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
A Section 1332 State Innovation Waiver requires that any state alternative to ACA coverage must meet which core standard?
Answer: Coverage must be at least as comprehensive and affordable as ACA coverage
Section 1332 waivers require that alternatives provide coverage that is at least as comprehensive, affordable, and available as the ACA, protecting consumers.
Which data source do ACA risk adjustment models primarily rely on to calculate enrollee risk scores?
Answer: Enrollee diagnosis codes from medical claims and encounter data
HHS risk adjustment models use diagnosis codes submitted in medical claims and encounter data to map enrollees to Hierarchical Condition Categories.
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:
Answer: A sign that healthy enrollees with no diagnoses are being undercounted in the risk score
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.
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?
Answer: 3 times more
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.
Which approach do ACA-compliant insurers use to mitigate financial risk from high-cost specialty drugs included in their pharmacy benefits?
Answer: Utilization management including prior authorization and step therapy
Prior authorization and step therapy require clinical justification and lower-cost alternatives before approving high-cost specialty medications, managing utilization risk.
A health insurer that significantly over-priced premiums relative to actual claims in the individual market will MOST likely face which ACA consequence?
Answer: Obligation to pay MLR rebates to policyholders
If an insurer spends less than 80% of individual market premiums on claims and quality, it must rebate the excess to enrollees under the MLR requirement.
Under ACA market stabilization rules, when can an insurer deny a mid-year enrollment application from an applicant claiming a qualifying life event?
Answer: When the applicant cannot provide documentation verifying the qualifying life event
CMS requires marketplaces and issuers to verify SEP eligibility through documentation, allowing denial when the qualifying event cannot be substantiated.