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CMS FFM Agent study materials
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CMS FFM Agent: Plan and benefit information

CMS FFM Agent · Work through your exam, one topic at a time.

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Plan and benefit information

Domain 3 tests how to read and explain QHP benefit designs: metal tiers, actuarial value, cost-sharing reductions, essential health benefits, networks, and required disclosures.

Plan design basics

  • Metal tiers reflect actuarial value (AV): Bronze 60%, Silver 70%, Gold 80%, Platinum 90%. AV is the share of covered benefits the plan pays for a standard population, not a promise about an individual's costs.
  • Catastrophic plans are available only to people under 30 or with a hardship exemption; they cover preventive services and a limited number of primary care visits before the deductible and are not APTC or CSR eligible.
  • CSR is available only on Silver plans at 100-250% FPL; the tiers raise AV to 94%, 87%, or 73%. A Silver plan with CSR can cost less overall than a Bronze plan with a lower premium.
  • Essential health benefits fall into 10 categories: ambulatory, emergency, hospitalization, maternity and newborn, mental health and substance use disorder, prescription drugs, rehabilitation, laboratory, preventive and chronic care, and pediatric oral and vision. EHBs have no annual or lifetime dollar limits.
  • Cost-sharing includes deductibles, copays, coinsurance, and the maximum out-of-pocket (MOOP). Premiums are not cost-sharing. In-network preventive services are covered with no cost-sharing.
  • Networks: HMO, PPO, EPO, and POS plans differ on referrals and out-of-network coverage. Emergency services are covered at in-network rates regardless of network. The No Surprises Act protects against balance billing for emergency care and certain out-of-network services.
  • Required consumer materials include the Summary of Benefits and Coverage, Uniform Glossary, provider directory, and formulary.

Worked example

A consumer at 180% FPL compares a Bronze plan with a $7,000 deductible and a Silver plan with CSR. Bronze has the lower premium, but at 180% FPL the Silver CSR plan has 87% AV and a much lower deductible. For a consumer with regular care, the Silver CSR plan often wins on total annual cost. The reasoning is to compare premium net of APTC plus expected cost-sharing, not premium alone.

Traps

  • Saying CSR applies to Bronze or Gold. It applies only to Silver.
  • Treating AV as an out-of-pocket cap; MOOP is the cap.
  • Assuming all plans cover out-of-network care or that preventive care is free out-of-network.
  • Ignoring formulary tiers and prior authorization when explaining drug costs.