CSFS Course 6
State Regulations and Federally Mandated Benefits
Where ERISA preemption ends and state authority begins, what states may regulate for a self-funded plan, and the federal benefit mandates that apply regardless.
225 practice questions · page 5 of 5, questions 201–225 · answers and explanations included · updated September 2026
25 questions on this page 5 of 5, each with the answer and the reasoning behind it. Read straight through, or quiz yourself on them and the ones you miss stay in rotation until you get them right.
- 201
Under the ACA's 2010 plan changes, which of the following rules regarding rescission of coverage applies to all plans, including grandfathered plans?
- •Plans cannot rescind coverage once an individual is enrolled unless there is fraud or intentional misrepresentation of material fact and the plan's terms prohibit such conduct
- •Plans cannot rescind coverage under any circumstances, even in cases of documented fraud
- •Plans may rescind coverage only with prior approval from the DOL and after a 60-day appeal period
- •Plans may rescind coverage within 90 days of enrollment for any reason, provided written notice is given
Show answer
Plans cannot rescind coverage once an individual is enrolled unless there is fraud or intentional misrepresentation of material fact and the plan's terms prohibit such conduct
The course states that a plan cannot rescind coverage once an individual is enrolled unless there is fraud or intentional misrepresentation of material fact and the plan's terms prohibit such fraud/misrepresentation. The sponsor must provide 30 days advance notice of rescission.
- 202
Under the ACA's elimination of lifetime limits on essential health benefits, what guidance did IRS, DOL, and HHS provide regarding standalone, active-employee HRAs?
- •Standalone HRAs are completely exempt from the annual and lifetime limit prohibitions regardless of whether they are integrated with a group health plan
- •Standalone HRAs are compliant as long as they provide at least $5,000 per year in benefits, even without integration
- •Standalone HRAs must provide unlimited benefits to comply, and no integration with another plan can cure a noncompliant HRA
- •Standalone, active-employee HRAs do not comply with the annual limit prohibition if they are not integrated with an employer's group health plan
Show answer
Standalone, active-employee HRAs do not comply with the annual limit prohibition if they are not integrated with an employer's group health plan
The course states that IRS, DOL, and HHS have indicated that standalone, active-employee HRAs do not comply with the annual limit prohibition if they are not integrated with an employer's group health plan. This effectively requires HRAs to be integrated with a group health plan to be compliant.
- 203
Under the ACA's 2010 plan changes regarding preventive health coverage, which of the following statements is correct?
- •Plans must cover all preventive services without cost-sharing, and this requirement applies to all plans including grandfathered plans
- •Plans must cover certain preventive services generally without cost-sharing, but this requirement does not apply to grandfathered plans
- •Plans must cover preventive services but may impose a copayment of up to $25, and grandfathered plans are exempt
- •Plans must cover preventive services without cost-sharing only for enrollees under age 65, and this applies to all plans
Show answer
Plans must cover certain preventive services generally without cost-sharing, but this requirement does not apply to grandfathered plans
The course states that plans must cover, generally without cost-sharing, certain preventive services (e.g., immunizations and infant screenings), effective for plan years beginning on or after September 23, 2010. This requirement does not apply to grandfathered plans.
- 204
Under the ACA's 2010 changes, the contraceptive coverage rule under preventive health coverage had evolving exemptions. According to the course, what was the final scope of exemptions?
- •An accommodation for all employers that objected on religious grounds, but no full exemption for any employer and no expansion for moral objections
- •An exemption for all nonprofit religious organizations, an accommodation for for-profit closely held corporations, but no expansion for moral objections
- •An exemption for some religious employers, an accommodation for some non-exempt religious organizations, and the rule was later expanded to also include employers with a moral objection
- •An exemption only for churches and houses of worship, with no accommodation available for religious organizations and no expansion for moral objections
Show answer
An exemption for some religious employers, an accommodation for some non-exempt religious organizations, and the rule was later expanded to also include employers with a moral objection
The course describes an evolving set of exemptions: an exemption from the contraceptive coverage rule for some religious employers, an accommodation for some non-exempt religious organizations available for plan years beginning on or after January 1, 2014, and the rule was later expanded to also include employers with a 'moral' objection.
- 205
Under the ACA's 2010 plan changes, emergency services must be covered in what manner?
