Quality Assurance & Compliance Flashcards
7 cards from real ACA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Assurance & Compliance flashcards as text
Which federal agency is primarily responsible for overseeing ACA quality reporting requirements for health insurers?
Answer: Centers for Medicare & Medicaid Services (CMS)
CMS oversees ACA quality reporting standards and compliance requirements for health insurers in the individual and small group markets.
Under ACA Section 1001, what percentage of premium revenue must large group insurers spend on clinical care and quality improvement (MLR standard)?
Answer: 85%
The ACA requires large group market insurers to spend at least 85% of premium revenues on clinical care and quality improvement activities.
What is the purpose of the ACA's quality improvement strategy requirement for qualified health plans (QHPs)?
Answer: To ensure plans implement activities that improve health outcomes and patient safety
QHP quality improvement strategies must address clinical quality, patient safety, health outcomes, and reducing health disparities.
Which ACA provision requires hospitals to report on a set of quality measures to avoid a payment penalty?
Answer: Hospital Value-Based Purchasing Program
The Hospital Value-Based Purchasing Program links Medicare payments to quality performance on clinical, patient experience, and safety measures.
Under the ACA, which type of accreditation can substitute for CMS certification reviews for QHPs in the Federally Facilitated Marketplace?
Answer: NCQA, URAC, or AAAHC accreditation
CMS recognizes accreditation from NCQA, URAC, and AAAHC as meeting certain quality review requirements for QHP certification.
What does the ACA's 'transparency in coverage' rule require health plans to disclose?
Answer: In-network and out-of-network cost-sharing information for all covered items and services
The Transparency in Coverage rule requires plans to publish machine-readable files and personalized cost estimates for covered items and services.
Under ACA Section 2719, what must health plans provide when they deny coverage or rescind a claim?
Answer: An internal and external appeals process with written notice
ACA Section 2719 requires non-grandfathered plans to maintain internal and external appeals processes and provide timely written notices of adverse decisions.