Risk Management & Mitigation 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 Risk Management & Mitigation flashcards as text
The ACA's risk adjustment model uses Hierarchical Condition Categories (HCCs) primarily to:
Answer: Predict relative medical costs based on enrollee diagnoses
HCCs group diagnosis codes to estimate each enrollee's expected medical costs, which feeds into the plan's overall risk score.
Which factor is NOT used in calculating a plan's risk score under the ACA risk adjustment methodology?
Answer: Premium amount charged by the plan
Risk scores are based on enrollee demographics and health status (HCCs), not on the premiums the plan charges.
A 'silver loading' strategy employed by some states after the CSR funding cuts is best described as:
Answer: Adding CSR costs only to silver plan premiums to inflate benchmark subsidies
Silver loading concentrates CSR cost increases on silver plans, inflating the benchmark premium used to calculate APTC and benefiting subsidized enrollees.
Under ACA rules, the maximum out-of-pocket limit mitigates financial risk for enrollees primarily by:
Answer: Capping total annual cost-sharing for covered in-network services
The annual out-of-pocket maximum stops enrollees from paying unlimited cost-sharing, protecting against catastrophic financial exposure for in-network covered services.
Which ACA mechanism specifically reduces financial risk for lower-income marketplace enrollees by reducing deductibles and copayments?
Answer: Cost-Sharing Reductions (CSRs)
CSRs reduce out-of-pocket costs for eligible silver plan enrollees with incomes between 100–250% FPL by requiring insurers to offer enhanced actuarial value.
An insurer concerned about risk selection from a short-term health plan market operating alongside its ACA-compliant plans should be MOST worried about:
Answer: Healthy individuals leaving the ACA pool for cheaper non-compliant plans
Short-term plans attract healthy people who can pass underwriting, leaving the ACA pool with sicker, higher-cost enrollees — classic adverse selection.
Under the ACA, which enrollee action most directly triggers a Special Enrollment Period that could pose adverse selection risk to insurers?
Answer: Loss of minimum essential coverage
Losing minimum essential coverage is a qualifying life event that opens a 60-day SEP, and people experiencing this often enroll because they now need care.