- •With prior authorization required within 48 hours and subject to out-of-network cost-sharing
- •Without prior authorization and as though services were in-network
- •Without prior authorization but subject to a separate emergency room copayment of up to $500
- •Without prior authorization only if the nearest emergency room is more than 30 miles away
Show answer
Without prior authorization and as though services were in-network
The course states that emergency services must be covered without prior authorization and as though services were in-network. This requirement applied to plan years beginning on or after September 23, 2010, but did not apply to grandfathered plans.
- 206
Under the ACA, self-funded group health plans must select a state's benchmark for determining what constitutes essential health benefits for purposes of the no-lifetime-limit and no-annual-limit rules. Why is this choice significant?
- •Essential health benefits are defined uniformly by HHS, so the state selection only affects reporting obligations rather than the substantive scope of covered benefits
- •Self-funded plans are exempt from essential health benefit requirements entirely, so the state selection is relevant only for Form 5500 filing purposes
- •The definition of essential health benefits varies by state, and employers with self-funded plans should select a state of their choosing to determine which benefits are deemed essential and thus subject to the prohibition on lifetime and annual limits
- •The state selection determines which state's insurance department has regulatory jurisdiction over the self-funded plan's compliance with the ACA
Show answer
The definition of essential health benefits varies by state, and employers with self-funded plans should select a state of their choosing to determine which benefits are deemed essential and thus subject to the prohibition on lifetime and annual limits
The course states that the definition of essential health benefits indicates that employers with self-funded group health plans should select a state of their choosing for purposes of determining what are essential health benefits. This is significant because the no-lifetime-limit and no-annual-limit rules apply specifically to essential health benefits, and the scope of those benefits varies by state benchmark.
- 207
Under the ACA's 2011 plan changes, a small employer can adopt a simple cafeteria plan with a safe harbor from nondiscrimination rules. What defines a small employer for this purpose?
- •An employer with an average of 100 or fewer employees
- •An employer with an average of 250 or fewer employees
- •An employer with an average of 50 or fewer employees
- •An employer with fewer than 100 full-time equivalent employees
Show answer
An employer with an average of 100 or fewer employees
The course states that a small employer (average 100 or fewer employees) can adopt a new type of cafeteria plan effective January 1, 2011. If adopted, the plan has a safe harbor from nondiscrimination rules if minimum employer contributions are made.
- 208
Under the ACA's plan changes effective in 2011 and 2013, which two changes affected over-the-counter medicine reimbursement and health FSA contributions, respectively?
- •All over-the-counter medicine including insulin was excluded from reimbursement through tax-advantaged accounts; and health FSA contributions were limited to $2,500 with no indexing
- •Over-the-counter medicine (other than doctor-prescribed and insulin) could no longer be reimbursed through health FSA, HRA, HSA, or Archer MSA; and health FSA salary reduction contributions were limited to $2,500 (as indexed)
- •Over-the-counter medicine could still be reimbursed if a prescription was obtained; and health FSA contributions were limited to $3,500 (as indexed) starting in 2011
- •Over-the-counter medicine was excluded from HSA reimbursement only; and health FSA contributions were limited to $5,000 (as indexed) starting in 2013
Show answer
Over-the-counter medicine (other than doctor-prescribed and insulin) could no longer be reimbursed through health FSA, HRA, HSA, or Archer MSA; and health FSA salary reduction contributions were limited to $2,500 (as indexed)
The course states that effective January 1, 2011, the cost of over-the-counter medicine (other than doctor-prescribed and insulin) could no longer be reimbursed through health FSA, HRA, HSA, or Archer MSA. Separately, effective for plan years beginning January 1, 2013, health FSA salary reduction contributions were limited to $2,500 (as indexed).
- 209
Under the ACA, the deduction for the Medicare Part D subsidy was affected in what way, effective for tax years beginning January 1, 2013?
- •The deduction for the Medicare Part D subsidy was converted from a deduction to a tax credit
- •The deduction for the Medicare Part D subsidy was delayed until the following tax year
- •The deduction for the Medicare Part D subsidy was eliminated
- •The deduction for the Medicare Part D subsidy was reduced by 50%
Show answer
The deduction for the Medicare Part D subsidy was eliminated
The course states that the deduction for the Medicare Part D subsidy was eliminated, effective for tax years beginning January 1, 2013. This change reduced the tax benefit that employers received for maintaining retiree prescription drug coverage.
