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 ACA mechanism allows states to waive certain ACA requirements to implement alternative coverage approaches if they meet specific waiver criteria?
Answer: Section 1332 State Innovation Waivers
Section 1332 waivers allow states to waive certain ACA market rules and exchange requirements if the alternative plan meets coverage, affordability, and scope standards.
Under ACA quality standards, what is the minimum timeframe within which a health plan must complete an expedited internal appeal for urgent care situations?
Answer: 72 hours
For urgent/expedited appeals, plans must make a determination within 72 hours of receiving the appeal request.
Which ACA reporting requirement asks insurers to justify premium rate increases of 10% or more?
Answer: Rate Review Program
The ACA's Rate Review Program requires insurers to submit justification for premium increases of 10% or more for review by states or CMS.
What does the ACA require of large employers (50+ FTEs) who fail to offer minimum essential coverage to full-time employees?
Answer: They may owe an employer shared responsibility payment (ESRP) if any employee receives a premium tax credit
Under the employer mandate, applicable large employers that fail to offer adequate coverage may owe an ESRP if at least one full-time employee receives a subsidized plan through the exchange.
Under ACA regulations, which standard must a health plan meet to demonstrate that its provider network is sufficient for enrollees?
Answer: Network adequacy standards requiring timely access to primary and specialty care within geographic distance limits
Network adequacy requires plans to ensure enrollees can access primary and specialty care within specified time and distance standards.
Under the ACA, how long must health insurers retain records related to MLR calculations and rebate payments?
Answer: Ten years
CMS regulations require issuers to retain all records supporting MLR calculations and rebate determinations for at least ten years.
Under ACA Section 2718, what must an insurer do if its administrative costs cause the MLR to fall below the required threshold in a given year?
Answer: Issue a rebate to policyholders by September 30 of the following year
Issuers that do not meet MLR standards must pay rebates to policyholders (or employers) by September 30 of the year following the reporting year.