ACA Quality Assurance & Compliance 2 — Questions and Answers
Question 1: Which federal agency is primarily responsible for overseeing ACA quality reporting requirements for health insurers?
- Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- Department of Labor (DOL)
- Federal Trade Commission (FTC)
- Office of Personnel Management (OPM)
Correct 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.
Question 2: Under ACA Section 1001, what percentage of premium revenue must large group insurers spend on clinical care and quality improvement (MLR standard)?
- 85% (Correct answer)
- 80%
- 75%
- 90%
Correct answer: 85%
The ACA requires large group market insurers to spend at least 85% of premium revenues on clinical care and quality improvement activities.
Question 3: What is the purpose of the ACA's quality improvement strategy requirement for qualified health plans (QHPs)?
- To ensure plans implement activities that improve health outcomes and patient safety (Correct answer)
- To set premium rate caps for all plans
- To require plans to offer only preventive services
- To mandate electronic health records for all enrollees
Correct 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.
Question 4: Which ACA provision requires hospitals to report on a set of quality measures to avoid a payment penalty?
- Hospital Value-Based Purchasing Program (Correct answer)
- Meaningful Use Program
- Hospital Readmissions Reduction Program
- Quality Payment Program
Correct 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.
Question 5: Under the ACA, which type of accreditation can substitute for CMS certification reviews for QHPs in the Federally Facilitated Marketplace?
- NCQA, URAC, or AAAHC accreditation (Correct answer)
- ISO 9001 certification
- Joint Commission hospital accreditation only
- State licensing alone
Correct answer: NCQA, URAC, or AAAHC accreditation
CMS recognizes accreditation from NCQA, URAC, and AAAHC as meeting certain quality review requirements for QHP certification.
Question 6: What does the ACA's 'transparency in coverage' rule require health plans to disclose?
- In-network and out-of-network cost-sharing information for all covered items and services (Correct answer)
- Insurer executive compensation above $500,000
- The names of all contracted physicians
- Claims denial rates by diagnosis code
Correct 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.
Question 7: Under ACA Section 2719, what must health plans provide when they deny coverage or rescind a claim?
- An internal and external appeals process with written notice (Correct answer)
- Only a written explanation with no further recourse
- A full refund of premiums paid during the denial period
- A referral to a state ombudsman only
Correct 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.
ACA Quality Assurance & Compliance 2
Which federal agency is primarily responsible for overseeing ACA quality reporting requirements for health insurers?