- 210
Under the ACA's 2014 plan changes, a plan cannot impose a waiting period that exceeds how many days?
- •120 days
- •30 days
- •60 days
- •90 days
Show answer
90 days
The course states that effective for plan years beginning on or after January 1, 2014, a plan cannot impose any waiting period that exceeds 90 days.
- 211
Under the ACA's 2014 codification of wellness HIPAA nondiscrimination regulations, the current 20% cap on wellness discounts/surcharges was raised. To what levels, and under what condition can the higher limit be reached?
- •The cap was raised to 30% of the cost of coverage, with HHS, IRS, and DOL authorized to increase it to 50% if the increase is due to a tobacco use prevention/reduction program
- •The cap was raised to 30% of the cost of coverage, with no provision for further increase beyond 30% under any circumstances
- •The cap was raised to 40% of the cost of coverage, with HHS authorized to increase it to 60% for any health-contingent wellness program
- •The cap was raised to 50% of the cost of coverage for all wellness programs, with no distinction between tobacco and non-tobacco programs
Show answer
The cap was raised to 30% of the cost of coverage, with HHS, IRS, and DOL authorized to increase it to 50% if the increase is due to a tobacco use prevention/reduction program
The course states that the ACA raised the current 20% cap on wellness discount/surcharge to 30% of coverage cost. It also allows HHS, IRS, and DOL to increase the amount to 50% if the increase is due to a tobacco use prevention/reduction program.
- 212
Under the ACA's 2014 plan changes, the no-discrimination-against-healthcare-providers rule has a specific limitation. Which of the following correctly describes what the rule does NOT require?
- •The rule does not apply to plans that exclusively use a closed-panel HMO network structure
- •The rule does not prevent plans from requiring prior authorization for specialist referrals from any provider type
- •The rule does not require plans to contract with any willing provider or to refrain from establishing varying reimbursement rates based on quality or performance measures
- •The rule does not require plans to cover services rendered by providers acting outside the scope of their license or certification
Show answer
The rule does not require plans to contract with any willing provider or to refrain from establishing varying reimbursement rates based on quality or performance measures
The course states that the ACA prohibits plans and insurers from discriminating against any healthcare provider acting within the scope of that provider's license or certification. However, the rule does not require plans to contract with any willing provider or to refrain from establishing varying reimbursement rates based on quality or performance measures.
- 213
Under the ACA's 2014 plan changes, what limit applies to out-of-pocket costs for in-network essential health benefits for non-grandfathered plans?
- •Out-of-pocket costs are limited to $2,000 for individual coverage and $4,000 for family coverage
- •Out-of-pocket costs are limited to 10% of the plan's total cost of coverage
- •Out-of-pocket costs are limited to those applicable to high-deductible health plans (HSA-related plans)
- •Out-of-pocket costs are unlimited for self-funded plans but capped for fully insured plans
Show answer
Out-of-pocket costs are limited to those applicable to high-deductible health plans (HSA-related plans)
The course states that out-of-pocket costs for in-network essential health benefits are limited to those applicable to high-deductible health plans (HSA-related plans), effective for plan years beginning on or after January 1, 2014. This requirement does not apply to grandfathered plans.
- 214
Under the ACA's 2014 plan changes regarding coverage for clinical trials, which of the following correctly describes the scope of the requirement?
- •Plans cannot deny participation in an approved clinical trial, deny routine costs of same, or otherwise discriminate based on participation in a clinical trial for treatment of certain cancers or other life-threatening conditions, and this does not apply to grandfathered plans
- •Plans cannot deny participation in clinical trials but may impose a 50% coinsurance rate on routine costs associated with the trial, and this applies to all plans
- •Plans must cover all costs of clinical trials including experimental treatments and investigational drugs, and this applies to all plans including grandfathered plans
- •Plans must cover routine costs of clinical trials for any medical condition, not limited to cancers or life-threatening conditions, and this does not apply to grandfathered plans
Show answer
Plans cannot deny participation in an approved clinical trial, deny routine costs of same, or otherwise discriminate based on participation in a clinical trial for treatment of certain cancers or other life-threatening conditions, and this does not apply to grandfathered plans
The course states that plans cannot deny participation in an approved clinical trial, deny routine costs of same, or otherwise discriminate based on participating in a clinical trial for treatment of certain cancers or other life-threatening conditions. This requirement does not apply to grandfathered plans.
