ACA Risk Management & Mitigation 5

Question 1

A Section 1332 State Innovation Waiver requires that any state alternative to ACA coverage must meet which core standard?

Accepted Answer

Coverage must be at least as comprehensive and affordable as ACA coverage

Answer

Section 1332 waivers require that alternatives provide coverage that is at least as comprehensive, affordable, and available as the ACA, protecting consumers.

Question 2

Which data source do ACA risk adjustment models primarily rely on to calculate enrollee risk scores?

Accepted Answer

Enrollee diagnosis codes from medical claims and encounter data

Answer

HHS risk adjustment models use diagnosis codes submitted in medical claims and encounter data to map enrollees to Hierarchical Condition Categories.

Question 3

An insurer notices that its risk score is being dragged down by a large number of enrollees with no claims during the year. The risk manager should recognize this as:

Accepted Answer

A sign that healthy enrollees with no diagnoses are being undercounted in the risk score

Answer

Enrollees with no claims generate no diagnosis codes, which lowers the plan's average risk score even if those enrollees have underlying conditions that were simply not captured.

Question 4

Under the ACA, the age rating band of 3:1 means that an insurer can charge older adults a maximum of how many times more than younger adults for the same plan?

Accepted Answer

3 times more

Answer

The ACA limits age-based premium variation so that the oldest adult (64) can be charged no more than three times the premium of the youngest adult (21) for the same plan.

Question 5

Which approach do ACA-compliant insurers use to mitigate financial risk from high-cost specialty drugs included in their pharmacy benefits?

Accepted Answer

Utilization management including prior authorization and step therapy

Answer

Prior authorization and step therapy require clinical justification and lower-cost alternatives before approving high-cost specialty medications, managing utilization risk.

(ACA) Affordable Care Act Certified Practice Test

(ACA) Affordable Care Act Certified Practice Test

ACA Risk Management & Mitigation 5