ACA Risk Management & Mitigation 4

Question 1

A health plan discovers its risk adjustment transfer payment will be significantly higher than expected. The BEST risk mitigation response is to:

Accepted Answer

Improve diagnosis coding accuracy and data submission completeness

Answer

Accurate and complete diagnosis coding ensures the plan's risk score reflects its true enrollee health burden, potentially reducing unexpected transfer obligations.

Question 2

Which ACA provision most directly mitigates the risk that large employers will drop coverage and shift employees to the marketplace?

Accepted Answer

Employer Shared Responsibility Payment (ESRP)

Answer

The ESRP (employer mandate) requires applicable large employers to offer affordable minimum-value coverage or pay a penalty, discouraging them from dropping coverage.

Question 3

Under the ACA's guaranteed issue requirement, which risk management tool do insurers use INSTEAD of medical underwriting to manage their risk pool?

Accepted Answer

Annual open enrollment periods with limited special enrollment

Answer

Since the ACA bans medical underwriting, insurers rely on limited open enrollment windows and SEP verification to prevent adverse selection.

Question 4

A risk manager at an insurance company wants to quantify the impact of high-cost claimants on plan financials. Which metric is MOST relevant?

Accepted Answer

Concentration of claims among top 1–5% of enrollees

Answer

A small percentage of enrollees typically generate the majority of medical costs, so analyzing claims concentration helps quantify catastrophic risk exposure.

Question 5

Which ACA rule prevents insurers from using 'death spirals' — where only sick people enroll, causing premiums to rise, driving healthy people out — by stabilizing the risk pool?

Accepted Answer

Community rating with age bands limited to 3:1

Answer

Community rating prevents insurers from charging sick enrollees more, while age bands (3:1 ratio) limit but don't eliminate age-based pricing variation.

(ACA) Affordable Care Act Certified Practice Test

(ACA) Affordable Care Act Certified Practice Test

ACA Risk Management & Mitigation 4