- 215
Under the ACA's administrative requirements, which of the following was effective as of March 23, 2010?
- •Employers cannot discharge or discriminate against an employee for objecting to, or refusing to participate in, a violation of certain provisions of the healthcare reform law
- •Employers must provide a Summary of Benefits and Coverage (SBC) to all plan applicants and enrollees
- •Employers must provide employees with a notice of health insurance exchanges and related items such as tax credits
- •Employers must report the aggregate cost of employer-sponsored health plan coverage on each employee's W-2
Show answer
Employers cannot discharge or discriminate against an employee for objecting to, or refusing to participate in, a violation of certain provisions of the healthcare reform law
The course states that effective March 23, 2010, the ACA's no-retaliation provision prohibits employers from discharging or discriminating against an employee for objecting to, or refusing to participate in, a violation of certain provisions of the healthcare reform law. The W-2 reporting, exchange notice, and SBC requirements all had later effective dates.
- 216
Under the ACA's administrative requirements regarding the Summary of Benefits and Coverage (SBC), which of the following correctly describes both the content requirement and the notice-of-change requirement?
- •The SBC must include a description of cost-sharing and coverage in at least 12-point font, with a glossary of standard terms, and 60 days advance notice of plan changes must be given if the change affects the SBC's contents (unless the change is in connection with open enrollment)
- •The SBC must include a description of cost-sharing in at least 10-point font with no glossary requirement, and 90 days advance notice of plan changes must be given for all changes
- •The SBC must include actuarial value calculations and premium breakdowns in any legible font, with 30 days advance notice of all plan changes regardless of whether they affect the SBC
- •The SBC must include provider network listings and formulary information in at least 12-point font, and no advance notice of changes is required if the change occurs during the plan year
Show answer
The SBC must include a description of cost-sharing and coverage in at least 12-point font, with a glossary of standard terms, and 60 days advance notice of plan changes must be given if the change affects the SBC's contents (unless the change is in connection with open enrollment)
The course states that the SBC must include various content and format requirements such as description of cost-sharing and coverage and must be in at least 12-point font. Applicants and enrollees also receive a glossary of standard terms. Additionally, 60 days advance notice of plan changes must be provided if the change affects the contents of the SBC, unless the change is in connection with open enrollment.
- 217
Under the ACA, what is the medical loss ratio requirement for insurers, and what must happen if the requirement is not met?
- •An insurer must file a corrective action plan with HHS if its loss ratio falls below 70% for two consecutive years
- •An insurer must provide a rebate to policyholders if not enough premium revenue is used for claims, healthcare quality improvement, or certain other expenses
- •An insurer must reduce premiums by 10% in the following year if its loss ratio exceeds 85%
- •An insurer must transfer excess premiums to the state exchange if its loss ratio exceeds 90%
Show answer
An insurer must provide a rebate to policyholders if not enough premium revenue is used for claims, healthcare quality improvement, or certain other expenses
The course states that an insurer usually must provide a rebate to policyholders if not enough premium revenue is used for claims, to improve healthcare quality, or for certain other expenses. Employers may want to amend plan documents to clarify how rebates are classified and used, in accordance with DOL Technical Release 2011-04.
- 218
Under the ACA's administrative requirements, Code Section 6055 and 6056 reporting apply to different entities. Which of the following correctly distinguishes these two reporting requirements?
