace?
For a marriage, coverage can take effect as of the date of marriage.
Which of the following groups can serve as Navigators?
Grantees that meet certain requirements to assist consumers in applying for and enrolling in health coverage through the Marketplace
Which of the following is NOT true about Marketplaces?
HHS operates all Marketplaces.
Under the Affordable Care Act, guaranteed issue means that:
Health insurance issuers must accept any individual and employer who applies for an individual market or group market plan, subject to certain exceptions.
Which statement best describes Medical Loss Ratio (MLR)?
MLR is a basic financial measurement that shows how much of the premium dollars a health insurance issuer spends on health care expenses or quality improvement activities, as opposed to profits or administrative costs.
Which of the following is NOT a best practice related to patch management, a critical business function for effective data risk management?
Only perform patch updates in case of an emergency, so as not to interrupt regular business activities
Which of the following is NOT considered a privacy incident?
Receipt of an email phishing for personally identifiable information
AV can be defined as...
The calculation of the average portion of the cost of providing EHB estimated to be paid by the health insurance plan for a standard population
Veterans Health Administration (VHA)
VHA is the health system for military veterans (from the Army, Navy, Marines, Air Force, or Coast Guard). All veterans should apply to the VHA to determine eligibility.
Your client wishes to appeal her eligibility determination. What steps can you take to assist her?
You can provide information on when an appeal may be appropriate. You can explain how to file an appeal. You can file the appeal for her, but only if she has completed a written document appointing you as her authorized representative.
Which of the following is NOT a best practice for assisting a consumer who receives a notice from the Marketplace requesting additional documentation to resolve a data inconsistency impacting his or her eligibility?
You should advise the consumer to wait, as the Marketplace will continue to establish eligibility for the current plan year based on his or her attestation.
If an individual completes the Marketplace application and is determined eligible for Medicaid, what should your next step be as an agent or broker?
You should refer the individual to his state Medicaid agency.
PII is defined as any information that can be used to distinguish or trace an individual's identity, either alone or when combined with other information that is ___________ a specific individual.
linked or linkable to
A Navigator may refer a consumer to general listings of agents and brokers for assistance if the consumer says he or she wants a specific QHP recommendation and agents/brokers are permitted to make plan recommendations under state law.
true
Agents and brokers must provide a Privacy Notice Statement to consumers in the Marketplace regarding the use and disclosure of PII.
true
Information security is achieved through implementing technical, managerial, and operational measures designed to protect the confidentiality, integrity, and availability of information.
true
Jennifer lives in a state that did not expand eligibility for its Medicaid program, but she would have qualified for Medicaid if it had. She qualifies for an exemption from the individual shared responsibility requirement.
true
Which of the following is NOT a step agents and brokers should take to help promote information security?
Allow clients to share their private login credentials with them
Which of the following are categories of EHB?
Ambulatory patient services Emergency services, hospitalization, and prescription drugs
A Marketplace can best be defined as:
A mechanism for organizing health insurance options to help consumers shop for coverage
Under the Affordable Care Act, which of the following reform coverage provisions are health insurance issuers required to provide?
A package of benefits known as essential health benefits
When signing up for insurance, a consumer understands that if a health insurance issuer does not spend enough of its premium dollars on health care services or quality improvement activities, that issuer must provide...
A rebate to refund the excess back to the consumer
Which combination best defines the modified adjusted gross income, or MAGI, calculation to determine a tax filer's eligibility for APTC and income-based CSRs?
Adjusted gross income, plus any excluded foreign-earned income, tax-exempt interest received or accrued during the taxable year, and non-taxable Social Security benefits
Which of the following is true about agent and broker compensation in the Marketplace?
Agents and brokers are compensated in accordance with their agreements with qualified health plan issuers and any state-specific requirements.
Which of the following does the Marketplace verify to determine an applicant's eligibility for health coverage through the Marketplace and eligibility for insurance affordability programs?
Citizenship or immigration status Income Incarceration status
Which of the following is NOT a Marketplace eligibility decision that can be appealed?
Determination of a qualified health plan's service area or provider network
Department of Defense (DoD) TRICARE
DoD TRICARE is health care for active or retired members of the military (i.e., people in the Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service, or the National Oceanic and Atmospheric Administration).
When can individuals enroll in a qualified health plan?
During the Open Enrollment period or during a special enrollment period for which the individual is eligible
A consumer worries she may develop chronic asthma because she has a family history, but she knows she will not be denied health insurance coverage due to the guaranteed issue provision of the Affordable Care Act. Guaranteed issue means that...
Health insurance issuers that offer individual policies in a state generally must offer all of their available individual market plans to all eligible individuals in the state, and must accept all eligible individuals who apply for coverage.
Which statement best describes the operational meaning of the termination or suspension of an agent's, broker's, or web-broker's Marketplace Agreement(s) with the Centers for Medicare & Medicaid Services (CMS)?
It means the agent, broker, or web-broker is no longer registered with the Marketplace and is not permitted to assist with enrollments through the Marketplace.
Medicare
Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant), and certain individuals exposed to environmental health hazards.
Which of the following would NOT be considered a privacy incident?
Overhearing a private conversation in the hallway
Which of the following best describes Marketplace eligibility for members of mixed immigration status households?
Some household members are not eligible for health insurance coverage through the Marketplace, while other household members are eligible for Marketplace coverage because they are United States citizens or lawfully present immigrants.
Which of the following statements is true 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.
Which of the following BEST describes information security?
The protection of information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction in order to provide confidentiality, integrity, and availability
Cynthia receives APTC to pay part of the premiums for her enrollment in a QHP. She has been paying her portion of the premiums in full since January. However, she failed to pay the July premium, which was due July 1. Which of the following is NOT a possible outcome if Cynthia fails to make any further premium payments?
The QHP issuer will terminate Cynthia's coverage with an effective date of September 30.
The Smith family enrolled in a QHP and elected to have the APTC for which they qualified ($800 each month) to be paid directly to the issuer to cover some of the cost of the monthly premium. In the middle of the plan year, Mr. Smith gets a promotion, increasing his household income. If Mr. Smith chooses not to report this income change to the Marketplace by visiting HealthCare.gov, what could happen?
The Smith family could have excess APTC (the difference between the APTC paid on the family's behalf and the allowed premium tax credit), all or a portion of which the family must repay.
Which of the following is NOT a requirement for an individual seeking coverage through the Individual Marketplace?
The individual must not have access to government-sponsored coverage or affordable employer-sponsored coverage.
Bill and Barbara are married and have two children under age 18. They do not have minimum essential coverage (or any other form of coverage that helps to pay the cost of medical care) for any family member for any month during 2018 and no one in the family qualifies for an exemption. Which of the following are Bill and Barbara responsible for paying?
The individual shared responsibility payment for the months they and their children were uninsured when they file their 2018 income tax return, which is due in April 2019 The entire cost of any medical care they or their children receive during the year
What is the allowable maximum surcharge for non-grandfathered coverage for an individual who legally uses tobacco?
The maximum surcharge is one and a half times the non-tobacco user's rate.