- •Section 6055 applies only to fully insured plans and requires reporting of premium amounts; Section 6056 applies to self-funded plans and requires reporting of claims experience data
- •Section 6055 applies to employers with fewer than 50 employees and requires reporting of coverage offered; Section 6056 applies to employers with 50 or more employees and requires reporting of premium tax credits received
- •Section 6055 requires all employers to report health plan costs on Form W-2; Section 6056 requires employers to report wellness program participation rates to HHS
- •Section 6055 requires insurers, employers sponsoring self-insured plans, and other entities offering minimum essential coverage to report about health coverage to IRS; Section 6056 requires employers with at least 50 full-time and full-time equivalent employees to report whether they offer minimum essential coverage to full-time employees and dependents
Show answer
Section 6055 requires insurers, employers sponsoring self-insured plans, and other entities offering minimum essential coverage to report about health coverage to IRS; Section 6056 requires employers with at least 50 full-time and full-time equivalent employees to report whether they offer minimum essential coverage to full-time employees and dependents
The course distinguishes these requirements: Section 6055 reporting requires insurers, employers sponsoring self-insured plans, and other entities offering minimum essential coverage to report to IRS about health coverage (including names of covered employees and dependents, portion of premium paid by employer). Section 6056 reporting requires employers with at least 50 full-time and full-time equivalent employees to report whether they offer full-time employees and dependents the opportunity to enroll in minimum essential coverage.
- 219
Under the ACA, the fully insured plan nondiscrimination rules were modeled on which existing Code section, and what is their enforcement status as described in the course?
- •Code Section 105(h)(2) regarding eligibility to participate and eligibility for benefits, and as of June 2024 the requirement is still in a non-enforcement category
- •Code Section 125 regarding cafeteria plan nondiscrimination, and the requirement was permanently repealed in 2018
- •Code Section 401(a)(4) regarding nondiscriminatory benefits, and the requirement has been fully enforced since 2012
- •Code Section 4980H regarding employer shared responsibility, and the requirement was delayed until 2025
Show answer
Code Section 105(h)(2) regarding eligibility to participate and eligibility for benefits, and as of June 2024 the requirement is still in a non-enforcement category
The course states that fully insured group health plans must satisfy the nondiscrimination rules of Code Section 105(h)(2) regarding eligibility to participate and eligibility for benefits. However, IRS guidance from December 2010 delayed the effective date, and as of June 2024, this requirement is still in a 'non-enforcement' category.
- 220
Under the ACA's tax incentives and penalties, what is the PCORI fee, and when did it first apply?
- •A one-time fee per covered employee paid by employers when first establishing a health plan, effective January 1, 2010
- •A quarterly fee based on total plan claims experience paid by TPAs, effective for plan years beginning after January 1, 2013
- •An annual fee per covered family paid by insurers only, with a fixed amount of $2.00 per covered life, effective January 1, 2011
- •An annual fee per plan participant that plan sponsors must pay, with the amount varying based on the year, first applying to plan years ending after October 1, 2012
Show answer
An annual fee per plan participant that plan sponsors must pay, with the amount varying based on the year, first applying to plan years ending after October 1, 2012
The course states that plan sponsors must pay annual fees per plan participant (the PCORI fee), with the amount varying based on the year. This fee applies to plan years ending after October 1, 2012.
- 221
Under the ACA's pay-or-play rules, an employer with at least 50 full-time and full-time equivalent employees that does NOT offer minimum essential coverage to at least 95% of full-time employees and dependents faces what penalty?
- •A $2,000 annual fee (increased for growth of insurance premiums, determined month-to-month) for each full-time employee, provided at least one full-time employee receives a premium tax credit or cost-sharing reduction through an Exchange
- •A $2,000 annual fee for each full-time employee regardless of whether any employee receives a premium tax credit through an Exchange
- •A $2,000 annual fee per full-time equivalent employee, including part-time employees counted on a proportional basis, with no Exchange enrollment trigger
- •A $3,000 annual fee for each full-time employee who enrolls in Exchange coverage and receives a premium tax credit, with no trigger requirement for other employees
Show answer
A $2,000 annual fee (increased for growth of insurance premiums, determined month-to-month) for each full-time employee, provided at least one full-time employee receives a premium tax credit or cost-sharing reduction through an Exchange
The course states that applicable large employers (50+ full-time and FTE employees) that do not offer minimum essential coverage to at least 95% of full-time employees and dependents are assessed a $2,000 annual fee (increased for growth of insurance premiums, determined on a month-to-month basis) for each full-time employee, but only if at least one full-time employee receives a premium tax credit or cost-sharing reduction through an Exchange.
- 222
Under the ACA, how does the $3,000 penalty differ from the $2,000 penalty in terms of when it applies and how it is calculated?
- •The $3,000 penalty applies when an employer fails to offer any coverage at all and at least one employee enrolls in Exchange coverage; it is assessed per total full-time employee like the $2,000 penalty
- •The $3,000 penalty applies when an employer offers coverage but the coverage fails to meet minimum value requirements; it is assessed per employee who declines employer coverage regardless of Exchange enrollment
- •The $3,000 penalty applies when an employer offers minimum essential coverage to at least 95% of full-time employees but a full-time employee nevertheless enrolls in Exchange coverage and receives a premium tax credit; it is assessed per employee who enrolls in the Exchange, not per total full-time employee
- •The $3,000 penalty applies when an employer with fewer than 50 employees offers non-compliant coverage; it is assessed per enrolled participant who files a complaint with the DOL
Show answer
The $3,000 penalty applies when an employer offers minimum essential coverage to at least 95% of full-time employees but a full-time employee nevertheless enrolls in Exchange coverage and receives a premium tax credit; it is assessed per employee who enrolls in the Exchange, not per total full-time employee
The course explains that the $3,000 penalty applies to employers with 50+ full-time/FTE employees that DO offer minimum essential coverage to at least 95% of full-time employees and dependents, but where a full-time employee nevertheless enrolls in a qualified health plan through an Exchange and receives a premium tax credit or cost-sharing reduction. The $3,000 fee is per such employee, unlike the $2,000 fee which is per total full-time employee.
- 223
Under the ACA, how did the additional payroll tax work, and what was the effective date?
- •An additional FICA and SECA payroll tax of 0.9% was imposed on individual wages over $200,000 ($250,000 for couples filing jointly), effective January 1, 2013
- •An additional FICA tax of 0.9% was imposed on all wages regardless of threshold, effective January 1, 2013
- •An additional FICA tax of 1.5% was imposed on individual wages over $250,000 ($500,000 for couples filing jointly), effective January 1, 2014
- •An additional SECA tax of 0.9% was imposed on self-employment income only, over $200,000, effective January 1, 2011
Show answer
An additional FICA and SECA payroll tax of 0.9% was imposed on individual wages over $200,000 ($250,000 for couples filing jointly), effective January 1, 2013
The course states that an additional FICA and SECA payroll tax of 0.9% was imposed for individual wages over $200,000 ($250,000 for couples filing jointly), effective January 1, 2013.
- 224
Under the ACA, large employers became eligible for the Exchange in what year, and what was the minimum size requirement?
- •2014, for employers with an average of 100 or more employees and at least 10 current employees
- •2015, for employers with an average of 50 or more full-time equivalent employees and at least one current employee
- •2016, for employers with an average of 51 or more employees regardless of current enrollment
- •2017, for employers with an average of 51 or more employees and at least one current employee
Show answer
2017, for employers with an average of 51 or more employees and at least one current employee
The course states that employers with an average of 51 or more employees (and at least one current employee) were allowed into the Exchange beginning in 2017. The state exchanges for individual and small employer markets were established no later than January 1, 2014.
- 225
The Consolidated Appropriations Act of 2021 (CAA) made several changes to health plan requirements. Which of the following correctly pairs two CAA provisions with their descriptions?
- •The No Surprises Act applies only to air ambulance services, and gag clauses are prohibited only in contracts between plans and pharmacy benefit managers
- •The No Surprises Act eliminates all out-of-network charges, and health plans must publicly post provider-specific negotiated rates but no attestation is required
- •The No Surprises Act provides protections for services received from out-of-network providers, and gag clauses in contracts with vendors are generally prohibited with an annual attestation required confirming removal
- •The No Surprises Act requires plans to cover all out-of-network services at in-network rates, and new fee disclosure rules apply only to insurers, not to brokers or consultants
Show answer
The No Surprises Act provides protections for services received from out-of-network providers, and gag clauses in contracts with vendors are generally prohibited with an annual attestation required confirming removal
The course describes several CAA provisions: the No Surprises Act provides certain protections for medical services received by an out-of-network provider with additional disclosures required. Separately, 'gag clauses' in contracts with vendors are generally prohibited and must be removed, with a related annual attestation that the clauses were removed now required. New fee disclosure rules also apply to brokers and consultants.
CSFS is the Certified Self-Funding Specialist designation. These are my own practice questions, written while studying for the exam. This site is not affiliated with, endorsed by, or connected to the organisation that administers the CSFS designation, and nothing here is official exam content or a substitute for the course material.
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